Recent advances in three-dimensional ultrasound virtual cystoscopy in modeling and local staging for urothelial carcinoma with histopathological correlation: a cohort prospective study.

Background: Bladder urothelial carcinoma is an alarming urologic malignancy. Complex factors like modelling and local staging can affect treatment strategy. However, local staging, particularly the muscle invasion status, significantly influences decisions regarding treatment strategies. Therefore, this study aims to evaluate the novel advances of three-dimensional (3D) ultrasound (US) imaging to assess local staging in comparison with conventional cystoscopy. Methods: Forty-three patients with painless haematuria and conventional cystoscopy findings of bladder mass underwent 3D US virtual cystoscopy. All specimens from conventional cystoscopy were processed histologically. Results: Out of 43 participants, 18 (41.9%) patients proved to have invasive urothelial carcinoma by histopathology. The 3D US had a sensitivity of 97.5% and a specificity of 100%; however conventional cystoscopy was accurate in only 53.5% of the studied cases. Furthermore, in the case of malignant ulcers, mural extension into both the submucosal and the muscle layers was more readily appreciated in multiplanar images. Conclusion: 3D US updates are promising for use in bladder tumour modelling and local staging; however, they can be of value in evaluating mural and extramural tumour extent and have proven accuracy.

Is quadratus lumborum block combined with low dose-spinal anesthesia an effective alternative to general anesthesia in patients undergoing percutaneous nephrolithotomy?

BACKGROUND: General anesthesia in high-risk patients has many complications and needs long preoperative preparations and postoperative intensive care unit (ICU). Therefore the present study aimed to evaluate the efficacy of combined low-dose spinal anesthesia with quadratus lumborum block (QLB) as an alternative to general anesthesia for patients undergoing percutaneous nephrolithotomy. PATIENTS AND METHODS: A prospective study was conducted at the urology department of Al-Azhar University Hospitals in Cairo, Egypt, from January 2021 to January 2022. The study included 60 patients of ASA ll-lll scheduled for percutaneous nephrolithotomy. All patients received low-dose spinal anesthesia (5 mg bupivacaine) and QLB (QL1-QL2-QL3) approaches. The primary observation parameter was the efficacy of this technique as an alternative to general anesthesia. The secondary parameters measured were evaluation of need for intraoperative narcotics, postoperative pain score (VAS), and patients satisfaction as assessed using a 5-point Likert Scale. RESULTS: None of the patients was given general anesthesia, and intraoperative sedation was given to nineteen patients (32.2%). No hemodynamic changes were observed in all patients. There was a significant correlation between the use of intraoperative sedation and stone site, intraoperative blood loss, and hospital stay. Pain intensity on VAS at rest and movement was low until the 24th postoperative hour. Patient satisfaction score was 3, 4, and 5 in 1 (1.7%), 4 (6.7%), and 55 (91.6%) patients, respectively. CONCLUSIONS: Combined low-dose spinal anesthesia with quadratus lumborum block is an effective alternative to general anesthesia in patients undergoing PCNL procedures with good postoperative analgesia. Patients with lower calyceal punctures have a lower incidence of intraoperative sedation requirements.

Safety and efficacy of percutaneous nephrolithotripsy in comorbid patients: A 3 years prospective observational study.

