A multicentric and nationwide predictive study role of T cell sub-population in the prevalence and prognosis of cryoglobulinemia among genotype 4 chronic hepatitis C patients.

The infection caused by the hepatitis C virus (HCV) is a significant global health concern. The prevailing genotype of HCV in Egypt is 4a, commonly referred to as GT-4a. A significant proportion exceeding 50% of patients infected with HCV experience extrahepatic manifestations (EHMs), encompassing a diverse range of clinical presentations. These manifestations, including essential mixed cryoglobulinemia (MC), can serve as initial and solitary indicators of the disease. The complete understanding of the pathogenesis of EHM remains unclear, with autoimmune phenomena being recognized as the primary causative factor. In this study, we examined the predictive significance of T-cell subpopulations in relation to the occurrence and prognosis of cryoglobulinemia in HCV patients. A total of 450 CHC genotype four treatment naïve patients were enrolled in this analytic cross-sectional study after thorough clinical, laboratory, and radiological examinations. All patients underwent laboratory investigations, including testing for cryoglobulin antibodies and measurements of CD4 and CD8 levels; two groups were described according to their test results: Group 1 consists of patients who have tested positive for cryoglobulin antibodies and Group 2 consists of patients who have tested negative for cryoglobulin antibodies. The exclusion criteria encompassed individuals with HIV infection or chronic HBV infection. Additionally, pelvi-abdominal ultrasonography was performed. Our study included 450 treatment naïve CHC patients (59% male, mean age 50.8 years). The patients were categorized according to their cryoglobulin antibodys test results into two groups: group A, CHC patients with cryoglobulin antibodies (Abs) negative (364 patients), and group B, CHC patients with cryoglobulin Ab positive (86 patients). Group B demonstrated a higher average age, elevated international normalized ratio, more prolonged duration of HCV infection, lower albumin, higher alanine aminotransferase, higher aspartate aminotransferase, higher bilirubin, lower CD8, lower CD4, and lower CD4:CD8 ratio. In contrast, 27 out of 86 (31.40%) patients in group B had symptoms; 85.8% had purpura and arthralgia, 74.3% had paresthesias, 86.7% had weakness, and 12.2% had non-Hodgkin's lymphoma. The levels of CD4 and CD8 were found to be decreased in chronic HCV patients with MC. T-cell subpopulation serves as a reliable indicator for assessing the prevalence and prognosis of MC in individuals with genotype 4 chronic hepatitis C. However, additional research is needed to further understand the development and spread of various emerging infectious diseases. Nevertheless, it is noteworthy that a critical threshold may exist beyond which EHM reaches a point of no return.

Long-term Outcome of Yang-Monti Ileal Replacement of the Ureter: A Technique Suitable for Mild, Moderate Loss of Kidney Function and Solitary Kidney.

OBJECTIVE: To present long-term outcome of Yang-Monti ileal ureter, with a focus on patients with mild/moderate loss of kidney function and solitary kidney. PATIENTS AND METHODS: Between March 2001 and December 2019, Yang-Monti ileal ureter was performed on 36 patients with ureteric defects and median age 46.5 years. Of these, 4, 14, 15 and 3 patients had stage 1, stage 2, stage 3a and stage 4a chronic kidney disease, respectively; 6 had solitary kidney. Patients were regularly followed for complications, morphological, and functional outcome. RESULTS: Ureteric stricture etiology was iatrogenic (16), Bilharzial (7), tuberculous (4), retroperitoneal fibrosis (5), malignancy (3), and gunshot injury (1). The median (range) ureteric defect length was 11 (8-16) cm. Four grade 1/2 postoperative Clavien-Dindo complications were noted. Median follow-up was 68 months (range 12-215). Intestinal obstruction developed in 1 patient and urinary tract infection in 10. At last follow-up, serum creatinine, split renographic clearance, and estimated glomerular filtration rate showed significant improvement compared to preoperative values, in the whole series, in cases with chronic kidney disease (stages 2, 3a and 3b) and solitary kidney. Four cases with chronic kidney disease (stage 3) showed deterioration of the kidney function parameters. Magnetic resonance urography showed improvement of hydronephrosis in most patients. No metabolic complications were noted. CONCLUSION: Yang-Monti Ileal ureter is durable and effective in improving kidney function with few complications. It can be safely used in cases of mild/moderate kidney function loss and solitary kidney. A threshold eGFR <40 mL/min/1.73 m2 is considered relative contraindication.

