Endoscopic combined intrarenal surgery in the prone split-leg position versus Galdakao-modified supine Valdivia position for the management of partial staghorn calculi.

OBJECTIVE: To evaluate and compare the outcome of ECIRS in the treatment of partial staghorn renal calculi in both prone split-leg positions versus GMSV positions with regard to; technical aspects, success rate, operative time, complications, safety, and effectiveness of both approaches. PATIENTS AND METHODS: Between October 2018 and August 2021, 66 patients with partial staghorn calculi were enrolled in this prospective comparative study. Patients were randomly divided according to a 1:1 ratio into two groups. Group A included 33 patients who were treated by (ECIRS) in the prone split-leg position, and group B included 33 patients who were treated by (ECIRS) in the Galdakao-modified supine Valdivia (GMSV) position. RESULTS: No significant statistical difference between both groups regarding the mean age (p = 0.448), mean body mass index (BMI) (p = 0.137), mean stone burden (p = 0.435), mean operative time (p = 0.541) and the number of calyces located in branched stones (p = 0.628). The mean hospital stay was 6.71 ± 1.12 days for group A and 6.66 ± 1.10 days for group B patients (p = 0.724). The final SFR was achieved in (29)87.87% and (30)90.9% of group A & B patients, respectively (p = 0.694). No significant difference was detected between both groups in perioperative complication rates. CONCLUSION: ECIRS is safe and effective in treating partial staghorn calculi either in the prone split-leg position or in the Galdakao-modified supine Valdivia position, with comparable outcomes and no statistically significant difference between both positions.

Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children.

Objective: To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups. Results: The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I-II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV-V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001). Conclusion: Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.

Primary leiomyosarcoma of the middle ureter: A rare case report with literature review.

Leiomyosarcoma is a rarely seen neoplasm of the ureter. Malignant tumors of smooth muscle of the ureter are extremely rare, and about 22 cases of leiomyosarcoma of ureter have been reported to date. A 57-year-old diabetic Pakistani man presented with a dull ache pain in the right flank. Past surgical history was three ureteroscopic surgeries for a ureteric stricture. Computed tomography showed a stricture with a peri-ureteral soft tissue mass of 11 mm x 5 mm at the middle third of the ureter at the level of common iliac vessels. laparoscopic excision with safety margin and right ureterovesical reimplantation is performed. Diagnosis of leiomyosarcoma of the right ureter was made, and one iliac lymph node was excised and was positive for tumor by pathologic examination. Although leiomyosarcoma is rarely seen in urinary tract, it should be considered in the differential diagnosis of ureteral stricture disease and retroperitoneal tumors.

Efficacy of Bladder Ultrasound in Prediction of Resolution of Vesicoureteral Reflux After Endoscopic Subureteral Hyaluronic Acid/Dextranomer (Deflux) Injection.

OBJECTIVE: To evaluate the efficacy of bladder ultrasound (US) in predicting the resolution of vesicoureteral reflux (VUR) after subureteral endoscopic Deflux injection in low-grade vs high-grade VUR patients. MATERIALS AND METHODS: Between 2014 and 2020, 160 children (220 ureters) were administered subureteral Deflux injection for treatment of primary VUR. The mean age at surgery was 72 months. Low-grade reflux (grades II-III) was observed in 190 ureters and high-grade reflux (grades IV-V) was observed in 30 ureters. Bilateral surgery was performed in 60 patients. All patients had follow-up using bladder US and voiding cystourethrography (VCUG) at 3 months and 12 months. Outcome included identification of Deflux mounds by bladder US and correlation of Deflux mounds identified with radiographic success rates of VUR on VCUG. RESULTS: Single Deflux injection showed radiographic success rates in 98% of low grade reflux patients and 26.7% of high grade reflux patients at last follow-up. Bladder US was able to detect Deflux mounds in 89% of low grade reflux and 43.3% of high grade reflux patients at last follow up. Our study demonstrated higher sensitivity, Positive predictive value and accuracy in Deflux detection by bladder US in low grade reflux vs high grade reflux patients. CONCLUSION: Bladder-US was highly sensitive for detection of Deflux implants. Bladder-US could be adjusted in follow-up of patients with low-grade reflux treated by Deflux injection, while VCUG could be preserved for follow-up of high-grade reflux, this will lead to reduction of unnecessary radiation exposure during VCUG for children with low grade reflux.

