Mohamed Youssif

Tamsulosin for the management of distal ureteral stones in children: A prospective randomized study

PURPOSE Based on efficacy demonstrated in the adult population, tamsulosin was evaluated with regard to facilitating ureteral stone expulsion in children presenting with distal ureteric calculi. PATIENTS AND METHODS A prospective randomized controlled study involving 61 children with distal ureteric calculi <12 mm was performed. The children were randomly divided into two groups. Group I (study group, n = 33) received tamsulosin and standard analgesia, and Group II (placebo group, n = 28) received standard analgesia and placebo. Patients were offered a closely monitored trial for spontaneous stone passage in the 4-week period prior to definitive therapy. The stone expulsion rate, number and duration of pain episodes, need for analgesia and possible side effects of medications were observed. RESULTS All patients completed the study and none were excluded due to side effects. No significant differences were found between the groups for age, gender and stone size. Mean patient age was 8.1 ± 6.8 years. There were 25 females and 36 males. The stone-free rate was 87.8% in Group I (29/33), compared with 64.2% (18/28) in Group II. A mean stone expulsion time of 8.2 and 14.5 days was recorded for Group I and II respectively, and this difference was statistically significant (P < 0.001). CONCLUSIONS Medical expulsion therapy for lower ureteric stones is a successful procedure in children. Tamsulosin demonstrated no clinically significant adverse effect, while proving to be a safe and effective treatment option.

Augmentation ureterocystoplasty in boys with valve bladder syndrome

OBJECTIVE Children with valve bladder syndrome represent the worst end of the posterior urethral valve spectrum. When conservative measures fail to control recurrent infections, prevent deterioration of the upper tract (in the form of increasing hydronephrosis and or worsening of kidney function) and improve incontinence, augmentation cystoplasty is considered. In most of these boys, renal insufficiency precludes the use of intestine for augmenting the bladder. Our aim was to evaluate the efficacy and safety of ureterocystoplasty in managing children with valve bladder syndrome. PATIENTS AND METHODS Eight boys (mean age 5 years) with valve bladder syndrome were included in this study. All boys had successful valve ablation at the time of presentation. When conservative treatment failed, ureterocystoplasty was scheduled. The entire ureter was folded and used in four boys after nephrectomy for a non-functioning kidney. The lower dilated ureter was used to augment the bladder, and transureteroureterostomy in two and re-implantation of the remaining ureter in two were performed. Radiological and urodynamic investigation was performed preoperatively and postoperatively at 3, 6 and 12 months. Improvement of hydroureteronephrosis was judged by ultrasound. RESULTS Bladder capacity (as measured during cystometry at 30 cmH(2)O) and compliance were significantly improved in all children following the procedure (P<0.001), and reached or exceeded the normal calculated capacity for age-matched boys. Hydroureteronephrosis improved in six boys (75%). The procedure avoids almost all the complications of enterocystoplasty. Clean intermittent self-catheterization was performed in all cases routinely after surgery, weaning off as judged by the voiding pattern of the child. CONCLUSION Ureterocystoplasty is an ideal option for augmenting the hypocompliant bladder in boys with valve bladder syndrome. The entire ureter or the dilated lower part can be used. This is a solution for boys with impaired renal function when enterocystoplasty cannot be performed.

Early Valve Ablation Can Decrease the Incidence of Bladder Dysfunction in Boys With Posterior Urethral Valves

