Electromotive Drug Administration in the Porcine Renal Pelvis: First Report.

Introduction: Electromotive Drug Administration (EMDA) amplifies drug delivery deep into targeted tissues. We tested, for the first time, the ability of EMDA to deliver methylene blue into the urothelium of the renal pelvis. Materials and Methods: In an anesthetized female pig, both proximal ureters were transected two inches distal to the ureteropelvic junction. An 8F dual lumen catheter and a 5F fenestrated catheter with an indwelling silver wire were inserted into both renal pelvises following which methylene blue (0.1%) was infused at a rate of 5 mL/min for 20 minutes. In one pelvis, a 4 mA positive pulsed electrical current was applied to the silver wire. Results: In contrast to the control pelvis, the EMDA side macroscopically exhibited dense homogeneous staining; microscopy revealed penetration of methylene blue into the urothelium/lamina propria. Conclusion: In the porcine renal pelvis, application of EMDA increased the penetration of a charged molecule into the urothelium/lamina propria.

Electromotive Drug Administration in the Ureter in an In Vivo Animal Model: Initial Report.

Introduction: Electromotive drug administration (EMDA) delivers a drug deeply into targeted tissues, such as the bladder. EMDA has never been applied to the ureter. Methods: In four in vivo porcine ureters, a unique EMDA catheter containing a silver conducting wire was advanced for the infusion of methylene blue. In two ureters, a pulsed current was delivered through an EMDA machine, whereas the other two ureters served as a control. After 20 minutes of infusion, the ureters were harvested. Results: In the EMDA ureter, there was diffuse staining of the urothelium; penetration of methylene blue occurred in the lamina propria and muscularis propria. In the control ureter, there was only patchy staining of the urothelium. Conclusion: In this first report of ureteral EMDA, a charged molecule penetrated beyond the urothelium into the lamina propria and muscularis propria of the porcine ureter.

Intra-operative stone culture as an independent predictor of systemic inflammatory response syndrome after percutaneous nephrolithotomy.

To evaluate the correlation between preoperative urine culture and stone culture findings during PCNL and choosing the appropriate antimicrobial treatment of patients with urinary tract infection or SIRS after PCNL. From April 2007 to March 2008, 51 patients aged 24-66 years underwent PCNL under general anesthesia. Statistical analysis was performed using SPSS software (v.18), the Kolmogorov-Smirnov test, Student's t test, and the Chi square or Fisher's exact tests. Before operation, 11 patients (21.6 %) had positive urine culture. Sixteen patients (31.4 %) had positive stone culture during operation. SIRS occurred in 13 patients (25.5 %). In female group (10 cases, 45.5 %), SIRS was significantly higher than male group (3 cases, 10.3 %) (P = 0.008). Positive stone culture was significantly more prevalent in cases with positive pre-operative urine culture than cases with negative pre-operative urine culture (P = 0.023). But positive stone culture in group with SIRS, was significantly more common than group without SIRS (P = 0.001). Also positive stone culture in female group had significantly higher than male group (P = 0.003). We found a significant, tenfold increase in the risk of developing SIRS after PNCL, only in patients with positive stone culture (OR = 9.96; 95 % CI = 2.37-41.85, P = 0.002). Positive stone culture is a significant predictor of SIRS after PCNL, regardless of other related factors. Therefore, in order to avoid using blind empirical antibiotic regimen and to reduce the risk of subsequent microbial resistance due to use of prevalent broad-spectrum antibiotics, it would be wise to choose appropriate antibiotic therapy based on the results of intraoperative stone culture.

Does sildenafil enhance the effect of tamsulosin in relieving acute urinary retention?

