Tadalafil versus tamsulosin as combination therapy with 5-alpha reductase inhibitors in benign prostatic hyperplasia, urinary and sexual outcomes.

PURPOSE: To compare the urological and sexual outcomes of using either tamsulosin/finateride or tadalafil/finasteride as combination therapies in patients with large prostate. PATIENTS AND METHODS: Selection criteria included prostate volume > 40 ml and IPSS > 7. Patients with severe erectile dysfunction (IIEF-erectile functions ≤ 10) were excluded. Patients were randomized into group I (tamsulosin/finasteride) and group II (tadalafil/finasteride). The primary endpoint was to define urinary and sexual function changes (IPSS, IPSS-quality of life, urinary flow rates and IIEF domains) within each group. The secondary endpoint was to compare the treatment induced changes between both groups. RESULTS: At 4th and 12th weeks, 131 and 127 patients were available in both groups, respectively. Both groups showed significant LUTS improvement (IPSS changes: - 4.9 ± 2.7 and - 4.3 ± 2.9 at 4th week and - 6.1 ± 3 and - 5.4 ± 2.8 points by the 12th week in both groups, respectively). Group I had better average flow rates at both follow-up visits. Meanwhile, maximum flow rates were comparable in both groups at 12th week (13.5 ± 3.9vs. 12.6 ± 3.7, p > 0.05). In group I, all IIEF domains were significantly lowered at both visits (p < 0.05). Group II showed significant increase in IIEF-erectile function scores (1.3 ± 1.1 and 1.8 ± 1.2 at the 4th and 12th weeks) with a transient significant reduction of IIEF-orgasm and sexual desire noted only by the 4th week (- 0.8 ± 0.4 and - 0.6 ± 0.4, respectively). CONCLUSION: Within three months, both combinations are comparably effective in improving BPH related LUTS. Tamsulosin/finasteride provided significantly better Qmax only at 4th week. Tadalafil/finasteride had the advantage of improving sexual performance over the other combination.

The effect of stone size on the results of extracorporeal shockwave lithotripsy versus semi-rigid ureteroscopic lithotripsy in the management of upper ureteric stones.

OBJECTIVES: To evaluate the role of stone size on the efficacy and safety of extracorporeal shockwave lithotripsy (ESWL) monotherapy vs ureteroscopy (URS) for managing upper ureteric stones. PATIENTS AND METHODS: The study design was a randomised prospective study of a total cohort of 180 patients with upper ureteric single stones of 0.5-1.5 cm. Half of the patients were managed by ESWL monotherapy, while the other half underwent URS with stone fragmentation using an ultrasound lithotripter (URSL). The success rate, re-treatment rate, auxiliary procedure (AP) rate, efficacy quotient, and complications were compared between the two groups. RESULTS: After single URSL and ESWL procedures 70/90 (77.8%) and 35/90 (38.9%) of the stones were successfully cleared, respectively (P < 0.001). The re-treatment rate after ESWL was significantly higher than in the URSL group (38.9% vs 11.1%, P < 0.001). Requiring an AP was not significantly different following ESWL (22.2%) and URSL (24.4%) treatment. The overall stone-free rate (SFR) at 3 months was significantly superior in the URSL group (88.9% vs 77.8%); however, both procedures had excellent results with no significant difference for stones of <1 cm (95.5% vs 92.9%, P > 0.05), compared to better results following URSL for stones of >1 cm (82.6% vs 64.6%, P < 0.05). CONCLUSION: Our present study supports that ESWL is recommended as a first-line non-invasive monotherapy for upper ureteric opaque stones of <1 cm, while URSL is recommended as a first-line treatment for stones of >1 cm. The results for URSL were superior with lower a re-treatment rate, rapid stone clearance in a very short time, and less radiation exposure. Therefore, stone size is an important factor for the final decision of the initial management of upper ureteric stones because it has a direct relation to the efficacy of ESWL, but it has no effect on the results of URSL.

Efficacy of extracorporeal shockwave lithotripsy, with modified position of the machine head in the treatment of lower calyceal stones in obese patients.