Extravesical Common Sheath Ureteral Reimplantation Versus Intravesical Techniques for Refluxing Duplex Systems in Children.

PURPOSE: Retrospective comparative study of the efficacy of extravesical non-dismembered common sheath ureteral reimplantation (ECSR) versus intravesical common sheath ureteral reimplantation (ICSR) techniques for the correction of vesicoureteral reflux (VUR) in complete duplex systems. MATERIAL AND METHODS: Between 2010 and 2019, ECSR was performed in 38 children (8 bilaterally), and the mean ages at presentation and at surgery were 31 and 57 months, respectively. The ICSR technique was performed in 25 units (25 patients). Voiding cystography and ultrasound of the kidney and bladder were performed 3 and 12 months postoperatively. We analyzed the surgical outcomes for both groups. RESULTS: The mean follow-up times for the ECSR and ICSR groups were 15 and 18 months, respectively. The success rate of the ECSR group was 93.5% at 3 months, improving to 95.7% at an average of one year; the rate of the ICSR group was 96% at 3 months and was the same after one year, with no significant difference between the two groups (p = .66). Postoperative complications were compared in the ECSR and ICSR groups: transient contralateral VUR was seen in 5 renal units versus 4, de novo hydronephrosis was seen in 3 units versus 2, and UTIs were observed in 3 patients versus 4. CONCLUSION: Both (ECSR) and (ICSR) surgeries are highly successful for the correction of VUR in uncomplicated complete duplex systems. The results of the extravesical approach are comparable with those of the intravesical technique with less morbidity and a shorter hospital stay. Thus, ECSR is our preferred technique when open surgical repair is indicated. ICSR should be reserved for complicated duplex systems necessitating concomitant reconstructive surgery.

A neglected double J ureteral stent for 10 years: A rare case report.

Complications of Double J stenting (DJS) include migration, fragmentation, and encrustation. In addition, forgotten stents with encrustations and stone formations are difficult to remove. We report the case of a stent "forgotten" for 10 years, concomitant with multiple ureteral stones and bladder calculus. Whole encrustation of the stent was observed. The patient underwent cystolithotripsy, ureteroscopic laser lithotripsy and stent removal. We report the longest period of forgotten DJS with maximum stone burden in the urinary system. To avoid this situation, patients should be educated regarding complications if the stent is not removed within a short period.

Fluoroscopy-free double-J stent placement through ureteroscope working channel postuncomplicated ureteroscopic laser lithotripsy: A novel technique.

OBJECTIVES: To report a technique for ureteroscopic laser lithotripsy (URSL) and retrograde placement of a double-J (DJ) stenting through the ureteroscope working channel without the use of a fluoroscope compared to the conventional technique. PATIENTS AND METHODS: Between June 2015 and December 2017, 170 patients selected for URSL for treatment of ureteral stones and DJ insertion was evaluated. Patients are divided into two groups according to the use of fluoroscopy. In Group A (100 patients), fluoroscope is used and group B (70 patients) without fluoroscopy guidance. In group B, URSL is performed first and followed by DJ insertion by the semi-rigid ureteroscope 8.5-11 Fr under vision without fluoroscopy. RESULTS: Stone free rate in 96% versus 94.3% for groups A and B respectively. This technique was successful in all the included patients: 166 retrograde DJ stenting post URSL for ureteric calculi and 4 cases for anuria. Group A are exposed to radiation with mean 26.6 seconds in URSL procedure and 4.8 seconds for DJ stenting. Group B was exposed to zero dose. For group A, the stents size was 6 Fr for 70% of patients and 15 % for 4.7 Fr and 15% for 7 Fr stenting. In Group B, stents of 4.7 Fr and length 24-26 cm were used in all patients. Failure of DJ insertion is reported in 9% for group A and 13 (18.5%) patients for group B. CONCLUSIONS: This study report the feasibility and efficacy of the completely fluoroscopy free URSL and DJ stenting to treat ureteric stones.

Vitamin D deficiency and lower urinary tract symptoms in males above 50 years of age.

