Early versus delayed penile prosthesis insertion for refractory ischemic priapism.

Objectives: Penile prosthesis insertion is a well-established therapeutic option in refractory ischemic priapism but there is a lack of standardization regarding the timing of surgery, the type of prosthesis (malleable or inflatable), as well as the possible complications. In this study, we retrospectively compared early versus delayed penile prosthesis insertion in patients with refractory ischemic priapism. Methods: 42 male patients who presented with refractory ischemic priapism during the period between January 2019 and January 2022 were included in this study. All patients had malleable penile prosthesis insertion by four highly experienced consultants. Patients were divided into two groups based on the time of the prosthesis insertion. 23 patients had immediate insertion of the prosthesis within the first week of the onset of priapism while the remaining 19 patients had delayed prosthesis insertion three months or later after the onset of priapism. The outcome as well as the intra- and the postoperative complications were recorded. Results: Postoperative complications such as prosthesis erosion and infection were higher among the early insertion group while the delayed insertion group had higher incidence of intraoperative complications such as corporal perforation and urethral injury. The insertion of the prosthesis was much more difficult among the delayed insertion group due to fibrosis which made dilatation of the corpora very difficult. The length and the width of the penile implant were significantly higher among the early insertion group as compared to the delayed insertion group. Conclusions: Early penile prosthesis insertion for refractory ischemic priapism is a safe and effective treatment option as delayed prosthesis insertion is more difficult and challenging due to corporal fibrosis and is associated with higher complication.

Thulium laser en bloc resection versus conventional transurethral resection of urinary bladder tumor: A comparative prospective study.

Background: Transurethral resection of bladder tumors (TURBT) is the standard management for urinary bladder tumors; however, new techniques as Thulium laser en bloc resection of bladder tumors (TmLRBT) have been introduced as a substitute to TURBT. Objectives: In this study safety, efficacy, and tumor recurrence after TmLRBT and TURBT were prospectively compared in patients with primary (<4 cm) bladder tumors. Patients and Methods: Between August 2019 and May 2021, patients with primary (<4 cm) bladder tumors were enrolled. Patients were randomized between the two procedures. All perioperative data were collected prospectively. Pathological specimen findings and recurrence rates were reported during follow-up visits. Results: Sixty patients underwent TURBT, and another 60 had TmLRBT. No significant differences were detected in patient demographics or preoperative tumor characteristics between the two groups. Operation time was less (28.2 vs. 38.9 min, P < 0.001), and rate of bladder perforation was lower with TmLRBT compared to TURBT (3.3% vs. 15.0%, P = 0.027). In the TmLRBT group, higher rate of muscle detection (95.0% vs. 78.3%, P < 0.001) in the pathological specimen, and lower rate of tissue destruction (0.0% vs. 21.6%, P < 0.001) were obtained compared to TURBT. Recurrence rate in cases of nonmuscle invasive bladder cancer was lower with TmLRBT (6.7% vs. 33.0%, P < 0.001). Conclusion: In this study, TmLRBT showed reduced operative time with lower perforation rates. Higher detection of detrusor muscle and less tissue destruction in the pathological specimen were obtained with TmLRBT, as well as lower rates of tumor recurrence. These findings suggest that TmLRBT is a safe and efficacious substitute to TURBT in tumors <4 cm.

Ultrasound-guided trans-incisional quadratus lumborum block versus ultrasound-guided caudal analgesia in pediatric open renal surgery: a randomized trial.

BACKGROUND: The caudal route is a common approach for postoperative analgesia; however, it is associated with limited duration of action. The quadratus lumborum block (QLB) may produce prolonged postoperative analgesia. Therefore, this study aimed to compare the postoperative analgesic efficacy of the ultrasound-guided caudal block with that of the ultrasound-guided transincisional QLB (TiQLB) in pediatric patients undergoing open renal surgery. METHODS: Forty patients of both sexes, aged 2-11 years, were randomly assigned to receive either caudal analgesia with 1.25 ml/kg of bupivacaine 0.2% (Caudal group; n = 20) or a QLB with 0.5 ml/kg of bupivacaine 0.2% (TiQLB group; n = 20) in addition to standard general anesthesia. Time to first analgesia was the primary outcome. Total analgesic consumption in the first 24 h postoperatively, pain scores, and the incidence of side effects were the secondary outcomes. RESULTS: The mean time to first analgesic requirement was significantly longer in the TiQLB group than in the Caudal group (18.8 ± 5.1 vs. 6.7 ± 0.7 h, P < 0.001). Total ketorolac consumption and pain scores were significantly lower in the TiQLB group (P < 0.001). A few cases of mild postoperative nausea and vomiting were noted among patients in both groups; however, the difference was not statistically significant. No incidence of pruritus, shivering, or respiratory depression was noted. CONCLUSIONS: Analgesia after the ultrasound-guided TiQLB with bupivacaine was superior to that after the ultrasound-guided caudal block, with similar side effects.

