Concerns about stone free rate and procedure events of percutaneous nephrolithotripsy (PCNL) for 2-4 cm kidney stones by standard-PCNL vs mini-PCNL- comparative randomised study.

BACKGROUND: To compare the efficacy and safety of standard percutaneous nephrolithotomy (PCNL) with mini- PCNL for kidney stones 2-4 cm. METHODS: Eighty patients were enrolled in a comparative study, they were randomly divided into mini-PCNL group (n = 40) and standard-PCNL (n = 40). Demographic characteristics, perioperative events, complications, stone free rate (SFR) were reported. RESULTS: Both groups showed no significant difference in clinical data about age, stone location, back pressure changes, and body mass index. The mean operative time was (95 ± 17.9 min) in mini-PCNL, and (72.1 ± 14.9 min). Stone free rate were 80% and 85% in mini-PCNL and standard-PCNL respectively. Intra-operative complications, post-operative need for analgesia, hospital stay were significantly higher in standard-PCNL compared to mini-PCNL (85% vs. 80%). The study followed CONSORT 2010 guidelines for reporting parallel group randomization. CONCLUSION: Mini-PCNL is an effective and safe treatment of kidney stones 2-4 cm, it has the advantage over standard-PCNL being has less intra-operative events, less post-operative analgesia, shorter hospital stay, while operative time and stone free rate are comparable when considering multiplicity, hardness, and site of stones.

Holmium Laser Enucleation vs Bipolar Plasmakinetic Enucleation of a Large Volume Benign Prostatic Hyperplasia: A Randomized Controlled Trial.

Objectives: To compare safety and efficacy of bipolar plasmakinetic enucleation of prostate (BPEP) vs holmium laser enucleation of prostate (HoLEP) for management of large benign prostatic hyperplasia (BPH) (>80 g). Patients and Methods: Patients with failed medical treatment, International Prostate Symptom Score (IPSS) >13, peak urinary flow rate (Qmax)<15 mL/s and prostate size ≥80 g were enrolled in this randomized controlled trial from November 2016 to February 2018 and managed by HoLEP (Group A; 33 patients) or BPEP (Group B; 31 patients). Patients on anticoagulants (AC) were not excluded. Patients were followed up for 12 months. Perioperative data were compared between both groups using Student's-t, Mann-Whitney, Paired-t, Wilcoxon signed rank, chi-square, or Fisher-exact tests as appropriate. Results: There was no significant difference between both groups in age, rate of presentation with urinary retention, recurrent hematuria, frequency of patients on ACs/antiplatelets, prostate size, prostate specific antigen (PSA), Qmax, IPSS, quality of life (QoL), and post-void residual urine (PVRU). Operative time was significantly longer in BPEP (p = 0.003) and catheterization duration (p = 0.019). Other perioperative parameters including level of Na+ and hemoglobin, resected tissue weight, hospital stay, and complications were not significantly different between both groups. There was no need for blood transfusion in all patients. There was significant postoperative improvement in IPSS, PVRU, QoL, PSA, and Qmax in each group. However, there was no significant difference between both groups in these parameters. Conclusion: HoLEP and BPEP are comparable regarding safety and efficacy for treatment of BPH (>80 g) including patients on ACs. However, BPEP required a longer catheterization duration and operative time. ClinicalTrials.gov Identifier: NCT03998150.

The MonteggiaFracture: literature review and report of a new variant.

INTRODUCTION: Giovanni Battista Monteggia first described the Monteggia fracture in 1814. The complexity of this injury was not fully appreciated until it was coined in English as a "Monteggia lesion" by Jose Luis Bado. The Bado classification divides Monteggia fractures into four types of true lesions, plus equivalent variants. CASE REPORT: This report describes a rare variant where the proximal radial disruption occurs through a Salter-HarrisType II fracture rather than a radial epiphysis dislocation. This is an unstable fracture configuration that has been successfully surgically treated by keeping to the principles of Monteggia fracture reduction. CONCLUSION: Even though this is not a classical dislocation of the radial head, this variant with a Salter-Harris fracture should be considered as one.

Clinical versus Pathologic staging of Renal Tumors: Role of Multi-Detector CT Urography.

