Mohamed Soliman

Minimally-invasive correction of ureteropelvic junction obstruction: do retrograde endo-incision techniques still have a role in the era of laparoscopic pyeloplasty?:

Background:This study was designed to review the long-term results and complications of the two techniques of retrograde endopyelotomy; ureteroscopic holmium laser endopyelotomy versus Acucise endopyelotomy. The results were then compared with the laparoscopic pyeloplasty results from a recent publication. Patients and methods: The study was conducted retrospectively from January 2004 to July 2007. Seventy-two patients with ureteropelvic junction obstruction (UPJO) underwent retrograde endopyelotomy using either ureteroscopic laser endoincision (42 patients) or fluoroscopic guided hot-wire balloon (Acucise) endoincision (30 patients). Preoperative radiological assessment included intravenous pyelogram (IVP), helical computerized tomography and diuretic renography. The follow-up period ranged from 12 to 42 months. Subjective success was guided by the change in the preoperative flank pain while objective success on radiological evaluation was documented by either nonobstructed curve of diuretic renogram and/or T1/2 less than 10 min. Results: The mean patient age was 42.6±7.5 years for the laser group and 39.2±15.1 years for the Acucise group (p = 0.24). The operative time was 66.8±22.2 min in the laser group and 59.8±20.3 min in the Acucise group (p = 0.84). By objective standards (renal scan), a total of 56 (77.8%) cases were successful (nonobstructed curve). This number included 34 cases in the laser group (80.9%) and 22 cases in the Acucise group (73.3%) (p = 0.2). Overall 16 failure cases were evident clinically within 1 year of the procedure (eight cases in each group). Most of the failure cases (13/16) presented with clinical obstructive symptoms during the early follow-up period (within 3 months postoperatively) and were then confirmed radiologically (six cases in the laser group and seven cases in the Acucise group) while only three patients had failures at 6, 9 and 11 months postoperatively. There was no statistically significant difference as regards intra-operative complications between the two groups (p = 0.4). Intra-operative bleeding was seen in three cases in the Acucise group while postoperatively it was reported in one case. Conclusion: The retrograde endopyelotomy approach is safe and effective for the treatment of patients with UPJO. Both ureteroscopic laser and the hot-wire balloon (Acucise) techniques have an important role in the management of UPJO, especially in secondary cases, and they provide comparable long-term objective and subjective outcomes. Laparoscopic pyeloplasty provides far better results but with higher costs, and requires well-equipped centers and involves a long learning curve.

Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study

Abstract Objective. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) versus penile skin flap (PSF) in the repair of long anterior urethral strictures. Material and methods. Patients with long anterior urethral strictures were randomized to receive either dorsal onlay BMG urethroplasty or PSF urethroplasty. All patients were evaluated preoperatively and during follow-up with the International Prostate Symptom Score (IPSS) and uroflowmetry. Success was reported when there were no obstructive symptoms on IPSS, with a peak urinary flow rate (Qmax) of at least 15 ml/s. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on urethrography. Results. The study included 19 and 18 patients in the BMG and PSF groups, respectively. The mean operative time was significantly shorter in the BMG than in the PSF group. The success rate was higher in the BMG than in the PSF group (89.5% vs 83.3%), but not statistically significant different. The PSF group included one case of extensive skin loss, three cases with superficial skin necrosis and two with minor penile torsion. In the BMG group, there were three cases of perioral numbness and another three had increased salivation. The incidence of troublesome postvoid urinary dribbling was significantly higher in the PSF than in the BMG group. After 6 months of urethroplasty, patient satisfaction was statistically significantly higher in the BMG than in the PSF group. Conclusions. BMG and PSF dorsal onlay urethroplasty had similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction for most patients.