Efficacy and safety of low-intensity extracorporeal shock wave therapy versus on-demand tadalafil for erectile dysfunction.

Objective: To compare outcomes of low-intensity extracorporeal shock wave therapy (LIESWT) versus 20 mg of Tadalafil in Erectile dysfunction (ED) patients. Materials and Methods: We performed a prospective study of 51 men with ED. Twenty-five were in the LIESWT group and 26 in the Tadalafil group. Patients in the LIESWT group received 6 sessions (2 per week) with an average of 6,000 shocks per session with the PiezoWave2 unit. Other patients self-administered Tadalafil on demand. The outcomes were assessed using the International Index of Erectile Function (IIEF-5) score, Erection Hardness Score (EHS) and Self-Esteem And Relationship (SEAR) questionnaire before, at 6 and 12 weeks after treatment. Treatment-related side effects and costs were recorded too. Results: The mean age in the LIESWT group was 43.7 years old, and in the Tadalafil group was 47 years old. After the 6 and 12-week follow-ups, both groups showed significant improvement when comparing the baseline values to the follow-up variables for all IIEF-5, EHS, and SEAR (P < 0.05). There was a notable statistical difference between the two groups regarding the side effects, as the shockwave group was with mild side effects (8%), while the Tadalafil group (44%) of patients had side effects (p < 0.05). This cost difference is statistically significant (p < 0.001). LIESWT is more costly compared to Tadalafil. Conclusion: LIESWT has a comparable short-term therapeutic efficacy with higher safety outcomes than on-demand 20 mg of Tadalafil for ED patients.

Dexmedetomidine Added to Bupivacaine versus Bupivacaine in Transincisional Ultrasound-Guided Quadratus Lumborum Block in Open Renal Surgeries: A Randomized Trial.

BACKGROUND: General anesthesia (GA) is the preferred anesthetic modality for open renal surgeries to ensure a patent airway while the patient is in the lateral decubitus position. However, these surgeries are usually accompanied by severe postoperative pain with increased requirements for multimodal pain management strategies. Regional blocks provide better postoperative pain control with less systemic opioid consumption. OBJECTIVES: The aim of this study was to describe the ultrasound (US)-guided transincisional quadratus lumborum block (TiQLB) as a new approach, and to compare the addition of dexmedetomidine to bupivacaine versus bupivacaine alone for TiQLB in combination with GA regarding postoperative analgesia and adverse effects in open renal surgery. STUDY DESIGN: A prospective, randomized, double-blind, controlled trial. SETTING: Ain Shams University Hospitals. METHODS: Eighty patients who were scheduled for an elective open renal surgery, aged 20 to 65 years, of either gender, and American Society of Anesthesiologists physical status I to II were enrolled in the study. They were randomly allocated into 2 equal groups: group dexmedetomidine-bupivacaine (DB) (n = 40) in which patients received combined GA plus TiQLB with 30 mL bupivacaine 0.25% plus 1 mu g/kg dexmedetomidine, and group bupivacaine (B) (n = 40) in which patients received combined GA plus TiQLB with 30 mL bupivacaine 0.25% only. The primary outcome was the total morphine consumption among both groups, whereas the secondary outcomes were the Visual Analog Scale (VAS) scores and the time to first analgesic requirement during the first 24 hours. Postoperative side effects, such as sedation, nausea, vomiting, shivering, pruritus, bradycardia, hypotension, and respiratory depression, were also recorded. RESULTS: Patients in the DB group experienced lower total morphine consumption and lower VAS scores when compared with patients in the B group (P < 0.001). Time to first analgesic requirement was prolonged in patients in the DB group (18.6 ± 2.4 hours) in comparison to patients in the B group (7.3 ± 1.1 hours). Ten minutes after the block there was a significant reduction in mean blood pressure and heart rate in the DB group than in the B group. Regarding postoperative adverse effects, sedation scores were higher in the DB group than in the B group, postoperative nausea, vomiting, and shivering were significantly higher in the B group than in the DB group. Bradycardia was significantly more frequent among the DB group. Although nonsignificant, pruritus was more frequent in the B group than in the DB group. No cases of respiratory depression were reported in both groups. LIMITATIONS: The used technique US-guided TiQLB could be performed in open renal surgeries only. CONCLUSIONS: The new approach US-guided TiQLB was effective and easy to be performed. Adding dexmedetomidine to bupivacaine in TiQLB was associated with potent and prolonged postoperative analgesia with fewer postoperative adverse effects. KEY WORDS: Quadratus lumborum block, dexmedetomidine, open renal surgery, postoperative pain, bupivacaine.