PURPOSE: To report the result of percutaneous nephrolithotripsy (PCNL) via standard nephrostomy tract in a single training institution. The perioperative complications in relation to the comorbid state are particularly assessed. PATIENTS AND METHODS: A prospective interventional study between January 2019 to November 2022, included 210 patients scheduled for PCNL. The average age was 40.3 ± 11.8 years (range 18- 67 years). Patients were categorized into two groups. The first group comprised 146 cases (69 .5%) with no associated co-morbidities while the second group 64 (30.5%) had co-morbidities such as obesity in 4 cases (1.9%), hypertension (HTN) in 24 cases (11.4%) cases, diabetes mellitus (DM) in 17 (8.1%) cases, history of recurrent stone surgery in 11 (5.2%) cases and more than one in 8 cases (3.8%). Co-morbidities, stone burden, location of stone, time of surgery, stay in the hospital, further operations, and negative events were among the reported data. Complications and the stone-free rate were the main outcome indicators. RESULTS: Intraoperative complications were reported in 40 (18.8%) patients (18 group 1 and 22 group 2) during PCNL. Bleeding occurred in 22 (10.5%) patients (9 group 1 and 13 group 2), blood transfusions were needed in 4 (1.9%) (2 group 1 and 2 group 2), extravasation was observed in 11 patients (5.2%) (6 group 1 and 5 group 2) and cardiac arrhythmia in 3 (1.4%) (1 group 1 and 2 group 2) patients. Postoperative complications occurred in 61 patients (29%) (24 group 1 and 37 group 2) in the form of fever in 10 patients (4.8 %) (3 group 1 and 7 group 2) and prolonged leakage in 50 patients (23.8%) (21 group 1 and 29 group 2). One patient of group 2 died from postoperative sepsis. Extravasation and postoperative leakage were higher in diabetic patients than in non-diabetics. Stonefree rate was 60.5% (127 of 210). Clinically significant residual fragments (CSRFs) found in 70 cases (33.3%) (33 group 1 and 37 group 2). In 13 cases (6.2%) (5 group 1 and 8 group 2), clinically insignificant residual fragments (CIRFs) were found. In 8 (3 group 1 and 5 group 2) of the 13 cases, spontaneous stone passage was observed within 4-6 weeks of surgery. Residual stones in three cases (1 group 1 and 2 group 2) were asymptomatic and 4 mm or less, whereas stones increased in two cases of group 2. Among all factors studied, stone burden was significantly correlated to both intraoperative and postoperative complications. The occurrence of postoperative fever increased with large stone burden. CONCLUSIONS: PCNL is a therapeutic modality that is effective, feasible, and safe for a wide range of patients with concurrent medical issues. A steep curve is required to reduce intraoperative and postoperative complications.

Erectile function after different techniques of bulbar urethroplasty: does urethral transection make a difference?

PURPOSE: We aimed to compare the impact of urethral transection after different techniques of bulbar urethroplasty on erectile function outcome. MATERIALS AND METHODS: We retrospectively reviewed the records for 245 patients who underwent different urethroplasty techniques for bulbar urethral stricture between February 2013 and January 2021. The comparison between the transecting and non-transecting cohorts included patients' demographics, clinicopathological features of the urethral stricture, post-urethroplasty erectile function, and success of urethroplasty. Outcomes were erectile function status verified by IIEF5-15 score at preoperative, three months, and 12 months post-surgery. We defined Post-urethroplasty ED as a decrease of 5 points or more. RESULTS: The urethroplasty success rate of the entire cohort was 86.9% after a mean follow-up of 45.59 ± 21 months. Out of 245 patients, 18 (7.3%) experienced 90-day complications. Transecting bulbar urethroplasty techniques were performed in 74 patients (30.2%), while non-transecting techniques were performed in 171 patients (69.8%). there were no differences between the cohorts regarding urethroplasty success (87.8% Vs. 86.5%, Mantel-Cox test p = 0.93) or postoperative complications (8.1% Vs. 7%, p = 0.73). Transient ED was evident in the transecting cohort as reported in 8.1% compared to 2.9% for the non-transecting (p = 0.07).Still, but de novo permanent ED was comparable (4.1% Vs. 2.9%, p = 0.65), for transecting and non-transecting, respectively. CONCLUSIONS: Unfortunately, some patients who undergo transecting techniques of bulbar urethroplasty experience transient erectile dysfunction that can improve within the first post- urethroplasty year; however, de novo permanent erectile dysfunction is uncommon after different techniques of bulbar urethroplasty and is not predisposed by urethral transection.

Evaluation of Rezum therapy as a minimally invasive modality for management of Benign Prostatic Hyperplasia: A prospective observational study.

