Semi-Rigid Ureteroscopy for Proximal Ureteral Stones: Does Adjunctive Tamsulosin Therapy Increase the Chance of Success?

OBJECTIVES: To assess the efficacy of adjunctive tamsulosin therapy in improving the success rate of laser-assisted semi-rigid ureteroscopy (URS) for removing proximal ureteral stones. PATIENTS AND METHODS: This prospective study included 165 patients with proximal ureteral stones ≥10 mm. The patients were randomly assigned to a tamsulosin group (Group I, n = 81) receiving tamsulosin 0.4 mg daily for 1 week pre-URS and a control group (Group II, n = 84) without tamsulosin therapy. Treatment consisted of URS using a semi-rigid ureteroscope (7.5 Fr), followed by intracorporeal holmium: YAG laser lithotripsy. The patients were followed up regularly for 8 weeks after URS. RESULTS: The operative time was 43.4 and 49.6 min in Groups I and II, respectively (p < 0.001). Scope to stone access rate was 93.8 and 82.1% in patients of Groups I and II, respectively (p = 0.022). The stone-free rate was significantly higher in Group I compared to Group II (74/81; 91.4% vs. 67/84; 79.8%; p = 0.035). The complication rate was significantly lower in Group I compared to Group II (17.3 vs. 38.1%, p = 0.003). Only minor complications were encountered and were managed conservatively. CONCLUSIONS: Tamsulosin therapy prior to semi-rigid URS improved ureteroscopic access to proximal ureteral stones, thus leading to an increased success rate and low morbidity.

The impact of adding low-dose oral desmopressin therapy to tamsulosin therapy for treatment of nocturia owing to benign prostatic hyperplasia.

PURPOSE: To evaluate the efficacy and safety of adding a low-dose oral desmopressin to tamsulosin therapy for treatment of nocturia in patients with benign prostatic hyperplasia (BPH). METHODS: Eligible patients with BPH and nocturia ≥2/night were randomly allocated to two treatment groups; the first of which received 3-month treatment scheme of daily oral dose of tamsulosin OCAS 0.4 mg and desmopressin MELT 60 mcg (D/T group), while the second one received tamsulosin OCAS 0.4 mg only (T group). Patients were followed on monthly basis and changes in the parameters from baseline to 3 months after treatment were assessed on I-PSS/QoL questionnaire, 7-day voiding diary, urinalysis, serum sodium, abdominal ultrasonography and uroflowmetry. RESULTS: A total of 248 patients were included within the study; 123 patients in the combined D/T group and 125 patients in T group. The frequencies of night voids decreased by 64.3% in D/T group compared to 44.6% in T group. The first sleep period, significantly increased from 82.1 to 160.0 min and from 83.2 to 123.8 min in D/T and T group, respectively; and significant differences between both groups were observed at the end of study (p < 0.001). I-PSS, QoL score, post-void residual urine volume and Q max were significantly improved with no statistical difference between both groups. No serious adverse effects were reported in both groups. CONCLUSION: The addition of low-dose oral desmopressin therapy to an α-blocker tamsulosin provides effective treatment for nocturia in patients with LUTS/BPH.

Diuresis and inversion therapy to improve clearance of lower caliceal stones after shock wave lithotripsy: A prospective, randomized, controlled, clinical study.