The safety of ureteral stenting with the use of potassium citrate for management of renal uric acid stones.

OBJECTIVES: The objective is to evaluate the relative risks of ureteric stents application while managing uric acid stones with potassium citrate in terms of stone encrustations and urinary tract infection (UTI). PATIENTS AND METHODS: We prospectively enrolled patients with renal uric acid stones who received K citrate from 2013 to 2018. Patient's demographics were collected. All patients were evaluated using noncontrast computed tomography (CT) scan to measure the stone size and density. JJ ureteric stent was inserted prior to the initiation of treatment. At follow-up, all patients underwent urine analysis for pH and to detect UTI. CT was repeated at 1 month and those patients who showed incomplete stone resolution underwent another course of treatment for another month. CT was repeated prior to stent removal. The presence of encrustations was inspected and collected. RESULTS: We collected 59 patients with a median age of 36 years (18-73) and median stone burden of 26 mm3 (15-50). The median stone density was 310 HU (175-498). Twenty-one patients (35.6%) received K citrate treatment for 1-month, while the remaining patients had 2 months treatment. Sixteen patients (27.1%) had a complete stone dissolution, 41 patients (69.5%) had more than 50% decrease of stone burden while only 2 patients (3.4%) had stones with poor dissolution. Four patients (6.8%) experienced UTI while 2 patients (3.4%) had visible JJ encrustations. Most of these complications occurred when the treatment was offered for the 2nd month. CONCLUSION: Short-term use of ureteral stents is safe during the management of uric acid stones with K citrate.

Oral dissolution therapy for renal radiolucent stones, outcome, and factors affecting response: A prospective study.

BACKGROUND: Urolithiasis is a widespread problem, that affects up to 10% of population. Uric acid stones come second to calcium stones in prevalence (around 10% of urolithiasis). Potassium citrate is currently the treatment of choice for urine alkalization with minimal side effects and high tolerability. AIMS AND OBJECTIVES: This study is trying to present the outcome of oral dissolution therapy (ODT) for treating radiolucent renal stones and evaluating factors affecting its success in a prospective manner. MATERIALS AND METHODS: Between 2015 and 2018, 147 patients with solitary radiolucent renal stones were offered ODT using potassium sodium hydrogen citrate (K citrate). The study included patients diagnosed by noncontrast computed tomography (NCCT) with stone size of 5-30 mm in the longest dimension and attenuation less than 600 Hounsfield units (HU). Patient compliance, blood pressure, creatinine level, K level, and tolerance to side effects were followed up at days 3, 7, and 15 and then monthly for 3 months. Follow-up renal ultrasound at 6-week intervals and a final NCCT at the end of treatment. Successful dissolution was defined as complete stone dissolution or residual that measures up to 2 mm in maximum length. Data were collected, tabulated, and analyzed using Stata 12.0 software (Stata Corporation, College Station, TX, USA). RESULTS: One hundred and thirty-nine patients were included in the analyses. The age was 45.1 ± 10.5 years. DJ stent was used in 47 (33.8%) patients. Overall response rate was 64.8%. The stone location within the kidney (pelvic or calyceal) showed no difference between responders and non-responders. Stone longest diameter was smaller in responders (17 ± 5.7 mm) versus 19.2 ± 6.1 mm in nonresponders (P value = 0.039). The mean stone attenuation value (HU) was also lower in responders (347.4 ± 68.5 HU) versus (428.9 ± 84.0 HU) in nonresponders with P < 0.001. DJ insertions seemed to have marginal effect on stone dissolution on univariate analysis but found insignificant in multivariate analysis. CONCLUSION: ODT is safe and effective in the treatment of radiolucent renal stones. The efficacy was affected by stone density and stone size with more tendencies to failure with bigger stones and denser stones. Double J stent insertion may facilitate dissolution rate. There was no effect of the baseline urinarypH, hyperuricemia, or stone location on the dissolution rate of the stones.

Outcome of staged buccal mucosal graft for repair of long segment anterior urethral stricture.

