Thermoexpandable Memokath stent: Usage and efficacy in ureteral and urethral strictures in Saudi Arabia.

Objectives: Double J (DJ) stent is widely used in cases of ureteric strictures as a temporary solution; however, it has certain limitations, such as the need for frequent exchange. Alternatively, a long-lasting thermoexpandable stent (Memokath™ 051) has been used to relieve ureteral obstructions in comorbid patients with multiple reported advantages, such as longer durability which avoids the need of frequent exchanges. In addition, it can be used in certain cases of urethral strictures. Our study is the first in the region to report the experience and outcome of Memokath stent with ureteral and urethral strictures. Materials and Methods: After local IRB approval, we retrospectively reviewed records of 21 patients who underwent insertion of Memokath 051 stent in the ureter and Memokath 045 in the urethra between 2013 and 2021. Indications of insertion, indwelling duration, and causes of removal were collected and analyzed by SPSS. Results: Twenty-one patients received 21 Memokath stents for 11 ureteral strictures and 10 urethral strictures. Fifty-five percent of ureteral strictures were malignant, and 27.3% of the benign ureteric strictures were transplant ureters. Ureteric memokath stents remained functioning for a mean of 16.1 months. Mean indwelling time for transplant ureteric memokath stents was 24.3 months. Total 4 ureteric stents had migrated, 4 stents blocked, and 2 stents were removed as planned and 1 stent removed due to febrile urinary tract infection (UTI). Ten urethral stents remained in place for mean of 14 months. Three stents were removed as planned with resolution of stricture, two were removed due to blockage, three stents had UTI, one was removed due to pain, and one stent remained functioning until the patient expired. Conclusion: Our outcome is comparable to other published studies, suggesting that ureteric Memokath stent is a better option with adequate indwelling time, especially in transplant ureters, in comparison with DJ stents. In addition, Memokath stents can be used in selected recurrent urethral strictures where surgical reconstruction is not feasible.

Long-term retroperitoneal lymph node dissection outcomes for nonseminomatous germ cell tumors with postchemotherapy retroperitoneal residual tumors, in a specialized hospital of Saudi Arabia.

Background: In men under the age of 35 years, testicular cancer is the most prevalent solid tumor. Additional treatment is necessary for many people with nonseminomatus germ cell tumors (NSGCTs). Whether in conjunction with chemotherapy or as a stand-alone procedure, retroperitoneal lymph node dissection (RPLND) continues to play a critical role in the treatment of these patients. There is a lack of information in Saudi Arabian literature about the long-term oncologic outcome of NSGCT following RPLND surgery. Objective: The study's goals were to identify clinical and pathological characteristics related with long-term survival following NSGCT for RPLND, as well as to assess the surgical and oncological results of this treatment. Methodology: From January 2010 to April 2021, nine adults who had had orchidectomy for testicular cancer and RPLND following treatment for the evidence of persistent NSGCT disease at our hospital were included in this retrospective research. Demographic information, laboratory results, radiological findings, staging, chemotherapy and radiotherapy status, surgical procedure details, perioperative problems, morbidity, and mortality were all acquired from patients' medical records. Rates of disease return and overall survival. SPSS was utilized for the data analysis. Results: During the study period, nine patients with NSGCT underwent RPLND, with a mean age of 28 years (5.4: standard deviation). The most common diseases were yolk sac and embryonal cell cancer. In addition to receiving neoadjuvant chemotherapy, all patients had a Clavien-Dindo score of 2, and there was no mortality after RPLND. Overall median survival time was 26, and disease-free survival time was 21 months. Overall survival at 1 year was 86%, and at 5 years, it was 66%. The prognosis of embryonal cell cancer was more optimistic than that of a tumor of the yolk sac. Conclusion: We have shown that RPLND has an extremely low rate of morbidity and postoperative problems. In terms of oncology, it results in adequate overall and disease-free survival rates, with low morbidity and postoperative complications.