OBJECTIVE: To improve the clearance of lower caliceal stones (LCSs) after shock wave lithotripsy (SWL) using a combination of intra-operative forced diuresis and inversion therapy. MATERIALS AND METHODS: One hundred and fifty-seven consecutive patients with symptomatic, single LCSs of 5-20 mm size were prospectively randomized into two groups. The first (study group, SG) underwent SWL at the time of the maximum diuresis with the patient in the Trendelenburg position with an angle of 30 degree, while the second group (control group, CG) underwent standard SWL. After the last SWL session, patients were followed-up regularly using plain abdominal X-ray and renal ultrasound. The primary endpoint of the study was the stone-free rate (SFR) at 12 weeks. RESULTS: A total of 141 patients completed the study treatment protocol and follow-up: 69 patients in SG and 72 patients in CG. Both groups were comparable in baseline data. SG showed significantly higher SFR at all follow-up time points. At week 12, 78.3% of SG were rendered stone free, whereas only 61.1% were stone free in CG (P = 0.030). Also, there was a significantly higher SFR for larger stones (>10 mm) and stones with higher attenuation value (>500 Hounsfield units) in SG than CG. Mild non-significant complications were reported in both groups. CONCLUSION: SWL with intraoperative forced diuresis and inversion seems to be an effective measure with minimal extra cost to improve LCS clearance post-SWL.

Bladder preservation multimodality therapy as an alternative to radical cystectomy for treatment of muscle invasive bladder cancer.

OBJECTIVE: • To evaluate the efficacy of a bladder preservation multimodality protocol for patients with operable carcinoma invading bladder muscle. MATERIALS AND METHODS: • In this prospective study, we included 33 patients with transitional cell carcinoma (TCC) (T2 and T3, Nx, M0) who were amenable to complete transurethral resection. • These patients refused radical cystectomy as their first treatment option. After maximum transurethral resection of bladder tumour (TURBT), all patients received three cycles of adjuvant chemotherapy in the form of methotrexate, vinblastin, adriamycin and cisplatin (MVAC) followed by radical radiotherapy. • Four weeks later, all cases had radiological and cystoscopical re-evaluation. • Complete responders were considered to be those patients who had no evidence of residual tumour. All patients were subjected to a regular follow-up by cystoscopy and tumour site biopsy conducted every 3 months. Abdomino-pelvic computed tomography and chest X-ray were conducted every 6 months. • The study endpoint was the response to treatment after completion of the first year of follow-up after therapy. RESULTS: • Out of 33 eligible patients, a total of 28 patients completed the study treatment protocol. Their mean ± SD age was 56.7 ± 6 years. Trimodal therapy was well tolerated in most of cases, with no severe acute toxicities. After 12 months of follow-up, a complete response was achieved in 39.3% and a partial response in 7.1%, with an overall response rate of 46.4%. • By the end of the first year, disease-free survival was reported in 39.3%, whereas 25% were still alive with their disease, giving an overall survival of 64.3% for all patients who maintained their intact, well functioning bladders. • Tumour stage and completeness of transurethral resection of bladder tumour were the most important predictors of response and survival. T2 lesions had complete and partial response rates of 69.2% and 23%, respectively, whereas T3 lesions had rates of 40% and 13.3%, respectively (P = 0.001). • The response rate in patients who had complete TURBT was 82.6% vs 20% in those with cystoscopic biopsy only (P = 0.001). In addition, disease-free survival was 72.7% in T2 patients and 27.3% in T3 patients (P = 0.001). CONCLUSION: • In the present study, bladder preservation protocol with MVAC and radical radiotherapy achieved suboptimal response rates at 1 year in patients with localized TCC invading bladder muscle. Patients with solitary T2 lesions that are amenable to complete TURBT achieved the best response rates. Longer follow-up is needed to verify these results. Patients with localized disease should be encouraged for radical cystectomy, which achieved better results.

Amelioration of gentamicin nephrotoxicity by green tea extract in uninephrectomized rats as a model of progressive renal failure.

