Mohammed Elgammal

Straddle injuries to the bulbar urethra: management and outcome in 53 patients

OBJECTIVE To describe our experience with blunt injuries to the bulbar urethra and their late sequelae to identify factors that may affect patient outcome. MATERIALS AND METHODS A retrospective study was performed on 53 male patients who presented, between January 2001 and December 2005, with blunt traumatic injury to the bulbar urethra. The definitive diagnosis of urethral rupture was made by retrograde urethrography, where urethral rupture was classified into partial or complete. The minimum follow-up period was 3 years. The initial management was either suprapubic cystostomy or endoscopic urethral realignment over a urethral catheter using a cystoscope to pass a guide-wire over which the catheter was inserted. Stricture formation was managed by visual internal urethrotomy (VIU) for passable strictures and urethroplasty (stricture excision and re-anastomosis) for impassable strictures or recurrence after VIU. The follow-up period was three years. The results were analyzed by SPSS software (chi-square and Students-t-test). RESULTS Stricture formation occurred in 19 of 22 patients (86%) with complete urethral rupture and in 10 of 31 (32%) with partial rupture (p < 0.001). Strictures occurred in 11 of 31 (35%) patients treated initially with suprapubic cystostomy and in 18 of 22 (82%) treated with primary urethral realignment (p < 0.001). The success rate after VIU was 15% (4 of 26 patients) and after urethroplasty it was 96% (24 of 25 patients) (p < 0.001). CONCLUSIONS Suprapubic cystostomy is better than urethral realignment and catheterization as primary management after straddle injury to the bulbar urethra. Stricture excision and re-anastomosis is better than VIU as delayed management for strictures that develop after straddle injury to the bulbar urethra.

Management of calculus anuria in children: experience of 54 cases.

OBJECTIVE To evaluate the outcome of different treatment plans for calculus anuria in children. PATIENTS AND METHODS Patients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine> or =3.5mg/dl, blood urea> or =100mg/dl, serum potassium> or =7meq/l and/or blood pH< or =7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine<3.5mg/dl, blood urea<100mg/dl, serum potassium level<7meq/l and blood pH>7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery. RESULTS Fifty-four patients were included. All patients regained normal serum creatinine levels within 72-120h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent. CONCLUSIONS Urinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery.

New concept in urethral advancement for anterior hypospadias

OBJECTIVE We report on our experience with urethral mobilization and advancement as a treatment for anterior hypospadias. PATIENTS AND METHODS From January 2004 to March 2007, 55 out of 160 children with anterior hypospadias were managed by urethral mobilization and advancement; 46 had a mean follow-up period of 25 months (range 6-38) and are the subjects of this report. Their ages ranged from 2.5 to 12 years with mean age 4.5 years. The dissection began proximally in the avascular plane above the tunica albuginea covering each corpus cavernosum medially until reaching beneath the corpus spongiosum up to the hypospadiac meatus. Tension-free urethral anastomosis was achieved. The ventral glans was incised deeply at the interballanitic groove. The two glans wings and ventral glanular mucosal flaps were mobilized laterally. Interrupted sutures were placed through the tunica albuginea of corpus spongiosum to the corpora cavernosa. The mobilized urethra was wrapped by dartos fascia. The urethral stent was removed 24h postoperatively. RESULTS Three-fold urethral mobilization was sufficient to achieve tension-free urethral anastomosis. A slit-like orthotopic meatus, with conically shaped glans and straight penis, was achieved in all but one subcoronal case with mid-glans meatal retraction during our early experience. Postoperative urethral fistula was not recorded in any patient. Satisfactory urinary stream for parents and child was reported in 42/46. Peak flow rate was within normal range (upper 50% percentile) in all. CONCLUSION Urethral mobilization should begin proximally. Three-fold penile urethral mobilization, deep interballanitic incision and wide dissection of the glans can provide a slit-like orthotopic meatus with conical glans and straight penis in cases of anterior hypospadias without hypoplastic distal urethra and persistent ventral curvature after penile skin degloving, regardless of the presence of unhealthy, narrow urethral plate, shallow glanular groove, and flat or small glans.

