Miniaturized Ambulatory Percutaneous Nephrolithotomy Versus Flexible Ureteroscopy in the Management of Lower Calyceal Renal Stones 10-20 mm: A Propensity Score Matching Analysis.

OBJECTIVE: To evaluate the efficacy of ambulatory mini percutaneous nephrolithotomy (Mini-PCNL) and flexible ureteroscope (F-URS) in treating 10-20 mm lower calyceal stones using propensity score matching analysis (PSM). PATIENTS AND METHODS: A retrospective analysis of 136 adult patients that underwent Mini-PCNL or F-URS for a single lower calyx calculus. Participants that underwent F-URS were allocated to Group I, while those who underwent Mini-PCNL were assigned to Group II. Patients were discharged on the same day and followed up by CT after 3 months. Both groups were matched by stone size and density using propensity stone matching (PSM) and the matched group were further compared. RESULTS: Before matching, there were statistical differences in stone size (P = .02), preoperative hydronephrosis (P = .004), and Hounsfield Unit (P = .04) between both groups. A logistic regression model was created between independent variables such as stone size and density. The new groups following PSM were statistically similar in terms of age, BMI, stone size, and HFU (P = .43, P = .74, P = .49, P = .36). The stone-free rates after PSM was not significantly higher in the Mini-PCNL group than the F-URS group (91.7% vs 81.7%, respectively P = .1) while the operative time for the F-URS group was significantly shorter than the Mini-PCNL group 54 (49-64.3) minutes vs 68.2 (62-73.5) minutes, respectively, P = .045. CONCLUSION: Ambulatory Mini-PCNL and F-URS have a comparable hospital stay, stone-free rates, and complication rates for treating lower calyceal stones 10-20 mm. Both techniques may be considered acceptable treatment options, with a prolonged operative time in Mini-PCNL.

Pneumatic vs laser lithotripsy for mid-ureteric stones: Clinical and cost effectiveness results of a prospective trial in a developing country.

OBJECTIVE: To compare the management of large ureteric stones (>10 mm) with ureterorenoscopy (URS) and laser or pneumatic lithotripsy, and their associated costs. PATIENTS AND METHODS: Our prospective study followed the tenets of the Declaration of Helsinki and included 101 patients with large mid-ureteric stones eligible for URS and lithotripsy, and was conducted between January 2018 and August 2019. Patients were randomly divided into two groups: Group 1 had laser lithotripsy, while the Group 2 had lithotripsy using a pneumatic energy source. RESULTS: Operative time was significantly longer in cases using pneumatic lithotripsy (P < 0.001). The stone-free rate (SFR) on the first postoperative day was 94% and 92.5% for laser and pneumatic lithotripsy respectively, and there were no statistically significant differences in terms of early (day 1) or late (day 30) SFRs between the groups. Complications were classified according to the Clavien-Dindo Grading System, all complications were Grade

Genital-Sparing Cystectomy versus Standard Urethral-Sparing Cystectomy Followed with Orthotopic Neobladder in Women with Bladder Cancer: Incidence and Causes of Hypercontinence with an Ultrastructure Study of Urethral Smooth Muscles.