RATIONALE: Gentamicin (GM) is an effective antibiotic against severe infection but has limitations related to nephrotoxicity. This study investigates whether green tea extract (GTE), an antioxidant, could ameliorate the nephrotoxic effect of GM in uninephrectomized rats. OBJECTIVES: The right kidneys of 40 rats were surgically removed and 1 week later the animals were divided into four groups (n = 10). Group 1 served as control, Group 2 as GTE group, Group 3 as GM group, and Group 4 as GM+GTE group. Kidney function, inflammatory cytokine TNF-α, oxidant and antioxidant parameters of renal tissue, as well as histopathological studies were assessed. MAIN FINDINGS: Injecting uninephrectomized rats with GM induced renal dysfunction as shown by significant elevations in serum creatinine and urea. Serum TNF-α and oxidative stress parameters (superoxide anion and lipid peroxides) were also significantly increased. On the contrary, antioxidative parameters [superoxide dismutase (SOD), catalase (CAT), and reduced glutathione (GSH)] were significantly decreased. Histopathological examination of renal tissue illustrated features of degeneration, marked cellular infiltration, tubular dilatation, and varying degrees of necrosis. GTE given to GM rats reduced these nephrotoxicity parameters. Serum creatinine, urea, and TNF-α were almost normalized in the GM+GTE group. The oxidative stress parameters were significantly decreased and the antioxidative parameters were significantly increased. CONCLUSION: GTE ameliorates GM-induced nephrotoxicity and oxidative damage by improving antioxidant defense and tissue integrity. Further human studies are necessary to demonstrate the antioxidant effects of GTE on renal diseases. Nevertheless, green tea (GT) may offer an inexpensive, nontoxic, and effective intervention strategy in subjects with a risk for GM-induced nephrotoxicity.

Protective effect of trapidil and l-arginine against renal and hepatic toxicity induced by cyclosporine in rats.

RATIONALE: Cyclosporine A (CsA) leads to renal and liver injury, production of free radicals and nitric oxide (NO) deficiency. This study investigates the possible protective effects of trapidil and L-arginine against CsA-induced tissue injury. OBJECTIVES: Forty adult male Wistar rats (180 +/- 20 g) were divided into five groups, eight animals in each. The first group served as control, second group served as CsA group, third group served as CsA + trapidil group, fourth group served as CsA + L-arginine group, and fifth group served as CsA + trapidil + L-arginine group. Kidney and liver functions, inflammatory mediators, cytokines, oxidant and antioxidant parameters as well as histopathological studies of renal and liver tissue were assessed in all groups. MAIN FINDINGS: CsA induced renal and hepatic dysfunction, which was confirmed by laboratory and histopathological examination. Administration of trapidil diminished the renal and liver injury and significantly attenuated the levels of serum creatinine, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNF-alpha), monocyte chemoattractant protein-1 (MCP-1), and oxidative stress, while it significantly elevated the level of serum nitric oxide and the activity of antioxidative stress. L-Arginine gave the same trend as trapidil, but trapidil effect was more pronounced. Coadministration of trapidil + L-arginine significantly ameliorated the toxic effect of CsA, but did not differ significantly from the effect of trapidil alone. CONCLUSIONS: Treatment with trapidil or L-arginine diminished the renal and hepatic CsA-induced toxicity. However, the effect of trapidil was more pronounced. Therefore, treatment with trapidil alone may be the most economic and effective as a potential therapeutic agent in CsA injury.

Radiologic Relation of the Colon to the Trajectory of Percutaneous Nephrolithotomy Access in Prone Versus Flank-free Modified Supine Position: A Prospective Study of Intra and Interindividual Influencing Factors.

OBJECTIVE: To compare the distance between the colon and the trajectory of percutaneous nephrolithotomy (PCNL) access both in prone and flank-free modified supine (FFMS) positions as measured on computed tomography and to study the effect of age, gender, BMI, side, and previous renal surgery as influencing factors. PATIENTS AND METHODS: In this prospective study, we included 367 patients scheduled for PCNL. All patients underwent low dose abdominal computed tomography both in prone and FFMS positions. Patients <18 years and those with previous colonic surgery or renal congenital anomalies were excluded. The perpendicular distance between the imaginary line of the renal access and the colon was measured. Findings were correlated to different influencing factors. RESULTS: Two hundred nineteen patients were males, and 148 were females. BMI of <30 were reported in 158 patients whereas BMI >30 in 209 patients. Data analysis showed that the mean perpendicular distance between colon and the renal access in FFMS and prone positions were 35.92 ± 0.22 mm and 17.78 ± 0.09 mm, respectively. In prone position only obesity, age, and overall interaction effect were the significant factors on the studied distance. In FFMS position, in addition to the effect of the prior factors, previous renal surgery also significantly reduces this distance. CONCLUSION: The distance between the colon and assumed PCNL trajectory at a puncture on the posterior axillary line was influenced mainly by patient position. In FFMS position the colon appears to be farther than in prone position. BMI and age significantly influence this distance to a lesser extent.

