Yasser Farahat

A Randomized Prospective Controlled Study for Assessment of Different Ureteral Occlusion Devices in Prevention of Stone Migration During Pneumatic Lithotripsy

OBJECTIVE To compare the safety and efficacy of two different ureteral occlusion devices (stone cone and entrapment net) in preventing retrograde stone migration during ureteroscopic pneumatic lithotripsy. Proximal migration of stone fragments during ureteroscopic lithotripsy is a common problem, especially when the pneumatic lithotripter is used for stone fragmentation. PATIENTS AND METHODS A total of 195 patients with proximal ureteric stones were prospectively randomized into one of three groups in this study, with 65 patients in each group. In group I, the Stone Cone was used as a ureteral occlusive device; in group II, the N-Trap was used; and in group III (control group), the patients underwent pneumatic lithotripsy without any ureteral occlusive device. RESULTS The ureteroscopic procedure was completed successfully in 180 patients; 63 patients in group I, 59 patients in group II, and 58 patients in group III. Patients in group I showed significantly lower incidence of stone migration compared with the other 2 groups (P <.05). Both ureteral occlusive devices significantly lowered the incidence of residual fragments (>3 mm), ureteral trauma, operative time, and the need for ureteral stenting compared with control group. The stone-free rate at 3 weeks was 95.24%, 83.05%, and 72.41% in groups I, II, and III, respectively. The patients in group I had a statistically significant stone-free rate compared with the other two groups (P <.05). Auxiliary procedures were required in 3 (4.76%), 10 (16.94%), and 16 cases (27.58%) in groups I, II, and III, respectively. CONCLUSION The use of Stone Cone or N-Trap is valuable during ureteroscopic pneumatic lithotripsy for treatment of proximal ureteral stones. Both devices significantly diminish residual fragments, the incidence of ureteral wall trauma, and the need for the auxiliary procedure. However, the stone cone was more effective in preventing proximal stone migration and the subsequent stone-free rate.

Role of Posterior Tibial Nerve Stimulation in the Treatment of Refractory Monosymptomatic Nocturnal Enuresis: A Pilot Study

PURPOSE We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis. MATERIALS AND METHODS We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup. RESULTS The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2. CONCLUSIONS Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Application of Small Intestinal Submucosa Graft for Repair of Complicated Vesicovaginal Fistula: A Pilot Study

PURPOSE Vesicovaginal fistula is a socially debilitating problem with important psychological and medicolegal implications. Complicated fistulas include large fistulas or those with failed prior repair attempts. The key to successful closure of such fistulas is the use of adjuncts such as a Martius, peritoneal or omental flap. Small intestinal submucosa is an acellular collagen matrix graft that is nonimmunogenic, biodegradable and ready to use off the shelf. We evaluated small intestinal submucosa as an interposition patch during complicated vesicovaginal fistula repair. MATERIALS AND METHODS A total of 23 women with a mean age of 33.5 years who had a complicated vesicovaginal fistula were enrolled in this clinical trial. Complicating factors were failed primary repair in 9 cases, excessive perifistulous scarring in 4 patients and a fistula 1.5 cm or greater in the remainder. Transvaginal repair was done in 7 low fistula cases and transabdominal repair was done in the remainder with a high fistula. A small intestinal submucosa patch was interposed in all cases at classic abdominal or vaginal repair. All patients were evaluated 1, 3 and 6 months postoperatively. RESULTS All patients who underwent vaginal repair were dry during followup. Of the 16 women who underwent transabdominal repair 14 were dry. The overall success rate was 91.3%. No reported allergic or inflammatory reactions were documented. CONCLUSIONS Using small intestinal submucosa as an interposition layer at anatomical vaginal and/or transabdominal repair of complicated vesicovaginal fistulas seems to be a simple, feasible solution.

A prospective randomised controlled study comparing bipolar plasma vaporisation of the prostate to monopolar transurethral resection of the prostate

Abstract Objectives To compare the safety and efficacy of bipolar transurethral plasma vaporisation (B-TUVP) as an alternative to the ‘gold standard’ monopolar transurethral resection of the prostate (M-TURP) for the treatment of benign prostatic hyperplasia (BPH) in a prospective randomised controlled study. Patients and methods In all, 82 patients indicated for prostatectomy were assigned to two groups, group I (40 patients) underwent B-TUVP and group II (42 patients) underwent M-TURP. The safety of both techniques was evaluated by reporting perioperative changes in serum Na+, serum K+, haematocrit (packed cell volume), and any perioperative complications. For the efficacy assessment, patients were evaluated subjectively by comparing the improvement in International Prostate Symptom Score and objectively by measuring the maximum urinary flow rate (Qmax) and post-void residual urine volume (PVR) before and after the procedures. Results In group II, there was a significant perioperative drop in serum Na+ (from 137.5 to 129.4 mmol/L) and haematocrit (from 42.9% to 38.2%) (both P < 0.001). Moreover, one patient in group II had TUR syndrome. The remote postoperative complication rate was (15%) in group I and comprised of stress urinary incontinence (5%), bladder outlet obstruction (5%), and residual adenoma (5%). In group II, the remote postoperative complication rate was (4.8%), as two patients developed urethral stricture. There were statistically significant improvements in micturition variables postoperatively in both arms, but the magnitude of improvement was statistically more significant in group II. Conclusion B-TUPV seems to be safer than M-TURP; however, the lack of a tissue specimen and the relatively high retreatment rate are major disadvantages of the B-TUVP technique. Moreover, M-TURP appears to be more effective than B-TUPV and its safety can be improved by careful case selection and adequate haemostasis.