Effect of Early Oxybutynin Treatment on Posterior Urethral Valve Outcomes in Infants: A Randomized Controlled Trial.

PURPOSE: We studied the effect of oxybutynin on bladder and upper urinary tract outcomes in infants following posterior urethral valve ablation. MATERIALS AND METHODS: Patients younger than 12 months old who had undergone primary endoscopic valve ablation for posterior urethral valves were screened for eligibility. Patients who had undergone urinary diversion or had other conditions that could affect lower urinary tract function were excluded. Study patients were randomized to either oxybutynin (0.2 mg/kg 3 times daily) until toilet training or active observation. The study end points were serum creatinine, estimated glomerular filtration rate, hydronephrosis improvement, vesicoureteral reflux resolution, febrile urinary tract infection and toilet training. RESULTS: A total of 49 infants (24 receiving oxybutynin and 25 undergoing observation) were enrolled between December 2013 and September 2015 and completed at least 1 year of followup. Oxybutynin was discontinued before toilet training in 5 patients due to facial flushing in 2, bladder and upper tract dilatation in 2, and cognitive changes in 1. After a median followup of 44.2 months (range 12 to 57.6) median serum creatinine and estimated glomerular filtration rate were not significantly different between the groups (p=0.823 and p=0.722, respectively). Renal units in the oxybutynin group had a greater likelihood of hydronephrosis improvement (61.9% vs 34.8%, p=0.011) and resolution of vesicoureteral reflux (62.5% vs 25%, p=0.023). Febrile urinary tract infection (29.2% vs 40%, p=0.404), completion of toilet training (70.8% vs 76%, p=0.748) and age at toilet training (p=0.247) did not differ significantly between the oxybutynin and observation groups. CONCLUSIONS: Oxybutynin enhances hydronephrosis improvement and vesicoureteral reflux resolution following primary endoscopic valve ablation in infants but periodic monitoring is warranted.

The value of immediate postoperative intravesical epirubicin instillation as an adjunct to standard adjuvant treatment in intermediate and high-risk non-muscle-invasive bladder cancer: A preliminary results of randomized controlled trial.

PURPOSE: We aimed at this study to test the value of immediate postoperative intravesical epirubicin instillation in intermediate and high-risk non-muscle-invasive bladder cancer patients. MATERIALS AND METHODS: After approval of Institutional Review Board, 260 patients were randomly allocated into 2 groups, including transurethral resection of bladder tumor (TURBT) alone in control group and TURBT plus immediate postoperative epirubicin (50 mg) in test group. Patients were monitored for postoperative complications. Adjuvant instillation therapy was administered according to risk categorization. Patients were followed every 3 months by cystourethroscopy and urine cytology. The primary end points were recurrence, progression, and/or death from cancer. RESULTS: Of the 260 patients, 236 were eligible and followed for a mean of 29 months. The 2 study groups were comparable regarding perioperative baseline demographic criteria. There was no statistically significant difference between the 2 groups regarding recurrence rate (27.1% vs. 26.2%), interval to first recurrence (16.3 ± 6.6 vs. 16.4 ± 6.4 months) or progression rate to muscle invasion (8.5% vs. 5.9%). Site, size, and number of recurrences were also comparable between the 2 groups. Recurrences and progression-free survival were comparable between the 2 groups (Log-rank P = 0.88 and 0.47, respectively). Postoperative complications were all low-grade according to modified Dindo-Clavian system, with no significant difference in their rate between the 2 groups. CONCLUSIONS: Immediate post-TURBT epirubicin instillation is ineffective in intermediate and high-risk non-muscle-invasive bladder cancer. It neither prolongs time to recurrence and/or progression nor reduces number of recurrences. We advocate strict specification of patient and tumor criteria in which immediate instillation is indicated.