Post-Transplant Ureteric Stricture Managed By Extra-Anatomical Stenting With Modification on the Originally Described Stent Location: A Case Report.

Ureteric strictures are a relatively uncommon complication following renal transplant, which may be managed endoscopically or surgically by repairing the stricture. Extra-anatomical bypass is a useful procedure in complex cases that bypasses the ureter by creating a subcutaneous route, although it is uncommonly used given its rare indication. We report a case of renal transplant ureteric stricture, in which we utilized a modified extra-anatomical stenting technique with a Detour® stent to avoid the fibrotic planes surrounding the lateral aspect of the kidney graft.

Renal Angiomyolipoma Causing Inferior Vena Cava Thrombus in a Young Girl With Tuberous Sclerosis.

Angiomyolipomas (AML), also known as hamartomas, are benign mesenchymal tumors of the kidneys which consist of vascular tissue, smooth muscles, and adipose tissue, with a higher prevalence in females than males. AML may be associated with tuberous sclerosis, and the growth of the mass may present as hematuria or flank pain. We present a case of a 14-year-old female patient who had a known case of tuberous sclerosis since early childhood. She has a history of numerous bilateral renal masses radiographically consistent with AML. A special and unique entity of our case is the age of presentation which is 14 years and the presence of TSC. In contrast to our case, which was invading the right renal vein and IVC at a young age, AML is well known for its benign nature. According to a recent literature review, the youngest patient reported was 16 years old. Typically, non-complicated AMLs less than 4 cm in size are managed by annual radiological imaging which is preferably a CT scan, while larger AMLs of more than 4 cm that present with perinephric hemorrhages or intralesional aneurysms are treated by partial nephrectomy or selective angioembolization. A radical nephrectomy and IVC thrombectomy are typically necessary due to the risks that the IVC thrombus carries as well as the AML itself and its unpredictable behavior. In cases like ours with the extension into the renal vein and IVC, the surgical approach is similar to the venous invasion of renal cell carcinomas.

Cystic fibrosis gene mutations and polymorphisms in Saudi men with infertility.

BACKGROUND: Some mutations of the cystic fibrosis transmembrane regulator (CFTR) gene may impair spermatogenesis or cause a congenital absence of the vas deferens that manifests as isolated male infertility. OBJECTIVE: Assess the frequency and analyze the spectrum of CFTR gene variations in Saudi men with primary infertility. DESIGN: Prospective, cross-sectional. SETTING: Tertiary care specialist hospital in Jeddah. PATIENTS AND METHODS: Genomic DNA was extracted from peripheral blood samples of Saudi men who presented with primary infertility to the outpatient andrology clinic with either azoospermia or oligoasthenoteratozoospermia. Polymerase chain reaction and direct sequencing were used to identify all variants of the CFTR gene. MAIN OUTCOME MEASURES: Proportion of the patients with a mutant CFTR gene and the spectrum of CFTR gene variations. SAMPLE SIZE: 50 infertile Saudi men. RESULTS: This study identified 10 CFTR gene variants in 7 (14%) subjects (100 chromosomes). The detected variants and polymorphisms were: c.1408G>A, c.4389G>A, c.2562T>G, c.869+11C>T, c.2909-92G>A, c.3469-65C>A, c.1210-6delT, c.1210-6T>A, c.2988+1G>A, and c.1210-13GT>TG. CONCLUSION: We demonstrated that 14% of the study subjects had one or more CFTR mutations and these were compounded in most of the affected patients. The spectrum of CFTR gene mutations in these subjects was similar to the mutations reported in other studies throughout the world. LIMITATIONS: Small sample size and the lack of a control group. CONFLICTS OF INTEREST: None.

A self-expanding thermolabile nitinol stent as a minimally invasive treatment alternative for ureteral strictures in renal transplant patients.

