Ultraslow full-power shock wave lithotripsy protocol in the management of high attenuation value upper ureteric stones: A randomized comparative study.

OBJECTIVES: To evaluate the efficacy and safety of ultraslow full-power shock wave lithotripsy protocol in the management of high attenuation value upper ureteric stones compared with slow-rate, power-ramping shock wave lithotripsy. METHODS: This was a randomized trial enrolling patients with a single high attenuation value (≥1000 HU) upper ureteric stones between January 2019 and July 2019. Ultraslow full-power shock wave lithotripsy (54 patients) was applied at a rate of 30 shock waves/min with power ramping from 6 to 18 kV for 100 shock waves, then a safety pause for 2 min, followed by ramping 18-22 kV for 100 shock waves, then a safety pause for 2 min. Then, full power (22 kV) was maintained until the end of the session. Slow-rate, power-ramping shock wave lithotripsy (47 patients) was applied at a rate of 60 shock waves/min with power ramping from 6 to 10 kV during the first 500 shock waves, then from 11 to 22 kV during the next 1000 shock waves, then maintained on 22 kV in the last 1500 shock waves. Up to three sessions were carried out with a follow up 3 months after the last session. The primary outcome was the stone-free rate. Perioperative data of the two protocols were compared. RESULTS: There was no significant difference in preoperative data. The stone-free rate was significantly higher in ultraslow full-power shock wave lithotripsy after single (92.6% vs 23.4%) and multiple (96.3% vs 63.8%) sessions. Most complications were mild, with no significant difference between both groups (9.3% vs 12.8%; P = 0.573). Logistic regression analysis identified ultraslow full-power shock wave lithotripsy protocol as the only significant independent factor for the stone-free rate (odds ratio 12.589, P = 0.025). CONCLUSION: Ultraslow full-power shock wave lithotripsy for high attenuation value upper ureteric stones is associated with a significantly higher stone-free rate, and with mild complications that are comparable to those of standard shock wave lithotripsy.

Ultraslow full-power shock wave lithotripsy versus slow power-ramping shock wave lithotripsy in stones with high attenuation value: A randomized comparative study.

OBJECTIVES: To compare the efficacy and safety of ultraslow full-power versus slow rate, power-ramping shock wave lithotripsy in the management of stones with a high attenuation value. METHODS: This was a randomized comparative study enrolling patients with single high attenuation value (≥1000 Hounsfield unit) stones (≤3 cm) between September 2015 and May 2018. Patients with skin-to-stone distance >11 cm or body mass index >30 kg/m2 were excluded. Electrohydraulic shock wave lithotripsy was carried out at rate of 30 shock waves/min for group A versus 60 shock waves/min for group B. In group A, power ramping was from 6 to 18 kV for 100 shock waves, then a safety pause for 2 min, followed by ramping 18-22 kV for 100 shock waves, then a safety pause for 2 min. This full power (22 kV) was maintained until the end of the session. In group B, power ramping was carried out with an increase of 4 kV each 500 shock waves, then maintained on 22 kV in the last 1000-1500 shock waves. Follow up was carried out up to 3 months after the last session. Perioperative data were compared, including the stone free rate (as a primary outcome) and complications (secondary outcome). Predicting factors for success were analyzed using logistic regression. RESULTS: A total of 100 patients in group A and 96 patients in group B were included. The stone-free rate was significantly higher in group A (76% vs 38.5%; P < 0.001). Both groups were comparable in complication rates (20% vs 19.8%; P = 0.971). The stone-free rate remained significantly higher in group A in logistic regression analysis (odds ratio 24.011, 95% confidence interval 8.29-69.54; P < 0.001). CONCLUSIONS: Ultraslow full-power shock wave lithotripsy for high attenuation value stones is associated with an improved stone-free rate without affecting safety. Further validation studies are required using other shock wave lithotripsy machines.

Holmium Laser Enucleation vs Bipolar Plasmakinetic Enucleation of a Large Volume Benign Prostatic Hyperplasia: A Randomized Controlled Trial.