Efficacy and safety of low-intensity shock wave therapy in penile rehabilitation post nerve-sparing radical cystoprostatectomy: a randomized controlled trial.

AIM: To evaluate the role of low-intensity extra corporeal shock wave therapy (LI-ESWT) in penile rehabilitation (PR) post nerve-sparing radical cystoprostatectomy (NS-RCP). MATERIALS AND METHODS: This study included 152 sexually active men with muscle invasive bladder cancer. After bilateral NS-RCP with orthotopic diversion by a single expert surgeon between June 2014 and July 2016, 128 patients were available categorized into three groups: LI-ESWT group (42 patients), phosphodiesterase type-5 inhibitors (PDE5i) group (43 patients), and control group (43 patients). RESULTS: Mean age was 53.2 ± 6.5 years. Mean ± SD follow-up period was 21 ± 8 months. During first follow-up FU1, all patients of the three groups had insufficient erection for vaginal penetration; with decrease of preoperative IIEF-EF mean score from 27.9 to 6.9. Potency recovery rates at 9 months were 76.2%, 79.1%, and 60.5% in LI-ESWT, PDE5i, and control groups, respectively. There was statistically significant increase in IIEF-EF and EHS scores during all follow-up periods in all the study groups (p < 0.001). However, there was no significant difference between the three groups during all follow-up periods. Statistical evaluation showed no significant difference in continence and oncological outcomes during all follow-up points among the three groups (p = 0.55 and 0.07, respectively). CONCLUSIONS: During last follow-up, 16% more patients in LI-ESWT group had recovery of potency as compared to the control group. Although the difference is not statistically significant, but of clinical importance. LI-ESWT is safe as oral PDE5i in penile rehabilitation post nerve-sparing radical cystoprostatectomy.

TOT for treatment of stress urinary incontinence: how should we assess its equivalence with TVT?

INTRODUCTION AND HYPOTHESIS: Synthetic mid-urethral slings are currently considered the treatment of choice for stress urinary incontinence (SUI). In this study, two types of slings are compared: TVT vs. TOT. METHODS: In a prospective randomized study, 40 patients underwent either TVT (19 patients) or TOT (21 patients). Stress-specific and overall success was evaluated. Perioperative complications were classified according to Clavien's classification. RESULTS: Mean duration of follow-up was 20 months. At last follow-up, stress-specific success rate was 94.6% in TVT vs. 81% in TOT. No significant difference was detected in terms of post-void residual urine, symptom score, and filling and voiding parameters. Thigh pain represented the main complication in the TOT group. CONCLUSIONS: Both TVT and TOT are effective procedures for treatment of SUI. When compared to each other, TOT seems to be inferior to TVT in terms of efficacy, causing less serious complications.

Urinary complications of migrated intrauterine contraceptive device.

The study aimed to present diagnosis and management of urinary complications resulting from migration of intrauterine contraceptive device (IUD). Between May 2002 and January 2007, eight women were treated for urinary complications because of migrated IUD. Persistent lower urinary tract symptoms were the main complaint in five cases, while one patient presented with urinary incontinence and two had suffered from right loin pain. Diagnosis was established after performing noncontrast computed tomography (NCCT) in all cases. Intravenous urogram (IVU) was carried out for evaluation of hydronephrosis in two cases. Cystoscopy was performed before surgical intervention in six cases. The interval between insertion of IUD and onset of symptoms ranged from 1 week up to 2 years. NCCT revealed complete intravesical position of the IUD with calculus formation on top in four cases and partial bladder wall penetration in the fifth. Cystoscopy confirmed the site of the IUD as detected by NCCT. In the last two cases, retroperitoneal migration of IUD had led to fibrosis around the right pelvic ureter. Intravesical IUDs and stones were successfully retrieved using transurethral endoscopy while suprapubic retrieval of the device was followed by repair of vesicouterine fistula in the fifth case and ureteroneocystostomy in the last two cases. Persistent lower urinary tract symptoms in women with IUD should raise the suspicion of intravesical migration. Noncontrast CT permitted excellent depiction of the site of migrated IUD for selection of proper management. Endoscopic retrieval is feasible and safe in cases with intravesical migrated IUD.

