One-stage versus staged ureteroscopy and percutaneous nephrolithotomy for simultaneous ureteral and renal stones.

Objectives: This study is aimed to investigate the outcome of one-stage ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL) for simultaneous ureteral and renal stones over 10years at a tertiary urology institute. Materials and methods: We retrospectively analyzed the data of patients who were operated on for simultaneous ureteral and renal stones from January 2011 to December 2020. Patients were divided into 2 groups: group A, who underwent one-stage URS and prone PCNL, and group B, who underwent staged procedures. The overall success, complications, operative time, and hospital stays were compared between the 2 groups. Results: Data for 190 patients were reviewed; mean age was 50 ± 13years old, and 146 (77%) were male. The one-stage (A) and staged (B) groups included 102 and 88 patients, respectively. Group A included older patients, with a high The American Society of Anesthesiologists score, while group B included more patients with multiple or staghorn stones. The one-stage group recorded shorter operative time (120 ± 12min vs. 140 ± 16min, p = 0.02) and shorter hospital stays (3days [2-6] vs. 4days [3-9], p = 0.06). Otherwise, both groups had equal outcomes in terms of success rates and complications. Conclusions: PCNL and URS can be performed in one-session for simultaneous ureteral and renal stones, except for multiple renal and staghorn stones. The results are comparable to those of the staged procedure in terms of success rate and complications, with the advantage of a shorter operative time and hospital stay.

Predictors of renal angioembolization outcome: A retrospective analysis with 148 patients at a tertiary urology institute.

Objective: The aim of this study was to evaluate the predictor of unsuccessful outcome of renal angioembolization (RAE). Knowing those predictors may help in avoiding unnecessary RAE procedures and their associated side effects, while helping to prepare for an alternate procedure and improving patient's overall satisfaction. Methods: A retrospective analysis between January 2006 and December 2018 was performed, and the indications for RAE were classified into post-traumatic, iatrogenic, renal tumors, and spontaneous. Patients who underwent RAE prior to nephrectomy were eliminated. Computed tomography angiography was performed in patients with normal renal function and those who had no contrast allergy, otherwise magnetic resonance angiography was performed. For the purpose of statistical analysis, we stratified patients into two main categories based on the final outcome-successful or failed. Results: Of 180 patients, 32 with negative angiography were eliminated, leaving 148 patients; 136 (91%) had successful outcomes after one or more trials and 12 had unsuccessful outcomes. The mean age was 45±15 years, and 105 (71%) were male. Neither gender, side of the lesion, presence of hematuria, indication for RAE, nor the type of lesion affected the outcome. On the other hand, renal anatomy with presence of accessory artery was the only predictor to failed RAE (p=0.001). Failed RAE trial was a predictor for nephrectomy as a secondary procedure (p=0.03). Conclusion: No pre-procedural predictors could anticipate the RAE outcome, and different indications can be scheduled to RAE, which is equally effective. The presence of accessory renal artery on diagnostic angiography is the only factor that may predict the failure of the procedure.

The accuracy of computed tomography in the diagnosis of upper urinary tract urothelial carcinoma in correlation with the final histopathology: A retrospective study in 275 patients at a Tertiary Urology Institute.

INTRODUCTION: Because the reports in the literature of radiologic investigations for upper tract urothelial cancer (UTUC) are limited by the number of patients, and included patients with different pathologies, we aimed to study the overall accuracy of computed tomography (CT) in the diagnosis of UTUC and their accuracy on predicting tumor location. METHODS: A retrospective review from 1990 to 2017 included patients who were treated for UTUC. Unenhanced CT scan was obtained first using Multi-Detector Computed Tomography (MDCT, Philips Medical Systems), then nonionic contrast medium, containing 350 mg iodine/ml was injected at 4 mL/s. Analysis was performed using SPSS®. RESULTS: Of 275 patients, complete data on CT was available on 270 (98%) patients. CT reported only two false positive and six false negative results and the overall accuracy was 96-97%. In comparison to the final pathological reports, CT/CTU detected 85% of the tumor location of in the renal pelvic and 50% of the calyceal tumors. In ureteric tumors, they detected distal (66/71= 93%) more than proximal ureteric tumors (60%). CONCLUSION: In our cohort, CT/ CTU has a high overall accuracy (97%) in diagnosing UTUC, capability to well visualize tumors of distal ureter and renal pelvis, but could miss calyceal tumors. The matter to rely only on CT without ureteroscopic biopsy in the diagnosis of UTUC especially if radical surgery is planned needs further prospective studies.

Iatrogenic ureteral injuries: a case series analysis with an emphasis on the predictors of late ureteral strictures and unfavorable outcome in different surgical specialties.