The long-term results of lingual mucosal grafts for repairing long anterior urethral strictures

Abstract Objective: To evaluate the long-term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts. Patients and methods; This study included 23 patients (mean age 36.3 years, range 21–62) who had a lingual mucosa onlay graft for managing a long anterior urethral stricture, and who were followed up for ⩾5 years. The mean length of the stricture was 4.6 cm. The International Prostate Symptom Score and uroflowmetry values were obtained before surgery, and at 3, 6 and 12 months afterwards, and annually thereafter. A retrograde urethrogram with a voiding cysto-urethrogram was taken before surgery, at catheter removal, after 3 and 6 months, and selectively thereafter. Results: The mean (range) follow-up was 66 (60–72) months. The cause of the stricture was trauma in nine patients, instrumentation in seven, idiopathic in four, urethritis in two and previous hypospadias repair in one. The surgery was successful in 20 of the 23 patients (87%), and a recurrent stricture developed in the remaining three. There were no fistulae or clinically perceptible graft sacculations, and no long-term donor-site complications. Conclusions: With a long-term follow-up, our series confirms the durability of lingual mucosal onlay grafts for treating long anterior urethral strictures. This procedure results in a long-term high success rate with few of the complications that occur primarily during the first year.

Does the type of urinary diversion affect the result of distal hypospadias repair? A prospective randomized trial.

Purpose: The purpose of this review is to evaluate different techniques in urinary diversion and urethral stenting in hypospadias surgery. Patients and methods: The surgical procedure included 192 tubularized incised plate (TIP) repairs for distal penile hypospadias. The patients were prospectively randomized into three groups: In group A, a urethral catheter was used as a stent and for diversion of urine (63 patients); in group B we use no urethral stenting (63 patients), only a suprapubic catheter; and in group C we use a suprapubic diversion and we put a small catheter in the anterior urethra only (66 patients). The urethral catheter was removed in group A at the 6th–7th postoperative day and in group C the urethral stent was removed at the 3rd–4th postoperative day. The suprapubic catheter was removed in both groups B and C at the 7th–9th postoperative day. All patients received an injection of antibiotics in the morning of the operation and daily until the day of catheter removal. All of the operations were performed by the same surgeon. Results: The mean ages of our patients were 3, 5, and 5 years in groups A, B, and C, respectively. The mean hospital stay was 5 days (3–8). Follow-up ranged from 8 to 48 months (mean of 21.5 ± 10.1 months). Bladder spasm was observed in 33% of our patients in group A while there were no cases of spasm in the other two groups with a statistically significant difference (p < 0.05). Fistula was reported in eight patients (12.7%) of our urethral catheter group A, while it was observed in three patients (2.3%) of our suprapubic diversion groups B and C with a statistically significant difference between the two groups (p < 0.05). Meatal stenosis was reported in eight patients in group B (12.7%; nonstented group) versus three patients of both groups A and C (2.4%; stented groups) with a statistically significant difference (p < 0.05). Conclusion: Suprapubic diversion is an important step in hypospadias repair as it provides a better success rate with a significantly lower rate of occurrence of fistula. However, the addition of a stent in the anterior urethra to suprapubic diversion avoids the development of meatal stenosis and also avoids the bladder spasm observed with a urethral catheter.

The role of pregabalin in relieving ureteral stent-related symptoms: a randomized controlled clinical trial

AbstractPurposeTo investigate the role of pregabalin in relieving USRS in patients with an indwelling double-J (DJ) stents.Patients and methodsA total of 500 adult patients with a unilateral single ureteral stone who underwent ureteroscopic stone management and required DJ stent insertion were prospectively included in our study. Patients were blindly assigned into four groups A, B, C and D. Those in group A were managed with combination of solifenacin 5-mg tablets and pregabalin 75-mg capsules bid. Patients in group B were managed with solifenacin 5-mg tablets. Those in group C were managed with pregabalin 75-mg capsules bid. Those in group D were control group. All patients were evaluated on day 15 postoperatively for stent-related symptoms using the Arabic translated and validated ureteral stent symptom questionnaire (USSQ). ResultsThe total USSQ score as well as general health index was significantly lower in group A as compared to other groups. In addition, urinary symptom index was significantly improved in both groups A and B as compared to group C and group D. Pain symptom index was significantly improved in both groups A and C as compared to groups B and D. No statistically significant difference was reported regarding sexual index and work performance index among the whole study groups.ConclusionPregabalin appears to be a well-tolerated, safe and effective drug in reducing most of USRS, especially relief of pain with subsequent improvement of patient’s quality of life. Its combination with solifenacin should be considered to manage patients with USRS as it shows a significant improvement in total USSQ score and general health index when compared to each drug alone.