CONTEXT: Extracorporeal shock wave lithotripsy (ESWL) has inferior results in the lower calyceal stones, especially in obese patients. AIMS: This study aimed at evaluating of the efficacy of extracorporeal shockwave lithotripsy, with modified position of the machine head in the treatment of single lower calyceal stones in obese patients. SETTINGS AND DESIGN: This was a prospective study (phase IV trial). SUBJECTS AND METHODS: We studied the anterior rotation of the shock wave machine head in obese patients for the treatment of lower calyx stones. From February 2015 to June 2019, 105 obese patients (body mass index [BMI] ≥35) having lower calyx stones (≤20 mm) underwent ESWL at our institute. The procedure was done in a supine position, and the head of the shock-wave machine was tilted anteriorly. ESWL was considered successful if the kidney was completely cleared of stones. STATISTICAL ANALYSIS USED: The statistical methods used were descriptive statistics, mean, standard deviation frequency analysis, Chi-square test, unpaired t-test test, and Pearson correlations (r). RESULTS: The mean BMI of these patients was 39.71 ± 2.8 kg/m2, the mean stone size was 17.4 ± 2.1 mm, the mean stone density was 767.1 ± 193.4 Hounsfield unit, and the mean of skin to stone distance (SSD) was 145.4 ± 4.5 mm. ESWL was successful in 86 (81.9%) patients; 13 patients (12.4%) showed complete success after the first session, while 37 (35.2%), 25 (23.8%), and 11 (10.5%) patients showed success after the second, third, and fourth sessions, respectively. ESWL failed in 19 (19.1%) cases. The success rate decreased significantly with higher stone density and SSD (P < 0.001), with negative correlations (r values) of -0.871 and -0.811, respectively. CONCLUSIONS: Anterior rotation of the head of the shock wave machine is a suitable option for the treatment of lower calyceal stones in obese patients.

Mirabegron versus Solifenacin in Children with Overactive Bladder: Prospective Randomized Single-Blind Controlled Trial.

PURPOSE: The purpose of this study is to investigate the efficacy and safety of mirabegron versus solifenacin in the treatment of newly diagnosed overactive bladder (OAB) in children. METHODS: We conducted a prospective randomized controlled study on pediatric patients with newly diagnosed OAB. Patients were randomized into 3 groups: mirabegron (50 mg once daily) in group I, solifenacin (5 mg) in group II, and placebo in group III. Before starting our treatment and at the end of the 3 months course, we obtained a 3-day voiding diary. This diary included incontinence episode per day, mean voided volume per micturition, mean number of micturition per day, and post-void residual urine. Moreover, the parents/patients were asked to rate symptom relief, and the adverse events were recorded throughout the study period. RESULTS: A total of 190 patients aged from 5 to 14 years completed this study. At the end of this trial, both groups I and II showed significant improvement versus placebo regarding our efficacy parameters with no significant difference between group I and II. The overall success rate based on assessment of symptom relief was significantly higher in the treated groups (87.5% in I and 90.2% in II) versus placebo (55.8%). Dry mouth was reported in 2.8, 10, and 0% and constipation in 2.8, 11.4, and 1.4% in group I, II, and III, respectively, without statistically significant difference between group I and placebo. However, there was a significant difference between group II and placebo regarding these side effects. CONCLUSION: Both mirabegron and solifenacin have comparable efficacy regarding the control of OAB symptoms in the newly diagnosed children, but mirabegrone seems to have less side effects.

Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study.

