Holmium laser ablation of anterior urethral valves: case report.

PURPOSE: To report a novel method for treating anterior urethral valves in children using the holmium:YAG laser. CASE REPORT: A 2-year-old boy presented with symptoms of urinary-outflow obstruction. A micturating cystourethrogram (MCUG) revealed an abrupt narrowing of the penile urethra. At cystourethroscopy, an anterior urethral valve without a diverticulum was visible. This was ablated endoscopically using the Ho:YAG laser. The child voided successfully and was discharged the next day. Repeat MCUG 6 months later revealed a normal-caliber urethra. CONCLUSION: Holmium:YAG laser ablation of anterior valves is a minimally invasive treatment modality that provided a satisfactory result and appears to be very promising.

Ureteric calculi in children: preliminary experience with holmium:YAG laser lithotripsy.

OBJECTIVE: To determine the efficacy and safety of holmium:YAG laser lithotripsy in children with ureteric calculi. PATIENTS AND METHODS: Between 1999 and 2003, 28 ureteroscopic laser procedures were carried out on 26 children (14 boys and 12 girls, mean age 6.5 years) with ureteric calculi. The mean (range) stone size was 1.21 (0.4-2.2) cm. At ureteroscopy the calculi were in the upper ureter in six (23%), mid-ureter in five (19%) and lower ureter in 15 (58%) patients. A rigid 8 F ureteroscope was used and the Ho:YAG laser energy delivered at 0.6-1.4 J and 6-10 Hz. All patients were evaluated after 3 months with intravenous urography to confirm stone clearance and to exclude ureteric stricture formation. RESULTS: The overall stone-free rate was 92% (24 children) after 28 ureteroscopic procedures. Stones were completely cleared in 83%, 80% and 100% of the procedures in the upper, mid- and lower ureters, respectively. In two children the procedure failed; they were salvaged by ureterolithotomy in one and extracorporeal shockwave lithotripsy in the other. During the procedures, a ureteric perforation was caused by several factors, including a technically difficult procedure and higher laser energy. At the mean (range) follow-up of 18 (3-39) months, low grade vesico-ureteric reflux was detected in two children, and there were no ureteric strictures in any. CONCLUSION: Holmium:YAG laser lithotripsy is an efficient and safe treatment for ureteric calculi in children.

Pediatric staghorn calculi: the role of extracorporeal shock wave lithotripsy monotherapy with special reference to ureteral stenting.

PURPOSE: Treatment for staghorn calculi in children represents a unique challenge. We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) monotherapy for the management of staghorn calculi in children with special reference to ureteral stenting. MATERIALS AND METHODS: From June 1992 to January 2001 we treated 42 children 9 months to 12 years old with staghorn stones using the Piezolith 2501 (Richard Wolf GmBH, Knittlingen, Germany) lithotriptor. The initial group of 19 patients underwent ESWL without prophylactic ureteral stenting, while in the latter group of 23 a Double-J (Medical Engineering Corp., New York, New York) ureteral stent was inserted immediately before the first ESWL session. Mean patient age, stone size, number of shock waves and ESWL sessions, hospital stay, stone-free rate and major complications were compared in the 2 groups. RESULTS: Overall 33 children (79%) were stone-free after 3 months. The 2 groups were comparable in regard to patient age, stone size, number of shock waves and ESWL sessions, and stone-free rates. Major complications developed in 21% of the unstented group, whereas none were observed in stented cases. This difference was statistically significant (p = 0.035). Seven post-ESWL auxiliary procedures were required in the unstented group to manage complications. Hospital stay was significantly longer in the unstented compared with the stented group (p = 0.022). At a followup of 9 to 102 months (mean 47) stones recurred in 2 children, who were treated with further ESWL. CONCLUSIONS: ESWL monotherapy was an efficient and safe modality for the treatment of staghorn calculi in children. Stented patients had fewer major complications and a shorter hospital stay. Prophylactic ureteral stenting is advisable before ESWL for staghorn calculi in children.

Paediatric ureteric calculi: efficacy of primary in situ extracorporeal shock wave lithotripsy.

