Tamer El-Husseiny

Comparison of Stent-Related Symptoms Between Conventional Double-J Stents and a New-Generation Thermoexpandable Segmental Metallic Stent: A Validated-Questionnaire-Based Study

INTRODUCTION Double-J stents revolutionized the minimally invasive management of ureteral strictures, but have significant morbidity. We compare stent-related symptoms and quality of life between a conventional Double-J stent and a novel thermoexpandable metal segmental ureteral stent (Memokath) in patients with ureteral strictures. MATERIALS AND METHODS Seventy patients with a conventional Double-J stent or a Memokath stent for ureteral strictures were mailed a validated ureteral stent symptom questionnaire, which is a multidimensional measure that evaluates stent-related morbidity in six sections: urinary symptoms, body pain, general health, work performance, sexual matters, and additional problems. Statistical analysis compared the differences in these parameters between the two groups. RESULTS Forty-one patients (58.5%) responded, 23 with a Double-J stent and 18 with a Memokath stent. A subgroup of 10 patients had both a Double-J and a Memokath stent. Nearly 70% of patients with Double-J stents experienced urine frequency <or=2 hours versus 47% with Memokath stents. About 31.8% of patients with Double-J stents were extremely bothered by urinary symptoms versus 5.6% with Memokaths. About 66.7% of patients with Double-J stents had a negative view toward living with their current urinary symptoms versus 35.3% with Memokath stents. DISCUSSION The ureteral stent symptom questionnaire revealed that pain, urinary symptoms index, and general health were statistically better in the Memokath group. The Memokath group significantly outperformed the Double-J stent group in terms of the light and heavy activity. In terms of future stent insertion, patients preferred the Memokath stent. In the subgroup who had experienced both stents, the Memokath questionnaire revealed improvements in the domain of pain and the lower urinary tract symptoms index, though this was not statistically significant. This may reflect the small size of the study population. There were improvements in general health and other quality-of-life parameters, and there was a tendency in favor of the Memokath.

Simultaneous Anterograde and Retrograde Endourologic Access: “The Barts Technique”

We present our technique for achieving simultaneous anterograde and retrograde endourologic access to manage complex and demanding cases.

Transurethral ethanol ablation of the prostate for symptomatic benign prostatic hyperplasia: long-term follow-up.

BACKGROUND AND PURPOSE Over the past decade, a variety of new minimally invasive therapies (MIT) have been developed for the treatment of patients with bladder outflow obstruction from benign prostatic hyperplasia (BPH). Transurethral ethanol ablation of the prostate (TEAP) has been introduced as a minimally invasive alternative treatment for patients with BPH. In this study, we present our experience and results of long-term follow-up of 54 months after treatment of symptomatic BPH with TEAP. PATIENTS AND METHODS Fifty-six men with symptomatic BPH were enrolled in our study; all patients were medically high-risk patients with multiple comorbidities. Procedures were performed under intravenous sedation combined with local urethral instillation of lidocaine jelly and a transrectal ultrasonography (TRUS)-guided periprostatic block. Dehydrated ethanol in a concentration of 95% to 98% was injected transurethrally by means of the Postaject Ethanol Injection System using a rigid cystoscope. RESULTS The following data were collected: International Prostate Symptom Score, prostate-specific antigen level, prostate volume using TRUS, maximum urine flow rate, and postvoid residual. There was sufficient response in 73% of our patients, while the remaining 23% showed an insufficient response and needed alternative treatment. CONCLUSION TEAP is an effective minimally invasive treatment option for medically high-risk symptomatic patients with BPH that can be performed as an outpatient procedure under regional anesthesia. The procedure is easy, available, inexpensive, safe, and rapid. Further larger-scale, long-term multi-institutional trials are needed.

Improving patient positioning to reduce complications in prone percutaneous nephrolithotomy.

Percutaneous nephrolithotomy (PCNL), the goldstandard treatment for complex and=or large stone burden, is traditionally performed with the patient in the prone position. There are concerns regarding PCNL in the prone position, especially in the morbidly obese patients and those with compromised cardiopulmonary status and with skeletal deformities. These are over and above the recognized surgical complications of PCNL. Nevertheless, prone PCNL is the classical second stage, after the standard first stage (lithotomy position) where retrograde contrast studies and=or ureteroscopy take place. In the prone position during PCNL, there is reduced lung compliance caused by reduced chest wall and diaphragmatic excursion as a result of abdominal compression. There is also a reduction in cardiac output. Patients have traditionally been placed on pillows and jelly rolls, with or without a roll bar under the rib cage to push the kidneys more posteriorly. All of these pose significant challenges to the anesthetist, while there are no relevant published studies touching these issues. During prone procedures there is also the issue of keeping the neck neutrally aligned and monitoring the endotracheal tube, to ensure no kinking of the tube occurs. Traditionally, the head is supported on a pillow to try to keep neutral neck alignment, or the head may be laterally rotated and rests on the pillow. However, musculoskeletal complications such as a stiff neck, hoarseness caused by vocal cord compression, and brachial plexopathies are reported with prone surgery, as a result of patient positioning. To address some of these issues and complications, supine and lateral position PCNL as well as PCNL in the modified Valdivia position have become more popularized. Although we have experience in performing PCNL in all of these positions, we have developed improvements in patient positioning to reduce the risk of anesthetic and musculoskeletal complications during prone PCNL.

‘Putting lead in your pencil’: self-insertion of an unusual urethral foreign body for sexual gratification:

We review motives for insertion of foreign bodies into the urethra and discuss presentation, diagnosis and management of such patients.