Primary versus secondary ureteroscopy for pediatric ureteral stones

OBJECTIVE To evaluate the outcome of primary versus secondary ureteroscopy for pediatric ureteral stones. PATIENTS AND METHODS A retrospective chart review study that included 66 children aged less than 12 years, who were subdivided into two groups: Group A, which included 42 children who had undergone primary ureteroscopy without pre-stenting; and Group B, which included 24 children who had undergone ureteroscopy after ureteric stenting. Kidneys, ureters and bladder radiographs were done on the first postoperative day to assess the degree of stone clearance and stent position. RESULTS Age, gender, stone location and stone size were not significantly different between both groups. In Group A, 31 (73.8%) children required ureteric dilation, 13 (31%) had a tight ureter that failed to respond to dilation, 25 (59.5%) displayed complete stone clearance, and of these, 13 (52%) needed postoperative stenting. One child experienced ureteric injury during stone disintegration and was stented for two weeks. Children in Group B experienced a 95.8% complete stone clearance rate, with no ureteric injury reported; postoperative stenting was performed in three (12.5%) children.. CONCLUSION Secondary ureteroscopy is preferable over primary ureteroscopy in pediatric populations because of a significantly lower need for ureteric dilation, shorter procedure time and better stone clearance rate..

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.

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.

MP44-20 PERSISTENT VESICOURETERAL REFLUX AFTER ILEOCECAL CYSTOPLASTY IN CHILDREN WITH VOIDING DYSFUNCTION

Objectives: To define incidence, risk factors and effect of persistent vesivoureteral reflux [VUR] after ileocecal cystoplasty in children with voiding dysfunction. Materials and methods: Between June 2008 and June 2013, children 5-18 years old, who had VUR before ileocecal cystoplasty without ureteral reimplantation, were included. Voiding cystourethrogram and pressure flow study were obtained before and 6-12 months after the operation. VUR was graded using the international reflux study committee classification. Grades I, II, and III were considered low grade. Grades IV and V were considered high grade. VUR persistence was analyzed in relation to age, sex, cause of voiding dysfunction, laterality, preoperative and postoperative maximum detrusor filling pressure, and preoperative grade of reflux. Attacks of febrile acute pyelonephritis were recorded and analyzed in relation to VUR persistence. Follow up period ranged from 12 to 55 months [mean 34.1]. Results: 25 refluxing renal units in 13 children [8 males and 5 females] were included. Age range was 6-16 years [mean 11.06]. The cause of voiding dysfunction was neurogenic in 8, dysfunctional voiding in 3, and valve baldder in 2. All of them had ileocecal cystoplasty with enforced in-situ appendicular catheterizable stoma. VUR was low grade in 4 renal units and high grade in 21. Postoperative low grade VUR was found in 13 renal units (52%), and no high grade VUR. Preoperative high grade reflux was significantly related to VUR persistence (Chi-square, p=0.023). Mean preoperative maximum detrusor filling pressure with persistent reflux was 61.1 ±5.8 cmH2O, and 72.1 ±10.3 cmH2O with cured reflux (t-test, p=0.003). 8 renal units in 6 patients had attacks of acute pyelonephritis. Persistent VUR was in 6 of them (Chi-square, p=0.007). Conclusions: Preoperative high grade VUR and low maximum detrusor filling pressure are risk factors for persistent VUR after ileocecal cystoplasty in children. Persistent VUR is a risk factor for acute pyelonephritis and may have a deleterious effect on the kidney. Published In: NULL , NULL , ودنلاروأ ىف دقعنملاو ةيعمجلا رمتؤملا Powered by TCPDF (www.tcpdf.org) page 1 / 1

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.