OBJECTIVE: To evaluate the efficacy of primary in situ extracorporeal shockwave lithotripsy (ESWL) for the treatment of ureteric calculi in children. PATIENTS AND METHODS: The Wolf 2500 Piezolith was used to treat 63 children (aged 4 months to 12 years) with 76 ureteric calculi, including 10 children with impacted calculi. The calculi were located in 14 upper, 13 mid and 44 lower ureters, and the stone burden varied from 4 to 17.8 mm (mean 12.6). All children aged < or = 10 years were treated under general anaesthesia; lithotripsy was attempted under intravenous sedation in the older children. RESULTS: At the 3-month follow-up, there was an overall successful outcome in 55 children (87%), which included 12 of 13, eight of nine (89%) and 35 of 41 (85%) of the children with upper, mid and lower ureteric calculi, respectively, and nine of the 10 with impacted calculi. Re-treatment was required in 20 (36%) patients, while auxiliary procedures after ESWL were required in three (6%). The major complications encountered were ureteric obstruction with sepsis in two children, bacteraemia in another and urinary retention due to a urethral stone fragment in a fourth child. CONCLUSIONS: In situ ESWL was an effective treatment modality for ureteric calculi at all levels in children, even when impacted. In the short term, complications were minimal, but the long-term effects need further assessment.

Paediatric ureteroscopy for ureteric calculi: a 4-year experience.

OBJECTIVE: To study the efficacy and safety of ureteroscopy in the management of paediatric ureteric calculi at various levels. PATIENTS AND METHODS: The records of 50 ureteroscopic procedures performed on 43 children (age range 6 months-12 years) for primary ureteric calculi or ureteric fragments after electrohydraulic shockwave lithotripsy (EHWL) were analysed retrospectively. The distribution of the calculi was in nine in the upper upper, seven in the mid and 30 in the lower ureter, with a mean stone burden of 1.26 cm. Ureteroscopy was performed with the 8.5/9.5/11.5 F Wolf ureteroscopes, and EHL was used as the primary method of fragmentation. Intravenous urograms were available in 34 children (79%) and micturating cystography (MCUG) was performed in 23 children (54%) during the follow-up. RESULTS: An overall stone-free status was achieved in 40 children (93%) after performing 47 ureteroscopies (94%). Stones were completely cleared in 78%, 100% and 97% of the procedures in the upper, mid and lower ureters, respectively. In three children the procedure failed and they were salvaged by uretero-lithotomy. During the procedures, an upper ureteric perforation occurred in one patient and a lower perforation in another. MCUG revealed low grade vesico-ureteric reflux in 17% of the patients, but close follow-up showed the reflux to be sterile and clinically insignificant. CONCLUSION: Ureteroscopy was safe and effective for the management of mid and lower ureteric calculi but the results for upper ureteric calculi were marginally inferior. Ureteroscopy must be performed judiciously to minimize ureteric injury in children. The incidence of vesico-ureteric reflux after mechanical dilatation of the intramural ureter was infrequent and clinically insignificant.

Effect of Y virilin on male infertility.

A prospective placebo controlled double blind study was conducted in patients attending male infertility clinics of our hospital to evaluate effects of a herbal formulation for male infertility--'Y-virilin'. In phase 1 forty patients with oligospermia with or without asthenospermia were randomly allocated to 2 treatment groups--Treatment Group A i.e. formulation under test and treatment Group B (Placebo). Therapy with these agents was given twice a day for 6 months. In phase 2, 12 patients with azospermia were administered either 'Y virilin' or the placebo (n = 6/Gp). In all patients along with semen analysis (sperm count, percentage of motile sperms and grade of motility) was done monthly for 6 months. Serum FSH levels were estimated before and at the end of therapy. A significant increase in sperm count was observed from 2-3 months in oligospermics receiving Y virilin as compared to basal values (p < 0.05). In Group B the follow-up sperm counts were either comparable to basal values or were lesser. However, the percentage and grade of motility did not differ in two groups at the end of respective treatment. No change was found in mean FSH value. During the therapy period incidence of conception was 20% in treatment Group A and 5% in Group B. Of the azospermic receiving 'Y-virilin' 50% showed a count of 10-20 millions/cmm while none from the placebo group. This study highlights the therapeutic potential of the tested formulation in the patients with infertility.

Surgical disconnection of lymphorenal communication for chyluria: a 15-year experience.