Pain in extracorporeal shock wave lithotripsy

Pain tolerance has long been identified as a factor influencing successful treatment of renal calculi by shock wave lithotripsy (SWL). We aimed to clarify which factors directly influence pain tolerance to predict which patients are likely to undergo successful treatment. We analysed retrospectively 179 patients who received their first SWL for a solitary kidney stone. All patients were on a non-opioid analgesia protocol and were treated on an outpatient basis. The target was to deliver 4,000 shock waves at an energy level of 4. In total, 53% of patients could tolerate the targeted shock wave number and energy and were retrospectively allocated into group A. Those who required a reduction in either energy levels or shock wave number were allocated in group B. Multivariate and univariate analysis showed that female patients, who are young with thin body habitus, have lower pain tolerance to SWL.

Simultaneous Antegrade/Retrograde Upper Urinary Tract Access: Bart's Modified Lateral Position for Complex Upper Tract Endourologic Pathologic Features

OBJECTIVE To determine whether the Barts modified lateral position is safe and effective for achieving simultaneous anterograde and retrograde access in complex upper urinary tract pathologic features. METHODS From November 2006 to September 2010, 45 procedures were performed, with the patients in the modified lateral position. The indication for these procedures was the presence of complex unilateral upper urinary tract pathologic features. The patients with muscular and/or skeletal abnormalities were excluded. All procedures were performed using simultaneous anterograde and retrograde access with the patient under general anesthesia. RESULTS The preoperative investigation protocol included assessment of the stone burden and location using enhanced abdominal computed tomography. The patients were routinely examined 6 weeks after the procedure with a combination of plain abdominal radiography and renal ultrasonography. For patients treated for conditions causing upper urinary tract obstruction (pelviureteral junction obstruction and/or ureteral strictures), a mercaptoacetyltriglycine renography was performed at 4, 12, and 24 months postoperatively. The mean patient age was 51.2 years (range 17-79). Stone clearance was achieved by a single combined procedure in 36 patients (80%). Successful recanalization was achieved in all patients with pelviureteral junction obstruction and ureteral strictures. In 4 patients (8.8%), persistent hematuria was noted, and 2 patients (4.4%) developed postoperative urinary sepsis and were treated conservatively. CONCLUSION Modification to the lateral position compares equally with contemporary percutaneous nephrolithotomy series. It provides wide exposure of the flank, allowing the choice of multiple access sites, enhanced control, and a wide angle for handling of the antegrade instruments. Two surgeons can work simultaneously, addressing complex endourologic pathologic features in high-risk patients.

The role of open stone surgery.

Abstract Objective: To highlight the role of open stone surgery in the management of urolithiasis in the current era of minimally invasive therapies. The introduction and continuous development of extracorporeal shockwave lithotripsy (ESWL), ureterorenoscopy and percutaneous nephrolithotomy (PCNL) over the past 30 years have led to a significant change in the current management of urolithiasis, where the indications for open stone surgery have been narrowed significantly, making it a second- or third-line treatment option. Methods: We reviewed the most recent guidelines published by the European Association of Urology and the American Urological Association, and reviewed reports through a MEDLINE search to identify the indications and current role of open stone surgery. Results: From the MEDLINE search, it was obvious that the number of papers published on open renal stone surgery has decreased during the last three decades, soon after the introduction of ESWL and PCNL. Conclusion: Although currently most patients with stones can be managed by minimally invasive therapy, we believe that open surgery still has a role, and therefore it is of great importance to recognise that a small group of patients with complex stone disease, and those with anatomical and physiological anomalies, will benefit from this treatment option.

A technique to flush out renal stone fragments during percutaneous nephrolithotomy.

There are a number of graspers and baskets to snare and remove stones during percutaneous nephrolithotomy (PCNL). These instrumental techniques can, however, cause inadvertent trauma to the renal mucosa and can be time consuming. Increasingly, these graspers and baskets are disposable, which also has financial implications. We use a simple technique to flush out fragments from the kidney during PCNL. Once fragments have been identified as a size that can pass through the Amplatz sheath, a cut nasogastric tube is inserted through the sheath--if possible next to or behind the fragments. It is repeatedly moved forward and backward in a jerking motion while saline is instilled under some pressure to create some turbulence. This results in the mechanical flushing out of stone fragments. We have found this to be a safe, effective, and reliable technique of stone extraction during PCNL.

Treating bladder-outflow obstruction with thermo-expandable prostate metal stents.

Bladder-outflow obstruction is a common age-related clinical entity due to a variety of benign and malignant diseases of the prostate. Surgical treatment is not suitable for high-risk elderly patients who seek minimally invasive management. We present a prostatic thermo-expandable metal stent for treating bladder-outflow obstruction. In this review, we include the design characteristics of this novel device, the performance assessment in comparison with alternative devices, the limitations, our personal clinical experience, as well as a long-term perspective. According to our experience among 127 patients (who underwent insertion of 192 stents) after 1, 2 and 3 years, 82, 61 and 47% of the original stents were functional without apparent complications, respectively. The mean single stent indwelling time was 1 year, with a maximum of 4 years. In 41% of patients, the stent needed to be removed and/or exchanged owing to stent encrustation (15%), migration (10%), penile pain (6%), bladder-outflow obstruction symptoms (5%), urinary incontinence (<3%), tissue granulation (<3%), recurrent urinary tract infections (<3%) or urethral stricture (<3%). The thermo-expandable prostatic stent seems to be an effective minimally invasive treatment of bladder-outflow obstruction, especially in high-risk patients.