Mohamed Adel Atta

Desire to Void and Force of Micturition in Patients with Intestinal Neobladders

PURPOSEnWe attempted to determine how patients with an orthotopic bladder perceive the desire to void and the force achieved to evacuate the bladder.nnnMATERIALS AND METHODSnA total of 24 men who had undergone post-cystectomy bladder substitution (ileocecal in 12, sigmoid in 6 and ileal in 6) was evaluated subjectively an objectively by pressure-flow study 1 to 3 years postoperatively.nnnRESULTSnDesire to void was felt at the base of the penis or in the perineum by 20 men (83%). Abdominal pressure contributed to intra-reservoir pressure by 51 to 54% in ileocecal, 20 to 24% in sigmoid and 23 to 25% in ileal neobladders.nnnCONCLUSIONSnPatients perceive the desire to void when drops of urine leak into the proximal urethra from an overfilled neobladder. Urine is evacuated mainly by abdominal straining for ileal neobladders, mainly by contraction for sigmoid neobladders, and by approximately equal contributions of contradiction and straining for ileocecal neobladders.

Early and Late Cystometry of Detubularized and Nondetubularized Intestinal Neobladders: New Observations and Physiological Correlates

PURPOSEnWe studied the volume and pressure changes with time in detubularized and nondetubularized neobladders.nnnMATERIALS AND METHODSnCystometry was performed at early and late followup in 54 male patients with post-cystectomy intestinal neobladders constructed from an intact ileocecal segment in 33, detubularized sigmoid in 11 and detubularized ileum in 10.nnnRESULTSnWith time the capacity of the neobladder increased in all 3 groups. Concomitantly, while intact ileocecal bladders showed an increase in intra-reservoir pressure and persistence of involuntary contractions, detubularized sigmoid and ileal bladders showed a decrease in intra-reservoir pressure and involuntary contractions.nnnCONCLUSIONSnIncreased capacity with time is not due to detubularization per se but rather to over distension, which is more marked in detubularized (109 to 112%) than in tubular (79%) segments. Detubularized intestinal neobladders not only offer a high capacity, low pressure and high compliant reservoir but these characteristics also are increased with time.

Detubularized Isolated Ureterosigmoidostomy: Description of a New Technique and Preliminary Results

PURPOSEnA technique is described to improve the evacuation pattern and, accordingly, the life-style of patients with ureterosigmoidostomy.nnnMATERIALS AND METHODSnAn inverted U-shaped sigmoid colon is detubularized, and the left colon is fixed in continuity to the posterior wall of the rectal ampulla in line with the anorectal canal. The ureters are reimplanted into the sigmoid pouch using the nipple technique.nnnRESULTSnAll 15 patients followed for 3 to 18 months postoperatively passed clear urine and solid feces separately, with good anal control and at convenient periods (urine 3 to 6 times and solid feces once daily). Urographic studies showed stabilization of renal morphology in 26 units, improved function in 3 and deterioration in 1. Dynamic study of the rectum in 3 patients showed a capacious rectosigmoid reservoir with low pressure.nnnCONCLUSIONSnThe technique of detubularized isolated ureterosigmoidostomy has important advantages over conventional ureterosigmoidostomy. Patients pass urine and feces separately and at convenient intervals with good anal control. The upper urinary tract is well preserved, and there is potentially less risk of colonic carcinogenesis.

Percutaneous silicon catheter insertion into the IVC, following percutaneous nephrostomy (PCN) exchange

Percutaneous nephrostomy (PCN) has been widely used to drain an infected, obstructed kidney. Few major complications have been associated with it. Few publications have reported the misplacement of nephrostomy tube into the inferior vena cava (IVC), following percutaneous nephrolithotomy. We report a case of a misplaced silicon catheter, through the left renal vein, extending into the IVC, following nephrostomy tube exchange. Our case was safely managed, and we concluded that although PCN and nephrostomy tube exchange are relatively simple procedures, they should be done cautiously, by a well-trained urologist, and preferably under ultrasound or fluoroscopic guidance.

A New Technique for Continent Urinary Reservoir Reconstruction

A new technique for urinary reservoir reconstruction has been applied to 14 patients following radical cystectomy. The sigmoid colon was used in 10 cases and the ileum in 4. The pouch is constructed of adjacent detubularized intestinal segments. The continence mechanism is achieved by the formation of a double-jacket intestinal tube anastomosed to the skin. All patients except 1 were continent during stressful situations and resting with easy catheterization of the pouch. Urodynamic study in 3 cases showed a low pressure sigmoid reservoir with an average of 15 cm. water, and the tube had good tone with an average of 35 cm. water and a 5.5 cm. functional length. The technique is simple, can be applied to either the sigmoid colon or ileum and results in urinary continence with easy catheterization.

Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients

Abstract Objectives: To assess whether the detubularised isolated ureterosigmoidostomy (DIUS) technique is safe for urinary diversion after radical cystectomy. Patients and methods: The study included 10 patients (mean age 61.8 years) with invasive bladder tumour, operated at the Alexandria University, Egypt. The diversion in all patients was through a DIUS, with ureteric reimplantation by an antirefluxing procedure, using an embedded-nipple technique. The patients were evaluated before and after surgery using radiological and manometric studies, and the results analysed statistically using Student’s t-test. Results: Nine of the 10 patients could differentiate between urinary and stool sensation, and evacuate them separately. The mean (range) daytime frequency was 4.1 (3–5) and the mean night-time frequency was 0.5 (0–1). Before and after surgery, the respective mean resting anal pressure was 71 and 74 cmH2O (P = 0.004), the volume at first desire to defecate was 54 and 72 mL (P = 0.004) and the maximum tolerable volume was 140 and 160 mL (P < 0.001). The anorectal inhibitory reflex was lost in all patients after surgery. The mean (SD, range) basal pouch pressure was 5 (3.33, 0–10) cmH2O, and the end pressure was 13.2 (4.42, 9–20) cmH2O. Conclusion: Although the Mainz II pouch has a documented efficacy for urinary diversion after radical cystectomy, the modifications we applied to the DIUS improved that method of diversion, by separating urine and stool evacuation, maintaining continence, and with a low frequency and better protection of the upper urinary tracts, resulting in an improvement in the patients’ quality of life.

The value of extended good quality transurethral resection of bladder tumour in the treatment of the newly diagnosed bladder cancer

Abstract Objective: To report our experience for the initial management of patients with newly diagnosed bladder tumours using our team approach for each case and using an aggressive extended transurethral resection of bladder tumour (TURBT) in order to investigate the real need for a routine ‘second-look’ cystoscopy in the current era. Patients and methods: The study included 50 consecutive patients admitted to the urology department, of our tertiary care centre, for management of newly diagnosed bladder cancer. Exclusion criteria included past history of bladder tumour, palpable mass on bimanual examination under anaesthesia, presence of residual tumour at the end of resection, and patients with tumours of the bladder dome as thorough resection is difficult to achieve in this area without an attendant risk. Patients that had pathologically confirmed carcinoma in situ were also excluded. White-light cystoscopy was used in all of the cases. Extended TURBT was defined as resection of the whole tumour, resection of the tumour base and 1 cm of apparently normal bladder wall around the circumference of the tumour. Results: The median (range) age of the patients was 52 (39–60) years. After initial TURBT, 10 patients (20%) were identified as having muscle-invasive bladder cancer. Of the remaining 40 patients, three had low-grade Ta disease, and so second biopsies were not taken. The remaining 37 patients had T1, grade 2–3 disease and none of them had evident residual disease at the site of tumour resection. Conclusion: Re-staging TURBT could be safely omitted for select groups of patients. An experienced surgeon and teamwork, together with an extended TURBT can accurately achieve complete tumour resection, with accurate tumour staging, on initial resection.

Renal cell carcinoma: Are we attacking a different tumor over the past 10 years?

OBJECTIVEnThere is a noticeable increase in the presentation of different types of urological malignancies at a younger age of presentation, in our institution. The objective of our study was to investigate cases presented with renal cell carcinoma, managed in the past 10 years for any possible epidemiological and cancer characteristics changes.nnnMETHODOLOGYnRetrospective data collection for cases managed by our institution in the time period (2002-2012) was done. We included patients with complete data and pathologically proven renal cell carcinoma at final diagnosis.nnnRESULTSnComplete data could be retrieved for 334 patients. The mean age of cases was 43.5 years, with 279 (83%), 200 (60%) and 128 (38%) of patients younger than 60, 50 and 40 years respectively. Males and females involvement were 191 (57%) and 143 (43%) respectively. By histopathology, 200 (60%) of patients had clear cell (CC) RCC and 134 (40%) patients had non-clear cell type (papillary or chromophobe). The mean tumor size was 10.9 cm and partial nephrectomy was applied for 16% of all the cases, including 65% for cases with tumor size less than 4 cm.nnnCONCLUSIONnThere is a marked increase in the prevalence of renal cell carcinoma in the past 10 years, among younger age group, with higher rate for involvement of female gender. RCC is tending to present with large tumor size and more prevalence of non-clear cell histopathology. The use of partial nephrectomy is accepted for patients presented with renal mass and can safely challenge larger sized tumors.

Corrigendum to "Detubularised isolated ureterosigmoidostomy (Atta pouch): Manometric and radiological studies in a sample of patients" [Arab J. Urol. 12 (2014) 197-203].

[This corrects the article DOI: 10.1016/j.aju.2014.02.003.].

Late recurrent urothelial carcinoma in the Studer neobladder: conversion to continent reservoir

Bladder cancer represents a considerable issue in Egypt and the Middle East. Radical cystectomy and orthotopic neobladder represent the standard of care for managing cases with invasive bladder tumour. There are few cases reported in the literature considering the urothelial recurrence in the urethra, connected to neobladder. We are presenting a rare case of a young female patient, with an aggressive urothelial tumour, recurring 13-year post-radical cystectomy, and the Studer neobladder. Our case was managed by urethrectomy and conversion of the neobladder into continent reservoir, with good short-term oncological and functional outcomes. We can conclude that bladder cancer cases should be followed thoroughly throughout their life. Follow-up urethroscopy and cytology should be done for all cases of post-radical cystectomy, regardless of patients’ symptoms. Key message Late urothelial recurrence of post-radical cystectomy is possible and, in our case, happened 13 years following surgery. The Studer neobladder can be safely converted into continent reservoir, allowing good functional outcomes. Also, recurrence in the Studer neobladder can be safely managed, allowing good oncological outcomes, without the need for any ureteroileal interventions.