Prognostic factors predicting successful response to sildenafil after radical cystoprostatectomy.

OBJECTIVES: To assess the efficacy and safety of sildenafil citrate in the management of erectile dysfunction (ED) following radical cystectomy (RC) and to define the different prognostic factors predicting the response to sildenafil in such a challenging group of patients. MATERIAL AND METHODS: One hundred patients with ED following RC participated in an open-label, non-randomized, prospective, dose-escalation study. The median age of the patients was 53 years and the mean period after RC was 80.7 +/- 54.8 months. The study duration was 12 weeks, comprising a 4-week run-in period followed by two active treatment periods of 4 weeks each with 50 and 100 mg of sildenafil. Patients were assessed by means of the International Index of Erectile Function (IIEF) questionnaire at baseline and after each treatment period. At the end of the study, the Global Efficacy Assessment Question was used to evaluate treatment satisfaction. Factors affecting the patient's response to sildenafil were assessed by means of uni- and multivariate analysis. RESULTS: The entire study group was suffering from severe ED at baseline, with a mean erectile function (EF) domain score of 6.5 +/- 0.93. EF scores improved to 12.2 +/- 7.76 and 18 +/- 10.3 with 50 and 100 mg of sildenafil, respectively. Sildenafil therapy significantly improved the ability of many patients to achieve and maintain an erection. The mean scores for question 3 of the IIEF were 1 +/- 0.14, 2.1 +/- 1.4 and 3 +/- 1.8 at baseline and with 50 and 100 mg of sildenafil, respectively, while the corresponding scores for question 4 were 1 +/- 0.10, 1.9 +/- 1.35 and 3 +/- 1.85. The satisfaction rate was 54%. The response was dose-dependent but the incidence of adverse effects increased from 6% with 50 mg of sildenafil to 34% with 100 mg. In univariate analysis, tumor histology and grade and postoperative partial tumescence were found to significantly impact the patient's response to sildenafil. In multivariate analysis, postoperative partial tumescence was the only independent predictive variable. CONCLUSIONS. Sildenafil was found to be a safe and satisfactory treatment for post-RC ED. The effect was dose-related. Patients with postoperative partial tumescence were the best responders.

Laparoscopic pyeloplasty: a prospective randomized comparison between the transperitoneal approach and retroperitoneoscopy.

PURPOSE: A prospective randomized study was performed to compare the results of laparoscopic dismembered pyeloplasty using transperitoneal and retroperitoneal approaches. MATERIALS AND METHODS: A total of 40 patients with primary ureteropelvic junction obstruction were included in the study. The patients were prospectively randomized between transperitoneal (20 patients, group 1) and retroperitoneal (20 patients, group 2) laparoscopic Anderson-Hynes pyeloplasty. All the patients were assessed preoperatively by excretory urography, diuretic isotope renography and computerized tomography angiography. The patients were followed at 3 and 6 months postoperatively, and then every 6 months. Evaluation was performed by excretory urography and diuretic renography. Both approaches were compared regarding operative time, morbidity, hospital stay, convalescence and functional outcome. The preoperative demographic data of the patients and radiological and operative findings were statistically correlated to the operative time. RESULTS: The preoperative data of both groups were comparable. All the procedures were successfully completed with laparoscopy. Mean operative times were 149 and 189 minutes for the transperitoneal approach and retroperitoneoscopy, respectively (p = 0.02). In groups 1 and 2 there were complications in 3 and 5 patients, respectively. Morbidity, hospital stay, convalescence and success rate had no significant differences between the groups. None of the patient parameters apart from the approach had a significant impact on operative time. CONCLUSIONS: Laparoscopic dismembered Anderson-Hynes pyeloplasty has a satisfactory functional outcome and low morbidity regardless of the approach. Nevertheless, with early experience retroperitoneoscopy is associated with a longer operative time.

Long-term outcome of visual internal urethrotomy for the management of pediatric urethral strictures.