Use of autologous rectus fascia in a new transobturator hybrid sling for treatment of female stress urinary incontinence: A pilot study

Abstract Objective.This article reports the early results of a novel sling used for the treatment of female stress urinary incontinence (SUI). This sling has a piece of autologous rectus fascia in its middle part and two arms of polypropylene mesh. Material and methods. The study included 44 women with SUI. The preoperative work-up involved complete history taking, physical examination, cough stress test (CST) and 1 h pad weight test (PWT). Two questionnaires, the Urogenital Distress Inventory – Short Form (UDI-6) and the Incontinence Impact Questionnaire – Short Form (IIQ-7), were also completed preoperatively. The previously described sling was then inserted via the transobturator route in all patients. Postoperatively, the previous work-up was repeated for objective evaluation of the procedure and the subjective improvement was assessed by the Patient Global Impression of Improvement scale. Results.At the end of the first year, 92.9% of the patients had a negative CST, 85.7% had 1 h PWT <1 g and the subjective cure rate was 90.5%. In addition, the scores for both UDI-6 and IIQ-7 were found to be decreased significantly (p < 0.001). The recorded complications included temporary urinary retention, dyspareunia, de novo urge incontinence and groin pain in 4.8%, 4.8%, 7.1% and 11.9% of patients, respectively. Conclusion. This hybrid sling appears to have good short-term efficacy and low cost.

Immediate and late management of iatrogenic ureteric injuries: 28 years of experience

Abstract Objective: To evaluate the long-term results after managing intraoperative and late-diagnosed cases of iatrogenic ureteric injury (IUI), treated endoscopically or by open surgery. Patients and methods: Patients immediately diagnosed with IUI were managed under the same anaesthetic, while those referred late had a radiological assessment of the site of injury, and endoscopic management. Open surgical procedures were used only for the failed cases with previous diversion. Results: In all, 98 patients who were followed had IUI after gynaecological, abdominopelvic and ureteroscopic procedures in 60.2%, 14.3% and 25.5%, respectively. The 27 patients diagnosed during surgery were managed immediately, while in the late-referred 71 patients ureteroscopic ureteric realignment with stenting was successful in 26 (36.6%). Complex open reconstruction with re-implantation or ureteric substitution, using bladder-tube or intestinal-loop procedures, was used in 27 (60%), 16 (35.5%) and two (4.5%) patients of the late group, respectively. A long-term radiological follow-up with a mean (range) of 46.6 (24.5–144) months showed recurrent obstruction in 16 (16.3%) patients managed endoscopically and reflux in six (8.3%) patients. Three renal units only (3%) were lost in the late-presenting patients. Conclusion: Patients managed immediately had better long-term results. More than a third of the late-diagnosed patients were successfully managed endoscopically with minimal morbidity. Open reconstruction by an experienced urologist who can perform a complex substitutional procedure was mandatory to preserve renal units in the long-term.

Validity of a sponge trainer as a simple training model for percutaneous renal access

Abstract Objective: To evaluate the efficacy of our simply designed trainer for junior urologists to acquire the initial skills for percutaneous renal access (PRA). Subjects and methods: Three sponge sheets (60 × 50 × 10 cm) were arranged horizontally over each other. A rectangular groove was made in the middle sheet to accommodate an inflated balloon of a Foley catheter, radio-opaque metal balls, metal rings, or a plastic tube that were sequentially placed for the four training tasks. In each session, 18 trainees were asked to pass a fluoroscopically guided puncture needle from a surface point to the placed object in middle sheet. Clinical impact of training was evaluated by an experience survey on a 5-piont Likert scale (for model usefulness, tactile and fluoroscopic-guidance feedback) and success rate in further mentored practice. Results: There was a gradual increase in tasks’ and sessions’ scores over the training sessions. According to the experience survey after first clinical practice, the mean (SD) score for overall model usefulness by trainees was 3.8 (0.9) with high fluoroscopic guidance reality [3.6 (1.1)] but poor tactile realism [2.3 (0.9)]. On mentored PRA, the success rate for trainees was 78.3%. Conclusion: Our early evaluation showed our novel, cost-effective and reproducible sponge trainer could be an effective training model for PRA with a beneficial impact on subsequent clinical practice.