AIM: To compare the efficacy and safety of silodosin versus tamsulosin as medical expulsive therapy for stones of lower-third ureter in children. PATIENTS AND METHODS: This prospective single-blind placebo-controlled randomized study included 167 pediatric patients who presented with distal ureteric stone (DUS) less than 1 cm. Patients were randomized into 3 groups; group I received silodosin 4 mg once daily, and group II received tamsulosin 0.4 mg while those in group III had placebo. The side effects of the used drugs, both rate and time of stone expulsion, and number of pain episodes were compared among the study groups for a maximum of 4 weeks. RESULTS: Follow-up data of our patients after treatment revealed that the stone expulsion rate was significantly higher and the time to stone expulsion was significantly shorter in group I (89.3%, 12.4 ± 2.3 days) and group II (74.5%, 16.2 ± 4.2 days) compared to group III (51.8%, 21.2 ± 5.6). However, a statistically significant difference between silodosin and tamsulosin groups in favor of the former one was reported regarding the 2 studied items. Meanwhile, pain episodes requiring analgesia were statistically fewer in group I and II in contrast to placebo group. Adverse events were comparable among all groups. CONCLUSION: Silodosin provides significantly better stone expulsion rate and shorter expulsion time than tamsulosin for treatment of DUS. Both medications showed good safety profiles in children. However, further studies are required on a larger scale to confirm our results. Assessment of drug safety on younger age-group is still needed.

Efficacy and safety of mirabegron versus solifenacin as additional therapy for persistent OAB symptoms after tamsulosin monotherapy in men with probable BPO.

PURPOSE: To investigate the efficacy and safety of mirabegron versus solifenacin as add-on for persistent OAB symptoms after tamsulosin monotherapy in men with probable BPO. PATIENTS AND METHODS: This prospective randomized single-blind study was conducted on patients with persistent OAB symptoms after at least 12 weeks of tamsulosin 0.4 mg. The patients were randomized into group A in which mirabegron (50 mg once daily) was added and group B in which solifenacin (5 mg once daily) was added. Before and 12 weeks after addition of either drugs, we assessed the efficacy of the treatment using the OABSS, IPSS, Q max, MVV/mic and PVR. RESULTS: Ninety two men were included in this study (46 patients in each group). All the study parameters were significantly improved after the 12-week treatment period in both groups except mean PVR which showed non-significant change in group A and a significant change in group B despite of being clinically irrelevant with only one case of acute urine retention. Overall, no significant difference has been observed between both groups after 12 weeks of treatment regarding all studied parameters except PVR. The incidence of side effects in group A was 10.9% versus 26.1% in group B. Main side effects included dry mouth in 2.2% and 8.7% and constipation in 2.2% and 6.5% in group A and B, respectively. CONCLUSION: Our results indicate that the addition of either mirabegron or solifenacin to patients with persistent OAB symptoms after tamsulosin monotherapy has significant efficacy in controlling these symptoms. The adequate balance between efficacy and tolerability reported in this study with mirabegron may result in better QOL and overall patient satisfaction if compared with antimuscarinics.

Lactate and intestinal fatty acid binding protein as essential biomarkers in neonates with necrotizing enterocolitis: ultrasonographic and surgical considerations.

BACKGROUND: Necrotizing enterocolitis (NEC) is a neonatal disease with its pathogenesis still not well understood, although it is hypothesized to be related to decreased perfusion of the intestinal wall. The current study aimed to evaluate the plasma lactate levels and assess the validity of plasma and urinary intestinal fatty acid binding protein (I-FABPp and I-FABPu/Cru respectively) in NEC. METHODS: The study included 55 neonates with variable Bell's stages who were comparable with 23 matched controls. Colorimetric assays of plasma lactate and ELISA assays of I-FABP in both serum and urine of the included neonates have been performed. RESULTS: There were significantly higher median levels of I-FABPp, I-FABPu and lactate among cases (2.84 ng/ml, 1.74 ng/g creat. and 32.34 mg/dl, respectively) compared with controls (0.16 ng/ml, 0.60 ng/g creat. and 15.33 mg/dl, respectively) with p ˂ 0.05 for all. I-FABPp at cut-off point >3.24 ng/ml showed 90% sensitivity, 72% specificity, PPV = 52.6%, NPP = 94.7%, while for I-FABPu (at cut-off point > 2.93 ng/g creat.) those values were 90%, 92%, 81.8% and 95.8% respectively, in discriminating stage IIIA from stage II with p = 0.001. In predicting surgical NEC, I-FABPp at the cut-off point of 6.95 ng/ml revealed 75% sensitivity, 100% specificity, PPV = 100%, NPP = 95%, while for I-FABPu (cut-off point>4.13 ng/g creat.) they were 100%, 76.19%, 44.4 %and 100%, p = 0.04. CONCLUSION: s: In addition to clinical judgment, sonographic data and plasma lactate, I-FABPp was shown to be a specific marker for early identification of surgical NEC, while I-FABPu could be more useful for differentiating Bell's stage II from stage III.

