Health related quality of life after urinary diversion. Which technique is better?

OBJECTIVE: To compare quality of life (QoL) after urinary diversion (UD) following radical cystectomy (RC) using validated questionnaires. PATIENTS AND METHODS: Between January 2011 and June 2016, 150 patients (121 men [80.7%] and 29 women [19.3%]) with invasive bladder cancer who underwent RC and UD were included in this prospective study. Patients were divided into 2 groups; group I included the orthotopic neobladder 50 (33.3%) and uretro-sigmoidostomy 41 (27.3%) and group II included uretero-cutanoustomy 33 (22.1%) and ileal conduit 26 (17.3%) patients. QOL was evaluated using the Functional Assessment of Cancer Therapy-Bladder Cancer. The erectile function (EF) was assessed using the Sexual Health Inventory for Men Questionnaire. Evaluation was done before and after one year postoperatively. RESULTS: The mean ±â€¯SD patient age was 55.0 ±â€¯7.9 and 59.5 ±â€¯8.5 years in both groups, respectively (p = 0.001). There was a significant difference in the physical, social/family, emotional and functional statuses that were significantly higher in group I. One year postoperatively, the emotional well-being became insignificantly different, but other QoL parameters remained significantly different between both groups. Regarding EF, there was a significant difference between patients who underwent nerve-sparing (No. 29) and non nerve-sparing RC (No. 59) (p < 0.001). CONCLUSIONS: Which type of diversion is the best is still a controversial topic. Egyptian patients may prefer the continent UD to avoid the urostomy appliance and its associated daily-life constraints. Detailed patient counseling and active participation of the patient in selecting the treatment methods are important for better postoperative QoL.

Retroperitoneal Varix ligation with sclerotherapy: a prospective randomized comparative study.

INTRODUCTION: The aim of this article is to compare the results of high varix ligation with and without sclerotherapy. MATERIAL AND METHODS: Between November 2014 and December 2015, sixty patients with varicocele were included in this study. Patients were divided into two equal groups; group I (underwent high varix ligation), and group II (underwent high varix ligation with a retrograde injection of 2 mL of 5% ethanolamine oleate in the lower end of the bisected gonadal vein). The operative time, intra- and postoperative complications, postoperative pain, improvement of semen parameters, incidence of recurrence and achieving of unassisted pregnancy were recorded for both groups. RESULTS: The age range was 19-34 years in group I and 21-37 years in group II. The operative time was shorter in group I (34.6 ±7.81 min) than group II (43.3 ±8.5 min) (P <0.001), which was statistically significant.Improvement of semen parameters and the occurrence of spontaneous pregnancy were insignificant between both groups. No intraoperative complications occurred. The postoperative complications were statistically insignificant in both groups. CONCLUSIONS: Combined varix ligation with retrograde sclerotherapy does not offer significant advantages over high varix ligation alone with a longer operative time and prolonged post-operative pain.

A modified onlay island flap vs. Mathieu urethroplasty for distal hypospadias repair: A prospective randomised study.

OBJECTIVE: To compare the outcome of a modified onlay island flap (MOIF) with that of the Mathieu urethroplasty for distal hypospadias repair. PATIENTS AND METHODS: In a prospective randomised study, 60 patients with coronal, subcoronal and distal penile hypospadias, with a urethral plate width of ⩽6 mm, and minimal or no chordee, underwent either MOIF using a midline longitudinal outer preputial skin flap passed ventrally by penile buttonholing through dartos fascia incision, or a Mathieu urethroplasty. Closed envelopes were used for randomly selecting patients for each procedure. The operative duration, complications, cosmetic outcome, urinary stream and relatives' satisfaction were reported for each procedure. RESULTS: Preoperative data (patients' age and site of urethral meatus) and operative duration were insignificantly different between the groups (P = 0.653, 0.786 and 0.710, respectively). There were no intraoperative complications in either group. The duration of follow-up was insignificantly different between the groups. Patients treated with the MOIF had a statistically significant lower complication rate (P = 0.036), and a better cosmetic outcome, urinary stream and relatives' satisfaction (P < 0.001 for all). CONCLUSIONS: The MOIF urethroplasty seemed to be better than the Mathieu urethroplasty in patients with distal hypospadias and narrow urethral plates. Further studies including more patients, and a longer follow-up with an objective evaluation of functional outcome should be encouraged to confirm these early results.

Evaluation of early endoscopic realignment of post-traumatic complete posterior urethral rupture.