OBJECTIVE: To evaluate safety and efficacy of Rezum therapy as a minimally invasive modality for management of benign prostatic hyperplasia in patients with prostate volume < 80cc and those with prostate volume > 80cc. METHODS: Between June 2020 and February 2023, A total of 98 patients diagnosed with BPH and managed by Rezum were included in this study. Patients were divided based on their prostate volume of either less than 80 cc or greater than 80 cc. We evaluated several parameters related to their condition, including prostate volume, post-voiding residual (PVR) before and after surgery, number of treatments received, maximum urine flow rate (Qmax) before and after surgery and mean follow- up periods. RESULTS: The mean age was 68 years (SD 11.2). The median prostatic volume was 62 cc (IQR 41, 17). A maximum of 9 treatments were administered. Six months was determined to be the average post-operative follow-up period (IQR: 3.5-7.2). The mean preoperative total PSA was 2.7 (IQR 1, 2), preoperative mean PVR was 79.8 cm3, preoperative mean Qmax was 8.2 ml/s (IQR 4.7-10.5), and median post-operative days until catheter removal was four days (IQR 3,1). Post-operative PVR was 24.7 cm3 (IQR 18.2, 29.4) and the mean post-operative Qmax was 18.3 ml/s (SD 6.3). Qmax levels significantly increased, by an average of 8.2 ml/s (SD 7.13) (p < 0.001). Similarly, a decrease of average PVR of 97.28 cm3 (SD 95.85) (p < 0.001) was detected, which is a substantial reduction. Between prostates less 80cc and those over 80cc, there were no appreciable differences in Qmax or PVR (p-values: 0.435 and 0.431, respectively). CONCLUSIONS: From our study, we conclude that Rezum water vapor thermal therapy, as a minimally invasive modality, is an effective and safe surgical option for management of benign prostatic hyperplasia of men with moderate to severe lower urinary tract symptoms (LUTS). This procedure has been shown to be effective in patients with varying larger prostate volumes.

Is scoring system of computed tomography based metric parameters can accurately predicts shock wave lithotripsy stone-free rates and aid in the development of treatment strategies?

OBJECTIVE: The objective was to determine the predicting success of shock wave lithotripsy (SWL) using a combination of computed tomography based metric parameters to improve the treatment plan. PATIENTS AND METHODS: Consecutive 180 patients with symptomatic upper urinary tract calculi 20 mm or less were enrolled in our study underwent extracorporeal SWL were divided into two main groups, according to the stone size, Group A (92 patients with stone ≤10 mm) and Group B (88 patients with stone >10 mm). Both groups were evaluated, according to the skin to stone distance (SSD) and Hounsfield units (≤500, 500-1000 and >1000 HU). RESULTS: Both groups were comparable in baseline data and stone characteristics. About 92.3% of Group A rendered stone-free, whereas 77.2% were stone-free in Group B (P = 0.001). Furthermore, in both group SWL success rates was a significantly higher for stones with lower attenuation <830 HU than with stones >830 HU (P < 0.034). SSD were statistically differences in SWL outcome (P < 0.02). Simultaneous consideration of three parameters stone size, stone attenuation value, and SSD; we found that stone-free rate (SFR) was 100% for stone attenuation value <830 HU for stone <10 mm or >10 mm but total number SWL sessions and shock waves required for the larger stone group were higher than in the smaller group (P < 0.01). Furthermore, SFR was 83.3% and 37.5% for stone <10 mm, mean HU >830, SSD 90 mm and SSD >120 mm, respectively. On the other hand, SFR was 52.6% and 28.57% for stone >10 mm, mean HU >830, SSD <90 mm and SSD >120 mm, respectively. CONCLUSION: Stone size, stone density (HU), and SSD is simple to calculate and can be reported by radiologists to applying combined score help to augment predictive power of SWL, reduce cost, and improving of treatment strategies.