PURPOSE Valve bladder syndrome represents the worst end of the posterior urethral valve spectrum. Recent data suggest that early valve ablation can provide the chance for the bladder to heal and improve dynamics. We tested the hypothesis that early valve ablation can decrease the incidence of bladder dysfunction in these boys. MATERIALS AND METHODS A total of 16 full-term males with prenatally diagnosed hydronephrosis and a full bladder proved postnatally to have posterior urethral valve were studied. Valve ablation was performed during the neonatal period (group 1). The records of 16 boys with posterior urethral valves who underwent valve ablation after age 1 year were obtained (group 2). Ultrasound was performed every month and urodynamics were performed every 6 months. At age 3 years voiding diary and toilet training results were obtained. The incidence of bladder dysfunction in the 2 groups was recorded according to clinical, ultrasound, voiding cystourethrogram and urodynamic parameters. RESULTS Mean followup was 3 years. Post-void residual urine, measured as more than 30% of expected bladder capacity for age, improved in 14 patients (87.5%) in group 1 and in 10 (62.5%) in group 2. Excluding cases of vesicoureteral reflux-renal dysplasia syndrome, vesicoureteral reflux was present in 20 renal units initially in group 1 and showed resolution or improvement in 16. In group 2 vesicoureteral reflux was present in 26 units and improved in 14. At last followup mean cystometric bladder capacity, measured at 30 cc H(2)O, in group 1 was 145 +/- 22 ml which was comparable to age matched normal bladder capacity. In group 2 mean +/- SD cystometric bladder capacity was 130 +/- 30 ml, which was significantly lower than age matched normal bladder capacity. Hypocompliance and instability were significantly lower in group 1. Toilet training was easier and yielded better results for dryness in group 1. Overall bladder dysfunction was present in 2 boys (12.5%) in group 1 and in 8 (50%) in group 2. CONCLUSIONS Neonatal valve ablation would protect the bladder and allow normal cycling, which helps in bladder healing. This underscores the importance of routine prenatal screening and early intervention at a specialized center.

Z-plasty for sculpturing of the bifid scrotum in severe hypospadias associated with penoscrotal transposition

PURPOSE Bifid scrotum is usually associated with scrotal and perineal hypospadias. Conventional surgical repair involves rotation of two scrotal flaps, joining them in the midline, and vertical skin closure. Dimpling of skin can occur, resulting in suboptimal aesthetic results. We describe a technique whereby the bifid scrotum is rebuilt and contoured using single or multiple Z-plasties. METHODS We repaired 43 children with scrotal, penoscrotal or perineal hypospadias and varying degrees of bifid scrotum. Age range was 5 months-18 years. Patients were divided into three groups: I) 26 children with primary perineoscrotal hypospadias who underwent two-stage hypospadias repair and had a Z-scrotoplasty during either the first or second stage repair; II) 11 children who had previous hypospadias surgery with vertical closure of scrotum, and who underwent secondary Z-scrotoplasty; III) 6 children with primary posterior hypospadias who had their scrotum repaired with midline vertical closure, serving as control. RESULTS 24 children in Group I and all patients in Group II achieved excellent aesthetic results, with rounded scrotum, no midline dimpling and no major complications. Midline dimple was encountered in 4 patients in Group III. CONCLUSIONS In repairing bifid scrotum associated with hypospadias, the principle of Z-plasty can be incorporated in scrotal contouring. This elongates, relaxes and interrupts the longitudinal tension of the midline closure. Multiple Z-plasties avoid contracture and scar formation, which are apt to result in recurrence of bifid scrotum.

Calculating the Number of Shock Waves, Expulsion Time, and Optimum Stone Parameters Based on Noncontrast Computerized Tomography Characteristics

OBJECTIVE To define the parameters that accompanied a successful extracorporeal shock wave lithotripsy (ESWL), namely the number of shock waves (SWs), expulsion time (ET), mean stone density (MSD), and the skin-to-stone distance (SSD). METHODS A total of 368 patients diagnosed with renal calculi using noncontrast computerized tomography had their MSD, diameter, and SSD recorded. All patients were treated using a Siemens lithotripter. ESWL success meant a stone-free status or presence of residual fragments <3 mm, ET was the time in days for the successful clearance of stone fragments. Correlation was performed between the stone characteristics, number of SWs, and ET. Two multiple regression analysis models defined the number of SWs and ET. Two receiver operating characteristic curves plotted the best MSD cutoff value and optimum SSD for a successful ESWL. RESULTS Three hundred one patients were ESWL successes. A significant positive correlation was elicited between number of SWs and stone diameter, density and SSD; between ET and stone diameter and density. Multiple regressions concluded 2 equations: Number of SWs = 265.108 + 5.103 x1 + 22.39 x2 + 10.931 x3 ET (days) = -10.85 + 0.031 x1 + 2.11 x2 x1 = stone density (Hounsfield unit [HUs]), x2 = stone diameter (mm), and x3 = SSD (mm). Receiver operating characteristic curves demonstrated a cutoff value of ≤ 934 HUs with 94.4% sensitivity and 66.7% specificity and P = .0211. The SSD curve showed that a distance ≤ 99 mm was 85.7% sensitive, 87.5% specific, P <.0001. CONCLUSION Stone disintegration is not recommended if MSD is >934 HUs and SSD >99 mm. The required number of SWs and the expected ET can be anticipated.