Objectives: To compare safety and efficacy of bipolar plasmakinetic enucleation of prostate (BPEP) vs holmium laser enucleation of prostate (HoLEP) for management of large benign prostatic hyperplasia (BPH) (>80 g). Patients and Methods: Patients with failed medical treatment, International Prostate Symptom Score (IPSS) >13, peak urinary flow rate (Qmax)<15 mL/s and prostate size ≥80 g were enrolled in this randomized controlled trial from November 2016 to February 2018 and managed by HoLEP (Group A; 33 patients) or BPEP (Group B; 31 patients). Patients on anticoagulants (AC) were not excluded. Patients were followed up for 12 months. Perioperative data were compared between both groups using Student's-t, Mann-Whitney, Paired-t, Wilcoxon signed rank, chi-square, or Fisher-exact tests as appropriate. Results: There was no significant difference between both groups in age, rate of presentation with urinary retention, recurrent hematuria, frequency of patients on ACs/antiplatelets, prostate size, prostate specific antigen (PSA), Qmax, IPSS, quality of life (QoL), and post-void residual urine (PVRU). Operative time was significantly longer in BPEP (p = 0.003) and catheterization duration (p = 0.019). Other perioperative parameters including level of Na+ and hemoglobin, resected tissue weight, hospital stay, and complications were not significantly different between both groups. There was no need for blood transfusion in all patients. There was significant postoperative improvement in IPSS, PVRU, QoL, PSA, and Qmax in each group. However, there was no significant difference between both groups in these parameters. Conclusion: HoLEP and BPEP are comparable regarding safety and efficacy for treatment of BPH (>80 g) including patients on ACs. However, BPEP required a longer catheterization duration and operative time. ClinicalTrials.gov Identifier: NCT03998150.

Mini vs standard percutaneous nephrolithotomy for renal stones: a comparative study.

To compare the outcome of mini-percutaneous nephrolithotomy (Mini-PNL) versus standard-PNL for renal stones. Retrospective study was performed between March 2010 and May 2013 for patients treated by Mini-PNL or standard-PNL through 18 and 30 Fr tracts, respectively, using pneumatic lithotripsy. Semirigid ureteroscope (8.5/11.5 Fr) was used for Mini-PNL and 24 Fr nephroscope for standard-PNL. Both groups were compared in stone free rate(SFR), complications and operative time using Student-t, Mann-Whitney, Chi square or Fisher's exact tests as appropriate in addition to logistic regression analysis. P < 0.05 was considered statistically significant. Mini-PNL (378) and standard-PNL (151) were nearly comparable in patients and stones criteria including stone burden (3.77 ± 2.21 vs 3.77 ± 2.43 cm2; respectively). There was no significant difference in number of tracts or supracostal puncture. Mini-PNL had longer operative time (68.6 ± 29.09 vs 60.49 ± 11.38 min; p = 0.434), significantly shorter hospital stay (2.43 ± 1.46 vs 4.29 ± 1.28 days) and significantly higher rate of tubeless PNL (75.1 vs 4.6%). Complications were significantly higher in standard-PNL (7.9 vs 20.5%; p < 0.001). SFR was significantly lower in Mini-PNL (89.9 vs 96%; p = 0.022). This significant difference was found with multiple stones and large stone burden (> 2 cm2), but the SFR was comparable between both groups with single stone or stone burden ≤ 2 cm. Logistic regression analysis confirmed significantly higher complications and SFR with standard-PNL but with significantly shorter operative time. Mini-PNL has significantly lower SFR when compared to standard-PNL (but clinically comparable) with markedly reduced complications and hospital stay. Most of cases can be performed tubeless. The significant difference in SFR was found with multiple stones or large stone burden (> 2 cm2), but not with single stones or stone burden ≤ 2 cm2.

Bilateral Single-session vs Staged Mini-percutaneous Nephrolithotomy for Renal Stones: A Comparative Study.

OBJECTIVE: To compare safety and efficacy of bilateral single-session mini-percutaneous nephrolithotomy (BSS-Mini-PNL) vs staged-Mini-PNL. PATIENTS AND METHODS: Adult patients with bilateral renal stones indicated for PNL were managed with BSS-Mini-PNL (45 patients and 90 renal units) and prospectively compared vs staged-Mini-PNL (55 patients and 110 renal units) between July 2014 and December 2017. Mini-PNL was done through 18-Fr tract in prone position under regional anesthesia and fluoroscopy using pneumatic lithotripsy. A semirigid ureteroscope (8.5/11.5 Fr) was used. Mann-Whitney, Student t, chi-square, or Fisher's exact tests were used as appropriate. RESULTS: Both groups were comparable in characteristics of stones and patients. Stone burden was 3.36 ± 1.61 vs 3.38 ± 1.18 cm2 in BSS-Mini-PNL vs staged-Mini-PNL, respectively. Staghorn stones were present in 13.3% vs 8.2% in BSS-Mini-PNL vs staged-Mini-PNL, respectively. There was no significant difference in the number of required tracts (1.34 ± 0.6 vs 1.25 ± 0.51 tract/renal unit) as well as the rate of tubeless Mini-PNL (81.1% vs 85.5%) or stone-free rate (90% vs 92.7%) in BSS-Mini-PNL vs staged-Mini-PNL, respectively. BSS-Mini-PNL had significantly shorter operative time (126.22 ± 37.2 vs 169.63 ± 61.28 minutes), shorter hospital stay (2 [1-8] vs 4 [2-16] days) and higher hemoglobin loss (1.1 [0.1-2.8] vs 0.5 [0.1-2.17] gm/d) than staged-Mini-PNL. The complications profile (17.8% vs 13.6%) and rate of blood transfusion (4.4% vs 3.6%) were comparable in BSS-Mini-PNL vs staged-Mini-PNL, respectively, without significant difference. CONCLUSION: BSS-Mini-PNL is comparable to staged-PNL as regard stone-free rate and complications according to the selection criteria of the present study. However, BSS-Mini-PNL is associated with significant reduction in the cumulative operative time and hospital stay, which are reflected on the overall cost.