Management of 'forgotten' encrusted JJ stents using extracorporeal shockwave lithotripsy: A single-centre experience.

Objective: To evaluate the role of extracorporeal shockwave lithotripsy (ESWL) for the management of 'forgotten' encrusted stents. Patients and Method: This is a retrospective study of 133 patients with forgotten JJ stents, treated between January 2015 and January 2018. Encrustation was mainly found in the renal coil of the stent with distal concomitant encrustation in the vesical and/or ureteric segment. After laboratory and radiological assessment, treatment started with ESWL for the renal encrustation before successful extraction. Auxiliary endourological procedures were used for the encrusted vesical or ureteric segments. Failed cases underwent open surgery. Results: The mean (SD; range) JJ stent indwelling time was 25.84 (10; 14-70) months. In all, 96 (72.2%) patients were seen after treatment for stone disease. In total, 94 patients (70.7%) were managed by ESWL monotherapy, whilst in 36 (27%) additional endourological procedures were required before successful extraction including: cystolithotripsy 19 patients (52.8%), ureteroscopic lithotripsy eight (22.2%), and percutaneous nephrolithotomy nine (25%). Open surgery was required in only three patients (2.3%). A mean of 0.28 procedures per patient was required before smooth stent extraction. The encrusted stents were removed after the first, second, third, and fourth ESWL sessions in 44 patients (33.1%), 43 (32.3%), 26 (19.5%), and 17 (12.8%), respectively. Patients with forgotten indwelling JJ stents for >2 years had significantly larger and harder encrustation at both JJ coils. Conclusion: ESWL proved a feasible first-line treatment for forgotten encrusted JJ stents. The indwelling time of forgotten stents in the urinary tract is associated with greater encrustation burden, density and multiple sites of encrustation. Abbreviations: CLT: cystolithotripsy; ESWL: extracorporeal shockwave lithotripsy; HU: Hounsfield unit; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; PCNL: percutaneous nephrolithotomy; URL: ureteroscopic lithotripsy.

Outcome of Modification of Dose and Time of Administration of Tamsulosin in Men with Abnormal Ejaculation.

INTRODUCTION: Alpha-adrenergic blockers are now the cornerstone medication in management of lower urinary tract symptom (LUTS); however, the associated treatment-related abnormal ejaculation could be a bothersome event. This is a comparative study among different methods of tamsulosin administration in terms of efficacy, recoverability of ejaculatory function, and quality of life (QoL) in men with tamsulosin-related abnormal ejaculation. PATIENTS AND METHODS: Sexually active men receiving tamsulosin for LUTS who were bothered by treatment-related abnormal ejaculation following initiation of tamsulosin were randomized into 3 groups; group A received intermittent-full-standard-dose, group B received low-dose-tamsulosin, and group C received full-standard-dose tamsulosin The status of ejaculatory function, IPSS, QoL score, and Q-Max were measured at baseline and 3 months later. RESULTS: A total of 93 men with mean age of 53.1 years were included in the study, 3-months after randomization, statistically significant improvements in IPSS, QoL index, and Q-Max in comparison to pre-treatment levels were noted. Restoration of normal ejaculation was reported by 74.1 and 90.3% of patients in group A and B, respectively, versus none in group C. The QoL score was significant when comparing group A to the other groups; finally, the Q-Max was significant when comparing group C to the other groups. CONCLUSION: For patients bothered by tamsulosin-related abnormal ejaculation, a significant improvement in the QoL, without deviation from the therapeutic purpose of treatment, can be achieved by administration of 0.4 mg tamsulosin every other day.

Validity of a sponge trainer as a simple training model for percutaneous renal access.

