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.

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.