INTRODUCTION AND HYPOTHESIS: We aimed to report the demographics and management of iatrogenic ureteral injuries (IUIs) with different surgical specialties. Moreover, our goal was to analyze the predictors of late ureteral strictures and secondary intervention after primary surgical management, and the final effect on the kidney. METHODS: A retrospective study, between 2006 and 2019, enrolled all patients undergoing urological, abdominal, and pelvic surgeries performed through open, laparoscopic, or endoscopic means. If IUIs were discovered intraoperatively, they were managed either by internal stent or surgical intervention following the standard procedure. For IUIs discovered postoperatively, either percutaneous nephrostomy (PCN) or double J (DJ) ureteral stents were inserted for later endoscopic or surgical management. The final outcomes were divided into two groups: patients with successful primary outcomes and those who required secondary intervention later. All predictors were compared between the two groups. RESULTS: Forty-eight patients were reviewed: 23 out of 48 (48%) from obstetrics and gynecology (ob/gyn) involving the lower ureter primarily with overall favorable outcomes (82%), 15 (31%) colorectal, and 10 (21%) urology with serious injuries affecting men in the upper ureter. The primary management included open surgery in 12 patients, and drainage (PCN or DJ) in 36 patients. Restoration of ureteral anatomy and kidney function was achieved in all, but 18 cases required a secondary correction, either endoscopically or surgically. Both early and late discovery resulted in the same outcome. On bivariate analysis, only the side of the injury (left side, p = 0.03), and the specialty (colorectal cancer surgeries, p = 0.01) were predictors for late ureteral strictures, and both sustained their significance in multivariate regression analysis. CONCLUSION: Iatrogenic ureteral injuries associated with ob/gyn surgeries involve the lower ureter, primarily with overall favorable outcomes (82%). Serious ureteroscopic IUIs affect men in the upper ureter with greater frequency. IUIs on the left side and colorectal cancer surgeries are the predictors for late strictures and secondary interventions.

Self-insertion of an odd urethral foreign body that led to Fournier's gangrene.

Self-inserted urethral foreign bodies (FBs) are rare. Neither reported case was the self-inflicted FB due to a lack of financial resources nor was either case complicated by Fournier's gangrene. We present a 54-year-old male who inserted a household pipe to relieve his urine retention. Unfortunately, the FB became stuck inside, perforated the urethra, and required perineal exploration. After it was removed, the urethra was closed over a 16F urethral catheter. The wound was complicated by severe infection and resulting Fournier's gangrene. This required an additional surgery for debridement and urine diversion. Retrospectively, it would have been better if the urethra had been left open with SP tube only. We are sharing a clinical lesson learned by the practicing urologist and surgeons. Conclusively, self-inserted FBs in the urethra may lead to a series of complications. Patients with limited financial resources need more attention and care because they may hurt themselves unintentionally.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE: In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification. METHODS: A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS®. RESULTS: Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality. CONCLUSION: Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Long-term outcomes of upper tract urothelial carcinoma: A retrospective evaluation of single-center experience in 275 patients.

OBJECTIVE: We aimed to report our 25-year experience on upper tract urothelial carcinoma (UTUC) on a larger number of patients with long-term follow-up at a single tertiary urology institute. MATERIAL AND METHODS: A retrospective study was conducted on 275 patients from 1990 to 2015. Basic patient demographic data with the laboratory and radiologic investigations were collected. We used 1997 TNM classification and the three-tiered WHO grading system. Data were collected using an SPSS® version 21 spreadsheet. RESULTS: The mean age was 59±11 years, and 88% of all the patients were male. Previous and concurrent bladder tumors were found in 16% and 26%, respectively. Computed tomography gave an overall accuracy of 96%. Open nephroureterectomy and bladder cuff excision was performed for 85%, and the remaining by laparoscopy and nephron-sparing surgeries. Tumor was pelvicalyceal, ureteric, and both in 40%, 40%, and 20% respectively. In 97% of the patients, the tumor was transitional cell carcinoma. Nearly two-thirds of the patients were of low grade and non-invasive in stage. Nearly half of the patients (46%) had bladder tumor recurrence after NU. Bladder, urethral, and contralateral recurrence, distant, local metastasis occurred in 46%, 2%, 1%, 7.5%, and 6%, respectively. CONCLUSION: UTUC is a unique disease with synchronous and metachronous urothelial tumor recurrence that requires long-term surveillance. The majority (two-thirds) of the patients are non-invasive in stage of grade II. Tumor stage is of paramount prognostic significance for survival; the five-year survival rate of T1 and T4 is 80% and 0%, respectively.

Extracorporeal shock wave lithotripsy for bilateral renal stones: A case report with serious complications that could be avoided.