BACKGROUND: Bladder cancer in women is an indication for radical cystectomy (RC) when the tumour is confined muscle-invasive bladder cancer (MIBC) of T2 N0M0, or high risk progressive non-muscle invasive bladder cancer (NMIBC). Radical cystectomy is either genital-sparing cystectomy (GSC) or standard urethra-sparing cystectomy (USC) that is followed with orthotopic ileal neobladder (ONB). Post-operative chronic retention "Hypercontinence" had been reported in different series following URS or GSC and ONB. In long-term follow-up, we evaluated the functional outcome of women who developed hypercontinence after USC or GSC and ONB. AIM: An ultrastructure study of female urethral smooth muscle was done to elucidate the underlying causes of hypercontinence. MATERIAL AND METHODS: Retrospective study was conducted on 71 women who underwent RC and ONB, 45women had undergone USC, and 26 women had GSC, follow-up ranged from 5 to 15 years. Ultrastructure studies were done on 5 urethral biopsy specimens from 5 women who had hypercontinence, and 4 biopsies were from a normal control. RESULTS: Follow-up showed that women who had undergone USC and ONB, 28.88% developed hypercontinence, where in the series of GSC and ONB three women out of 26 developed hypercontinence (7.80%). Three women who had hypercontinence following USC and ONB, they developed stones in the ileal pouch. Ultrastructure study of urethral smooth muscles in women who had hypercontinence showed organized collagen fibrils, absent myelin sheath, and non-detected lymphatic vessels. Normal urethra showed collagen fibrils within the interstitial matrix, preserved myelin sheath of nerve fibres, the presence of lymphatic vessels in the matrix. CONCLUSION: The present study shoes that GSC with ONB leads to the minimal incidence of hypercontinence (7.80%), while standard USC lead to higher incidence (28.88%). Ultrastructure changes of the female urethra who had hypercontinence were fibrotic changes, loss of myelin sheath and minimal vascularity, their findings explains the underlying cause of hypercontinence and support the technique of GSC rather than the standard USC.

The ex vivo and in vivo Characteristics of New DrillCutTM Prostate Morcellator after Holmium Laser Enucleation of the Prostate: A Pilot Study.

INTRODUCTION: The DrillCutTM morcellator is marketed for its fast and highly efficient removal of prostatic tissue and a higher level of patient safety. However, a paucity of publications has looked into its actual efficacy and safety. The aim of our study was to evaluate its ex vivo and in vivo efficiency and to compare its results with other devices presented in the literature. PATIENTS AND METHODS: We conducted a prospective pilot study on patients who underwent holmium laser enucleation of the prostate (HoLEP) from 2017 to 2018 using the Top-Down technique. Enucleated adenomas were morcellated using the DrillCutTM morcellator. We collected both preoperative and operative data. Operative data included the enucleated adenoma weight and operative time. Various morcellator parameters were collected including morcellation time and efficiency. We recorded the encountered complications and device malfunction. Ex vivo characteristics were evaluated in terms of morcellation speed and aspiration power. RESULTS: Sixty consecutive patients with a median age of 72.8 years were included. The enucleated adenoma was retrieved in 12.5 min (4-58). The median resected prostatic weight was 90 g (44-242). The DrillCutTM efficiency was calculated as 6.46 g/min (2.7-15). Only one patient had a simple bladder mucosal injury. Device malfunction was encountered in 4 patients (6.6%) due to blockage of the morcellator blades. The ex vivo aspiration speed was 52 s/L, while the morcellation power was 14 g/2 min. CONCLUSION: Our results showed that the DrillCut morcellator was effective and safe in managing our patients post-HoLEP. The DrillCutTM has better ex vivo morcellation power but modest aspiration speed in comparison to other morcellators.

Expression of ERG Protein and TMRPSS2-ERG Fusion in Prostatic Carcinoma in Egyptian Patients.

AIM: Prostate cancer (PCa) is the second most common cancers in men worldwide. Its incidence can be influenced by several risk factors including genetic susceptibility. Therefore the search for the expression of a certain gene (ERG) and its rearrangement could give us clues for proper identification of PCa. And the study of ERG expression and its comparison to FISH in Egyptian patients can show whether ERG immunophenotype could be used instead of FISH, as it is cheaper. MATERIALS AND METHODS: This study was performed on 85 cases of PCa, showing 30 cases with HGPIN and 30 cases of prostatic hyperplasia. All were immunohistochemistry stained using ERG monoclonal rabbit antihuman antibody was used (clone: EP111). FISH analysis was performed in 38 biopsies of PCa cases to detect TMRPSS2-ERG rearrangement using the FISH ZytoLight TriCheck Probe (SPEC TMRPSS2-ERG). RESULTS: ERG expression was found in 26% of PCa cases and 20% of HGPIN cases. FISH analysis showed fusion of 21 cases of PCa (out of 22 cases showing ERG immunoexpression). CONCLUSION: Our findings emphasise that only malignant and pre-malignant cells and not benign cells from the prostate stain positive. ERG expression may offer a simpler, accurate and less costly alternative for evaluation of ERG fusion status in PCa.