INTRODUCTION: Our ability to diagnose renal cell carcinoma (RCC) has increased in the past 30 years as a result of the extensive application of imaging techniques, such as ultrasonography, computed tomography, and magnetic resonance imaging. Multi-detector computed tomography (MDCT) remains the most appropriate imaging modality for the diagnosis and staging of RCC. The aim of this work was to compare the findings of MDCT with surgical pathology to determine the accuracy of delineating tumor size, localization, organ confinement, lymph node metastases, and the extent of tumor thrombus in the renal vein and inferior vena cava. METHODS: The clinical, surgical, and anatomo-pathologic records of 99 patients treated by nephrectomy (radical or partial) for solid renal tumors at Theodor Bilharz Research Institute and Nasser Institute from 2005 to 2011 were reviewed retrospectively. All cases were staged pre-operatively with abdominal MDCT (pre- and post-contrast enhancement) in addition to the routine biochemical, hematological, and radiological work-up. The tumors' histologic types were determined according to the WHO classification of renal tumors in adults in 2004, and staging was updated to the TNM 2010 system. Data were analyzed using the t-test. RESULTS: The mean age was 52 (range 21-73). Seventy-eight patients were males, and 21 patients were females (Male/Female ratio: 3.7:1). There were no significant differences in the mean tumor size between radiographic and pathologic assessments in different tumor stages. The overall incidence of lymph node invasion in surgical specimens was 76%, whereas MDCT showed a positive incidence in 68.4% of cases (false negative result in 7 cases, 7.6%). CONCLUSION: Our findings indicated that MDCT urography is an accurate method to estimate renal tumor size, lymph node, vascular and visceral metastases preoperatively. Also, preoperative staging of renal tumors with MDCT represents a valuable and accurate tool.

COMPUTED TOMOGRAPHY VERSUS PLAIN RADIOGRAM IN EVALUATION OF RESIDUAL STONES AFTER PERCUTANEOUS NEPHROLITHOTOMY OR PYELONEPHROLITHOTOMY FOR COMPLEX MULTIPLE AND BRANCHED KIDNEY STONES.

This study compared the efficacy of computed tomography of the urinary tract (CT urography) versus plain X-ray of the urinary tract (KUB) in detection and evaluation of the significance of residual stone after percutaneous nephrolithotripsy (PCNL) or surgical pyelonephrolithotomy (SPNL) for complex branching or multiple stones in the kidney. A retrospective prospective archival cohort of 168 patients underwent PCNL or SPNL for large stag horn or multiple stones in the kidney were evaluated, they were 113 patients who underwent SPNL, and 55 patients underwent PCNL. In all patients they had KUB second day of the operation, those who had multiple kidney punctures in the PCNL procedure for multiple stones, or multiple nephrotomies in the SPNL procedure, or had a radiolucent stones had an additional imaging with CT urography. Indications for the CT urography were cases of radiolucent stones and multiple small calyceal stones detected pre-operatively. The study was conducted between March 2010 and December 2014, data weie retrospectively analyzed. Preoperatively multiple or branching stones were diagnosed with intravenous urography and CT urography. Stone size and location were mapped pre-operatively on a real-size drawing, and three dimensional computed construction images in multiple planes. All patients were informed about the advantages, disadvantages and probable complications of both PCNL and SPNL before the selection of the procedure. Patients decided the type of the surgery type by themselves and written informed consent was obtained from all patients prior to the surgery. Patients were in two groups according to the patient's preference of surgery type. Group 1 consisted of 113 patients who underwent SPNL and Group 2 consisted of 55 patients treated with PCNL. Detection of residual stones stone postoperatively using KUB and CT urography was evaluated in both groups. There was statistical significance between the two imaging methodology in detection of residual stones after PCNL and/or SPNL. CT urography detected stones of 2 mm and up to 5mm which was not visualized with KUB. CT urography was statistically significant and precise in detecting the radiolucent stones of uric acid, urate, and phostate stones which were not detected by KUB.

AMBULANT FLEXIBLE CYSTOSCOPY FOR FOLLOW-UP OF Ta-TI UROTHELIAL CARCINOMA OF THE URINARY BLADDER: PAIN PERCEPTION AND COST EFFECTIVE.