BACKGROUND AND PURPOSE: Ureteral obstruction in renal transplant allografts secondary to strictures can pose a challenging problem. Its incidence is reported between 0.5% and 4.7%. Usually, open surgical repair is performed. We present a series of patients in whom a metal Memokath™ 051 stent has been used as a minimally invasive treatment alternative. METHODS: We analyzed our data on the use of thermo-expandable metallic Memokath 051 stents for ureteral strictures in renal transplant patients. RESULTS: Between 2003 and 2010, eight male kidney recipients with a mean age of 49 years and obstructed ureters after kidney transplantation were treated with ureteral Memokath insertion. In six patients, the obstruction was at the level of the anastomosis, and in two, at the pelviureteral junction. After a mean follow-up of 4 years, half of the stents are in situ providing a good graft function. The average indwelling time is 4 years. Spontaneous resolution of the stricture without the need for further stent insertion was seen in three patients after a mean indwelling time of 7.3 months. There was one treatment failure in a patient with an obstructed, dilated, and convoluted ureter that was unable to withhold the stent in situ. No perioperative complications were recorded in this series. The overall success rate was 87%. CONCLUSION: Ureteral stent placement with the Memokath 051 is a safe minimally invasive treatment alternative for ureteral strictures in renal transplant recipients.

Peer-mentoring junior surgical trainees in the United Kingdom: a pilot program.

BACKGROUND: Peer-mentoring has attracted substantial interest in various healthcare professions, but has not been formally integrated into postgraduate surgical training. This study aimed to assess the feasibility and acceptability of a peer-mentor scheme among junior surgical trainees in the United Kingdom. METHOD: Trainees entering the first year of core surgical training (CST) in a single postgraduate school of surgery were allocated a mentor in the second year of CST. Allocation was based on location of the initial clinical placement. An anonymised questionnaire regarding the mentorship scheme was sent to all participants in the third month following its introduction. RESULTS: 18 trainees participated in the scheme, of whom 12 (67%) responded to the questionnaire. All respondents had made contact with their allocated mentor or mentee, and no trainees had opted out of the scheme. Areas in which the mentees received guidance included examinations (83%), CV development (67%), and workplace-based assessments (67%). All respondents felt that the mentor scheme was a good addition to CST. Suggestions for improvement of the scheme included introduction of structured meetings and greater engagement with allocated mentors. CONCLUSIONS: A pilot peer-mentoring scheme was well received by junior surgical trainees. Consideration should be given to expansion of this scheme and more rigorous assessment of its value.

The floppy iris syndrome - what urologists and ophthalmologists need to know.

INTRODUCTION: Benign prostatic hyperplasia (BPH) and cataract formation are common in older people. Medical management of symptomatic BPH is often preferred to surgical treatment as surgery increases the risk of morbidities, whereas, surgery is the main form of treatment to restore sight in patient with cataract. The clinical treatment of BPH is either alpha-1 adrenergic antagonist alone or combination of alpha reductase inhibitor and alpha adrenergic receptor (AR) antagonist. There are four alpha-AR antagonists currently available to treat BPH. The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin. Women are more likely to develop cataract than men and some recent studies showed that tamsulosin is effective in treating female lower urinary tract symptoms and thereby can cause IFIS during cataract surgery. EVIDENCE ACQUISITION: We performed a critical review of the published articles and abstracts on association of IFIS with alpha-blockers and other medications as well as other medical conditions. EVIDENCE SYNTHESIS: Tamsulosin is the most common cause of formation of IFIS. However, not all patients given tamsulosin develop IFIS and cases have been reported without any tamsulosin treatment. CONCLUSION: Tamsulosin is a recognized cause to impede mydriasis and lead to IFIS during cataract surgery. Urologist should collaborate with their ophthalmology colleagues and general practitioner during prescribing tamsulosin in patients with history of cataract or waiting for planned cataract surgery. The increasing life expectancy and growth of older people will increase the number of men and women who suffer from lower urinary tract symptoms as well as cataract. Therefore, further research and studies are required to properly understand the relation of alpha blockers and IFIS.