OBJECTIVE: To compare the safety and efficacy of combined therapy using sildenafil and tamsulosin for management of acute urinary retention (AUR) with tamsulosin alone in patients with benign prostate hyperplasia (BPH). MATERIALS AND METHODS: 101 patients were enrolled in a randomized placebo-controlled study from June 2009 to April 2012. Patients presenting with an initial episode of spontaneous AUR underwent urethral catheterization and then prospectively randomized to receive tamsulosin 0.4 mg plus sildenafil 50mg in group A and tamsulosin 0.4 mg plus placebo in group B for three days. Urethral catheter was removed three days after medical treatment and patient's ability to void assessed at the day after catheter removal and seven days later. Patients who voided successfully were followed at least for three months. RESULTS: Mean age of patients was 59.64 ± 3.84 years in group A and 60.56 ± 4.12 years in group B (p value = 0.92). Mean prostate volume and mean residual urine were comparable between both groups (p value = 0.74 and 0.42, respectively). Fifteen patients in group A (success rate: 70%) and nineteen patients in group B (success rate: 62.7%) had failed trial without catheter (TWOC) at 7th day following AUR (p value = 0.3). No significant difference was noted between both groups regarding the rate of repeated AUR at one month and three month follow-up period (p = 0.07 and p = 0.45, respectively). CONCLUSION: It seems that combination therapy by using 5-phosphodiesterase inhibitor and tamsulosin has no significant advantages to improve urinary retention versus tamsulosin alone.

Intermittent perirenal instillation of bupivacaine after tubeless percutaneous nephrolithotomy under spinal anesthesia: a double-blind, placebo-controlled clinical trial.

BACKGROUND AND PURPOSE: Pain at the surgery site is a common complaint in patients who experience percutaneous nephrolithotomy (PCNL). The aim of this double-blind, randomized clinical trial is evaluation of the effect of scheduled infusion of bupivacaine on postsurgical pain and narcotic consumption after tubeless PCNL under spinal anesthesia. PATIENTS AND METHODS: Forty patients were randomly divided into two groups. A small caliber fenestrated feeding tube was placed into the nephrostomy tract under direct vision in a manner in which its tip lied close to the renal capsule. The study group received infusion of diluted bupivacaine while physiologic saline was injected in the control group. Each patient was given the same dose every 6 hours until 24 hours after the surgical procedure. RESULTS: Mean pethidine injection was significantly lower in the group who underwent bupivacaine instillation (20.5±14.5 vs 3.97±2.4 mg: P=0.009). There was no significant difference between mean visual analogue scale (VAS) score in these two groups after 6 and 12 hours while it was significantly lower after 18 and 24 hours in the patients who had received bupivacaine. Mean time to the first analgesic request was significantly longer in the study group (11.35 vs 6.44 hours: P=0.001). CONCLUSION: Intermittent perirenal instillation of bupivacaine via the nephrostomy tract after PCNL decreases the need for more systemic narcotics and provides acceptable analgesia in the postoperative period.

Does sildenafil enhance the effect of tamsulosin in relieving acute urinary retention?

Objective To compare the safety and efficacy of combined therapy using sildenafil and tamsulosin for management of acute urinary retention (AUR) with tamsulosin alone in patients with benign prostate hyperplasia (BPH). Materials and Methods 101 patients were enrolled in a randomized placebo-controlled study from June 2009 to April 2012. Patients presenting with an initial episode of spontaneous AUR underwent urethral catheterization and then prospectively randomized to receive tamsulosin 0.4mg plus sildenafil 50mg in group A and tamsulosin 0.4mg plus placebo in group B for three days. Urethral catheter was removed three days after medical treatment and patient’s ability to void assessed at the day after catheter removal and seven days later. Patients who voided successfully were followed at least for three months. Results Mean age of patients was 59.64 ± 3.84 years in group A and 60.56 ± 4.12 years in group B (p value = 0.92). Mean prostate volume and mean residual urine were comparable between both groups (p value = 0.74 and 0.42, respectively). Fifteen patients in group A (success rate: 70%) and nineteen patients in group B (success rate: 62.7%) had failed trial without catheter (TWOC) at 7th day following AUR (p value = 0.3). No significant difference was noted between both groups regarding the rate of repeated AUR at one month and three month follow-up period (p = 0.07 and p = 0.45, respectively). Conclusion It seems that combination therapy by using 5-phosphodiesterase inhibitor and tamsulosin has no significant advantages to improve urinary retention versus tamsulosin alone. .

Evolution of laparoscopic live donor nephrectomy: a single-center experience with 1510 cases over 14 years.