CONTEXT: Lower urinary tract symptoms (LUTSs) in elderly males are usually related to benign prostatic hyperplasia (BPH) in the majority of cases. It is estimated that BPH affects half of men above the age of 50 years. Recently, a relationship between Vitamin D deficiency and LUTS in elderly males has been reported. AIMS: The aim of this study was to analyze Vitamin D levels in males aged above 50 years presenting with LUTS. SETTINGS AND DESIGN: This is a prospective case-control study. PATIENTS AND METHODS: This was a case-control study in which males above 50 years of age who presented with LUTS (Group A) were compared with a control group (Group B) without LUTS. Both groups were investigated regarding Vitamin D level, prostate-specific antigen (PSA), International Prostatic Symptoms Score (IPSS), prostate size, flow rate, serum calcium levels, and abdominal ultrasonography. STATISTICAL ANALYSIS USED: Statistical software package (SPSS Inc., Chicago, IL, USA) was used for the statistical analyses, performing t-test for quantitative data to compare between the two groups. Pearson's correlation coefficient "r" test was calculated between two quantitative, continuous variables in Group A. P <0.05 was considered statistically significant. RESULTS: A total of 150 patients were studied. There were 70 and 80 patients in Groups A and B, respectively. The mean age of Group A patients was 60.32 ± 11.93 years versus 58.12 ± 10.55 years for Group B patients (P > 0.05). The mean value of Vitamin D level was 40.82 ± 29.46 nmol/L in Group A and 70.25 ± 22.42 nmol/L in Group B (P < 0.001). The mean value of prostate size was 50.12 ± 23.24 g in Group A and 30.68 ± 4.90 g in Group B (P < 0.001). The mean serum calcium level was 2.4 ± 0.14 mmol/L and 2.50 ± 0.15 mmol/L in Groups A and B, respectively (P < 0.001). The mean value of PSA in Group A was 2.24 ± 1.95 ng/ml versus 2.11 ± 0.45 ng/ml in Group B (P < 0.001). The mean value of IPSS in Group A was 13.38 ± 5.32 ml/s versus 3.41 ± 2.42 ml/s in Group B. The mean value of Q max in uroflowmetry in Group A was 11.5 ± 2 ml/s versus 15.4 ± 1 ml/s in Group B. CONCLUSIONS: Men older than 50 years of age with LUTS have lower levels of Vitamin D compared to men without LUTS.

Correlation of Bladder Histopathologic Changes Due to Double-J Stenting to the Period of Stenting: A Preliminary Study.

OBJECTIVES: To study the histopathologic changes in the urinary bladder associated with Double-J (DJ) stenting and the correlation between these changes and the period of stenting. METHODS: In a 2-year period, a retrospective study was carried out on 30 patients indicated for DJ stenting. These patients underwent cold-cup cystoscopic biopsies from the ipsilateral ureteral orifice at the time of removal of DJ stents. RESULTS: The mean age of the 30 patients included in our study was 43.6 ± 8.6 years (range 26-74 years). The stent size used was 4.7 and 6F. The stent duration was 2 weeks in 2 patients, 4 to 6 weeks in 18 patients, 6 to 12 weeks in 6 patients, and more than 12 weeks in the remaining 4 patients. Stent placement was optimum in all patients. The histopathologic study of 30 biopsies showed mild, acute eosinophilic inflammatory reactions with edema in patients with stenting less than 14 days. Acute lymphocytic eosinophilic cystitis with edema was found with stents of 2 to 6 weeks. Brunn's nests were reported with stents more than 6 weeks. Cystitis cystica was seen in those who had stents more than 12 weeks. CONCLUSIONS: Our study shows that acute and chronic allergic inflammatory changes can be seen around the bladder coil of the DJ stents. It is of major importance for the urologist to limit the use of DJ stents to highly indicated cases only and for a short interval.

Management of equivocal (early) Fournier's gangrene.

BACKGROUND: Fournier's gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG. METHODS: This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011-2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients' demographics, vital signs, laboratory finding and clinical findings were reported. RESULTS: A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2. CONCLUSIONS: Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.

Fluoroscopy free flexible ureteroscopy with holmium: Yttrium-aluminium-garnet laser lithotripsy for removal of renal calculi.