22-year-old male patient with irrelevant medical history presented with bilateral renal stones; multiple stones in right renal pelvis measured 10, 11, and 11mm and another one on the left side measured 12mm. Extra corporeal shock wave lithotripsy (ESWL) was done first on the left side, but after 400 shocks and total energy of 20 Storez Medical Lithotripsy Index only, the stone wasn't visible. Then, the operator switched to the right side and a he completed the session. A day after, the patient presented with bilateral renal colic, gradual rising of renal function and imaging showed bilateral steinstrasse with bilateral hydroureteronephrosis. Patient was managed with insertion of bilateral ureteric stents and had another session of ESWL on the right side. We concluded that bilateral simultaneous ESWL for bilateral renal stones doesn't affect the renal function on the long-term outcome, but still carries the risk of bilateral obstruction and acute renal injury.

Muscle-invasive bladder and urethral cancer recurrence after surgical management of upper tract urothelial carcinoma: A review of 305 patients.

OBJECTIVE: Bladder cancer recurrence after management of upper tract urothelial carcinoma (UTUC) is a common disease. Although the incidence and risk factors for the development of noninvasive bladder tumor have been reported in many series, rare studies have reported on muscle invasive bladder cancer (MIBC) and its urethral recurrence. We aimed to report the incidence, risk factors and survival rate for the development of MIBC and urethral tumors after surgical management of UTUC. MATERIAL AND METHODS: We retrospectively reviewed patients who were surgically treated for UTUC from 1983 to 2013. The tumor was categorized according to the 1997 TNM staging and the 3-tiered WHO grading systems. The primary endpoint of this study was the occurrence of any post-treatment MIBC and its urethral recurrences. We studied the possible risk factors that may contribute to the development of such pathology as well as the prognosis of this pathology. RESULTS: A total of 297 patients were eligible for analysis. Intravesical tumor recurrence was observed in 139 (46.8%) patients and radical cystectomy was warranted for 36 patients (MIBC or multicentric bladder recurrence). Twenty-seven patients were fit for surgery with ileal loop conduit was the urinary diversion for the majority, and others received radiotherapy. Ureteral tumor was the only statistically significant risk factor (p=0.001) and the incidence increased as the ureteral tumors became more distal (p=0.01). Occurrence of invasive or multicenteric bladder recurrence was a predictor for local, urethral recurrence and distant metastasis (p=0.016, 0.0001 and 0.01 respectively). Seven patients had urethral urothelial carcinoma; 5 were diagnosed at the time of cystectomy and 2 were discovered later (1 and 3 years after cystectomy). CONCLUSION: MIBC is a relatively uncommon (6%) post UTUC, and ureteral tumors, especially distal in location, are the independent risk factor. Extended surveillance for those patients is needed. Urethral cancer recurrence is rare (2%); most cases are localized in the posterior urethra, they are noninvasive, and may develop even after cystectomy.

Coincidental Bladder Cuff Transitional Cell Carcinoma in Nephroureterectomy Specimens: Risk Factors, Prognosis and Clinical Implementation.

PURPOSE: There is a lack of reporting of the bladder cuff pathology in the literature and ongoing debate regarding the role of bladder cuff excision (BCE) in the prognosis in patients with upper tract urothelial carcinoma (UTUC). We aimed to know the risk factors, the survival, and the clinical course of such pathology. MATERIALS AND METHODS: The study was retrospective, from 1983-2013 on 305 patients who had diagnosed with UTUC. Patients were managed by radical open/ laparoscopic nephroureterectomy with bladder cuff excision. The tumor was staged using 1997 TNM classification and the 3-tiered WHO grading system was used for grading. Patients who found to have a malignant bladder cuff on the final pathology were further analyzed for the risk factors for such disease and its effect on survivaltheir outcomes. RESULTS: 13/ 281 (4.6%) cases were found to have malignant bladder cuff. Regarding tumor stage; one case was diagnosed with Tis, eight had T1 and four cases had T2 malignant bladder cuff. All cases were with pure ureteric or multifocalcentric tumors, and none had pure pelvicalyceal tumors (p = .001).Local recurrence at the surgical site and distant metastasis were significantly higher among patients with malignant bladder cuff (p = .001 and .002 respectively), and the last sustained its significance in multivariate analysis. Those patients had a poor prognosis when compared to non-malignant bladder cuff cases (Log Rank test, p = .001)Conclusion: Ureteric tumor is the only independent risk factor for malignant bladder cuff at the final pathology and is associated with increased risks for invasive bladder tumor, distant metastasis and poor survival in comparison with non-malignant bladder cuff. In a clinical implementation, BCE is considered as a mandatory step in management of ureteric tumors, while it could be omitted in pure and low grade renal pelvis tumors.

Risk factors and prognosis of intravesical recurrence after surgical management of upper tract urothelial carcinoma: A 30-year single centre experience.