OBJECTIVE: To present the results of surgical lymphorenal disconnection and its advantages in patients with severe chyluria. PATIENTS AND METHODS: Seventy-eight patients (40 men and 38 women, age 22-58 years) with severe chyluria of variable duration (5 months to 14 years), underwent surgical disconnection of the lymphorenal communication after confirming the diagnosis of chyluria by urine examination for fat globules, lymphangiography to delineate the side, site and extent of lymphorenal communication, and cystoscopy to decide the side to be operated. The areolar tissue containing dilated lymphatics travelling to the kidney in the perirenal and hilar region was dissected and divided between ligatures, thus stripping these structures completely; only one side was operated at a time. RESULTS: All 78 patients were available for a minimum follow-up of 1 year, with the longest follow-up 15 years. Lymphangiography showed unilateral communication in 52 (66%) and bilateral in 26 (34%). If the patient was given a high-fat meal before surgery, the intra-operative visualization of the lymphatics was improved. With unilateral surgery, clearance was achieved in 74 (94%) immediately, with final success in 69 (88%) patients. Of the 26 (34%) patients with bilateral lesions, nine (12%) required bilateral surgery, giving a clearance rate of 97%. In two cases of failure, repeat surgery was successful in one; thus the overall success rate was 98%. CONCLUSION: Lymphorenal disconnection for chyluria is simple, successful as a permanent cure and with almost negligible complications. Bilateral lymphorenal communication seen on lymphangiography does not always warrant bilateral surgery.

Male reproductive function in uraemia: efficacy of haemodialysis and renal transplantation.

OBJECTIVE: To evaluate the impact of maintenance haemodialysis and live-related renal transplantation on the reproductive potential of men with end-stage renal disease. PATIENTS AND METHODS: The plasma levels of testosterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were determined, and semen analysed, in 19 men (22-41 years old) with advanced uraemia after 6 months of dialysis and again 6 months after renal transplantation. Eight patients who had azoospermia or severe oligospermia underwent testicular biopsy after 6 months of dialysis and again 6 months after the transplant. RESULTS: Following dialysis, levels of testosterone were low in 17 patients and levels of LH and FSH were elevated in 15 and eight patients, respectively. Four patients each had azoospermia and severe oligospermia. The testicular tissue was hypospematogenic in three patients, showed late-maturation arrest in four and germ cell aplasia in one. After renal transplantation, testosterone and LH levels returned to normal in 15 and 13 patients, respectively, while FSH levels became normal in only two patients. The recovery of testosterone and LH levels after transplantation was statistically significant. Semen quality improved in 13 patients, with the improvement in sperm density and motility being statistically significant. Testicular histology revealed normal spermatogenesis in four patients, while three continued to show late-maturation arrest. The wives of five of the transplanted patients conceived. CONCLUSIONS: The impairment of testicular function seen in advanced uraemia is not reversible by maintenance haemodialysis. In contrast, after successful transplantation, steroidogenic function became almost normal while spermatogenic function showed a striking if incomplete recovery.

Post-surgical recurrent varicocele: efficacy of internal spermatic venography and steel-coil embolization.

OBJECTIVE: To delineate the venographic anatomy of the varicoceles which recur following conventional inguinal varicocele ligation and to determine the therapeutic efficacy of steel-coil embolization as assessed by improvements in seminal parameters and paternity. PATIENTS AND METHODS: Thirty-nine patients with post-surgical recurrent varicoceles underwent bilateral internal spermatic venography approached through the right femoral vein. The collateral venous channels were identified and occluded using appropriate sizes of steel coils. RESULTS: The procedure was technically successful in 33 patients (85%). Analysis of the 33 venograms showed a unilateral left-sided recurrent varicocele in 28 patients (85%) and bilateral recurrent varicoceles in five patients (15%). The mid and lower parallel collateral channels were observed in 27 patients (82%). The recurrences were treated easily with stainless steel-coil embolization. Five patients were lost to follow-up. Of the remaining 28 patients the sperm count and motility became normal in 16 (57%); only the motility improved in three patients (10%) while in nine patients (33%) there were no changes in either of the seminal parameters. Five patients achieved paternity. CONCLUSIONS: Internal spermatic venography allowed a precise anatomical definition of the recurrent varicocele and the use of steel-coil embolization provided satisfactory improvements in sperm quality and paternity.

Alpha blocker prazosin for the treatment of benign prostatic hypertrophy (BPH).

In this study medical treatment with alpha blocker-prazosin is compared with transurethral resection of prostate (TURP) in 62 patients suffering from benign enlargement of prostate with a gland size of less than 20 gms. After thorough interrogation patients were offered either TURP or prazosin therapy. Symptom scoring, residual volume of urine and urinary flow rates were estimated in both the groups before and 3 months after the therapy. 23.5% patients in prazosin group while 90% of patients in TURP group had significant improvement. This distinctly brings out the superiority of TURP for benign enlargement of prostate.

Anterior urethral valve in an adolescent boy.

A 14 year old boy with a relatively uncommon anterior urethral valve is described herein.