Visual internal urethrotomy for management of urethral strictures in boys: a comparison of short-term outcome of holmium laser versus cold knife.

PURPOSE: To compare efficacy and safety of visual internal urethrotomy (VIU) using holmium laser (Ho:YAG) (group A) versus cold knife (group B) in children with urethral strictures. It may be the first comparative study on this issue in children. METHODS: This study compared Ho:YAG group, which was evaluated prospectively from January 2014 till January 2016, versus cold knife group, which was a historical control performed from March 2008 till February 2010. Children ≤ 13 years old with urethral strictures ≤ 1.5 cm were included successively. Recurrent cases, congenital obstructions and cases with complete arrest of dye in voiding cystourethrography were excluded. Scar tissue was incised at twelve o'clock. Outcome was compared using Student's t, Mann-Whitney, Chi-square or Fisher exact tests as appropriate. RESULTS: Each group included 21 patients. Mean age was 6.27 ± 3.23 (2-13) years old. Mean stricture length was 1.02 versus 1 cm in group A versus B, respectively (p = 0.862). Ten cases of penile/bulbous strictures and another 11 cases of membranous strictures were found in each group. There was no significant difference between both groups in preoperative data. Success rate for initial VIU was 66.7% in group A versus 38% in group B (p = 0.064). This was associated with significantly higher Qmax in group A (mean 16.52 vs 12.09 ml/s; p = 0.03). Success rate after two trials of VIU was 76.2% for group A and 47.61% for group B (p = 0.057). No complications were reported in both groups. CONCLUSION: Laser VIU has a higher success rate than cold knife VIU for urethral strictures ≤ 1.5 cm in children with significantly higher Qmax. Both are easy to perform, low invasive and safe.

Risk factors for urological complications following living donor renal transplantation in children.

The aim of this study was to detect possible risk factors for UC and UTI following pediatric renal Tx and effect of these complications on outcome. One hundred and eight children who underwent living donor Tx between 2009 and 2015 were retrospectively included. Extraperitoneal approach was used with stented tunneled extravesical procedure. Mean recipient age was 9.89 ± 3.46 years while mean weight was 25.22 ± 10.43 kg. Seventy-three (67.6%) recipients were boys while 92 (85.2%) were related to donors. Urological causes of ESRD were present in 33 (30.6%) recipients (14 [13%] posterior urethral valve, 16 [14.8%] VUR, and 3 [2.8%] neurogenic bladder). Augmentation ileocystoplasty was performed in 9 (8.3%) patients. Mean follow-up was 39.3 ± 17.33 months. UC were detected in 10 (9.3%) children (leakage 4 [3.7%], obstruction 3 [2.8%], and VUR 3 [2.8%]) while UTIs were reported in 40 (37%) children. After logistic regression analysis, UC were significantly higher in children with cystoplasty (44.4% vs 6.1%; P = .001). UTIs were significantly higher in girls (51.4% vs 30.1%; P = .001) and in children with urological causes of ESRD (51.5% vs 30.7%; P = .049). UC and UTI were not significantly associated with increased graft loss or mortality. UC were significantly higher in children with cystoplasty while UTIs were significantly higher in girls and children with urological causes of ESRD. Presence of UC did not affect the rate of graft loss or mortality due to its early detection and proper management.

The role of voiding cystourethrography in asymptomatic unilateral isolated ureteropelvic junction obstruction: A retrospective study.