Sildenafil citrate in combination with tamsulosin versus tamsulosin monotherapy for management of male lower urinary tract symptoms due to benign prostatic hyperplasia: A randomised, double-blind, placebo-controlled trial.

OBJECTIVE: To assess the additive effect of sildenafil citrate to tamsulosin in the treatment of lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) in men with or without erectile dysfunction (ED). PATIENTS AND METHODS: In all, 150 men with untreated LUTS/BPH with or without ED were randomised to receive sildenafil 25 mg once daily (OD) or placebo OD (night time) combined with tamsulosin 0.4 mg OD (day time) for 6 months. Changes from pre-treatment scores in International Prostate Symptom Score (IPSS), IPSS-quality of life (QoL) score, maximum urinary flow rate (Qmax), and the five-item version of the International Index of Erectile Function questionnaire (IIEF-5) were assessed at 3 and 6 months. Safety profiles were assessed by physical examination and monitoring clinical adverse events. RESULTS: Group A comprised of men who received tamsulosin and sildenafil (75 men), whilst those in Group B received tamsulosin and placebo (75). The IPSS was significantly improved in Group A compared to Group B, at -29.3% vs -13.7% (P = 0.039) at 3 months and -37% vs -19.6% (P = 0.043) at 6 months after treatment. Qmax significantly improved in both groups compared with before treatment (P < 0.001). The IIEF-5 scores improved more in Group A than in Group B, at 58.7% vs 11.7% at 3 months and 62.4% vs 12.4% at 6 months after treatment (both P < 0.001). CONCLUSION: Sildenafil citrate combined with tamsulosin improved LUTS, erectile function, and patient QoL more than tamsulosin monotherapy with the merit of a comparable safety profile in patients with LUTS/BPH.

Supine transgluteal vs prone position in extracorporeal shock wave lithotripsy of distal ureteric stones.

OBJECTIVE: To evaluate of efficacy of transgluteal (supine) approach for shock wave lithotripsy (SWL) in treatment of distal ureteric stones. PATIENTS AND METHODS: This prospective, randomized, comparative study was conducted on 98 patients. Patients were randomly assigned into 2 groups: group A (n = 49; prone position) and group B (n = 49; supine position, transgluteal). Inclusion criteria included patients with radiopaque lower ureteric stones ≤10 mm. Exclusion criteria included radiolucent stones, stones >10 mm, the need for any auxiliary procedure, and any contraindication for SWL. Post-SWL evaluation included plain x-ray of kidney, ureter, and bladder at 2 weeks after treatment and then at monthly intervals after treatment for 3 months. Stone-free status was defined as no residual stone fragments visible on plain x-ray. Treatment failure was defined as persistence of stone fragments at 3 months or the need for ureteroscopy. RESULTS: Stone-free rate after 1 treatment session was achieved in 44.9% and 75.5% for prone and supine positions, respectively. Proceeding to ureteroscopy, after failure of the second SWL session to clear the stones, was done in 34.7% and 8.2% for prone and supine positions, respectively. The overall success rate for SWL treatment in prone and supine groups was 65.3% and 91.8%, respectively (P <.001). CONCLUSION: Transgluteal SWL while patient in supine position proved efficacy for treatment of distal ureteric stones. Larger group studies comparing the results of SWL in supine position with those of prone position and also with those of ureteroscopy may enrich our data to reach a consensus for the ideal management of distal ureteric stones.