OBJECTIVE: This study evaluated the outcomes of laparoscopic donor nephrectomy (LDN) and proposed modifications for kidney donation surgery. From February 1997 to February 2011, 1510 LDNs were performed. PATIENTS AND METHODS: Surgical modifications included a modified open access technique for entry into the abdominal cavity, using vascular clips for safe and cost-effective control of the renal pedicle, control of the lumbar veins, and adrenal vein using bipolar cautery instead of clips, and leaving the gonadal vein intact with the ureter. Kidneys were extracted by hand through a Pfannenstiel incision. Heparin was not used after the first 300 cases to prevent potential hemorrhagic complications. RESULTS: Although three major vascular injuries occurred using the closed access method that were managed successfully, no access-related complications occurred using the modified open access technique. Clip failure did not happen in any cases. Patient and graft survival at 1 year post-transplantation were 96.5% and 95.5%, respectively, and at 5 years post-transplantation were 95.3% and 89.5%, respectively. CONCLUSION: The proposed surgical modifications are based on 14 years of experience and 1510 cases, and make LDN simple, safe, and cost-effective. The excellent recipient and graft outcomes with minimal morbidity obtained further confirm that LDN can be considered as the gold standard for kidney donation surgery.

Percutaneous nephrolithotomy in high-risk patients: a single-center experience with more than 350 cases.

PURPOSE: To assess the surgical outcomes and peri- and postoperative complications following percutaneous nephrolithotomy (PCNL) in high- and low-risk patients according to the American Society of Anesthesiologists (ASA) score. MATERIALS AND METHODS: We reviewed the patient records of 2,281 cases older than 18 years who had undergone PCNL in the 3 previous years. The patients were divided into two groups: a low-risk group (ASA score 1, 2: 1,922 cases) and a high-risk group (ASA score 3, 4: 359 cases). RESULTS: Analysis of the location and size of the stone, number and type of access, surgical approach, post-PCNL serum hemoglobin and decrease in glomerular filtration rate revealed no significant difference between the two groups. The stone-free rate was similar in both groups and the hospital stay in the high-risk patients was significantly greater than in the low-risk cases. 95% of low-risk and 91% of high-risk cases had surgical complications compatible with grade ≤II (Clavien system) and overall distribution of different grades of surgical complications was similar between the two groups (p = 0.177). CONCLUSION: Success rate and surgical complications of PCNL in high-risk patients were comparable to low-risk patients. It seems that PCNL may be a safe and effective procedure even in high-risk patients.

Laparoscopic vesicovaginal fistula repair: report of five cases, literature review, and pooling analysis.

OBJECTIVE: This study assessed the safety and efficacy of laparoscopic repair of vesicovaginal fistula (VVF) by literature review and pooling analysis, and this is the first report of the experience of using this approach in a patient with a history of radiotherapy. SUBJECTS AND METHODS: Five patients with VVF, including one with a history of cervical cancer and radiation, underwent laparoscopic repair from August 2010 to December 2011 performed by the same experienced surgeon. RESULTS: The surgical procedure was uneventful in all of the patients, and no conversion to open surgery was required. Mean operation time was 134 minutes (range, 100-185 minutes). Mean blood loss was 300 mL (range, 250-370 mL), and no one required blood transfusion. Mean hospital stay was 4 days (range, 3-6 days). Laparoscopic repair was successful in 4 patients at the mean follow-up period of 8 months (range, 2-15 months), even in the patient with a history of radiotherapy. VVF recurred in 1 subject, who underwent repeat laparoscopic repair, and 2-month follow-up revealed no fistula. CONCLUSIONS: Laparoscopic surgery may be a good alternative to the open approach to manage even complicated VVF if it is performed by skilled surgeons.

Supine percutaneous nephrolithotomy: con.

Advocates of supine percutaneous nephrolithotomy (PCNL) consider several theoretical advantages for this procedure. Despite the potential advantages of the supine PCNL, the majority of urologists have remained reluctant to perform this technique. This reluctance may be related to successful outcomes of prone PCNL and technical difficulties associated with supine PCNL. Feasibility of supine PCNL has been shown in different series and the current evidence, although limited and not fully organized, implies the application of this technique for patients with simple stones who are at high anesthesiological risk. However, there is no convincing evidence to support performing supine PCNL in morbidly obese patients and those with complex and multiple stones. Further randomized clinical trials of large sample size and high methodological quality are required to recommend extensive application of supine PCNL as an alternative to prone PCNL.