INTRODUCTION: The presence of concomitant vesicoureteric reflux (VUR) and ureteropelvic junction obstruction (UPJO) is uncommon. Nevertheless, the reported VUR coexisting with asymptomatic unilateral isolated hydronephrosis (AUIH) requiring pyeloplasty for correction of UPJO was of low grade and mostly resolved during conservative follow-up. Therefore, VCUG may be not indicated in these children except if voiding symptoms, urinary tract infection (UTI), dilated ureters, or bladder and ureteric abnormalities are suspected. OBJECTIVES: The aim was to evaluate the need for VCUG in infants <1 year old with AUIH for whom a dismembered pyeloplasty was indicated for correction of UPJO. METHODS: Ninety-six children <1 year old with pyeloplasty carried out from January 2012 to March 2014 were retrospectively included. Children with voiding symptoms or dilated ureter, duplex system, fused kidneys, bilateral dilatation, or any bladder abnormality on ultrasound were excluded. Anderson-Hynes pyeloplasty was performed through a flank incision. Preoperative VCUG was analyzed in relation to outcome and any UTI during follow-up. The Student t test, Mann-Whitney U test, or Fisher exact test were used to compare variables. RESULTS: Five children had concomitant VUR with UPJO. Most of the children were circumcised during the first postnatal week. The remaining few children were circumcised at the time of pyeloplasty. Side, grade of detected VUR, and complications (18.75%) (postoperative or during follow-up) are presented in the Table. Outcomes in children with and without VUR were not different. Dismembered pyeloplasty was successful in children with VUR and with no complications except for non-febrile UTI in one child only. Ureters were still not dilated at the last follow-up. DISCUSSION: The required imaging in infants with AUIH is still a subject of debate. As we expected, there was a low incidence of associated VUR in the present study. They were of low grade without any complications during follow-up and without affecting the outcome. The present study has its limitations, including the retrospective nature and short follow-up. However, as at least 2 years of follow-up were documented without any harm or ureteric dilation, VUR will mostly resolve. The present study is strengthened by inclusion of infants only. CONCLUSIONS: Our data suggest that VCUG is not indicated in infants with AUIH requiring pyeloplasty for correction of UPJO. VCUG will not affect the treatment decision, operative outcome, or postoperative complications. VCUG may be indicated in case of suspected voiding symptoms, UTI, dilated ureters, or bladder and ureteric abnormalities.

Dismembered Pyeloplasty in Infants 6 Months Old or Younger With and Without External Trans-anastomotic Nephrostent: A Prospective Randomized Study.

OBJECTIVE: To compare the outcome of dismembered pyeloplasty in infants with and without external nephro-ureteric stent (ENUS) for treatment of congenital ureteropelvic junction obstruction. METHODS: This is a parallel, randomized comparative study between October 2013 and September 2014. Thirty infants ≤6 months old with ureteropelvic junction obstruction indicated for dismembered pyeloplasty were randomly assigned (block randomization, closed envelope method) into two groups: group A (stentless) and group B (ENUS). Infants with solitary kidney, gross pyuria, huge pelvis, vesicoureteric reflux, or other renal anomalies were excluded. Operative data, complications, and ultrasonographic and nuclear scintigraphy criteria were compared after at least 18 months of follow-up using Student t, Mann-Whitney U, Kruskal-Wallis, chi-square, and Fisher exact tests when appropriate. Occurrence of urinary leakage was the primary outcome. RESULTS: Included patients completed the study with intention-to-treat analysis. All children had normal renal function. The mean operative time was 85.3 ± 6.3 (60-90) minutes in group A and 92.6 ± 15.3 (70-120) minutes in group B (P = .2). Although there was a significant postoperative improvement in each group in split renal function and anterior-posterior renal pelvis diameter, there was no significant difference between both groups. The mean hospital stay for group A and group B was 5.9 ± 2 (4-10) days versus 3.5 ± 0.8 (2-5) days, respectively (P < .001). Postoperative urinary leakage was reported only in group A (40%). All complications were managed by double J insertion. Auxiliary interventions were higher in group A. The overall success rate was 93.4%. Redo pyeloplasty was performed in one case in each group. CONCLUSION: ENUS significantly reduces hospital stay and complications. It saves the infant hazards of auxiliary interventions under general anesthesia for management of leakage or double J removal if placed at time of pyeloplasty.

Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition.