V11-02 AVICENNA ROBOFLEX, FOR ROBOTIC ASSISTED RETROGRADE INTRARENAL LASER LITHOTRIPSY OF THE KIDNEY STONES, LARGER THAN 2 CM.

RESULTS: Access-related complications are often encountered in patients who require pre-operative anticoagulation or in whom a urinary tract infection may be identified pre-operatively. Addressing these issues preemptively is imperative to patient safety. Further, several risk factors for bowel injury may be addressed with meticulous knowledge of the patient0s anatomy pre-operatively. In certain cases, anatomic abnormalities necessitate laparoscopic or CT-guided access. Finally, the main difficulties at the time of obtaining access for PCNL are discussed at length, including inadvertent vascular access, extravasation of contrast, guidewire kinking, obstruction of the access tract by a staghorn calculus, bowel injury, and pleural injury. Inadvertent vascular access is often addressed by redirecting the guidewire into the collecting system. In rare cases, use of the access sheath, or balloon, to tamponade bleeding, may be required. Extravasation often necessitates re-puncture, while guidewire kinking may be rectified with the assistance of a rigid, open-ended catheter. Access for staghorn calculi may be achieved with the assistance of retrograde ureteroscopy, or maneuvering past the stone edge with a grasping forceps. Bowel injury should be addressed with drainage of the urinary tract separate from the bowel and broad spectrum antibiotics. Finally, pleural injury necessitates rapid identification to ensure expedient placement of a chest tube. CONCLUSIONS: Access-related complications can introduce significant morbidity to an otherwise successful PCNL. We demonstrated some crucial skills to avoid the difficulties that are often encountered at the time of obtaining access, as well as several techniques that can be used in a timely fashion to address access-related injuries.

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.

V6-11 THE NEW DEVELOPMENTS OF THE ROBOTIC ASSISTED RETROGRADE INTRA-RENAL SURGERY (RA-RIRS) WITH AVICENNA ROBOFLEX

Jens Rassweiler*, Heilbronn, Germany; Kemal Sarica, Istanbul, Turkey; Petrisor Geavlete, Bucharest, Romania; Nida Zafer Tokatli, Ankara, Turkey; Jan Klein, Ulm, Germany; Olivier Traxer, Paris, France; AbdulQadir Al Zarooni, Yasser Farahat, Umm Al Quwain, United Arab Emirates; David M. Hoenig, Long Island, NY; Guido Giusti, Milan, Italy; Volkan Tugcu, Istanbul, Turkey; M. Abdurrahim Imamoglu, Ankara, Turkey; Ahmet Yaser Muslumanoglu, Istanbul, Turkey; Murat Savas, Antalya, Turkey; Remzi Saglam, Ankara, Turkey; Anup Patel, London, United Kingdom

MP34-08 LIMITATION OF NEEDLE DEVIATION DURING TRIANGULATED PERCUTANEOUS RENAL ACCESS: INITIAL EXPERIENCE WITH A NOVEL SIMPLE DEVICE

INTRODUCTION AND OBJECTIVES: For triangulated percutaneous renal access (PRA), non-intended mediolateral deviation of Chiba needle is common under oblique fluoroscopy. We aimed to limit this deviation after proper alignment with target calyx (vertical fluoroscopy), providing only one needle-movement plane (cephalocaudal; under oblique fluoroscopy). METHODS: Device consists of radiolucent cylinder (12x2cm). Starting from edge 2 longitudinally placed opposing and parallel 6cm radiopaque lines (ROLs) are placed over the cylinder wall. In line with the ROLs, a longitudinal tunnel (6x0.2cm) and an opposite hole allowing Chiba needle passes diagonally from the tunnel exiting from the hole. During PRA, the tunnel is aligned with target calyx (under vertical fluoroscopy where the two ROLs are placed over each other i.e appear as one line pointing to the desired calyx), cylinder is fixed to patients’ back by silk-sutures (the needle freely moves only within the tunnel cephalocaudally, fixation of cylinder will prevent needle’s meidolateral drifts, while the hole acts as fulcrum) and the puncture is monitored simply under oblique fluoroscopy (for angle/depth) Study design: four junior urologists (still on mentored practice training) did both 20 non-device assisted and 20 device assisted PRA. The fluoroscopic time (FT) required getting inside the calyx, number of needle re-adjustment trials (NRATs) and access-related complications were monitored. RESULTS: Mean FT and median NRATs decreased after device-assistance (47 10.7seconds and 0 trials) in comparison to 76.2 14.7seconds and 4 trials without device-assistance (p<0.05). PRA-failures (taken-over by mentors) were 5% and 25% with and without device-assistance. CONCLUSIONS: For junior urologists, current device stabilized the needle during triangulated PRA allowing minimal or no unintended mediolateral deviation during targeting the desired calyx.

Futuristic Concept in Management of Female SUI: Permanent Repair Without Permanent Material

Stress urinary incontinence (SUI) is defined as the complaint of involuntary leakage of urine on exertion or on sneezing or coughing (Abrams et al, 2002). Female SUI is a common distressing health problem, affecting large number of women worldwide, with prevalence rates ranging from 12.8% to 46.0% (Botlero et al, 2008). SUI is considered the most common type of urinary incontinence among women and presents about 50 % of these populations, while mixed urinary incontinence presents 36 % and only 14 % are due to urge urinary incontinence (Hannestad et al, 2000). SUI has a negative impact on women quality of life specially their social, physical, occupational, psychological, and sexual aspects of life.