INTRODUCTION: to report our experience with 41 patients treated by early endoscopic realignment of complete post-traumatic rupture urethra. MATERIALS AND METHODS: The study includes patients presented to our institute, between May 2004 and April 2009, with post-traumatic complete posterior urethral disruption. Preoperative retrograde urethrography, voiding cystourethrography and abdominopelvic CT were performed to evaluate the urethral defect length, the bladder neck competence, the prostate position, and the extent of the pelvic hematoma. Within the first week after trauma, antegrade and retrograde urethroscopy were performed to identify both urethral ends and insert urethral catheter. Patients were followed up by pericatheter retrograde urethrogram monthly postoperatively till catheter removal on disappearance of extravasation. Retrograde urethrography, voiding cystourethrography and urethroscopy were performed 1 month after the removal of the catheter. Follow-up abdominal ultrasound and uroflowmetry monthly till 6 months, bimonthly till 1 year, and every 3 months thereafter were encouraged. Urinary continence and postoperative erectile dysfunction were assessed by direct patient interview. RESULTS: Forty one patients in the age group 17-61 years (mean 37.9) were treated. Patients were followed up for. CONCLUSIONS: Early endoscopic realignment for complete posterior urethral rupture is a feasible technique with no or minimal intraoperative complications. The technique is successful as the definitive line of therapy in reasonable number of patients and seems to render further future interventions for inevitable urethral stricture easier.

Comparing non contrast computerized tomography criteria versus dual X-ray absorptiometry as predictors of radio-opaque upper urinary tract stone fragmentation after electromagnetic shockwave lithotripsy.

The objective of this study was to assess the value of dual X-ray absorptiometry (DXA) in comparison to non contrast computed tomography (NCCT) density as possible predictors of upper urinary tract stone disintegration by shock wave lithotripsy (SWL). This study included 100 consecutive patients, with solitary renal stone 0.5-2 cm or upper ureteral stone up to 1 cm. DXA to calculate stone mineral density (SMD) and stone mineral content (SMC) was done. NCCT was performed to measure Hounsfield units (HU). SWL was performed with an electromagnetic lithotripsy, plain X-ray documented disintegration after SWL. Successful treatment was defined as stone free or complete fragmentation after 1 or 2 sessions of SWL. The impact of patients age, sex, body mass index, stone laterality, location, volume, length, mean SMC and SMD, HU and Hounsfield density (HD), skin to stone distance (SSD) and number of shock waves were evaluated by univariate and multivariate analysis. Only 76 patients were available for follow-up. Success of disintegration was observed in 50 out of 76 patients (65.8 %). On multivariate analysis, SMC and number of shock wave were the significant independent factors affecting SWL outcome (p = 0.04 and p = 0.000, respectively). SMC as detected by DXA is a significant predictor of success of stone disintegration by SWL. SMC measured by DXA is more accurate than HU measured by CT. Patients with high stone mineral content (SMC greater than 0.65 g) should be directly offered another treatment option.

Sensitivity and specificity of ultrasonography in predicting etiology of azoospermia.

OBJECTIVE: To determine the sensitivity and specificity of different ultrasound (US) modalities in predicting an obstructive vs a nonobstructive etiology of azoospermia. MATERIALS AND METHODS: A total of 268 azoospermic men with available histopathologic slides were separated into obstructive (n = 104) and nonobstructive (n = 164) groups. Scrotal US studies, including color Doppler and transrectal US examinations, were performed in all patients and compared with the testicular biopsy results as the reference standard. RESULTS: We found that a decreased testicular volume and intra- and extratesticular varicocele were the most common abnormalities detected using scrotal US in those with nonobstructive azoospermia. In contrast, epididymitis, spermatocele, and duct ectasia were the most common findings in those with obstructive azoospermia. The sensitivity and specificity of scrotal US in detecting nonobstructive azoospermia was 75% and 72%, respectively, and for detecting obstructive azoospermia was 29.8% and 87%, respectively. Prostatic midline cysts, ejaculatory duct calcification, dilated seminal vesicle, and/or vassal ampullae were the most common abnormalities detected using transrectal US for obstructive azoospermia. The sensitivity and specificity of transrectal US in detecting obstructive etiology was 45% and 83%, respectively, and for functional etiology was 39% and 88%, respectively. CONCLUSION: Scrotal US was more sensitive in detecting functional azoospermia and more specific in detecting obstructive azoospermia. However, transrectal US was more sensitive in detecting obstructive azoospermia and more specific in detecting functional azoospermia. Both tests had greater specificity than sensitivity for obstructive azoospermia, indicating that US has the ability to exclude more than to diagnose cases of obstructive azoospermia. However, US is unlikely to completely replace testicular biopsy.

Prepuce preserving versus conventional Mathieu urethroplasty for distal hypospadias - a prospective randomized study.

OBJECTIVES: To evaluate the impact of prepuce preservation during Mathieu repair for distal hypospadias. METHODS: This prospective randomized comparative study, carried out in Assiut University Hospital, between 2006 and 2009, included 200 patients with distal penile or coronal hypospadias. They underwent either Mathieu repair with prepuce preservation (group I, n = 100) or traditional Mathieu repair with circumcision (group II, n = 100). Follow up was at 2 weeks, and 1 and 3 months postoperatively, which only 153 patients completed (I: n = 86 and II: n = 67). RESULTS: The mean operative time was 64.5 min in group I and 121.7 min in group II (p < 0.001). All patients in group I developed postoperative preputial edema. Patients from group I who had a successful operation underwent circumcision at least 3 months later. Urethrocutaneous fistulae developed in 7 and 6 patients in group I and II respectively (p = 0.967). Fistula closure was done at least 3 months postoperatively, and there was no significant difference in success between the two groups. Two cases of glanular dehiscence were detected (one in each group); the patient from group I had a successful onlay island flap repair. CONCLUSIONS: Preputial preservation during Mathieu repair is a time-saving procedure with similar complication rate to traditional repair. Valuable local tissue is preserved to deal with complications that may occur.