OBJECTIVES: The aim of this study was to describe the management protocol for intermittent testicular torsion (ITT) in adults and report the outcome of this clinical condition, which is commonly overlooked in adults. SUBJECTS AND METHODS: Sixty-three patients were included in the study. The inclusion criterion was the presence of sudden intermittent testicular pain over a duration of 3 months. All the patients underwent clinical examination, urine analysis, culture, and scrotal ultrasound with Doppler. The testicle was in an abnormal or in transverse lie and/or could easily be twisted. Scrotal support and analgesia were given for 1 month, then patients were offered orchidopexy or conservative treatment. Nineteen patients chose orchidopexy while 44 chose conservative treatment. Follow-up ranged from 3 months to 2 years. The improvement was assessed using a visual analog pain score. The outcome of the treatment was compared between the surgical and conservative groups using a χ2 test. RESULTS: The median age of the patients was 28 years (range: 17-50). Of the 19 patients who underwent orchidopexy, the pain resolved or visual analog pain scores improved (median 1/10) in 18 (94.7%) cases. On the other hand, 21 of the 44 (47.7%) cases that chose the conservative approach claimed their pain resolved or improved (visual analog pain scores: median 3/10) with a median of 13 months of follow-up. CONCLUSION: In this study, scrotal orchidopexy proved to be superior to conservative measures in cases of ITT in adults.

Mini-percutaneous nephrolithotomy for stones in anomalous-kidneys: a prospective study.

To evaluate safety and efficacy of minipercutaneous nephrolithotomy (Mini-PNL) in management of stones in different types of renal anomalies. Patients with stones ≥2 cm or SWL-resistant stones in anomalous-kidneys treated by Mini-PNL between March 2010 and September 2012 were included prospectively. Mini-PNL was done under regional anesthesia in prone position with fluoroscopic guidance through 18 Fr sheath using semirigid ureteroscope (8.5/11.5 Fr) and pneumatic lithotripter. All patients were followed-up for 2-3 years. Stone-free rate was defined as absence of residual fragments ≥2 mm. Student-T, Mann-Whitney, Chi square (χ 2), Fisher-exact, one way ANOVA or Kruskal-Wallis test were used for analysis. Mini-PNL was performed for 59 patients (20 horseshoe, 15 malrotated, 7 polycystic, 13 duplex and 4 ectopic pelvic-kidneys). Mean age was 40.18 ± 12.75 (14-78) years. Mean stone burden was 31.72 ± 21.43 (7.85-141.3) mm2. Two tracts were required in 7 (11.9 %) patients. Tubeless Mini-PNL with double-J insertion was performed in all patients except two. Operative time was 50.17 ± 18.73 (15-105) min. Hemoglobin loss was 0.44 ± 0.30 (0-1.4) g/dL. Complications were reported in 15 (25.4 %) patients. No pleural injury, sepsis, perinephric-collection or renal-pelvis perforation were reported. Stone-free rate was 89.8 % (converted to open-surgery in one patient, second-look PNL in two patients, auxiliary SWL in three patients). Stone-free rate improved to 98.3 % after retreatment and auxiliary SWL. Site of puncture was mostly upper calyceal in horseshoe-kidney (80 %), mid calyceal in polycystic-kidney (85.7 %) and lower calyceal in duplex-kidney (46.2 %). Punctures were also significantly infracostal in horseshoe-kidney (100 %) and supracostal in both duplex (53.8 %) and malrotated-kidneys (66.7 %). Mini-PNL is safe for management of stones in anomalous-kidney with SFR comparable to standard-PNL but with less complications.

Internal versus external ureteric stents for uretero-ileal anastomosis after laparoscopic radical cystectomy with orthotopic neobladder: A prospective comparative study.

OBJECTIVE: To prospectively compare the use of external ureteric stents with internal JJ stenting of the uretero-ileal anastomosis in patients undergoing laparoscopic radical cystectomy (LRC) with a Y-shaped ileal orthotopic neobladder (ON). PATIENTS AND METHODS: The study included 69 patients undergoing LRC with ON. Patients were grouped according to the type of uretero-ileal stents used. An external ureteric stent was used in Group A (33 patients) and a JJ stent was used in Group B (36). We prospectively compared the duration of hospital stay, the incidence of short- and intermediate-term complications in the two study groups. RESULTS: The mean (SD) follow-up periods were 29.18 (3.94) and 28.19 (3.37) months for patients in Groups A and B, respectively. Perioperative patient characteristics were comparable in the two study groups. The use of JJ stenting was associated with a shorter hospital stay compared with external stenting, at a mean (SD) of 14.63 (3.74) and 6.8 (3.03) days in Groups A and B, respectively (P < 0.001). The incidence of urinary leakage was comparable in the two study groups, at 6.1% in Group A vs 8.3% in Group B (P = 1.0). Strictures of the uretero-ileal anastomosis occurred in two patients (6%) in Group A and confirmed by intravenous urography. All strictures were treated with antegrade JJ fixation. CONCLUSION: JJ stents could be used as an effective alternative to external ureteric stents to support the uretero-ileal anastomosis. JJ stenting is associated with a shorter hospital stay and similar complication rates compared with external stenting in patients undergoing LRC with ON.