OBJECTIVE: To evaluate the feasibility of access sheath insertion and ureteric stent placement without image guidance in flexible ureteroscopic lithotripsy with holmium:yttrium-aluminium-garnet laser for renal stones. PATIENTS AND METHODS: Between March 2014 and October 2015, 80 patients with renal stones treated with flexible ureteroscopic laser lithotripsy were evaluated. Indications for surgery were renal obstruction, failed shockwave lithotripsy (SWL), stones in polycystic kidneys, and mal-rotated kidneys. A 6.5-F Cobra flexible ureteroscope was used in all cases with an access sheath of 12 F, 35/45 cm in length. Fluoroscopy was not intended for use in all cases and postoperative JJ stenting was optional. The perioperative complications were listed and the collected data were analysed. RESULTS: The study included 80 patients (66 male, 14 female), with a mean (SD; range) age of 48.2 (8; 28-54) years and a stone burden of 13 (3.5; range 6-23) mm. In all, 26 patients had a stone burden of >15 mm and 48 patients had lower calyceal stones. The mean (SD; range) operative time was 71.5 (20; 25-130) min. Overall, 76 (95%) access sheath insertions were performed successfully without the use of fluoroscopy. JJ stenting was used in 22 patients (27.5%). The mean (SD; range) hospital stay was 10 (8.5; 10-36) h. After one session, a stone-free rate (SFR) of 87.5% was achieved (93.3% for stones of <15 mm). A single session was successful in 87.9% of cases with lower calyceal stones, with a SFR of 91.7% for post-SWL failure cases. The perioperative complication rate was 15%. CONCLUSION: Access sheath insertion without fluoroscopic guidance is feasible. This technique reduces radiation exposure in patients requiring flexible ureteroscopy.

Management of upper ureteral stones exceeding 15 mm in diameter: Shock wave lithotripsy versus semirigid ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy.

OBJECTIVES: We conducted a retrospective study to evaluate the efficacy and outcome of shock wave lithotripsy versus semirigid ureteroscopy in the management of the proximal ureteral stones of diameter exceeding 15 mm. METHODS: During the 2009-2014 study period, 147 patients presenting with the proximal ureteral stones exceeding 15 mm in diameter were treated. Both shock wave lithotripsy and ureteroscopy with laser lithotripsy were offered for our patients. A 6/8.9 Fr semirigid ureteroscope was used in conjunction with a holmium:yttrium-aluminum-garnet laser. The stone-free rate was assessed at 2 weeks and 3 months post-treatment. All patients were evaluated for stone-free status, operation time, hospital stay, perioperative complications, and auxiliary procedures. RESULTS: Of the 147 patients who took part in this study, 66 (45%) had undergone shock wave lithotripsy and 81 (55%) underwent ureteroscopy. At the 3-month follow-up, the overall stone-free rate in the shock wave lithotripsy group was 39/66 (59%) compared to 70/81 (86.4%) in the ureteroscopic laser lithotripsy group. Ureteroscopic laser lithotripsy achieved a highly significant stone-free rate (p = 0.0002), and the mean operative time, auxiliary procedures, and postoperative complication rates were comparable between the two groups. CONCLUSION: In terms of the management of proximal ureteral stones exceeding 15 mm in diameter, ureteroscopy achieved a greater stone-free rate and is considered the first-line of management. Shock wave lithotripsy achieved lower stone-free rate, and it could be used in selected cases.

Efficacy of bipolar "button" plasma vaporization of the prostate for benign prostatic obstruction, compared to the standard technique.

OBJECTIVE: The objective of the following study is to evaluate the efficiency of transurethral plasma vaporization of the prostate in saline bipolar plasma vaporization of the prostate (BPVP) using the button electrode and comparing it to the standard transurethral resection of the prostate (TURP). PATIENTS AND METHODS: During the period of the year between 2007 and 2013, 152 patients with benign prostatic hyperplasia were rolled in our study. Fifty-two patients were underwent BPVP and 100 TURP. All patients were evaluated preoperatively, 24 h and at 3 months postoperatively. International Prostate Symptom Score (I-PSS), quality-of-life (QOL) score, Qmax and Qave and post void residual (PVR) urine. Operative time, hospital stay, catheterization time, and complications were reported. Mean serum Hb, hematocrit and serum sodium changes were reported preoperatively and within 24 h postoperatively in both groups. Statistical analysis is performed using SPSS program version 20 for windows. RESULTS: Mean age at surgery was 60.8 ± 8 (range 63- 92) and 66 ± 8.6 (range 50-83) for BPVP and TURP groups, respectively. Mean prostatic volume was 46 ± 11 (range 30-92) and 43 ± 8 (range 30-80) in both groups, respectively. Patients from both series had similar preoperative characteristics. The mean operative duration 53 ± 21 1 ± 2.1 (range 1-7) versus 3 ± 3.3 (range 3-8) days (P value 0.0001) were significantly (range 20-80) versus 62 ± 16 min (range 30-126) (P value 0.004), catheterization period 2 ± 0.28 ( range 2-4) versus 3 ± 3.2 (range 2-7) days (P value 0.03). CONCLUSIONS: BPVP has superior efficacy in short-term results and less complication rates compared with classic TURP.