Management of the looping vas deferens during laparoscopic orchiopexy.

PURPOSE: A number of variables should be assessed during laparoscopic orchiopexy, including vas anatomy. A looping vas deferens enters the inguinal canal and loops back to the abdominal cavity. This anatomical variant is not uncommonly encountered. Some groups considered this condition in their laparoscopic classification of nonpalpable testis. We present our experience with managing the looping vas during laparoscopic orchiopexy. MATERIALS AND METHODS: We identified this condition in 18 procedures. In 14 cases it was possible to bring the vas back to the abdominal cavity. In 3 cases the loop could not be brought back laparoscopically and an inguinal incision was used. After the vas was dissected free and dropped into the abdominal cavity pneumoperitoneum was resumed and the procedure was completed laparoscopically. A Web based survey was done to test the value of this method. RESULTS: A total of 17 procedures were completed successfully with preservation of the vas deferens while in 1 the vas was inadvertently cut. A looping vas did not significantly affect operative time. All 18 testes were viable and retained the scrotal position on followup scrotal Doppler ultrasound. CONCLUSIONS: Verification of vasal anatomy is a crucial step that should be completed before any dissection. Bringing a looping vas back to the abdominal cavity is usually feasible laparoscopically but in a few cases this may require a small incision to dissect the vasal loop from its inguinal attachments.

Can Bcl-XL expression predict the radio sensitivity of bilharzial-related squamous bladder carcinoma? A prospective comparative study.

BACKGROUND: Local pelvic recurrence after radical cystectomy for muscle invasive bilharzial related squamous cell carcinoma accounts for 75% of treatment failures even in organ confined tumors. Despite the proven value of lymphadenectomy, up to 60% of patients undergoing cystectomy do not have it. These factors are in favor of adjuvant radiotherapy reevaluation. objectives: to evaluate the effect of adjuvant radiotherapy on disease free survival in muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder and to test the predictability of radio-sensitivity using the anti apoptotic protein Bcl-XL. METHODS: The study prospectively included 71 patients, (47 males, 24 females) with muscle invasive bilharzial related squamous cell carcinoma of the bladder (Stage pT2a-T3N0-N3M0) who underwent radical cystectomy in Assiut university hospitals between January 2005 and December 2006. Thirty eight patients received adjuvant radiotherapy to the pelvis in the dose of 50Gy/25 fractions/5 weeks (Group 1), while 33 patients did not receive adjuvant radiotherapy (group 2). Immunohistochemical characterization for bcl-xL expression was done. Follow up was done every 3 months for 12 to 36 months with a mean of 16 ± 10 months. All data were analyzed using SPSS version 16. Three years cumulative disease free survival was calculated and adjusted to Bcl-XL expression and side effects of the treatment were recorded. RESULTS: The disease free cumulative survival was 48% for group 1 and 29% for group 2 (log rank p value 0.03). The multivariate predictors of tumor recurrence were the positive Bcl-XL expression (odd ratio 41.1, 95% CI 8.4-102.3, p < 0.0001) and radiotherapy (odd ratio 0.19, 95% CI 0.05-0.78, p < 0.02). With Cox regression, the only independent multivariate predictor of radio-sensitivity was the Bcl-XL expression with odd ratio 4.6 and a p value < 0.0001. All patients tolerated the treatment with no life threatening or late complications during the period of follow up. CONCLUSIONS: Adjuvant radiotherapy for muscle invasive bilharzial related squamous cell carcinoma of the urinary bladder has potential effectiveness and minor side effects. Moreover, Bcl-XL expression is a valuable tool for predicting those who might not respond to this adjuvant treatment.

Combined Mathieu and Snodgrass urethroplasty for hypospadias repair: a prospective randomized study.

OBJECTIVES: To evaluate the outcomes of combined Mathieu and Snodgrass urethroplasty for distal hypospadias repair and to compare them with the two techniques separately. METHODS: Between January 2006 and February 2009, patients with distal hypospadias were prospectively randomized to undergo one of the three following urethroplasty techniques: Mathieu urethroplasty, Snodgrass urethroplasty or a combination of the two. Operative time, intraoperative, early and late postoperative complications were reported for each procedure. RESULTS: 101 patients were included in this study. The Mathieu technique was used for 30 patients, Snodgrass repair was carried out in 37 patients and 34 patients underwent the combined technique. Operative time ranged from 43 to 120 min. Eight patients developed urethrocutaneous fistulae. Meatal stenosis was encountered in five cases. Thirty-seven patients had rounded meatus, while a slit-like urethral opening was found in 64 cases. CONCLUSIONS: In our hands, the combined Mathieu and Snodgrass urethroplasty technique provided a better cosmetic outcome than the Mathieu technique with no incidence of meatal stenosis as seen with the Snodgrass technique.