Ultrasound-guided percutaneous sclerotherapy of simple renal cysts with n-butyl cyanoacrylate and iodized oil mixture as an outpatient procedure.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of ultrasound guided percutaneous sclerotherapy of symptomatic simple renal cysts with n-butyl cyanoacrylate (NBCA) and iodized oil mixture as an outpatient single session procedure. MATERIALS AND METHODS: A total of ninety two patients with 100 symptomatic simple renal cysts (larger than 5 cm) were treated by ultrasound (US)-guided percutaneous aspiration and injection of NBCA and iodized oil mixture. The patients (68 men and 24 women, mean age, 42.4 ± 10.5 years) were treated with as out-patients. The volume of the treated cysts was calculated with periodic noncontrast enhanced CT examinations 3, 6 and 9, months after the procedure. The procedure was considered successful at follow-up CT when there was total ablation or greater than 80% reduction of size with resolution of symptoms, respectively. Failure was defined as less than 80% reduction and/or persistent symptoms. RESULTS: The sclerotherapy was technically successful in all patients. The diameter of the cysts ranged between 5.5 and 13.5 cm (mean, 8.8 ± 1.4 cm), and 1.5 and 3.8 cm (mean, 2.1 ± 0.4 cm) before and after sclerotherapy, respectively (P < 0.001). Average diameter reduction was 83.7% during the follow-up period. The mean follow- up lasted 7.1 months (3-11 months). Flank pain resolved in 86 of 92 symptomatic patients (93.48%). In six patients, the symptoms decreased slightly. The procedure was successful in 98 of 100 cysts (98%), demonstrated by follow-up CT. The only two failed cyst was larger than 10 cm in diameter and don't required any further treatment. We did not observe any procedure related complications. CONCLUSION: Ultrasound guided percutaneous sclerotherapy with NBCA and iodized oil mixture for management of symptomatic simple renal cysts was found to be a real time, effective, safe, well tolerated, alternative and simple technique that can be carried out by urologists as an outpatient procedure.

Is unilateral transversus abdominis plane block an analgesic alternative for ureteric shock wave lithotripsy?

BACKGROUND: Various sedative and analgesic techniques have been used during shock wave lithotripsy (SWL). AIM: This study aimed at evaluating the efficacy of ultrasound-guided unilateral transversus abdominis plane (TAP) block as an analgesic technique alternative during ureteric SWL. SETTINGS AND DESIGN: Prospective randomized comparative study. MATERIALS AND METHODS: Fifty patients scheduled for ureteric SWL were randomly allocated into two equal groups: Group (F) received 1.5 mcg/kg fentanyl intravenous and group (T) received unilateral TAP block with injection of 25 ml of bupivacaine 0.25% (62.5 mg). STATISTICAL ANALYSIS: Statistical analysis was performed using SPSS program version 19 and EP16 program. RESULTS: The visual analog scale was significantly less in group (T) than in group (F) both intra-operatively (at 10, 20, 30, and 40 min) and postoperatively (at 10 min intervals in the postanesthesia care unit [PACU]) (P < 0.001). Rescue analgesia with pethidine during the procedure and in the PACU was less (P < 0.001) in the group (T) than group (F) with a median of 20 mg versus 55 mg, respectively. The higher sedation scores observed in group (F) at 15, 25, and 35 min during the procedure, and at 20 min during the PACU time were statistically highly significant (P < 0.001), but only significant at 10 min (P = 0.03) and 30 min (P = 0.007) during the PACU time. There was also highly significant decrease (P < 0.001) in the time of PACU stay in group (T) (38.2 ± 6.6 min) compared with group (F) (89.2 ± 13.39 min). We recorded 6 patients in group (F) (24%) who have developed respiratory depression (respiratory rate < 10 breaths/min) compared to 0% in group (T) (P = 0.022). In addition, in group (F) nausea was noted in 8 patients (32%) and vomiting in 6 patients (24%), which was statistically significant when compared to group (T) (0%) (P = 0.01 and 0.022, respectively). CONCLUSION: Ultrasound-guided unilateral TAP block is an effective alternative analgesic technique during ureteric SWL.

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.