PURPOSE: We evaluated the long-term results of visual internal urethrotomy for pediatric urethral strictures to evaluate the efficacy and final outcome of this procedure in children and to evaluate the risk factors for stricture recurrence. MATERIALS AND METHODS: The computerized surgical records of our hospital were reviewed to identify children who underwent visual internal urethrotomy between 1980 and 2001. Hospital and followup clinical charts were then reviewed. Many variables were analyzed, including age, etiology, length and site of the strictures, and catheter duration. Only patients with a minimum followup of 2 years were included. Regular self-catheterization was not used by any child. RESULTS: A total of 31 patients (mean age 11.2 years, range 2 to 18) were identified. Followup ranged from 2 to 20 years, with a mean of 6.6 years. The most common etiology for stricture formation was failed previous urethroplasty and post instrumentation (35.5% and 32.3%, respectively). The success rate after initial urethrotomy was 35.5% (11 of 31 patients). Mean interval to first recurrence was 26 months. A second urethrotomy improved the success rate of 58.1%. Eight patients required 2 or more urethrotomies, of whom half required open urethroplasty. Among the evaluated variables only stricture length shorter than 1 cm was associated with good results. CONCLUSIONS: Visual internal urethrotomy provides a safe first line therapeutic option for pediatric urethral strictures shorter than 1 cm, independent of etiology and location. For patients with more than 1 recurrence or with strictures longer than 1 cm, who are at high risk for recurrence after internal urethrotomy, open urethroplasty remains the treatment of choice.

Prediction of success rate after extracorporeal shock-wave lithotripsy of renal stones--a multivariate analysis model.

OBJECTIVES: To define prognostic factors that affect the success rate after extracorporeal shock-wave lithotripsy (ESWL) of renal calculi and to estimate the probability of stone-free status using a regression analysis model. MATERIAL AND METHODS: Between February 1992 and February 2002, 2954 patients with single or multiple radiopaque renal stones (<30 mm) underwent ESWL monotherapy. The results of treatment were evaluated after 3 months of follow-up. Treatment success was defined as complete clearance of the stones with no residual fragments. The stone-free rate was correlated with stone features and patient characteristics using the chi2 test. Factors found to be significant using the chi2 test were further analyzed using multivariate regression analysis. RESULTS: At 3-month follow-up, the overall stone-free rate using ESWL monotherapy was 86.7%. Failure to disintegrate the stones was observed in 7.3% of cases (n = 216) and failure to clear the fragmented stones occurred in 6% (n = 177). Repeat ESWL was needed in 53% of cases. Static steinstrasse occurred in 4.9% of cases (n = 146) and post-ESWL auxiliary procedures were required in 4% (n = 118). Using the chi2 test, patient age (p < 0.001), stone size (p < 0.001), location (p < 0.001), number (p < 0.001) and nature (p = 0.003), radiological renal picture (p < 0.001) and congenital renal anomalies (p < 0.001) had a significant impact on the stone-free rate. Multivariate analysis excluded stone nature from the logistic regression model while other factors maintained their statistically significant effect on success rate, indicating that they were independent predictors. A regression analysis model was designed to estimate the probability of stone-free status after ESWL. The sensitivity of the model was 83%, the specificity 91% and the overall accuracy 87%. CONCLUSION: Patient age, stone size, location and number, radiological renal features and congenital renal anomalies are prognostic factors determining stone clearance after ESWL of renal calculi. Our regression model can predict the probability of the success of ESWL with an accuracy of 87%.

Use of single layer small intestinal submucosa for long segment ureteral replacement: a pilot study.