OBJECTIVE: To review the incidence, predictors and prognosis of bladder cancer recurrence after management of upper tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: We retrospectively reviewed patients who were surgically treated for UTUC from 1983 to 2013. The tumours were categorised according to the 1997 Tumour-Node-Metastasis (TNM) staging and the three-tiered World Health Organization grading systems. The primary endpoint was the occurrence of any intravesical recurrence after treatment. We studied the possible risk factors that may contribute to development of intravesical recurrence, as well as the prognosis of the patients who had recurrence. RESULTS: In all, 297 patients were eligible for analysis. Recurrent bladder tumours occurred in 139 patients (46.8%). The mean (range) time to recurrence after surgery was 33 (6-300) months. Neither sex, past history of bladder tumours, concomitant bladder tumour, the side of the tumour, UTUC stage, grade, presence of carcinoma in situ or multicentricity at the time of diagnosis of UTUC, were significant predictors of intravesical tumour recurrence. Ureteric tumour was the only identified risk factor (P = 0.02). Post-treatment bladder recurrence was a significant predictor of later urethral recurrence (P = 0.002). CONCLUSIONS: In our present series, bladder cancer recurrence of urothelial malignancy occurred in nearly half of the patients after surgical management of UTUC. Ureteric tumour was the only identifiable risk factor, thus patients with ureteric tumours may benefit from prophylactic intravesical chemoimmunotherapy. Bladder recurrence does not appear to affect the cancer-specific survival after surgical management of UTUC.

Non-transitional cell carcinoma of the upper urinary tract: A case series among 305 cases at a tertiary urology institute.

Non-transitional cell carcinomas (non-TCC) of the upper urinary tract as squamous cell carcinoma (SCC), adenocarcinoma, and small cell carcinoma (SmCC) are rare with few case reports in the literature. We retrospectively reviewed our patients who surgically treated for upper tract urothelial carcinoma from 1983 to 2013 for non-TCC pathological cancer characteristics and survival. Among 305 patients, only 5 (1.6%) cases were found: One case of SmCC, another had adenocarcinoma, and 3 SCC cases. None of them had intravesical recurrence and the cancer-specific survival for non-TCC cohort is markedly decreased (log-rank = 0.01) compared to TCC patients.

Histopathologic Characteristics of Upper Tract Urothelial Carcinoma With an Emphasis on Their Effect on Cancer Survival: A Single-Institute Experience With 305 Patients With Long-Term Follow-Up.

INTRODUCTION: Tumor stage and grade represent the best established predictors for the prognosis of upper tract urothelial carcinoma (UTUC). However, controversies still exist regarding the role of tumor necrosis, location, and multifocality in the prognosis of UTUC. We share our experience with 305 patients, reporting on the pathologic features in detail, cancer characteristics, and survival. MATERIALS AND METHODS: We retrospectively reviewed the data from patients who had undergone surgery for UTUC from 1983 to 2013. The tumors were staged according to the 1997 TNM classification and the 3-tiered World Health Organization grading system. Cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. RESULTS: A total of 305 patients were eligible for analysis. The 5-year CSS for grade 1, 2, and 3 was 88%, 84%, and 60%, respectively. The CSS for stage pT1, T2, T3, and T4 was 82%, 70%, 62%, and 0%, respectively. On univariate analysis, tumor stage, tumor grade, positive lymph node status, and micropapillary invasion had adverse effects on survival (P = .006, P = .045, P = .01, and P = .005, respectively). On multivariate analysis, only stage and micropapillary variant maintained significance (P = .01). Multicentricity and tumor location affected CSS in the early follow-up period but did not in the late follow-up period. Neither carcinoma in situ nor adverse pathologic variants affected survival. CONCLUSION: The tumor stage and presence of a micropapillary variant are of paramount prognostic significance for survival in patients with UTUC. The tumor grade and lymph node status are also good predictors. In our series, multifocality and tumor location affected early and mid-term survival with no significant effects on late survival.

Preejaculatory illness syndrome: Two cases of a rare psychosomatic disorder.

Human ejaculation happens in the orgasmic phase of the human sexual response cycle. Among psychosomatic ejaculatory disorders that may happen before ejaculation, we present two cases of preejaculatory illness syndrome. The two cases shared common symptoms of sympathetic over activity, the sensation of impending death, and muscle atonia with subsequent failure to ejaculate. Depression, anxiety disorders, and family histories of psychiatric problems were noticed as risk factors. Medical conditions that may lead to panic attack type symptoms were eliminated before the final diagnosis. After the failure of empirical medications, symptoms became controlled with fluoxetine. Patients reported a recurrence of the symptoms on trying to stop the prescribed medication. On the last follow-up, they still take fluoxetine on a regular base with satisfactory sexual life.