The management of bladder lithiasis in the modern era of endourology.

The recent evolution in the management of vesical lithiasis is a result of the major advancements of modern endourology. The ideal method for achieving stone clearance, however, remains an issue of debate and evidence-based recommendations are lacking. Contemporary literature focuses on management options, such as extracorporeal shockwave lithotripsy, transurethral, percutaneous and minimally-invasive surgery, as well as state-of-the-art energy sources. Issues of particular interest include the results of comparative studies, the management of lithiasis in the paediatric population and the recent challenge of the traditional dogma that dictated BPH surgery for the management of vesical lithiasis secondary to bladder outlet obstruction.

Endourological management of ureteric strictures after kidney transplantation: Stenting the stent.

The incidence of ureteric obstruction after kidney transplantation is 3-12.4%, and the most common cause is ureteric stenosis. The standard treatment remains open surgical revision, but this is associated with significant morbidity and potential complications. By contrast, endourological approaches such as balloon dilatation of the ureter, ureterotomy or long-term ureteric stenting are minimally invasive treatment alternatives. Here we discuss the available minimally invasive treatment options to treat transplant ureteric strictures, with an emphasis on long-term stenting. Using an example patient, we describe the use of a long-term new-generation ureteric metal stent to treat a transplant ureter where a mesh wire stent had been placed 5 years previously. The mesh wire stent was heavily encrusted throughout, overgrown by urothelium and impossible to remove. Because the patient had several previous surgeries, we first considered endourological solutions. After re-canalising the ureter and mesh wire stent by a minimally invasive procedure, we inserted a Memokath® (PNN Medical, Kvistgaard, Denmark) through the embedded mesh wire stent. This illustrates a novel method for resolving the currently rare but existing problem of ureteric mesh wire stents becoming dysfunctional over time, and for treating complex transplant ureteric strictures.

Use of a long-term metal stent in complex uretero-ileal anastomotic stricture.

Uretero-ileal anastomotic stricture is a potentially serious late complication after ileal conduit formation, with a reported incidence of 3-9%. The standard management technique is open surgical revision of the anastomosis with reimplantation of the affected ureter. This is technically challenging and has potential significant morbidity for the patient. Advances in endourological techniques now offer a variety of less-invasive treatment options, like balloon dilatation or laser ureterotomy followed by stent insertion. What happens when such open and minimally invasive techniques fail? Recently, using a combined antegrade and retrograde approach, we inserted a novel, semi-permanent, dual-expansion thermo-expandable metallic alloy stent across a recurrent ileal-ureteric stricture. We describe the technique and potential advantages of this minimally invasive method. This minimally invasive treatment option is of interest, as in contrast to other stents, it does not require routine change, and is resistant to corrosion and urothelial ingrowth, hence ensuring ease of exchange or removal if required.

New developments in the use of prostatic stents.

Bladder outflow obstruction is a very common age-related clinical entity due to a variety of benign and malignant diseases of the prostate. Surgical treatment under general or regional anesthesia is not suitable for high-risk elderly patients who seek minimally invasive management. Unfortunately, for patients who are not fit for transurethral and/or laser prostatectomy, few treatment options remain, other than long-term catheterization and insertion (under local anesthesia) of a prostatic stent. In this review, we present developments in the use of prostatic stents.

Human papillomavirus is detected in transitional cell carcinoma arising in renal transplant recipients.