OBJECTIVE: To evaluate the efficacy of our simply designed trainer for junior urologists to acquire the initial skills for percutaneous renal access (PRA). SUBJECTS AND METHODS: Three sponge sheets (60 × 50 × 10 cm) were arranged horizontally over each other. A rectangular groove was made in the middle sheet to accommodate an inflated balloon of a Foley catheter, radio-opaque metal balls, metal rings, or a plastic tube that were sequentially placed for the four training tasks. In each session, 18 trainees were asked to pass a fluoroscopically guided puncture needle from a surface point to the placed object in middle sheet. Clinical impact of training was evaluated by an experience survey on a 5-piont Likert scale (for model usefulness, tactile and fluoroscopic-guidance feedback) and success rate in further mentored practice. RESULTS: There was a gradual increase in tasks' and sessions' scores over the training sessions. According to the experience survey after first clinical practice, the mean (SD) score for overall model usefulness by trainees was 3.8 (0.9) with high fluoroscopic guidance reality [3.6 (1.1)] but poor tactile realism [2.3 (0.9)]. On mentored PRA, the success rate for trainees was 78.3%. CONCLUSION: Our early evaluation showed our novel, cost-effective and reproducible sponge trainer could be an effective training model for PRA with a beneficial impact on subsequent clinical practice.

The Influence of Body Mass Index on Outcomes in Ureteroscopy: Results from the Clinical Research Office of Endourological Society URS Global Study.

INTRODUCTION: Although ureteroscopy (URS) has been established as a viable treatment for stones in obese patients, its safety and success has not been fully elucidated. The current study describes the worldwide prevalence of obesity in patients with urolithiasis and examines trends in URS outcomes, safety, and efficacy. METHODS: This study utilized the Clinical Research Office of the Endourological Society (CROES) URS Global Study, which was a prospective, multicenter study including 11,885 patients treated with URS for urinary stones at 1 of 114 urology departments across 32 countries. The relationship between body mass index (BMI), diabetes, and creatinine, with retreatment, stone-free rates, complications, and long hospital stay, was examined with a multivariate logistic regression analyses. RESULTS: Of the 10,099 URS patients with BMI data, 17.4% were obese and 2.2% were super obese. Overall, 86.7% patients were stone free and 16.8% required retreatment. Higher BMI was associated with lower stone-free rates, and any deviation from normal weight was associated with higher retreatment rates. In multivariate analysis controlling for several variables including stone size, the association between BMI and lower stone-free rates with higher retreatment rates persisted. Intraoperative complications occurred in 518 (5.1%) patients, and 343 (3.4%) experienced a postoperative complication. Postoperative complications were more frequent in the underweight and super obese subjects, and there was no relationship between BMI and intraoperative complications. DISCUSSION: Although URS for stone disease was found to be an overall safe procedure for obese and super obese patients, efficacy of the procedure may be lower compared with normal-weight subjects and higher retreatment rates may be necessary.

Goserelin acetate before transurethral resection of moderately enlarged benign prostatic hyperplasia: Prospective randomised-controlled clinical trial.

OBJECTIVE: To evaluate the impact of a luteinising hormone-releasing hormone (LHRH) agonist, goserelin acetate (GA), on surgical blood loss during transurethral resection of the prostate (TURP), as well as its histopathological effect on prostatic microvessel density (MVD). PATIENTS AND METHODS: Patients who underwent TURP due to benign prostatic enlargement (60-100 mL) were randomly subdivided into two equal groups according to whether they received preoperative GA administration (3.6 mg; group A) or not (group B). Evaluation parameters were operative time, weight of resected prostatic tissue, perioperative haematocrit (HCT) changes, estimation of intraoperative blood loss, and suburethral and stromal prostatic MVD. Effects of GA on prostate weight and any possible side-effects were also monitored. RESULTS: In all, 35 and 33 patients were included in groups A and B, respectively. Operative time and HCT values' changes were significantly less in group A (P < 0.05). Also, operative blood loss (both total and adjusted per weight of resected tissue) was lower in group A, at a mean (SD) of 178.13 (77.71) mL and 3.74 (1.52) mL/g vs 371.75 (91.09) mL and 8.59 (2.42) mL/g (P < 0.001). The median MVD in both suburethral [8 vs 11 vessels/high-power field (HPF)] and stromal tissues (9 vs 17 vessels/HPF) were significantly lower in group A (P < 0.001). Side-effects were minimal. CONCLUSION: A single dose of GA, a LHRH agonist, before TURP is safe and effective in reducing surgical blood loss. It significantly reduced MVD in both suburethral and stromal nodular prostatic tissues without regional discrepancy.

