Rami Alazab

Clinical comparison of conventional testicular sperm extraction and microdissection techniques for non-obstructive azoospermia.

Background We compared the efficacy of microdissection testicular sperm extraction (microdissection TESE) and conventional TESE in patients with non-obstructive azoospermia (NOA) and related the positive sperm recovery to certain variables: follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, testicular volume and histology. Methods Sperm retrieval rates (SRR) in patients with NOA who underwent microdissection TESE (n = 65) or conventional TESE (n = 68) were compared and related to the different variables. Results SRR by microdissection TESE (56.9%) was significantly higher than conventional TESE (38.2%). There was a positive relation between the SRR and increased testicular volume or decreased FSH levels. No effect of Testosterone or Prolactin levels on SRR by using either technique was observed. Sperm were recovered from those with hypospermatogenesis in 84% and 92.9% by conventional and microdissection TESE, respectively (P = 0.3). In cases of maturation arrest the SRR was 27.3% and 36.4%, respectively (P = 0.6). In cases of Sertoli-cell-only syndrome (SCOS) the SRR was 6.2% and 26.9%, respectively (P = 0.03). No major operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism. Conclusions Microdissection TESE significantly had twice better probability of success of SRR when compared to conventional TESE. No secure pre-operative prognostic elements of sperm recovery exist for NOA patients. Microdissection TESE appears to be recommendable in cases of atrophied testicles, high FSH concentration, or when SCOS with high FSH concentration can be predicted. Keywords Microdissection TESE; Sperm retrieval; Non-obstructive azoospermia; Histopathology; FSH concentration; Orchidometry

Urodynamic Detrusor Overactivity in Patients with Overactive Bladder Symptoms

Purpose To evaluate the relationship between urodynamic detrusor overactivity (DO) and overactive bladder (OAB) symptoms in men and women. Methods We reviewed the records of adult males and females who attended a tertiary referral center for urodynamic evaluation of OAB syndrome symptoms with the presence or absence of DO. DO was calculated for symptoms alone or in combination. Results The overall incidence of DO was 76.1% and 58.7% in male and female OAB patients, respectively. Of men 63% and 61% of women with urgency (OAB dry) had DO, while 93% of men and 69.8% of women with urgency and urgency urinary incontinence (OAB wet) had DO. Of women, 58% who were OAB wet had stress urinary incontinence symptoms with 26.4% having urodynamic stress incontinence. 6% of men and 6.5% of women with OAB symptoms had urodynamic diagnosis of voiding difficulties with postvoid residual greater than 100 mL. Combination of symptoms is more accurate in predicting DO in OAB patients. The multivariate disease model for males included urge urinary incontinence (UUI) and urgency while for females it included UUI and nocturia. Conclusions There was a better correlation in results between OAB symptoms and the urodynamic diagnosis of DO in men than in women, more so in OAB wet than in OAB dry. Combination of symptoms of the OAB syndrome seems to have a better correlation with objective parameters from the bladder diary, filling cystometry, and with the occurrence of DO.

Do all patients with newly diagnosed prostate cancer need staging radionuclide bone scan? a retrospective study

PURPOSE Define a group of patients with newly diagnosed prostate cancer, whose risk of bone metastasis is low enough to omit a bone scan staging study. MATERIALS AND METHODS From 2003 to 2009, the medical records of patients who were newly diagnosed with prostate cancer were retrospectively reviewed. The data collected included: age, digital rectal examination, serum prostate specific antigen (PSA), Gleason score, clinical T stage, and bone isotope scan. Patients were divided into two groups according to the results of bone isotope scan; positive group and negative group. A univariate and multivariate binary logistic regression was used to analyze the results. RESULTS Of the 106 patients, 98 had a complete data collection and were entered into the study. The median age of the patients was 70.5 years and patients with a positive bone scan was 74 years, significantly higher than for patients with negative scans (69 years) (p=0.02). Bone metastasis was detected in 39 cases (39.7%). In all patients with clinical T1-2 stage, a Gleason score of <8 and PSA≤20 ng/mL, the bone isotope scans were negative. In univariate analysis, PSA (>20 ng/mL) and Gleason score (>7) were independently predictive of positive bone scan, while clinical stage was not. CONCLUSION Staging bone scans can be omitted in patients with a PSA level of ≤20 ng/mL, and Gleason score<8. Our results suggest that by considering the Gleason score and PSA, a larger proportion of patients with prostate cancer could avoid a staging bone scan.

Emergency double-J stent insertion following uncomplicated Ureteroscopy: risk-factor analysis and recommendations.

PURPOSE Emergency double-J (DJ) stenting following ″uncomplicated″ ureteroscopic (UURS) stone treatment is both morbid and costly. Our study aims at identifying those patients who are more likely to require such an extra procedure. Handling of this complication will also be highlighted. MATERIALS AND METHODS 319 cases of UURS cases were selected out of 903 patients, who were admitted for URS stone treatment at King Abdullah University Hospital during the period from May, 2003 to December, 2010. Thirty-eight of them (11.9%) had emergency post-URS DJ stenting within 24 hours of discharge. The medical records of all UURS cases were retrospectively reviewed. Comparison in demographic and stone-related variables was made using 2-paired t-test with P < 0.05. Operative findings of 38 stented patients were outlined. RESULTS Significant risk factors for emergency stenting were noted in males with larger (> 1.5 cm) and proximal stones (38 stented vs. 281 unstented). Operative risk factors among the 38 patients were: initial procedure time > 45 minutes (42.1%), ureteral wall edema (21.1%), repeated access for stones > 1.5 cm (21.1%), impacted stone (10.5%) and ignored or missed stones/fragments (4.6%). CONCLUSIONS The need for emergency DJ stenting following UURS stone treatment is not uncommon. The routine insertion is impractical and weakly-supported. With risk-factor stratification, selective and individualized DJ stenting policy is recommended.