Randomized, double-blind, placebo-controlled trial to compare solifenacin versus trospium chloride in the relief of double-J stent-related symptoms.

PURPOSE: We aimed to compare the safety and efficacy of solifenacin versus trospium chloride and compare each drug versus placebo regarding the relief of stent-related symptoms following uncomplicated ureteroscopic lithotripsy (URSL). METHODS: In a prospective, randomized, double-blind study, 210 eligible patients who underwent URSL with double-J stent insertion were recruited and randomly assigned to either the first group, receiving solifenacin (10 mg), second group, receiving trospium chloride (60 mg), or the third group, receiving placebo (one tablet). All patients were kept on study medication once daily during the entire 2-week postoperative period. All subjects were asked to complete a brief-form questionnaire to assess the lower urinary symptoms, stent-related body pain and hematuria, preoperatively and 2 weeks postoperatively. RESULTS: There were no statistically significant differences among the study groups in terms of mean age, gender, anthropometric measurements, stone and stent criteria. The overall symptom score, urgency, urge incontinence, flank pain, urethral pain and gross hematuria scores were significantly lower in solifenacin group compared to trospium chloride and placebo groups (p < 0.001). Concerning frequency and nocturia, there was no significant difference in mean scores across all groups. Drug-related side effects, particularly constipation, were higher in trospium group than in solifenacin one. CONCLUSIONS: Solifenacin treatment showed significant improvement in almost all domains of stent-related symptoms than trospium. In terms of safety and tolerance, both drugs were comparable. Future studies should be designed to address the impact of combined drugs and lower doses in the management of DJ stent-related symptoms.

Low-dose bacille Calmette-Guérin for non-muscle-invasive bladder cancer: Results of a prospective study.

OBJECTIVE: To evaluate the efficacy and safety of low-dose (45 mg) intravesical bacille Calmette-Guérin (BCG) therapy in the treatment of patients with non-muscle-invasive bladder cancer (NMIBC), as intravesical BCG is the most acceptable adjuvant therapy for NMI transitional cell carcinoma of the bladder. However, in the standard regimen, undesirable effects are the main cause of treatment discontinuation. PATIENTS AND METHODS: The present study included 37 men with primary NIMBC. All patients underwent complete TURB and 2 weeks later, a 6-week course of 45 mg BCG diluted in 50 mL isotonic saline was instilled into the bladder and retained for 2 h. Patients were evaluated for BCG efficacy (recurrence with or without progression) and safety by documentation of minor and/or major side-effects. RESULTS: There were no major or severe side-effects and no treatment discontinuations. Local adverse effects occurred in 20 patients, while systemic effects, in the form of fever, occurred in six patients (16.2%). There was recurrence in 14 patients (37.8%) after 18-34 months, with disease progression (muscle invasion) in four (10.8%) after 6-18 months. The recurrence index was 0.39/100 patients/month and the mean (range) tumour-free period was 30.97 (7-36) months. CONCLUSION: Low-dose BCG intravesical therapy is an effective adjuvant treatment in NMIBC. However, this needs to be validated in future studies and in comparison with other proposed doses and/or regimens.

LAPAROSCOPIC MANAGEMENT OF DISTAL URETERIC STONE IN BILHARZIAL URETER: RESULTS OF A SINGLE CENTER PROSPECTIVE STUDY.

