Extracorporeal shock wave lithotripsy as first line treatment for urinary tract stones in children: outcome of 500 cases.

PURPOSE: The continued evolution of stone treatment modalities, such as endourologic procedures, open surgery and shock wave lithotripsy, makes the assessment of continuous outcomes are essential. Pediatric urolithiasis are an important health problem allover the world, especially in Middle East region. We evaluate the safety, efficacy and factors affecting success rate and clearance of stones in children treated with shock wave lithotripsy. PATIENT AND METHODS: Between 2005 and 2010, a total of 500 children with stones in the upper urinary tract at different locations were treated by Extracorporeal shock wave lithotripsy (ESWL) in our department, Sohag University, Egypt. We have used the Siemn's Lithostar Modularis machine, Germany. A total of 371 boys and 129 girls with the average age of 8.63 ± 5 years, and a range from 9 months to 17 years were included in this study. Diagnosis of their urinary calculi was established either by the use of abdominal ultrasound, plain X-ray, intravenous urography, or CT scan. The stones were located in the kidney in 450 (90%) patients; 298 (66%) pelvic, 26 (5.7%) upper calices, 57 (12.6%) mid calices, and lower calices in 69 (15.3%) patients. The average of their stone sizes was 12.5 ± 7.2 mm. The other 50 children their stone were located in the proximal ureteral stones in 35 patients (70%); middle third in 5 (10%) patients and in the distal ureter in 10 (20%) patients. The average ureteral stone size was 7.5 ± 3.2 mm. All children were treated under general anesthesia with adequate lung and testes shielding using air foam. We treated the distal ureteral stones of young children in the supine position through greater sciatic foramen and lesser sciatic foramen as the path of shockwave instead of prone position, which is not a comfortable or natural position and could adversely affect cardiopulmonary function especially under general anesthesia. Localization was mainly done by ultrasound, and X-ray was only used to localize ureteral calculi. For follow-up, we have used abdominal ultrasound, plain X-ray, and CT scan if needed to confirm stone disintegration and clearance. RESULTS: The overall success rate for renal and ureteral calculi was 83.4 and 58.46%, respectively. The re-treatment rate was 4% in renal group and 28% for the ureteral group. No serious complications were recorded in our patients. Minor complications occurred in 15% of our patients; renal colic was reported in 10% of our treated patients, and repeated vomiting was reported in 5% that respond to antiemetics. In the renal group; children with history of pervious urologic surgical procedures had low success rate of stone clearance after ESWL. In the ureteral group stone burden, stone location, had a significant impact on stone clearance outcome. CONCLUSION: This study showed that SWL in pediatric age group for both renal and ureteral stone is cost effective, safe with an acceptable re-treatment rate; however children with large stone burden or previous urologic surgery have low success rate.

Finasteride for treatment of refractory hemospermia: prospective placebo-controlled study.

OBJECTIVE: Finasteride had been used to control frequent hematuria due to BPH. In this study, we tried to test the efficacy of finasteride to control refractory idiopathic hemospermia lasting for more than 3 months for which conservative treatment has failed. PATIENTS AND METHODS: In a period from 1998 to 2008, 70 patients with hemospermia presented to urology department, Sohag university hospital. Only 24 patients were diagnosed as having refractory hemospermia of idiopathic nature. They were divided and randomized into two equal groups, 12 patients each. One group received finasteride 5 mg daily for 3 months, and the second group received placebo. Patients were followed at monthly intervals both subjectively and objectively by semen analysis and TRUS for three successive months and after 1 year. RESULTS: In the finasteride-treated group, 8 patients (66.7%) have demonstrated a remission of the episodes of their hemospermia symptom within 2-5 weeks after the start of treatment. We confirmed this subjective improvement by repeated semen analysis. Patients continued treatment for 3 months without recurrence of bleeding. On the other hand, only three patients (25%) in placebo group mentioned the disappearance of their symptom after a period of 1-2 months on treatment. On semen analysis, those three patients showed considerable number of RBCs (>50/HPF). CONCLUSION: Finasteride could be safely used as a treatment for patients with idiopathic refractory hemospermia after exclusion of the other organic causes. However, our results are preliminary, and larger series with longer follow-up are required to confirm the results.