Ambulant flexible cystoscopy is the standard procedure in the urological practice for follow-up of Ta-T1 urothelial carcinoma (UC) due to its ability to survey the bladder for a variety of indications. It is the principal means of diagnosis and surveillance of bladder tumors. The follow-up of patients treated for Ta-T1 UC is of great importance because of the high incidence of recurrence and progression of the disease, whereby patients with Ta-T1 UC undergo cystoscopy every three months. The aim of this study to evaluate the procedure of ambulant flexible cystoscopy in proper diagnostic follow-up of Ta-T1 UC, patient's acceptance in regard to pain tolerance, non-hospital stay and expenses. Twenty one patients (18 male and 3 female) were diagnosed before as Ta-T1 UC by rigid cystoscopy and transuretheral resection of bladder (TURB) lesion scheduled for follow up by flexible cystoscopy under local anesthesia using 20 ml 2% lidocain gel on an ambulatory bases. Comparison was done using a cohort of 32 patients who underwent the procedure of follow-up of Ta-T1 cystoscopy and TURB using rigid cystoscopy and resectoscope. Seventeen patients 80.9% (16 male and 2 female) proved to be bladder free from recurrent lesion, 4 patients {19.1 %} (3 males and one female) which revealed recurrent lesions in spite of that the urinary bladder was free in pelvic ultrasonography. Cold cup biopsy from the lesions sent for histopathological examination which revealed recurrence of the tumor in 3 patients (two patients with Ta and one patient T1. TURB was done to have complete resection in 4 patients, the histopathological examination revealed ulcerating mucosa and free lamina propria in 3 specimens, and T2 in the fourth specimen. Comparison between the 2 groups revealed more patient's acceptance for the flexible cystoscopy group as regard pain tolerance, non-hospital stay and expenses. Ambulatory flexible cystoscopy with 20 ml of 2% lidocaine gel anesthesia is tolerated well by patients, with advantage of no hospital stay in the regular follow up of Ta-T1 tumors, pain perception was accepted by all patient provided delayed cystoscopy after lidocaine-gel instillation.

Detour technique, Dipping technique, or Ileal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder.

BACKGROUND: Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated. DESIGN AND PARTICIPANTS: From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder. SURGICAL PROCEDURES: Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter. RESULTS: Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J. CONCLUSION: After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

Detour technique, Dipping technique, or IIeal bladder flap technique for surgical correction of uretero-ileal anastomotic stricture in orthotopic ileal neobladder

ABSTRACTBackground:Uretero-ileal anastomotic stricture (UIAS) is a urological complication after ileal neobladder, the initial management being endourological intervention. If this fails or stricture recurs, surgical intervention will be indicated.Design and Participants:From 1994 to 2013, 129 patients were treated for UIAS after unsuccessful endourological intervention. Unilateral UIAS was present in 101 patients, and bilateral in 28 patients; total procedures were 157. The previous ileal neobladder techniques were Hautmann neobladder, detubularized U shape, or spherical shape neobladder.Surgical procedures:Dipping technique was performed in 74 UIAS. Detour technique was done in 60 renal units. Ileal Bladder flap was indicated in 23 renal units. Each procedure ended with insertion of double J, abdominal drain, and indwelling catheter.Results:Follow-up was done for 12 to 36 months. Patency of the anastomosis was found in 91.7 % of cases. Thirteen patients (8.3%) underwent antegrade dilatation and insertion of double J.Conclusion:After endourological treatment for uretero-ileal anastomotic failure, basically three techniques may be indicated: dipping technique, detour technique, and ileal bladder flap. The indications are dependent on the length of the stenotic/dilated ureteral segment. Better results for long length of stenotic ureter are obtained with detour technique; for short length stenotic ureter dipping technique; when the stenotic segment is 5 cm or more with a short ureter, the ileal tube flap is indicated. The use of double J stent is mandatory in the majority of cases. Early intervention is the rule for protecting renal units from progressive loss of function.

Value of Computed Tomography for Predicting the Outcome After Percutaneous Nephrolithotomy.

INTRODUCTION: Computerized tomography of the urinary tract (CT-UT) has been established as the diagnostic procedure of choice for urinary stones. This study aimed to evaluate its role in predicting the outcome of percutaneous nephrolithotomy (PCNL) in terms of stone free rate and residual fragments. METHOD: This prospective cohort study was conducted on 34 patients in the Urology Department of Theodor Bilharz Research Institute from January 2013 to March 2014. The patients who had large and/or multiple renal stones, including staghorn stones, in 19 renal units scheduled for PCNL were included in this study. All had a pre-operative CT-UT to determine the stones' characteristics and renal anatomy. CT-UT, together with a kidney-Ureter-Bladder (KUB) film, was taken on the first post-operative day. The data were analyzed by SPSS version 17 using independent-samples t-test and the chi-squared test. RESULTS: CT-UT showed a statistical significant sensitivity in detecting residual fragments over standard KUB, yet this significance was lost when corrected to significant residual. Stone size and density were independent factors for the presence of residual stones. CONCLUSION: CT-UT post PCNL was sensitive to detect residual fragments, yet it showed no superiority over standard KUB in detecting significant residual.