Reconstruction of an amputated glans penis with a buccal mucosal graft: case report of a novel technique.

Penile amputation is a rare catastrophe and a serious complication of circumcision. Reconstruction of the glans penis may be indicated following amputation. Our report discusses a novel technique for reconfiguration of an amputated glans penis 1 year after a complicated circumcision. A 2-year-old male infant presented to us with glans penis amputation that had occurred during circumcision 1 year previously. The parents complained of severe meatal stenosis with disfigurement of the penis. Penis length was 3 cm. Complete penile degloving was performed. The distal part of the remaining penis was prepared by removing fibrous tissue. A buccal mucosal graft was applied to the distal part of the penis associated with meatotomy. The use of a buccal mucosal graft is a successful and simple procedure with acceptable cosmetic and functional results for late reconfiguration of the glans penis after amputation when penile size is suitable.

Role of the urethral plate characters in the success of tubularized incised plate urethroplasty.

BACKGROUND: Today, tubularized incised plate (TIP) urethroplasty is the most commonly performed operation for distal and mid-penile hypospadias. Reports from different centers worldwide confirm its nearly universal applicability and low complications rate. AIM: Evaluation of the urethral plate characters and its effect on the outcome of TIP urethroplasty. MATERIALS AND METHODS: Between 2010 and 2013, 100 children with primary distal penile hypospadias underwent TIP urethroplasty. Urethral plates were categorized as flat, cleft, and deeply grooved. Postoperatively, patients were followed-up for evaluation of meatal stenosis, fistula formation, and glandular dehiscence at 1(st), 3(rd) and 6(th) months. Patients were followed-up for urethral calibration by urethral sound 8 Fr at 3(rd) and 6 months follow-up. Data were statistically analysed using Epi info program to correlate between the width, plate shape, and complications. RESULTS: Mean age at surgery was 4.3 years. Patients were followed-up for an average period of 6.4 months. Pre-operative location of the meatus was reported as coronal in 46, subcoronal in 50 and anterior penile in 4 cases. Urethral plate characters were flat in 26 cases, cleft in 52, and deeply grooved in 22. Urethral plate width was >8 mm in 74 cases and <8 mm in 26. Patients with urethral plate <8 mm had a statistically significant higher fistula rate (P = 0.004) and failed 8 Fr calibrations in 26.9% (P = 0.01) compared with the patients with urethral plate >8 mm. In addition, we also founds higher fistula rate and failed 8 Fr calibrations in flat urethral plate. CONCLUSIONS: An adequate urethral plate width (>8 mm) is essential for successful TIP repair. Lower success rates with flat plates may need buccal mucosal augmentation to improve the results.

Testicular Biopsy Histopathology as an Indicator of Successful Restoration of Spermatogenesis after Varicocelectomy in Non-obstructive Azoospermia.

PURPOSE: We aimed to evaluate the efficacy of using testicular biopsy histopathology as an indicator of the success of loupe-assisted subinguinal varicocelectomy in non-obstructive azoospermia (NOA) patients. MATERIALS AND METHODS: In a 2-year period, a prospective study was carried at Minoufiya University Hospital on 20 NOA patients with clinical bilateral varicoceles. These patients underwent loupe-assisted subinguinal varicocelectomy with simultaneous testicular biopsy. All patients were evaluated by determining their hormonal profile and performing semen analyses and scrotal Doppler and transrectal ultrasonography. Two semen analyses showing azoospermia were performed before the surgery and two semen analyses were received at 3 and 6 months post-operatively for follow-up. RESULTS: The mean age was 29.9±6.7 years, and the mean follow-up duration was 17.3±8.3 months. We noted the restoration of spermatogenesis in six men (30% of all patients). Testicular biopsy results were as follows: hypospermatogenesis in 7 patients, maturation arrest in 3, and Sertoli cell-only syndrome in 10. The improvement in the sperm counts of these patients ranged from 3 million to 15 million/mL. Sperms were recovered in the hypospermatogenesis (6 patients, 85.5%) patients only, but other patients with testicular biopsy results of Sertoli cell-only or maturation arrest did not show any improvement in their semen parameters. CONCLUSIONS: Testicular biopsy results showed that hypospermatogenesis patients have a better chance of improvement in their semen analysis after varicocelectomy in contrast to NOA patients with Sertoli cell-only syndrome or maturation arrest.