Lingual mucosal graft in treatment of Peyronie disease.

OBJECTIVE: To evaluate the use of lingual mucosal graft (LMG) as a substitute for tunica albuginea in the treatment of Peyronie disease (PD). PATIENTS AND METHODS: Seventeen patients, reporting normal erectile function, with PD interfering with sexual function were operated on by plaque excision and grafting with LMG. Preoperative assessment included: the International Index of Erectile Function-5 score, penile duplex, and penile curvature angle measurement. Postoperative erectile function and penile deformity were assessed every 3 months for 9-18 months. RESULTS: Mean age of the patients was 52 (± 4.7) years and mean angle of deformity was 60° (± 5.1). Donor site complications occurred in the form of mild transient swelling, numbness, and pain. Postoperative assessment showed complete penile straightening in 15 patients with mild curvature recurrence (<20°) in 2 patients at the third month. De novo mild erectile dysfunction was reported by 1 patient who responded to low-dose phosphodiesterase type 5 inhibitor. Patients' and partners' satisfaction was reported in 16 (94%) patients. These results remained stable until the end of the follow-up period. CONCLUSION: LMG seems to be a valuable substitute for tunica albuginea in cases of PD. It is readily available and shows early graft take. It also proved safety, reliability, feasibility, and a satisfactory short-term outcome for the treatment of PD.

The use of an acellular collagen matrix in penile augmentation: A pilot study in Saudi Arabia.

OBJECTIVES: To assess the use of an acellular collagen matrix (Pelvicol, Bard Medical, Covington, GA, USA), a successful agent for reconstructive surgery, for enhancing penile girth. PATIENTS AND METHODS: Between June and December 2011, 18 patients (mean age 24 years, range 19-38) had their penis augmented with Pelvicol; the mean (range) penile circumference was 9.2 (7-13) cm before treatment. They were divided into two groups; the first (10 patients) had a Pelvicol sheet of 8 × 12 cm inserted through a V-Y suprapubic incision and wrapped around the shaft in a bilayer under the dartos fascia, but not covering the urethra, with division of the suspensory ligament. The second group of eight patients had the Pelvicol inserted through a subcoronal degloving incision and placed in one layer. The penile circumference was measured at 6 and 12 months after surgery. Patient satisfaction at 1 year after surgery was assessed as 'poor', 'unsatisfied', 'moderately satisfied', 'highly satisfied', or 'excellent'. RESULTS: The mean (range) increase in girth (circumference) was 2.8 (2-3.2) cm in group 1 and 1.7 (1.2-2) cm in group 2. In group 1, two patients were highly satisfied, four moderately satisfied and four unsatisfied; in group 2, three were moderately satisfied and five unsatisfied. Complications were common in both groups, with five patients in group 1 and three in group 2 developing severe penile oedema and ischaemic shaft ulcers. Removal of the graft was required in two patients in each group. CONCLUSION: This pilot study shows that Pelvicol is not an ideal option for enhancing penile girth, and the method of placement did not apparently influence the result.

Randomized controlled trial to compare the safety and efficacy of tamsulosin, solifenacin, and combination of both in treatment of double-j stent-related lower urinary symptoms.