PURPOSE: Previous studies have demonstrated successful use of small intestinal submucosa (SIS) as a tube for replacing short segment (11 mm) proximal ureteral defects. However, such small segment ureteral defects could be managed by resection re-anastomosis. We evaluated the use of 1-layer SIS as a tube for the replacement of long segment ureteral defects. MATERIALS AND METHODS: The ureters of 5 female mongrel dogs were accessed through a median laparotomy incision. A 4 cm segment of mid ureter was resected on the right side. The right ureteral segments were replaced by tubularized SIS segments using 6-zero polydioxanone interrupted sutures. Internal pigtail stents were left for 6 weeks. All animals were sacrificed at 12 weeks. Ureteral patency was assessed by excretory urography and magnetic resonance urography 7 and 12 weeks after the initial procedures. Inflammation and regeneration were assessed histologically. RESULTS: At 12 weeks all ureters on the experimental side were completely occluded with significant hydroureteronephrosis and the subsequent deterioration of kidney function. At autopsy there was failure to calibrate any of the experimental ureters with a 3Fr catheter. Although histologically urothelium and muscular cells had proliferated over the graft, they were embedded in an intense fibrotic and inflammatory process. CONCLUSIONS: Technically 1-layer SIS was easily modeled, providing the conditions for watertight anastomosis. The regeneration of urothelium and muscle was induced and supported by the graft. However, functional replacement was not successful. One-layer SIS is not a suitable material for replacing long segment (4 cm) ureteral defects.

Long-term results of a prospective randomized study comparing two different antireflux techniques in orthotopic bladder substitution.

PURPOSE: We compared the long-term functional results following two different reflux prevention techniques in orthotopic ileal bladder substitution in a prospective controlled randomized study. METHODS: The study included 60 patients for whom orthotopic bladder replacement was indicated. The treated patients were prospectively randomized into two groups: group I (30 patients) underwent ileal W neobladder with serous lined extramural tunnel and group II (30 patients) received hemi-Kock pouch with intussuscepted nipple valve. Laboratory evaluation included estimation of serum creatinine while radiological studies included IVU and voiding studies. Urodynamic evaluation was an integral part of our investigation. RESULTS: Patients and tumor characteristics were comparable between both groups. No operative or postoperative mortality were observed in either. Early complications were encountered in 5 (16.7%) and 4 (13.3%) patients in the two treated groups respectively (p=0.72) and most were treated conservatively. Twenty patients in group I and 19 in group II were evaluable. The mean follow up was 73.9+/-6.6 and 72.9+/-5.6 months in the treated groups respectively. Day and night time continence was comparable between both groups. Ascending studies demonstrated reflux in 3 (7.7%) of the reimplanted units in group I versus 2 (5.3%) in group II (p=0.81); IVU showed uretero-ileal anastomotic strictures in 2 renal units with both the serous lined extramural tunnel (5.1%) and the ileal nipple valve (5.3%) techniques (p=0.98). One patient in group I had pouch stone compared with 5 in group II (p=0.08). Urodynamic characteristics were also comparable in both groups. CONCLUSION: The study provided evidence that the long-term functional results following serous lined extramural tunnel are as equal as the nipple valve. Furthermore, it spares the use of extra-bowel length, does not need staples and allows retrograde endoscopic procedures.

The use of halofuginone in limiting urethral stricture formation and recurrence: an experimental study in rabbits.

PURPOSE: We developed a reproducible animal model for the induction of urethral stricture in the rabbit and evaluated the role of halofuginone in limiting stricture formation. MATERIALS AND METHODS: A total of 20 New Zealand male rabbits were used in the first phase of the experiment. Bulbar urethral stricture was induced by electrocoagulation. The animals were then randomly assigned to 2 groups of 10 each, which received a diet containing halofuginone or a normal diet. In the second phase electrocoagulation induced stricture was treated with visual internal urethrotomy in 45 rabbits. These rabbits were randomly assigned to 2 groups, namely a halofuginone and a control group. RESULTS: In the first phase stricture developed in 2 study rabbits (20%) vs 10 controls (100%). In the second phase 37 rabbits were evaluable (8 died). Recurrent stricture was observed in 5 of the 18 study rabbits (27%) vs 14 of the 19 controls (73%). CONCLUSIONS: Halofuginone is effective in limiting the occurrence of de novo urethral stricture and recurrent stricture after visual internal urethrotomy. This antifibrotic molecule may become an important therapy to treat urethral stricture and/or recurrence following endoscopic manipulation of stricture in humans.