Immediate and late management of iatrogenic ureteric injuries: 28 years of experience.

OBJECTIVE: To evaluate the long-term results after managing intraoperative and late-diagnosed cases of iatrogenic ureteric injury (IUI), treated endoscopically or by open surgery. PATIENTS AND METHODS: Patients immediately diagnosed with IUI were managed under the same anaesthetic, while those referred late had a radiological assessment of the site of injury, and endoscopic management. Open surgical procedures were used only for the failed cases with previous diversion. RESULTS: In all, 98 patients who were followed had IUI after gynaecological, abdominopelvic and ureteroscopic procedures in 60.2%, 14.3% and 25.5%, respectively. The 27 patients diagnosed during surgery were managed immediately, while in the late-referred 71 patients ureteroscopic ureteric realignment with stenting was successful in 26 (36.6%). Complex open reconstruction with re-implantation or ureteric substitution, using bladder-tube or intestinal-loop procedures, was used in 27 (60%), 16 (35.5%) and two (4.5%) patients of the late group, respectively. A long-term radiological follow-up with a mean (range) of 46.6 (24.5-144) months showed recurrent obstruction in 16 (16.3%) patients managed endoscopically and reflux in six (8.3%) patients. Three renal units only (3%) were lost in the late-presenting patients. CONCLUSION: Patients managed immediately had better long-term results. More than a third of the late-diagnosed patients were successfully managed endoscopically with minimal morbidity. Open reconstruction by an experienced urologist who can perform a complex substitutional procedure was mandatory to preserve renal units in the long-term.

Intraprostatic injection of botulinum toxin-A in patients with refractory chronic pelvic pain syndrome: The transurethral vs. transrectal approach.

OBJECTIVE: To evaluate the outcome of an intraprostatic injection of botulinum toxin-A (BTX-A) in men with refractory chronic prostatitis-associated chronic pelvic-pain syndrome (CP/CPPS) and to compare the efficacy of the transurethral and transrectal routes. PATIENTS AND METHODS: In an uncontrolled randomised clinical trial conducted in men with refractory CP/CPPS, the patients were classified into two groups according to the route of BTX-A injection; transurethral (group 1, 28 patients) and transrectal ultrasonography-guided (group 2, 35 patients). The chronic prostatitis symptom index (CPSI), maximum urinary flow rate (Q max) and white blood cell (WBC) count in expressed prostatic secretion (EPS) were measured before and at 3, 6 and 12 months after the injection. A significant clinical improvement (SCI, defined as a reduction of 4 points or a 25% decrease in total CPSI score) was correlated with patient age, prostate volume and symptom duration. RESULTS: In group 1, the pain and quality-of-life domain scores improved, but statistically significantly only at 6 months. The voiding score improved at all follow-up visits. In group 2 there was a significant improvement in all the CPSI domain scores at all follow-up visits, except for pain, which was insignificantly improved by 12 months. The SCI ratings in groups 1 and 2 were 36%, 79% and 57%, and 49%, 89% and 74% in group 2 at the three follow-up visits, respectively. The Q max was significantly improved in both groups during the follow-up (except at 12 months in group 1). There was a significant reduction in the mean WBC count in the EPS in patients with inflammatory prostatitis. Both prostate volume and symptom duration were significantly associated with a lower SCI rating. CONCLUSION: BTX-A is an available treatment option for patients with refractory CP/CPPS. It is more effective in patients with a small prostate and short symptom duration. The transrectal route provided better results than the transurethral route. More prospective longer term studies are needed.

The long-term results of lingual mucosal grafts for repairing long anterior urethral strictures.