Gonadal infection: a risk factor for the development of adolescent varicocele

Objective The aim of this study was to determine whether a relationship between previous gonadal infections and adolescent varicocele occurrence exists. Patients and methods All adolescents who presented with varicocele at Tanta Urology Department during the period from January 2006 to March 2011 were included in this study. Patients were evaluated for age, clinical presentation, previous history of epididymitis or epididymo-orchitis, laterality, and grading of varicocele. Examination of testicular consistency and ultrasound measurement of testicular volume were carried out for all patients to define those with testicular atrophy. Results Sixty-three boys were included in this study. The mean patients’ age was 15.6 years (range: 10–18, SD; 1.6 years). Twenty-nine (44.4%) boys had signs of testicular atrophy (testes are soft in consistency with ultrasound-detected volume smaller than that normal for age) either unilateral or bilateral. About 28.6% of patients (18 boys) had a history of epididymitis or epididymo-orchitis either associated with mumps or of unknown etiology. Of those patients, six boys had previous history of single attack, 10 boys had two attacks, and two boys had more than two attacks of epididymo-orchitis. A significant positive correlation was seen between the incidence of epididymo-orchitis attacks and the grade of varicocele (rs=0.63, 95% confidence interval: 0.21–0.85, P<0.05). Patients with past history of epididymo-orchitis were significantly more liable (4.1 times) of developing testicular atrophy as compared with those without a history of epididymo-orchitis (95% confidence interval: 1.517–11.097, P<0.05). Conclusion History of epididymo-orchitis is significantly a potential risk factor for the development of adolescent varicocele with subsequently higher risk for testicular atrophy. We advise routine ultrasonographic examinations in patients with previous history of epididymo-orchitis both for possible early detection of varicocele and to avoid testicular atrophy in this cohort of patients. However, more studies on a larger scale are still warranted.

MP13-06 CAN INTRAVESICAL ADMINISTRATION OF ANTIFIBRINOLYTIC AGENT POTENTIATE THE ACTION OF BACILLUS CALMETTE- GUERIN AFTER TRANSURETHRAL RESECTION OF NON–MUSCLE INVASIVE BLADDER CANCER?: MULTICENTER PROSPECTIVE RANDOMIZED CONTROLLED STUDY.

transurethral resection (TUR) and additional adjuvant instillation in intermediate risk non-muscle invasive bladder cancer (NMIBC) to reduce the risk of recurrence. Pirarubicin (THP), an anthracycline analogue, is widely used reagent for intravesical instillation chemotherapy. Several studies have showed that THP can rapidly penetrate tumor tissue after intravesical instillation. Therefore long instillation time (e.g. 120 min) may not be required for its prophylactic effect against recurrence since it may reduce the risk of adverse events such as cystitis and hematuria without compromising its efficacy. However, there is no high level evidence regarding optimized intravesical THP instillation time in terms of both toxicity and efficacy. METHODS: This randomized, prospective, open-label trial intended to enroll 160 pts with primary NMIBC with intermediate risk based on EORTC criteria. All pts received initial THP instillation within 24 hr after TUR and then intended to continue weekly repetitive THP instillation for a total of 9 treatments. Pts who seemed likely to be at intermediate risk were provisionally registered and then randomized into two groups with different intravesical THP retention times before TUR, (a) 30 min versus (b) 120 min. Follow-up period is 4 years. Primary endpoint is change from baseline in quality of life (e.g. OABSS and IPSS), which will be evaluated prior to THP intravesical instillation. Secondary endpoint is recurrence-free survival. RESULTS: 126 pts were enrolled for provisional registration in this trial and randomized before TUR-B. After excluding pts due to the result of pathology by TUR-B such as benign disease, T1 G3 tumor and concomitance of CIS, 29 pts were assigned to group (a) (30 min), and 26 pts to group (b) (120 min). There is a trend that group (a) is less prone to increase in OABSS after 3rd instillation compared to group (b), which is not statistically significant. Log-rank test shows that there is no significant difference in recurrence-free survival between the groups during follow-up period (HR1⁄42.161, 95% C.I.: 0.4317-10.82, p1⁄40.3484). CONCLUSIONS: Shortening intravesical instillation period to 30 min has little effect on reducing the adverse effect of THP. However, it does not compromise the prophylactic effect on recurrence in intermediate risk NMIBC pts.