BACKGROUND: Long anterior urethral stricture due to variable etiological factors constitutes a challenge for reconstruction. We evaluated our centers experience with cases of long anterior urethral stricture due to different etiologies that were managed by 2-stage substitution urethroplasty using buccal mucosal graft procedure. METHODS: During the period between November 2009 and November 2016. All cases with long anterior urethral stricture that were planned for substitution urethroplasty in our department were enrolled in this study. The first stage was excision of most fibrotic areas of the urethral plate, the remaining of the urethra is laid open and augmented with buccal mucosal graft for second stage closure after 6-9 months. RESULTS: The study included 123 patients who underwent first stage, 105 patients of them underwent second stage urethroplasty. Eighteen cases were missed after first stage. The mean (range) age was 38.4 (17-60 years). The mean (range) stricture length was 8.3 (4-13 cm). The cause of stricture was idiopathic in 47, inflammatory in 15, lichen sclerosus in 26 and post failed hypospadias repair in 35 patients. First stage was complicated by graft contracture in 11 (8.9%) patients that needed re-grafting, 5(4.1%) patient had bleeding from the buccal mucosa site that needed haemostatic sutures, oral numbness was reported in 7 (5.7%) patients. Second stage was complicated by wound dehiscence in 2(1.9%) patients, restricture in 11 (10.5%), fistula in 6 (5.7%) patients, meatal stenosis in 3 (2.9%). The overall success rate was 79.1% (83 cases out of 105) with a mean (range) follow-up of 34.7 (10-58 months). CONCLUSIONS: Staged urethroplasty using buccal mucosal graft procedure is an effective surgical option for patients with long anterior urethral strictures especially for patients with lichen sclerosus and those with failed previous surgical repair.

ß-catenin and SKP2 proteins as predictors of grade and stage of non-muscle invasive urothelial bladder carcinoma.

BACKGROUND: To evaluate the expression of beta-catenin (ß-catenin) and SKP2 proteins in superficial bladder cancer cases and their correlation with tumor grade and stage. METHODS: After institutional review board approval, we retrospectively evaluated the expression of ß-catenin and SKP2 proteins in tissue specimens from patients with non-muscle invasive bladder cancer (NMIBC) and compared their results with a cohort of chronic nonspecific cystitis's. Then we and explored these markers association with tumor grade and stage. RESULTS: A total of 40 patients were retrospectively identified, 50% was NMIBC and the rest were chronic nonspecific cystitis. ß-catenin was expressed in 18 (90%) patients of the NMIBC group in comparison to 14 (70%) of the control group with (P=0.1), while SKP2 protein was only expressed in NMIBC groups (P=0.03). A statistically significant correlation was identified between nucleocytoplasmic localization of ß-catenin and SKP2 with tumor grade, stage. CONCLUSIONS: ß-catenin and SKP2 expression are providing promising results for differentiating higher grade and stage non muscle invasive bladder cancers.

More Favorable Pathological Outcomes in Men with Low Risk Prostate Cancer Diagnosed on Repeat versus Initial Transrectal Ultrasound Guided Prostate Biopsy.

PURPOSE: We assessed the pathological outcomes after radical prostatectomy in men with favorable risk prostate cancer diagnosed on first/initial biopsy compared to those of men who were diagnosed on a subsequent/repeat prostate biopsy. MATERIALS AND METHODS: We identified 422 patients who met National Comprehensive Cancer Network® very low (199) and low risk (223) prostate cancer definitions who instead underwent radical prostatectomy. In each risk category we compared adverse pathological outcomes, defined as Gleason score upgrading, extraprostatic extension, seminal vesicle invasion and positive surgical margins, between men diagnosed on initial prostate biopsy vs repeat/subsequent prostate biopsy after a negative biopsy(-ies). RESULTS: There were no significant differences in the baseline clinical and demographic characteristics between the groups. However, men who were diagnosed on initial prostate biopsy demonstrated a higher median maximum cancer percent per single core (p <0.001) and higher median percent of positive cores (p <0.001). Compared to repeat/subsequent prostate biopsy, men diagnosed on initial prostate biopsy had a higher Gleason score upgrade (7 or greater) (57.7% vs 42.1%, p=0.005) and extraprostatic extension (14.1% vs 5.4%, p=0.01). On stratified analysis comparing initial prostate biopsy to repeat/subsequent prostate biopsy, very low risk disease was associated with Gleason score upgrade (49.3% vs 31.8%, p=0.02) and low risk disease demonstrated higher rates of extraprostatic extension (19.9% vs 6.0%, p=0.02). CONCLUSIONS: The likelihood of adverse pathological outcomes at radical prostatectomy is lower in men diagnosed with favorable risk prostate cancer on repeat/subsequent prostate biopsy than in men diagnosed on initial prostate biopsy, and may represent an important consideration in risk stratifying cases of favorable risk prostate cancer.