Transobturator vaginal tape (inside-out) for stress urinary incontinence after radical cystectomy and orthotopic reconstruction in women.

OBJECTIVES: To evaluate the safety and clinical efficacy of the transobturator vaginal tape 'inside-out' (TVT-O) procedure for managing new-onset stress urinary incontinence (SUI) after radical cystectomy (RC) and orthotopic W-neobladder construction in women. PATIENTS AND METHODS: Between January 2004 and June 2010, 57 women were treated with RC and orthotopic ileal neobladder reconstruction. Six of these patients (median age 44 years, range 39-62; grade 2 muscle-invasive squamous cell carcinoma in four and transitional cell carcinoma in two) developed de novo SUI that was moderate in four and severe in two. The median (range) duration of SUI was 11 (9-18) months. All six patients underwent TVT-O for control of their SUI. RESULTS: Four patients were completely dry day and night (three of them can initiate voiding and one cannot, and uses intermittent catheterization). One patient improved, as assessed by using fewer pads (from 5-7 pads to 1 pad/day and night). She can initiate voiding but has minimal leakage only on moderate exertion. One patient who had severe SUI showed no improvement. Patients were followed for a mean (range) of 18 (17-32) months, with no deterioration in the continence status. CONCLUSION: These encouraging results confirm the safety and clinical efficacy of TVT-O for managing new-onset SUI after RC and ileal neobladder construction, although a larger survey and a longer follow-up are needed.

Orthotopic diversion after cystectomy in women: A single-centre experience with a 10-year follow-up.

OBJECTIVE: To evaluate and update the clinical and surgical outcome of orthotopic diversion in an eligible cohort of women with bladder carcinoma. PATIENTS AND METHODS: From 1999 to 2010, 78 women (mean age 42.4 years) had a radical cystectomy (RC) with orthotopic diversion using ileal neobladder reconstruction to treat invasive bladder carcinoma. The mean (SD) follow-up was 62 (25) months. RESULTS: The histopathological pattern was squamous cell carcinoma in 52 (67%) patients, transitional cell carcinoma in 17 (22%), mixed in four (5%) and undifferentiated carcinoma in five (6%). Three patients were completely incontinent day and night. Stress urinary incontinence after this surgery was reported in 11 (14%) patients, with daytime continence reported in 64 (82%); 59 (76%) patients were completely continent day and night. Chronic retention developed in nine (12%) patients. There was pouch prolapse through the vaginal stump in five (6%) patients, and a pouch-vaginal fistula in seven (9%). Sexual dysfunction was reported in 45 (69%) patients of 65 sexually active women. Stones formed in the pouch in five (6%) patients, while there were renal stones in four renal units. Oncological recurrence was reported in 15 (19%) patients, which was local in 11 (14%) and distant in four (5%). CONCLUSION: The long-term results showed that orthotopic neobladder construction after RC in women provides oncological safety and is functionally effective with proper surgical technique. Removal of the gynaecological organs during RC in women might be unnecessary for low-grade, low-stage tumour.

Buccal mucosa graft for ureteral stricture substitution: initial experience.

OBJECTIVES: To evaluate the use of buccal mucosa tubal graft for reconstruction of extensive ureteral stricture. MATERIAL AND METHODS: Between April 2006 and July 2008, 5 patients (mean age, 51.2 years) underwent reconstructive ureteral surgery for ureteral obstruction using buccal mucosa graft. The indication of surgery was extensive ureteral stricture of a 4.4-cm average length (range, 3.5-5.0). The site of stricture was in the proximal and the middle ureter in 3 and 2 patients, respectively. The causes of stricture were postinflammatory (3 cases) and iatrogenic after ureteroscopic procedures for impacted stones (2 cases). RESULTS: All 5 patients underwent successful ureteral defect replacement using buccal mucosal tube. The intraoperative course was uneventful without any major complications. Mean operative time was 106 minutes (range, 85-130). With a mean follow-up of 24 months (range, 14-39), the operated kidneys showed no obstruction. CONCLUSIONS: Oral buccal mucosal tubal graft for reconstruction of extensive ureteral stricture is a good available option. Although the results of this initial experience are encouraging, a bigger series and longer follow-up is recommended to evaluate our procedure.