Mohamed Gadelmoula

Percutaneous nephrolithotomy in children: A preliminary report.

Objectives: The recurrence of pediatric nephrolithiasis, the morbidity of repeated open surgical treatment as well as our experience in percutaneous nephrolithotomy (PNL) in adult patients, all derived us to shift to PNL for managing renal stones >1.5 cm in pediatric patients. Our aim of this study is to evaluate the safety and efficacy of PNL in pediatric patients. Materials and Methods: During the period of the month between May 2011 and April 2013, 38 children (47 renal units) underwent PNL for renal stones 1.5-5 cm in length. Patient demographics, stone characteristics, and clinical outcome were prospectively studied. Data of those who underwent conventional and tubeless PNL were compared. Median follow-up period was 12 months (range: 6-24). Results: The median age at presentation was 8-year (range: 3-12). The operative time ranged from 30 to 120 min (median 90). Overall stone clearance rate was 91.5% after single PNL. The median hospital stay was 3 days. Auxiliary procedures were successful for the remaining 4 patients (nephroscopic clearance in one and shockwave lithotripsy in 3). Tubeless PNL was performed in 17 renal units with a comparable outcome to conventional ones. The perioperative complications were noted in 5/47 (10.6%) of all procedures (Clavien Grade II in 4 and Clavien Grade IIIa in 1) and were managed conservatively. Conclusions: Percutaneous nephrolithotomy for renal stones in pediatric patients is safe and feasible if performed by a well-experienced endourologist. Tubeless PNL is a better choice for children.

The laparoscopic management of symptomatic renal cysts: A single-centre experience

Abstract Objectives: To present our experience of treating symptomatic renal cysts by different techniques of laparoscopic decortication, as there are many treatment options for such cysts, each of them with advantages and drawbacks. Patients and methods: Between January 2002 and December 2012, 51 patients underwent laparoscopic renal-cyst decortication; 15 of them had recurrent cysts after percutaneous aspiration. A retroperitoneal approach was adopted in 44 cases, transperitoneal in four and laparo-endoscopic single-site surgery (LESS) cyst decortication in three (two of them had bilateral renal cyst decortications in the same session). All patients were diagnosed by ultrasonography and computed tomography to determine the Bosniak classification of the cyst. Pain and cyst recurrence were assessed during the follow-up. Results: All procedures were completed successfully, with no major intraoperative complications. The mean (range) operative duration was 56 (35–125) min, affected by the site and number of cysts unroofed. All patients were symptom-free except one, who had a recurrent large cyst, anteriorly located, and who underwent open cyst decortication. Conclusions: Laparoscopic decortication of symptomatic renal cysts should be the standard of care, especially after failed percutaneous aspiration or decortication. LESS cyst decortication is a promising technique, especially with bilateral pathology. It is feasible with conventional laparoscopic instruments and gives a better cosmetic outcome.

Long anterior urethral stricture: Reconstruction by dorsally quilted penile skin flap

Objectives: We’d like to present our experience in treating long (>5 cm) anterior urethral stricture by penile skin flap as dorsal on-lay in one-stage procedure. Patient and Methods: Between January 1998 and December 2010, 18 patients (aged from 28-65 years) presented with long urethral stricture, 5.6-13.2 cm, (penile in 6, bulbar in 2, and combined in 10 cases), those were repaired utilizing long penile skin flaps placed as dorsal on-lay flap in one-stage (Orandi flap 6 cm in 6 cases, circular flaps 7-10 cm in 8, and spiral flaps 10-15 cm in 4). Uroflowmetry and RUG were done following catheter removal and at 6 and 12 months. Results: The urethral patency was achieved in 77% of patients. The complications were fistula in 1 patient (5.5%), re-stricture occurred in 3 patients (16.6%) that required visual internal urethrotomy (VIU), and 2 patients (11%) showed curvature on erection that did not interfere with sexual intercourse. Diverticulum (penile urethra) was seen in 1 patient (5.5%) containing stones and was excised surgically. There was penile skin loss in 3 patients (16.6%). All patients completed at least one year follow-up period. Conclusion: Free penile skin flaps offer good results (functional and cosmetic) in long anterior urethral stricture. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.

Health related quality of life after urinary diversion. Which technique is better

OBJECTIVE To compare quality of life (QoL) after urinary diversion (UD) following radical cystectomy (RC) using validated questionnaires. PATIENTS AND METHODS Between January 2011 and June 2016, 150 patients (121 men [80.7%] and 29 women [19.3%]) with invasive bladder cancer who underwent RC and UD were included in this prospective study. Patients were divided into 2 groups; group I included the orthotopic neobladder 50 (33.3%) and uretro-sigmoidostomy 41 (27.3%) and group II included uretero-cutanoustomy 33 (22.1%) and ileal conduit 26 (17.3%) patients. QOL was evaluated using the Functional Assessment of Cancer Therapy-Bladder Cancer. The erectile function (EF) was assessed using the Sexual Health Inventory for Men Questionnaire. Evaluation was done before and after one year postoperatively. RESULTS The mean ± SD patient age was 55.0 ± 7.9 and 59.5 ± 8.5 years in both groups, respectively (p = 0.001). There was a significant difference in the physical, social/family, emotional and functional statuses that were significantly higher in group I. One year postoperatively, the emotional well-being became insignificantly different, but other QoL parameters remained significantly different between both groups. Regarding EF, there was a significant difference between patients who underwent nerve-sparing (No. 29) and non nerve-sparing RC (No. 59) (p < 0.001). CONCLUSIONS Which type of diversion is the best is still a controversial topic. Egyptian patients may prefer the continent UD to avoid the urostomy appliance and its associated daily-life constraints. Detailed patient counseling and active participation of the patient in selecting the treatment methods are important for better postoperative QoL.