No doubt, Bilharzial ureters are complicated by distal stricture due to precipitation of Bilharzial ova in distal ureter. These cases are associated with poorly functioning and grossly hydronephroic kidneys that hinder endoscopic manipulation of the coexistent distal, high burden, long standing impacted stones. Thus, laparoscopic uretrolithotomy was performed in 51 bilharzial patients with distal ureteric stones 4 trocars were used. The ureter was opened directly over the stone and the stone was extracted. A double-J stent was inserted into the ureter which was closed by 4-0 polyglactin running suture. The results showed that among 51 cases 33 males and 18 females; the mean age was 40.13 years. the mean stone size was 2.73 cm. Conversion to open surgery was in only one case; the mean operative time 92.05 (range 75-120 minutes); postoperative pain score ranged from 20 to 60, the mean number of PO analgesic request was 1.72 (range 1-3); it was once in 21, twice in 23 and thrice in 7 cases. Hospital stay ranged from 2 to 5 with a mean of 2.74 days; total duration of follow up ranged from 7 to 12 with a mean of 9.68. Stone recurrence reported in 4 cases; ureteric stricture reported in 2 cases. Stone free rate was reported to be 100%.

The clinical significance of HER2 protein amplification/expression in urinary bladder lesion.

OBJECTIVE: To evaluate HER2 oncoprotein expression by both immunohistochemical (IHC) staining and fluorescence in situ hybridisation (FISH) in different benign and malignant bladder lesions, and the effect of bilharzial infestation on this expression. PATIENTS AND METHODS: In a prospective controlled study, 72 patients were classified into a control group, and groups with cystitis, urothelial carcinoma, and squamous cell carcinoma (SCC). HER2 was detected using standard IHC staining and FISH in all groups. The correlation of HER2 expression with tumour type, stage and grade in relation to normal urothelium and cystitis was assessed. The effect of schistosomal infestation was evaluated. RESULTS: HER2 expression was statistically significantly higher in patients with malignant lesions than in the other groups, and in high-stage and -grade tumours than in low-stage and -grade tumours. The use of FISH increased the detection of HER2-positive tumours. Schistosomal infestation did not affect HER2 expression in patients with transitional cell carcinoma. CONCLUSION: High-stage and -grade bladder malignancies expressed HER2 much more than did benign lesions. FISH is more sensitive for detecting HER2 expression. The treatment of HER2-positive tumours might benefit from novel targeted-treatment protocols.

Laparoscopic management of distal ureteric stones in a bilharzial ureter: Results of a single-centre prospective study.

OBJECTIVE: To determine the efficacy and safety of the laparoscopic management of an impacted distal ureteric stone in a bilharzial ureter, as bilharzial ureters are complicated by distal stricture caused by the precipitation of bilharzial ova in the distal ureter. These cases are associated with poorly functioning and grossly hydronephrotic kidneys that hinder the endoscopic manipulation of the coexistent distal high burden of, and long-standing, impacted stones. PATIENTS AND METHODS: We used laparoscopic ureterolithotomy, with four trocars, to manage 51 bilharzial patients (33 men and 18 women; mean age 40.13 years) with distal ureteric stones. The ureter was opened directly over the stone and the stone was extracted. A JJ stent was inserted into the ureter, which was then closed with a 4-0 polyglactin running suture. RESULTS: The mean stone size was 2.73 cm. Conversion to open surgery was required in only one patient. The mean operative duration was 92 min, the postoperative pain score was 20-60, the mean (range) number of analgesic requests after surgery was 1.72 (1-3), comprising once in 21 patients, twice in 23 and thrice in seven. The mean hospital stay was 2.74 days, and the total duration of follow-up was 7-12 months. The stone recurred in four patients and a ureteric stricture was reported in two. All patients were rendered stone-free. CONCLUSION: Laparoscopy is a safe and effective minimally invasive procedure for distal ureteric stones in a bilharzial ureter with hydronephrosis.

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.

Diagnostic and Prognostic Significance of Serum and Tissue Galectin 3 Expression in Patients with Carcinoma of the Bladder.