Anuria in a 9-month-old infant resulting from ureteral cystine stones.

Pediatric urolithiasis and calcular anuria in early infancy are rare. Cystine stones may develop in utero or during early infancy. We report the case of a female 9-month-old infant with obstructive anuria resulting from cystine stones in a single functioning unit. She presented to the emergency department owing to the absence of micturition for 3 days. Radiological investigations revealed four left ureteral stones and an atrophic right kidney resulting from a calcular obstruction. Her laboratory values were as follows: serum creatinine 6.7 mg/dl, Na 132 mEq/l, K 6 mg/dl, and hematocrit 32%. An urgent percutaneous nephrostomy tube was inserted into the left side for urinary drainage, and her serum levels of creatinine and K returned to normal within 3 days. A left ureterolithotomy was the final management. Stone analysis revealed pure cystine crystals.

Polydimethylsiloxane injection versus open surgery for the treatment of vesicoureteral reflux in complete duplex systems.

PURPOSE: We compared the efficacy of subureteral polydimethylsiloxane injection (Macroplastique, Uroplasty, Inc., Minneapolis, Minnesota) versus open surgery for correction of varying degrees of reflux in complete duplex systems. MATERIALS AND METHODS: Between 1997 and 2000 polydimethylsiloxane injection was performed in 15 females (22 refluxing moieties). Mean patient age at presentation and at surgery was 54 and 94 months, respectively. Extravesical common sheath reimplantation (ECSR) was performed in 34 children (bilateral 10) with a mean age at presentation and at surgery of 31 and 57 months, respectively. Voiding cystourethrography and ultrasound were performed at 3 months. In cases of persistent reflux repeat voiding cystourethrography was performed at followup. We then analyzed the surgical outcome for both groups. RESULTS: Mean followup for the injection and ECSR groups was 12 and 15 months, respectively. The success rate per moiety after injection was 68% at 3 months, which increased to 81.8% at 12 months. One patient had contralateral vesicoureteral reflux and none had de novo hydronephrosis, urinary tract infection or complications postoperatively. The success rate of ECSR was 95.5% at 3 months, which improved to 97.7% at an average of 15 months (p <0.04). After ECSR transient contralateral vesicoureteral reflux was seen in 4 renal units, de novo hydronephrosis was seen in 2 units and 4 patients had urinary tract infections. CONCLUSIONS: Although endoscopic subureteral polydimethylsiloxane injection was simple and successful in more than 80% of patients with low grade vesicoureteral reflux in duplex systems, it is less effective than surgery with regard to elimination of reflux.

Correlation of vesicoureteral reflux with degree of hydronephrosis and the impact of antireflux surgery.

PURPOSE: We correlated the degree of hydronephrosis (HN) to the grade of vesicoureteral reflux (VUR) and assessed the impact of antireflux surgery on the resolution/persistence of HN. MATERIALS AND METHODS: Between 1997 and 2000, 308 patients (476 units) underwent antireflux surgery for primary or secondary VUR. Surgical procedures included extravesical reimplantation (291 ureters), intravesical reimplantation (48) and endoscopic polydimethylsiloxane injection (137). The degree of HN was categorized as mild (grade 1 to 2) or moderate/severe (grade 3 to 4). VUR was grade I in 44 cases, II in 145, III in 203 and IV to V in 84. Followup renal ultrasound was performed at 3 and 12 months postoperatively. Statistical analysis consisted of a contingency table and chi-square test for independence. RESULTS: Preoperative HN existed in 123 refluxing units, and was mild in 4 (9%), 11 (7.5%), 39 (19%) and 28 (33%), and moderate/severe in 0, 2 (1.4%), 14 (7%) and 25 (30%) of grade I, II, III and IV to V VUR cases, respectively. The degree of preoperative HN correlated with VUR grade (p <0.0001). At 3 months postoperatively HN resolved in 50.4%, improved in 16.3%, persisted in 30% and worsened in 3.3% of units. At 15 months postoperatively HN resolved in 80 units (65%) and persisted in 43 (35%). Patients with preoperative moderate/severe HN constituted 56% of those with persistent HN. CONCLUSIONS: Our data indicate that the presence and degree of preoperative hydronephrosis are closely related to VUR grade. Furthermore, antireflux surgery resulted in a high resolution rate of hydronephrosis. Persistent postoperative hydronephrosis did not require any intervention.