Corporeal Body Grafting Using Buccal Mucosa for Posterior Hypospadias With Severe Curvature

PURPOSE Severe penile curvature correction by corporeal body grafting has been successfully performed using various grafts and biomaterials. We present our initial experience with buccal mucosa as a free corporeal graft to correct severe penile curvature as part of a multistage approach to posterior hypospadias repair. MATERIALS AND METHODS A total of 12 children with a mean age of 6.2 years (range 4 to 8) with posterior hypospadias and severe ventral chordee (greater than 45 degrees) necessitating ventral grafting underwent correction using buccal mucosa. Preoperative androgen supplement was given when penile and glanular size was significantly small for age. Buccal mucosa was harvested from the inner side of the cheek or the lower lip. The harvested graft was defatted, fashioned and fixed to the ventral corporeal defect. The pre-grafting penile angle, immediate post-grafting angle and penile angle at 6 months were assessed. RESULTS All children had penoscrotal or perineal hypospadias, 4 had partial androgen insensitivity syndrome and 1 underwent multiple previous failed repairs. Androgen was given preoperatively in 3 children. After chordee release and urethral plate transection the penile angle was between 45 and 80 degrees. Mean graft length and width was 2.5 and 1.6 cm, respectively. All children had a straight penis at the end of the procedure and none required additive dorsal plication. At the last followup at 12 months all children had a straight penis except 2 with mild curvature (less than 10 degrees). No complications were noted with this technique. CONCLUSIONS Preliminary results of the novel use of buccal mucosa as a corporeal graft for severe chordee appear satisfactory. Longer term followup is needed to further document these data.

Partial Penile Disassembly for Isolated Epispadias Repair

OBJECTIVES Isolated male epispadias defect is present in 10% of cases of epispadias-exstrophy complex. Surgical repair of epispadias malformation remains debatable as evident by the different techniques adopted. The current study presents our experience in partial penile disassembly for isolated epispadias repair. METHODS Epispadias repair was performed on 11 male patients aged 4 to 13 years. Two were penopubic, 6 penile, and 3 glanular. All cases were fresh. Extensive disassembly of penile components was performed to the corporal attachments down to the horizontal branches of pubic bones. The corporal bodies were separated with the urethral plate left attached to 1 corpus to preserve its blood supply. Urethral plate was tubularized and then transported from dorsal to ventral position by using corporal rotation technique. Glanuloplasty was then performed. Patients were followed up for 6 to 12 months. RESULTS The penis had a satisfactory cosmetic appearance with no significant dorsal chordee. Two cases were transformed to subcoronal hypospadias, as it was difficult to bring the urethral plate to the tip of the glans because of its shortening. One child had a minute penopubic fistula that was repaired at a later stage. CONCLUSION Partial penile disassembly technique restores the anatomic relationship of the penile components. Our repair of partial penile disassembly is a simple modification of the Mitchell technique for isolated epispadias repair.

