Mohamed F. Abdelhafez

Minimally invasive percutaneous nephrolitholapaxy (PCNL) as an effective and safe procedure for large renal stones

Study Type – Therapy (case series)

Minimally Invasive Percutaneous Nephrolithotomy: A Comparative Study of the Management of Small and Large Renal Stones

OBJECTIVE To compare the safety and efficacy of minimally invasive percutaneous nephrolitholapaxy (MIP) between small (<2 cm) and large (>2 cm) renal calculi, because although MIP has proved its efficacy in small lower caliceal stones, the efficacy in large renal calculi has been questioned. MATERIALS AND METHODS The data from 191 consecutive minimally invasive percutaneous nephrolithotomy (MIP) procedures at a single institution from January 2007 to March 2011 were reviewed retrospectively. All stone sizes and complexity were included (98 were <2 cm and 93 were ≥ 2 cm). We performed a comparative analysis of procedures for calculi <2 cm and ≥ 2 cm regarding the stone-free rate, the need for auxiliary procedures, and complications. The Student t test for parametric continuous variables and the chi-square test or Fischers exact test for nominal variables were applied. RESULTS The primary stone-free rate was significantly lower for the large than for the small stones (76.3% vs 90.8%, P = .007), and the secondary stone-free rate after one auxiliary procedure (second-look percutaneous nephrolithotomy, ureterorenoscopy, or shock wave lithotripsy) was not significantly different between the 2 groups (94.6% vs 98.9%, P = .1). The total complication rate was not significantly different (26.9% vs 19.4%, P = .2) between the 2 groups either. Grade III complications occurred in 5.2% of all patients, and no grade IV or V complications were observed. CONCLUSION Using MIP, the total stone-free rate was greater for the small than for the large calculi; however, most patients could be rendered stone-free with the use of one auxiliary procedure. The high success rate and low rate of higher grade complications justify the application of MIP for large stones.

Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon’s preference?

Abstract Objective: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. Materials and methods: A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student’s t test, chi-squared test or Fisher’s exact test. A p value less than 0.05 was considered statistically significant. Results: Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02). Conclusion: MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon’s preference.

The management of the persistent Müllerian duct syndrome.

Abstract Objectives: To report the findings and management of patients with persistent Müllerian duct syndrome (PMDS). Patients and methods: Nineteen phenotypically male patients (aged 8 months to 27 years) presented with testicular maldescent. All of them had normal male external genitalia. Two of them had had a previous diagnosis of persistent Müllerian structures. All patients were karyotyped, and had a hormonal profile, diagnostic laparoscopy, retrograde urethrocystogram, gonadal biopsies, and surgical management according to the findings. The follow-up was based on a clinical examination, abdominal ultrasonography (US) and scrotal colour-Doppler US at 3 and 6 months after surgery, and every 6 months thereafter. Results: Diagnostic laparoscopy showed the presence of persistent Müllerian structures in all 19 patients. All patients had a normal male karyotype (46XY). Ten patients had a laparoscopic excision of their Müllerian structures while the remaining nine patients had their Müllerian structures left in place. No malignant changes were found in the excised Müllerian tissues. Of the 37 gonadal biopsies taken, 31 (84%) indicated normal testes. Conclusions The incidence and prevalence of PMDS are not well estimated. Müllerian structures should be removed whenever possible to avoid the risk of malignant transformation. The early diagnosis of PMDS makes possible the excision of Müllerian structures and a primary orchidopexy. A long-term follow-up is needed for patients with intact Müllerian structures and magnetic resonance imaging might be a better method than US for that purpose. Most of the patients had normal testicular histology, which might allow fertility.

The "I-Pouch": Results of a new ileal neobladder technique

Abstract Objective. The aim of this study was to investigate perioperative, oncological and functional outcomes of the “I-Pouch” neobladder. Materials and methods. From 2002 to 2011, 97 patients (72 men, 25 women, median age 65, range 42-84 years) underwent radical cystectomy with I-Pouch neobladder reconstruction. Complications were graded according to the Clavien-Dindo classification. Oncological and functional outcomes were assessed. The median oncological and functional follow-up was 41 months (range 3-107 months) and 18 months (3-111 months), respectively. Results. In the total cohort, the 5 year cancer-specific survival was 67.9%. The major 30 and 90 day complication rates were 14.4% and 17.5%, respectively. Open reimplantation for ureterointestinal stricture was necessary in two (2.1%). Of the 95 functionally evaluable patients postoperatively, 93 urinated spontaneously (97.9%) and two patients (2.1%) required clean intermittent catheterization to empty their neobladder. The median postvoid residual urine volume (PVR) was 0 ml (range 0-200 ml). One patient had postoperative reflux (1%), as evidenced by voiding cystography. The median number of urinary tract infections per year was 0 (range 0-2) and showed no association with increased PVR (p = 0.18). Conclusions. The perioperative, oncological and functional outcomes of the I-Pouch are comparable to those of other types of ileal neobladder. An advantage of the I-Pouch is that the implantation of the ureters lies on the neobladder floor, which facilitates later instrumentation of the upper tract.