AIMS: We investigated the role of human papillomavirus (HPV) in the development of transitional cell carcinoma (TCC) arising in renal transplant recipients. METHODS: Genomic DNA was extracted from 10 microm paraffin embedded sections of five TCCs arising in five renal transplant recipients using the QIAamp DNA mini kit according to the manufacturer's instructions. beta-globin PCR was performed to test DNA adequacy. Samples were tested for the presence of HPV DNA by broad spectrum HPV PCR method using non-biotinylated SPF10 primers (SPF1A, SPF1B, SPF1C, SPF1D, SPF2B, SPF2D) which amplify a short 65 bp fragment. Positive bands were identified on a 3% gel. Positive samples underwent a second HPV PCR and were amplified using biotinylated SPF10 primer set, which amplifies the same 65 bp region of the L1 open reading frame. INNO-LiPA line probe assay was then performed to genotype the samples which uses a reverse hybridisation principle. RESULTS: Four of five TCCs examined were positive for HPV. The high risk HPV16 was detected in three cases whereas in the fourth case an unclassifiable HPV genotype was present. In all DNA samples, beta-globin amplification was successful. CONCLUSIONS: Our results indicate that HPV and in particular HPV16 may play an aetiological role in the development of TCC in renal transplant patients.

Laparoscopic cranial plication in pelviureteral junction obstruction by aberrant lower pole artery.

BACKGROUND AND PURPOSE: The standard management for pelviureteral junction (PUJ) obstruction is a laparoscopic dismembered pyeloplasty. We present the initial results of our experience of laparoscopic cranial transposition of lower-pole crossing vessels in the management of adult PUJ obstruction where crossing vessels were identified. PATIENTS AND METHODS: All patients during the last 2 years who presented with PUJ obstruction caused by crossing lower-pole vessels underwent a laparoscopic transposition of the artery to a more cranial position and, in fact, plicated within the renal pelvis well above the PUJ to reduce the size of the baggy renal pelvis. Patients were followed up postoperatively with mercaptoacetyl triglycine renography as well as clinical symptom review at 3 months, 6 months, and then yearly. RESULTS: Seven patients have undergone this procedure so far. The mean follow-up period at present is 14 months (range 8-22 months). All patients had a nonobstructive renogram curve at 3 months and 6 months. One patient has had renography at 22 months, which still shows a nonobstructive drainage pattern. All patients have had a resolution of their pain and urinary tract infections. The mean operative time, including the retrograde study and Double-J stent insertion was 121 minutes (range 110-131 min) with a mean blood loss of 30 mL. The mean hospital stay was 2 days. There were no complications. CONCLUSIONS: Although currently the number of patients is small and follow-up is short, this procedure appears to be effective in relieving both symptoms and obstruction in patients with lower-pole crossing vessels. Other benefits include shorter operative time, less blood loss, as well as no risk of anastomotic stricture and urine leak when compared with a dismembered pyeloplasty. The Double-J stent can be removed within a few days (typically 5 in our hands) or even shorter where logistically feasible. This reduces stent-related complications.

A training model for suprapubic catheter insertion: the UroEmerge suprapubic catheter model.

Suprapubic catheter insertion is a fundamental practical skill that all clinicians should be familiar with, yet there are great practical difficulties in training in this area. A training model was designed to facilitate teaching, and then this model was subsequently tested in an emergency urology practical skills course.

The artificial urinary sphincter.

Urinary incontinence (UI) is regarded as a major health issue affecting a large sector of the population. The International Continence Society defines UI as the complaint of involuntary leakage of urine that is objectively demonstrated and is a social and hygienic problem. It is caused by a wide range of factors and it has a great negative impact on the lifestyle of patients, as well as a burden on the healthcare system, since it affects an estimated 10 million patients in the USA. Approximately 50% of all nursing home residents and between 15 and 30% of women over the age of 65 years have UI. The treatment modalities vary according to the underlying causes and the results are often unsatisfactory. With the introduction of the artificial urinary sphincter there has been a dramatic change in the management of refractory cases of UI. The artificial urinary sphincter is a device, usually in the form of an inflatable silicone cuff, inserted around the bladder neck or around the bulbous urethra in adult males. It mimics the biological urinary sphincter by providing a competent bladder outlet during urinary storage and an open outlet to permit voluntary voiding. In this review we give an overview of UI and the artificial urinary sphincter as a method of treatment.