BACKGROUND: Galectins are group of proteins found in the cytoplasm, nucleus, cell surface and extracellular matrix. Galectin 3 (Gal-3) displays pathological expression in a variety of processes such as tumorigenesis. PATIENTS AND METHOD: 70 patients classified into the control group, cystitis group, transitional cell carcinoma group, and squamous cell carcinoma group were enrolled in this study which aimed to detect the serum level and the intensity of tissue expression of Gal-3. RESULTS: Both serum level and tissue expression of Gal-3 were statistically higher in bladder cancer patients compared to the other groups. Gal-3 level expression increased from low to high grade urothelial tumors, with a statistically significant increase of its level and expression between muscle invasive and non-muscle invasive Ta urothelial tumors. CONCLUSION: The serum Gal-3 level is sensitive and specific for the diagnosis of bladder cancer. The prognostic significance of tissue expression is to be confirmed.

Galectin 3 for the diagnosis of bladder cancer.

OBJECTIVE: To evaluate serum levels of galectin-3 (G-3) in patients with bladder cancer and a control group, as a potential diagnostic and prognostic serum tumour marker. PATIENTS AND METHODS: Between November 2012 and January 2013, 55 patients (median age 58 years) were enrolled into three groups, i.e., a control, those with transitional cell carcinoma (TCC) or those with squamous cell carcinoma (SCC). The serum G-3 level was measured the night before cystoscopy. The levels of G-3 levels were correlated with tumour type, stage and grade, and in relation to levels in normal urothelium. The results were analysed statistically using the Mann-Whitney U-test, the Kruskal-Wallis test and the receiver operating characteristic curve, as appropriate. RESULTS: The median serum G-3 level was 100, 720 and 920 pg/mL in the control, TCC and SCC groups, respectively, with very significantly greater G-3 levels in both the TCC and SCC groups than in the control group. Patients with high-grade TCC had a statistically significantly greater serum G-3 level than those with low-grade tumours, as did those with muscle-invasive TCC than those with Ta tumours. CONCLUSIONS: The level of G-3 can aid as a diagnostic marker in patients with either TCC or SCC of the bladder, but the prognostic significance of G-3 remains to be confirmed.

Single-step renal dilatation in percutaneous nephrolithotomy: A prospective randomised study.

OBJECTIVE: To perform an economical single-step renal dilatation (RD) during percutaneous nephrolithotomy (PCNL), using directly a 30-F Amplatz dilator over the central Alken dilator, in a trial to reduce the operative duration and radiation exposure during RD while avoiding an exchange of dilators that might increase the risk of blood loss. PATIENTS AND METHODS: In a prospective randomised study including 49 patients divided into two groups, the first had RD before PCNL using the standard metallic telescopic dilators (Alken), and the second had RD using the 30-F Amplatz dilator over the central Alken dilator. The operative duration, with X-ray exposure, was calculated. The procedure outcome in terms of complications, stone-free rates and hospital stay was evaluated statistically. RESULTS: The tract was dilated correctly in all cases. The operative duration and X-ray exposure was shorter in patients undergoing single-step RD (P < 0.05). There were perioperative complications, according to the Clavien grading system, in 17 (34%) patients but there was no statistically significant difference between the groups. The stone-free rates were comparable in both groups. CONCLUSION: A single-step RD during PCNL is feasible, with a shorter operative duration and X-ray exposure. The outcomes were comparable with those of a standard metallic telescopic RD.

Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre experience.