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. VI. Unusual Events in Urolithiasis: 1. Long-Standing Urethral Stones without Underlying Anatomical Abnormalities in Male Children

Objectives: The study aimed to present our center’s experience with long-standing urethral stones in male children with normal urethra. Materials and Methods: Retrospective search of our center data was done for the cases of long-standing urethral stones with normal urethra in male children during the period July 2001 – June 2016. Demographic and clinical data were studied. Results: Of more than 54,000 urolithiasis procedures, 17 male children (0.031%) were operated for long-standing urethral stones with normal urethra. In 14 cases (82.4%), residence was rural and parental education levels were low or none. All children were regularly prompted voiding with a history of difficulty or dysuria. All the stones lodged in the posterior urethra with an approximate mean duration of 2 months. The mean stone size of 11.29 ± 3.88 mm and rough surfaces in 88.2% of cases represented the main predisposing factors. Major complications included rectal prolapse in 1 case and vesicoureteral reflux in 3 cases. Endoscopic push-back was followed by disintegration in 76.5% or cystolithotomy in 17.7%, while it failed in 1 case that was treated by cystolithotomy. Conclusions: Long-standing urethral stones in male children with normal urethra are very rare misdiagnoses. Stone topography and sociocultural factors predisposed to their lodgments and negligence. Endoscopic treatment is the best approach.

Is Concealed Epispadias a Rare Variant

OBJECTIVE To present our experience with concealed epispadias and to estimate its actual share in the isolated male epispadias cases and its effect on the surgical outcome. MATERIALS AND METHODS Consecutive patients with isolated male epispadias treated in our center between 2008 and 2015 were classified into concealed and classic epispadias. The 2 groups were compared regarding age at presentation, meatal location, incontinence, dorsal curvature, success rate, and complications. RESULTS Out of 51 patients with isolated male epispadias, 11 (21.6%) were concealed: 7 balanic and 4 penile shaft epispadias. Concealed epispadias cases were found to have significantly delayed age at presentation, more distal meatal location, and less incontinence rate than classic epispadias cases. None of the surgical outcome parameters showed significant difference between the 2 groups. CONCLUSION Concealed epispadias represents about one-fifth of isolated male epispadias cases. Impediment and delay of diagnosis are its main clinical impacts, with insignificant effect on the surgical outcome.

1424 QUALITY OF LIFE ANALYSIS IN PATIENTS FOLLOWING RADICAL CYSTECTOMY AND ORTHOTOPIC URINARY DIVERSION: A SINGLE-INSTITUTION COMPARISON OF STUDER- AND I-POUCH NEOBLADDER

INTRODUCTION AND OBJECTIVES: The aim of this study was to evaluate health-related QoL differences in patients with different ileal neobladder substitutes of 40cm (I-Pouch) and 60cm (StuderPouch, S-Pouch) length. METHODS: Of a total of 171 ileal neobladder procedures (I-pouch: 91 pat., S-pouch: 80 patients) performed in a tertiary academic center between 2002 and 2011 we evaluated QoL aspects in 61 patients (51 men, 12 women) who underwent radical cystectomy for bladder cancer. Thirty-three patients (26 men, 7 women) underwent an I-pouch and 28 (19 men, 9 women) an S-pouch procedure. The following questionnaires were used: the EORTC QLQ-C30, QLQBLM30 and the GIQLI (evaluating changes bowel habits). Additionally, we assessed the rate of vitamin B12 supplementation, bicarbonate substitution and recurrent urinary tract infections. Median follow-up was 66 months (IQR: 41-104; total range: 9-161. RESULTS: Median age at surgery was 68 (IQR: 43-84) in the I-Pouch and 66 years (IQR: 39-74) in the S-Pouch group (p 0.47). Patients with an I-pouch reported similar QLQ-C30 overall health status (median: 6, IQR: 4-6) compared to patients with an S-pouch (median: 5; IQR: 4-6; p 0.24). Patients with I-Pouch reported better QLQ-C30 QoL status (median: 6, IQR: 5-6) compared to patients with an S-Pouch (median 5, IQR: 4-6; p 0.037). Patients with an S-pouch reported better QLQ-BLM30 general health status (median 19, IQR: 11-26) compared to patients with an I-pouch (median: 29, IQR: 26-34; p 0.001). The median GIQLI score was 0.5 in patients with an I-pouch (IQR: 0-3) and 2 (IQR: 0.75-5) in patients with an S-pouch (p 0.11). Median number of recurrent UTIs was 0 (IQR: 0-2) in patients with an I-Pouch and 1 (IQR: 0-4) in patients with an S-pouch (p 0.036). Patients with an S-pouch tended to be on vitamin B12 substitution compared to I-pouch patients (p 0.07). No significant difference was noted with regard to the rate of bicarbonate substitution between both groups (p 0.57). CONCLUSIONS: In this long-term study, patients with an Ipouch experienced a lower rate of recurrent UTIs and tended to be at lower risk of vitamin B12 supplementation. These findings may be attributable to the reduced length of ileum used for the formation of the pouch. The heterogeneity of findings suggests that questionnaires, as the QLQ-C30 and -BLM30 are not valid enough to adequately address QoL aspects in patients with ileal neobladders. These data hint at the necessity to develop neobladder-specific questionnaires to adequately address QoL issues in different ileal neobladders.