OBJECTIVE: To evaluate the long-term results of repairing long anterior urethral strictures with lingual mucosa onlay grafts. PATIENTS AND METHODS: This study included 23 patients (mean age 36.3 years, range 21-62) who had a lingual mucosa onlay graft for managing a long anterior urethral stricture, and who were followed up for ⩾5 years. The mean length of the stricture was 4.6 cm. The International Prostate Symptom Score and uroflowmetry values were obtained before surgery, and at 3, 6 and 12 months afterwards, and annually thereafter. A retrograde urethrogram with a voiding cysto-urethrogram was taken before surgery, at catheter removal, after 3 and 6 months, and selectively thereafter. RESULTS: The mean (range) follow-up was 66 (60-72) months. The cause of the stricture was trauma in nine patients, instrumentation in seven, idiopathic in four, urethritis in two and previous hypospadias repair in one. The surgery was successful in 20 of the 23 patients (87%), and a recurrent stricture developed in the remaining three. There were no fistulae or clinically perceptible graft sacculations, and no long-term donor-site complications. CONCLUSIONS: With a long-term follow-up, our series confirms the durability of lingual mucosal onlay grafts for treating long anterior urethral strictures. This procedure results in a long-term high success rate with few of the complications that occur primarily during the first year.

Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study.

OBJECTIVE: The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) versus penile skin flap (PSF) in the repair of long anterior urethral strictures. MATERIAL AND METHODS: Patients with long anterior urethral strictures were randomized to receive either dorsal onlay BMG urethroplasty or PSF urethroplasty. All patients were evaluated preoperatively and during follow-up with the International Prostate Symptom Score (IPSS) and uroflowmetry. Success was reported when there were no obstructive symptoms on IPSS, with a peak urinary flow rate (Qmax) of at least 15 ml/s. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on urethrography. RESULTS: The study included 19 and 18 patients in the BMG and PSF groups, respectively. The mean operative time was significantly shorter in the BMG than in the PSF group. The success rate was higher in the BMG than in the PSF group (89.5% vs 83.3%), but not statistically significant different. The PSF group included one case of extensive skin loss, three cases with superficial skin necrosis and two with minor penile torsion. In the BMG group, there were three cases of perioral numbness and another three had increased salivation. The incidence of troublesome postvoid urinary dribbling was significantly higher in the PSF than in the BMG group. After 6 months of urethroplasty, patient satisfaction was statistically significantly higher in the BMG than in the PSF group. CONCLUSIONS: BMG and PSF dorsal onlay urethroplasty had similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction for most patients.

The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: A long-term study at two academic centres.

OBJECTIVE: To determine the incidence of symptomatic and 'silent' obstruction after ureteroscopic procedures. PATIENTS AND METHODS: In all, 1980 patients underwent ureteroscopy for ureteric calculi in two large centres. The methods of disintegration, auxiliary procedures used and type of stenting were considered. Intraoperative complications, in addition to the size and site of the stone, were assessed in relation to postoperative obstruction. The mean (range) follow-up was 42 (12-68) months, with patients assessed after 3-6 months and yearly thereafter. The postoperative evaluation included an assessment of pain, renal ultrasonography, a plain abdominal film, intravenous urography, and a diuretic renal scan in some cases to confirm obstruction. RESULTS: The success rate of stone removal was 98.5%. The failures were related to the size of the stone (>2 cm; P < 0.001). In eight patients there was a ureteric perforation, and six of these developed a ureteric stricture. A stricture also occurred in 12 patients (0.6%) during the follow-up; these included nine of 204 with stones of >2 cm (4.4%), compared to three (0.17%) of 1746 patients with stones of <2 cm (P < 0.001). Fourteen patients presented with pain (0.7%), and five had no obstruction, while in nine (0.46%) the pain was associated with obstruction. There was silent obstruction in three cases (0.15%). The negative and positive predictive values for pain were 99.8% and 64.3%, respectively. CONCLUSIONS: Radiographic surveillance for stricture formation and obstruction is mandatory in patients who are symptomatic after ureteroscopy, and for up to 18 months in patients with intraoperative complications or with a stone of >2 cm in the proximal ureter.