Impact of density of schistosomal antigen expression in urinary bladder tissue on the stratification, cell type, and staging, and prognosis of carcinoma of the bladder in Egyptian patients.

BACKGROUND: Infection with urinary schistosomiasis and its severity are oncogenic factors for developing carcinoma of the bladder, whether it is urothelial carcinoma (UC) of a transitional cell type (TCC) or non-urothelial of squamous cell carcinoma (SCC). In UC it is not defined whether it is schistosomal or not. This led to controversial results in expression of tumour markers, tumour prognosis, and response to therapy. OBJECTIVES: We assessed the application by immunohistochemistry method (IHC) for detection of schistosomal antigen in bladder cancer tissue samples to differentiate UC associated with or without schistosomiasis. Urothelial carcinoma stage, grade, and progression were correlated with the density, intensity, and index of schistosomal antigen expression. Follow up was done for 2-5 years. DESIGN AND PARTICIPANTS: Archival tissue samples of 575 patients were studied: 515 urothelial carcinoma, 30 patients with SCC associated with schistosomiasis, and a control group of 30 patients without schistosomiasis. MEASUREMENTS: Expression of schistosomal antigen in tissue was done by IHC using monoclonal antibodies (MAbs) against schistosomal antigens (SA). Correlation of intensity of antigen expression to clinical and pathological data was analysed. RESULTS AND LIMITATIONS: We identified 3 parameters of antigen expression: density, intensity and index with 4 grades for each. SCC-group was 100% positive. UC was positive in 61.4% distributed as follows: Ta: 37.5%, T1: 62%, and muscle invasive T2-4 were 64%. Upstaging, metastases and recurrence were correlated with high index in T1 and T2-4 tumours. CONCLUSION: Urothelial carcinoma associated with schistosomiasis was defined by the positive expression of schistosomal antigens in tissues detected by lHC using MAbs against schistosomal haematobium. Upstaging and progression of T1 and T2-4 were correlated with high density, intensity, and index of antigen expression. Non-schistosomal UC had negative expression for schistosomal antigen, which was detected in 36.5% of cases. These results would be of significance in differentiating schistosomal from non-schistosomal bladder cancer of UC and would predict the prognosis in T1, T2-3 tumours. Implementation of IHC using MAbs against SA in UC would help in planning the proper therapy. Schistosomiasis should be considered as an oncogene for UC in endemic areas.

Dipping technique for ureteroileal anastomosis in orthotopic ileal neobladder: 20-year experience in 670 patients-no stenosis with preservation of the upper tract.

Objectives. Many techniques were described for ureteroileal anastomosis in orthotopic bladder substitution, ranging from nonrefluxing to refluxing techniques, all aiming at preservation of the upper tract. We describe our technique of dipping the ureter into the ileal pouch, which is simple and had no complications. Patients and Methods. Our technique implies dipping the ureter in the lateral side of the pouch, in right and left corners, with two rows of four sutures fixing the seromuscular layer of the ureter to the seromuscular layer of the ileal pouch. The procedure was applied in both normal ureteric calibre and dilated ureter. Total number of procedures done was 1,340 ureters in 670 patients after radical cystectomy for invasive carcinoma of the bladder of urothelial and nonurothelial cancer. Results. Followup of patients every six months and onward did not show stenosis in the ureteroileal anastomotic site. Filling of the ureter with contrast dye on ascending pouchogram was observed in patients who had considerably dilated ureters at the time of cystectomy. Normal ureter did not show clinical reflux but radiological filling of the ureter when the intravesical pressure exceeded the leak point pressure. Time to perform the dipping technique was 5-7 minutes for each site. Conclusion. Dipping technique for ureteroileal anastomosis in orthotopic ileal neobladder avoids the incidence of stenosis, preserves the upper tract, is a fast procedure, stands the evaluation in long-term followup, and was practiced successfully for twenty years.