Does the duration of infertility affect semen parameters and pregnancy rate after varicocelectomy? A retrospective study

OBJECTIVES The most common indication for treatment of varicocele is still male subfertility. The aim of this study was to explore the effect of infertility duration on semen parameters and spontaneous pregnancy rate after varicocelectomy. MATERIALS AND METHODS The medical records of 183 infertile patients with clinical varicocele were retrospectively reviewed. The patients were divided into three groups according to the duration of infertility (group I, 1-3 years, group II, 3-6 years and group III, > 6 years). Total sperm motility counts (TMCs) before and after varicocelectomy and spontaneous pregnancy rate among these groups were statistically compared. RESULTS The greatest changes, regarding preoperative and postoperative TMCs and spontaneous pregnancy rate were noticed between group I and III. Preoperative TMCs in group I and III was 15.2 ± 1.2, 7.8 ± 1.4, respectively (p < 0.05). Postoperative TMCs in group I and III was 33.7 ± 2.5, 25.2 ± 1.9, respectively (p < 0.05). An overall spontaneous pregnancy rate of 34.4% was achieved after inguinal varicocelectomy. The greatest spontaneous pregnancy rate was achieved in Group I (37.3%), and the lowest pregnancy rate in Group III (26.3%) (P < 0.05). CONCLUSIONS Surgical varicocelectomy improves the total sperm motility counts especially in patients who have a TMCS more than 5 million and improves the spontaneous pregnancy rates. The improvement in the spontaneous pregnancy rates after varicocelectomy correlates negatively with the duration of infertility. Therefore, duration of infertility should be considered in treating a patient with a varicocele as a cause of infertility.

Prostate cancer in Jordanian-Arab population: ERG status and relationship with clinicopathologic characteristics

TMPRSS2/ERG fusion was found to be the most common genetic event in prostate adenocarcinoma. There is a strong correlation between the fusion and ERG-positive immunostaining. Many studies showed racial variation in ERG expression in prostate cancer patients. There is no data however on the rate of ERG-positive cancer in Jordanian or Arab population. We evaluated the frequency and the significance of ERG fusion in Jordanian-Arab population using immunohistochemistry for ERG. The cohort included 193 prostate cancer specimens: 109 needle core biopsies, 45 radical prostatectomies, 37 transurethral resections of prostate, and 2 enucleation specimens. We found ERG reactivity in 64 (33.2%) of evaluated cases. The observed ERG frequency in the Jordanian-Arab population is lower than the one documented in North America, but it is higher than in Asian patient cohorts. The ERG positivity was significantly associated with lower baseline prostate-specific antigen but was unrelated to patient age, Gleason Score, or the novel Gleason Grade Groups. In the 45 prostatectomy cases, ERG did not correlate with the pathologic stage, margin, nodal status, and the biochemical recurrence, and it did not appear to represent an important prognosticator.

Spontaneous Nephrocutaneous Fistula: Rare Complication of Xanthogranulomatous Pyelonephritis

Renocutaneous fistulae may occur as a result of chronic infection, especially in the setting of calculous disease.1 Spontaneous renocutaneous is rare.2 Usually nephrocutanous fistula developed in patient with previous renal surgery, trauma, tumors, and chronic urinary tract infection with abscess formation. We report a case of spontaneous nephrocutaneous fistula. A 37-year-old women previously well presented to ER department with purulent discharge and a palpable mass on the left lumbar area. CT scan with IV contrast fistulous tract seen within the subcutaneous plane in Left lumbar region tracking towards retroperitoneal space, and in continuity with of left kidney. The patient underwent ‘Left nephrectomy with excision of fistulous tract’ after long course of antibiotics.

Xanthogranulomatous Orchitis: Rare Case with Brief Literature Review

Xanthogranulomatous reaction is uncommon non neoplastic reaction involving multiple organs, commonly kidney and gallbladder. Its rarely involve testicle. We report 69-year old man present to clinic with right testicular swelling for six month duration. Testicular markers within normal range. Us scrotum revealed right large avascular heterogeneous mass inside testicle. Right inguinal orchiectomy done and revealed Xanthogranulomatous orchitis.

A Case of Compartment Syndrome in the Scrotum and Inguinal Area Complicating Idiopathic Nephrotic Syndrome of Childhood

Idiopathic nephrotic syndrome (INS) is a kidney disease characterized by massive proteinuria. Protein loss leads to decreased oncotic pressure shifting the fluids into the interstitial space causing edema, complications such as infections and thromboembolism occur. We report a 7-year-old, diagnosed with NS presenting with a relapse. He developed ascites and scrotal edema followed by severe scrotal pain and redness, progressing rapidly to ecchymosis in the inguinal areas not in continuity with the scrotum. Ultrasound with color Doppler was inconclusive, scrotal exploration was done along with skin incision in the inguinal areas and scrotum, which appeared to relieve the condition rapidly.

Advanced Uropathy in a Child With Underactive Bladder: Unusual Presentation, Treatment, and Long-term Follow Up

Underactive bladder in children is characterized by low voiding frequency; straining, hypotonic high capacity bladder, and significant residual urine. The usual presentation is recurrent urinary tract infections. Accurate evidence-based diagnosis and treatment is crucial. Subjective and objective improvement and regain of normal voiding can be achieved in response to bladder rehabilitation program and correction of serious complications.