MP51-09 PRIMARY VERSUS DEFERRED URETEROSCOPY FOR MANAGEMENT OF CALCULUS ANURIA: A PROSPECTIVE RANDOMIZED TRIAL

INTRODUCTION AND OBJECTIVES: The role of ureteroscopy (URS) in management of acute renal failure caused by ureteral calculi could be primary or deferred after ureteral stenting. In this study we evaluate both approaches as regards the feasibility and clinical outcome. METHODS: Between January 2012 and December 2014, 150 patients with anuria / oliguria with a significant increase in serum creatinine due to ureteral stones (114 men and 36 women); including 72 solitary functioning kidney. Patients were prospectively randomized according to timing of ureteroscopic intervention into two groups; deferred URS group (69 patients who were treated initially by ureteral stenting then URS in another session) and primary URS group (81 patients who were treated by emergency URS). Follow up was at least 6 months postoperatively. RESULTS: Stone distribution was: 56% lower ureteral, 32% mid ureteral, and 12% upper ureteral. Both groups were comparable at presentation. Complete ureteroscopic stone clearance was 87 % and 75.3% for deferred and primary URS groups respectively (p1⁄40.097). Normal renal function returned in 94.2% of deferred URS vs. 97.5% of primary URS (p1⁄40.414). Deferred URS group had 2.9 % overall complication rate in comparison to 9.9 % for primary URS group (p1⁄40.109). Ureteral perforation/pyelonephritis was noted in 6.2% of primary URS group only (p1⁄40.043). Median number of maneuvers required till stone clearance was one (range 1-5) for primary URS vs. two (range 2-3) for deferred URS (p < 0.001). The cost of primary URS was significantly lower (p < 0.001). On multivariate analysis, lower ureteral calculi (OR 13.03, 95% CI 4.0741.7, p<0.001) and deferred URS (OR 2.84, 95% CI 1.077.49, p1⁄40.035) were independent predictors for eventless successful URS. CONCLUSIONS: Deferred URS is still the standard treatment for calculus anuria. Primary URS is feasible but technically demanding and has higher complication rate especially for middle/upper ureteral calculus anuria.

Down-regulated claudin-7 immunoexpression in urothelial carcinoma of the urinary bladder

Abstract Objectives: To analyse the gene-expression level of claudin-7 in urothelial carcinoma (UC) of the urinary bladder, and its relationship with clinicopathological variables. Materials and methods: This study included 68 specimens of UC of the bladder, comprising 35 with non-muscle-invasive (NMI), stage Ta–T1, and 33 with muscle-invasive (MI) tumours, T2–T4, and 26 of normal urothelium (NU). Total RNA was extracted and 1 μg was reverse transcribed using a cDNA kit. RT-PCR was conducted using SYBR Green I dye to examine the expression levels of the target gene (claudin-7) and the housekeeping gene glyceraldehyde-3-phosphate dehydrogenase. Using confocal-laser scanning light microscopy, immunohistochemistry (IHC) was used to validate the RT-PCR data. The correlation between claudin-7 and the clinicopathological variables was assessed. Results: Claudin-7 was down-regulated in UC samples compared to NU samples (P < 0.001). NMI (Ta–T1) tumours had significantly higher claudin-7 expression than MI (⩾pT2) tumours (P = 0.012). There was no significant difference between patients with G1-2 tumours and those with G3 tumours (P = 0.19). There was no significant difference between patients with recurrent NMI UC and those with no recurrence (P = 0.61). IHC showed a lower expression of claudin-7 in the UC samples than NU samples, and in MI UC than in NMI UC. Conclusions: These results indicate that a reduced expression of claudin-7 correlates with the invasiveness and progression of UC of the urinary bladder. Further studies are needed to validate claudin-7 as a marker for UC.

Phalloplasty for an amputated phallus in intersex patients.

Abstract Objective: To report our experience of phalloplasty using a radial forearm free-flap (RFF) and insertion of a penile prosthesis for the amputated phallus. Patients and methods: Phalloplasty was carried out in nine intersex patients with ambiguous genitalia as a result of female circumcision, with a consequent partial or complete excision of theirmicrophallus. Sixmonths later a penile prosthesiswas inserted in the periostium of the lower border of the symphysis pubis in the first six patients. Results: All patients were fully satisfied with the size and cosmetic appearance of their penis. One patient had a urinary fistula that was closed surgically. All of the patients are continent. The penile prosthesiswas implanted successfullywith no complications. Conclusions: Phalloplasty using a RFF and insertion of a penile prosthesis for the amputated phallus are technically feasible, with good clinical and functional outcomes.