Factors that predict the spontaneous passage of ureteric stones in children

Abstract Objective:To study the natural history of stone passage in children with ureterolithiasis and to define factors predictive of spontaneous passage. Patients and methods: In all, 72 children with ureteric stones were evaluated; patients with ureteric calculi of >10 mm were excluded, as were those with absolute indications for surgical stone removal. Stone size, location, side, presence of hydronephrosis, perinephric stranding and degree of the tissue-rim sign were estimated by unenhanced helical computed tomography (UHCT). All patients were sent home with no administration of an α-blocker. The stone status was evaluated by a plain abdominal film or CT at ≈6 weeks after the initial diagnostic evaluation. The time from the initial complaint to the passage of the stone was recorded for each patient. Results: In all, 54 (75%) children with ureteric stones of ⩽6 mm eventually passed their stones spontaneously. However, stones of <4 mm and those in the distal ureter had a significantly higher spontaneous passage rate and shorter time to stone passage (P < 0.05). The UHCT findings of a higher degree of the tissue-rim sign, hydronephrosis and perinephric fat stranding were associated with a lower likelihood of stone passage. Conclusions: The rate of spontaneous passage of ureteric stones in children varies with stone location, and perinephric stranding on UHCT seems to be useful for predicting the possibility of spontaneous passage. In cases with unfavourable signs an early intervention might have better outcomes than conservative therapy.

Ureteroscopy in infants and preschool age children: technique and preliminary results.

Introduction We present our experience with the use of semirigid ureteroscopy for the treatment of ureteric stones in children less than or equal to 6 years of age. Material and methods The records of 21 children (12 female, 9 male) with an average age of 4.7 years (range 8 months to 6 years) treated with semirigid ureteroscopy between June 2006 and July 2010 were reviewed. In 13 ureteral units 7Fr semirigid ureteroscopy was carried out in a retrograde manner to treat stone disease, while an adult ureteroscope (9.5 fr) was used in the remaining patients. Stones were located in the upper ureter in 2 cases, middle ureter in 2 cases, and lower ureter in 17 cases. Ureteral dilation was not required in all patients. Results Stone size varied from 4 to 13 mm (mean 6 mm). The management of stones in 18 (90.7%) children was straightforward and a single ureteroscopy was required to clear the ureters. In 2 (6.2%) children, repeat ureteroscopy was undertaken to render the ureters stone free, and in 1 child (3.1%) it was not possible to remove the stone. Stones were fragmented with pneumatic lithotripsy in 12 cases and stones were removed mechanically without fragmentation in the remaining 9 cases. Intraoperative complications occurred in 2 (9.3%) children and included extravasation (1 patient), which was managed with ureteral stenting and stone upward migration (1 patient). Early postoperative complications included pyelonephritis (1 patient). Mean follow-up was 6.4 (3-36) months. Incidence of stricture at the site of stone impaction was not detected in any patients. None of the patients managed without a post-operative stent required subsequent intervention. Conclusions In the hands of an experienced surgeon, ureteroscopy in young children can be a safe and efficient treatment for ureteral stones that can be performed without ureteral dilation. Routine ureteral stenting is not a requirement when the procedure is relatively atraumatic. Further studies and longer follow-up are necessary to determine the success of this technique.

Does pentoxifylline enhance the recovery of erectile function after a T-shunt procedure for prolonged ischaemic priapism? A prospective randomised controlled trial.

Abstract Objective:To evaluate the role of oral pentoxifylline for enhancing the recovery of erectile function (EF) in patients who had a T-shunt, a technically simple procedure for treating prolonged ischaemic priapism, as the recovery of EF has been reported in many patients treated by this procedure. Patients and methods: This prospective randomised study was conducted on 40 patients with prolonged ischaemic priapism treated with a T-shunt. Patients were randomly divided into two groups; group A received oral pentoxifylline from the second day after surgery for 3 months, and group B received placebo. Patients were followed for 18 months. Results: The pain resolved in all patients, and EF recovered in 15 patients in group A and 10 in group B within 3 months. All patients but three had recovery of EF within the 18-month follow-up. Six patients had recovery of EF by using on-demand 50 mg sildenafil. The three patients who did not recover EF had a penile prosthesis implanted after the end of the study. Conclusion: Pentoxifylline had no significant effect on the recovery of EF after a T-shunt procedure, but a larger study (double-blinded) is required for a more accurate assessment of any beneficial effect of pentoxifylline after a T-shunt procedure.