Purpose. We evaluated the effectiveness and safety of tamsulosin, solifenacin, and combination of both in reducing double-J stent-related lower urinary symptoms. Materials and Methods. A total of 338 patients with double-J ureteral stenting were randomly divided, postoperatively, into 4 groups. In group I (n = 84), no treatment was given (control group), group II (n = 85) received tamsulosin 0.4 mg daily, group III (n = 84) received solifenacin 10 mg daily, and group IV (n = 85) received a combination of both medications. Before insertion and 2 weeks after, all patients completed the International Prostate Symptom Score (IPSS), quality of life component of the IPSS (IPSS/Qol), Overactive Bladder Questionnaire (OAB-q), and Visual Analogue Pain Scale (VAPS) questionnaire. Results. The demographics and preoperative questionnaires scores of all groups were comparable. There were statistically significant differences in all scores in favour of groups II, III, and IV as compared to control group (P value < 0.005). Group IV showed statistically significant differences in total IPSS, QoL score, and OAB-q score as compared to groups II and III (P value < 0.001). Conclusions. Combined therapy of tamsulosin and solifenacin significantly alleviated lower urinary symptoms associated with double-J stents as compared to either medication alone.

Single vs. double dartos layers for preventing fistula in a tubularised incised-plate repair of distal hypospadias.

OBJECTIVE: To compare the outcome of a single vs. a double-layer dartos interposition for preventing a fistula after tubularised incised-plate (TIP) distal hypospadias repair. PATIENTS AND METHODS: We retrospectively reviewed the records of patients with primary distal hypospadias who had the hypospadias repaired between February 2009 and June 2011, operated by one surgeon (S.A.K.). In all of the children a standard TIP urethroplasty was performed, which was covered by a dartos fascial flap fashioned using one of two techniques, i.e. in Group I (48 patients) double dartos preputial flaps were used, and in Group II (52 patients) a single dorsal dartos flap was used and transposed ventrally via a 'buttonhole'. The fistula rate and other complications related to each group were recorded. RESULTS: The mean (range) follow-up was 12 (6-22) months for Group I and 14 (6-24) months for Group II. The result was considered a success in 96% of Group I and 92% of Group II. In Group I there were no fistulae, while in Group II there were four fistulae (8%) detected; this difference was statistically insignificant (P = 0.1). Meatal stenosis was associated with a fistula in one patient in Group II but not in the other three. In Group I a meatal stenosis developed late after complete healing of the urethroplasty, with no associated fistula. The repair broke down in one patient in Group I (2%). CONCLUSION: A double-dartos neourethral cover in TIP hypospadias repair seems to be more effective than a single layer for preventing a fistula, despite there being no statistically significant difference between the groups. However, the protective effect of double-dartos flaps must be appropriately evaluated in a prospective, randomised and controlled study in more patients.

Selenium and lycopene attenuate cisplatin-induced testicular toxicity associated with oxidative stress in Wistar rats.

OBJECTIVE: To investigate the potential protective effects of selenium and lycopene, either alone or in combination, for cisplatin-induced oxidative stress and testicular dysfunction in male rats. METHODS: A total of 50 adult male Wistar rats were divided into 5 groups of 10 animals each, as follows: control group (treated with placebo); cisplatin-alone group; cisplatin + lycopene group; cisplatin + selenium group; and cisplatin + selenium + lycopene group. The weights and dimensions of testes, epididymes, and accessory glands as well as sperm concentration, motility, and proportion of normal morphology were assessed. Testicular tissue malondialdehyde (MDA) and glutathione (GSH) levels, as well as superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and catalase (CAT) activities, and plasma testosterone were determined. RESULTS: Cisplatin treatment caused significant reductions in weights and dimensions of testes, epididymes, and accessory glands, sperm concentration, motility, and proportion of normal morphology, enzymatic and nonenzymatic antioxidants, and plasma testosterone levels. There was significantly increased MDA. The co-administration of selenium and lycopene, either separately or in combination, significantly attenuated the harmful effects of cisplatin-induced lipid peroxidation, oxidative stress, loss of genital organ weight and dimensions, as well as function of reproductive organs collectively in the Wistar rat model. The combination of selenium and lycopene was more effective than supplementation of either agent alone in preventing cisplatin-induced testicular damage. CONCLUSION: Selenium and lycopene supplementation reduced cisplatin-induced testicular toxicity, improved testicular function and prevented cisplatin-related injury to the rat testes by suppression of oxidative stress.