OBJECTIVES: To assess the feasibility of performing percutaneous nephrolithotomy (PCNL) with the patient supine. Although PCNL with the patient prone is the standard technique for treating large (>2 cm) renal stones including staghorn stones, we evaluated the safety and efficacy of supine PCNL for managing large renal stones, with special attention to evaluating the complications. PATIENTS AND METHOD: In a prospective study between January 2010 and December 2011, 54 patients with large and staghorn renal stones underwent cystoscopy with a ureteric catheter inserted, followed by puncture of the collecting system while they were supine. Tract dilatation to 30 F was followed by nephroscopy, stone disintegration using pneumatic lithotripsy, and retrieval using a stone forceps. All patients had a nephrostomy tube placed at the end of the procedure. The results were compared with those from recent large series of supine PCNL. RESULTS: The median (range) operative duration was 130 (90-210) min, and the mean (SD) volume of irrigant was 22.2 (3.7) L. One puncture was used to enter the collecting system in 51 renal units (94%), while three units (6%) with a staghorn stone needed two punctures. The stone clearance rate was 91%, and five patients had an auxiliary procedure. There were complications in 15 patients (28%). All patients were stone-free at a 3-month follow-up. CONCLUSION: Supine PCNL is technically feasible; it has several advantages to patients, urologists and anaesthesiologists. It gives stone-free rates and a low incidence of organ injury comparable to those in standard prone PCNL.

Prostate-sparing cystectomy: Potential functional advantages and objective oncological risks; a case series and review.

OBJECTIVES: Prostate-sparing cystectomy (PSC) has been debated over the last decade; our aim was to assess the functional results and to evaluate the oncological outcome after PSC, to judge the value of this technique. PATIENTS AND METHODS: Twenty-six men (median age 62 years) who were candidates for radical cystectomy were operated between 2004 and 2009 in the urology departments of Foch Hospital, Suresnes, France, and Theodor Bilharz Research Institute, Giza, Egypt. They all underwent a PSC with orthotopic bladder substitution. The functional results were assessed at 1, 3 and 6 months, with the final results evaluated at 1 year. Incontinence was classified according to pads used per day, and erectile function after PSC was assessed using the International Index of Erectile Function questionnaire. There was a strict follow-up for oncological failure, with special attention given to the remnant of the prostate and prostatic urethra. RESULTS: The final functional results were assessed at 1 year, with daytime continence achieved in 22 patients (95%) and nocturnal leak in four (13%). At 1 year, 18 patients (83%) reported having erections on sexual stimulation. The median follow-up was 43 months, with an overall incidence of recurrence of 30% and a median time to metastasis of 30 months. At 36 months, the overall survival rate was 81%, with a tumour-free survival rate of 70%. CONCLUSION: PSC was no better than standard radical cystectomy, and should only be offered to patients who prefer preservation of their sexual function and continence over appropriate tumour control.

Laparoscopic management of primary pelvi-ureteric junction obstruction: Single-centre experience.

OBJECTIVE: To evaluate the effect and safety of laparoscopic pyeloplasty in the treatment of pelvi-ureteric junction obstruction (PUJO). PATIENTS AND METHODS: In 34 patients, laparoscopic dismembered pyeloplasty was used to treat primary PUJO. Information was obtained for symptoms, results of a nuclear scan before and after surgery, intraoperative blood loss, operative duration, stenting method, and hospital stay. Under general anaesthesia and in the flank position, a 10 mm trocar was first placed above the umbilicus; three 5 mm working ports were then placed. The ureter and pelvis were freed from surrounding adhesions. The obstructive pelvi-ureteric segment was then excised, and the opened point of the ureter spatulated. Ureteropyeloplasty between the lower pole, pelvis and spatulated ureter was made using a 4-0 polyglactin suture around a JJ stent. RESULTS: The mean (SD) preoperative nuclear scan result was 23.6 (6.4) mL/min, with retention of tracer. The median operative duration was 200 min, and the median blood loss 120 mL. All patients were stented with a JJ stent. The mean hospital stay was 5 days. The final results were assessed at 6 months after surgery, when the mean (SD) nuclear scan result was 30 (7.4) mL/min. CONCLUSION: Laparoscopic pyeloplasty is a safe and effective option which can produce satisfactory results both clinically and radiologically.