Lower calyceal and renal pelvic stones in preschool children: A comparative study of mini-percutaneous nephrolithotomy versus extracorporeal shockwave lithotripsy.

OBJECTIVES: To compare outcomes of the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy for lower calyceal and renal pelvic stones in preschool children. METHODS: From January 2010 to December 2014, single renal pelvic or lower calyceal calculi 10-25 mm in size in children (age ≤6 years) treated by either extracorporeal shockwave lithotripsy (64 patients) or the mini-percutaneous nephrolithotripsy technique (54 patients) were included. Extracorporeal shockwave lithotripsy was carried out by using a Dornier electromagnetic lithotripter. The mini-percutaneous nephrolithotripsy technique was through 14-Fr renal access using a 9.5-Fr semirigid ureteroscope with holmium:yttrium aluminium garnet lithotripsy. The two study groups were compared using Mann-Whitney, χ(2) -test or Fisher's exact test. RESULTS: Stone parameters were similar in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups in all patients, and in the pelvic (39 Miniperc, 52 extracorporeal shockwave lithotripsy) and lower calyceal (15 Miniperc, 12 extracorporeal shockwave lithotripsy) subgroups. Stone-free rates in the mini-percutaneous nephrolithotripsy technique and extracorporeal shockwave lithotripsy groups were 88.9% versus 43.8% (P < 0.001) and 94.4% versus 81.2% (P = 0.032) after first and last sessions, respectively. In the renal pelvis, they were 87.2% versus 50% (P < 0.001) and 94.9% versus 84.6% (P = 0.179), whereas in the lower calyx, they were 93.3% versus 16.7% (P < 0.001) and 93.3% versus 66.7% (P = 0.139) after first and last sessions, respectively. Retreatment rates in the mini-percutaneous nephrolithotripsy technique versus extracorporeal shockwave lithotripsy were 7.4% versus 50% (P < 0.001), 7.7% versus 46.2% (P < 0.001), and 6.7% versus 66.7% (P = 0.003) in all patients, renal pelvic and lower calyceal stones, respectively. No significant difference was found in complications (P = 0.521). Auxiliary procedures were required in 9.4% and 1.9% of children in the extracorporeal shockwave lithotripsy and mini-percutaneous nephrolithotripsy technique groups, respectively. CONCLUSIONS: The mini-percutaneous nephrolithotripsy technique has significantly higher stone-free rates than extracorporeal shockwave lithotripsy for renal pelvic and lower calyceal stones (10-25 mm), with a lower retreatment rate and without a significant increase in complications.

Outcomes of living donor renal transplantation in children with lower urinary tract dysfunction: a comparative retrospective study.

OBJECTIVES: To compare outcomes of renal transplantation (RTx) in children with end-stage renal disease (ESRD) resulting from lower urinary tract dysfunction (LUTD) vs other causes. PATIENTS AND METHODS: A database of children (<18 years old) who underwent RTx between May 2008 and April 2012 was reviewed. Patients were divided into those with LUTD (group A, n = 29) and those with other causes of ESRD (group B, n = 74). RTx was performed after achieving low intravesical pressure (<30 cmH2 O) with adequate bladder capacity and drainage. The groups were compared using Student's t-test, Mann-Whitney, chi-squared or exact tests. Graft survival rates (GSRs) were evaluated using Kaplan-Meier curves and the log-rank test. RESULTS: The mean ± sd (range) age of the study cohort was 5.05 ± 12.4 (2.2-18) years. Causes of LUTD were posterior urethral valve (PUV; 41.4%), vesico-ureteric reflux (VUR; 37.9%), neurogenic bladder (10.3%), prune belly syndrome (3.4%), obstructive megaureter (3.4%) and urethral stricture disease (3.4%). There was no significant difference in age, dialysis duration or donor type. In group A, 25 of the 29 patients (86.2%) underwent ≥1 surgery to optimize the urinary tract for allograft. Pretransplant nephrectomy was performed in 15 of the 29 patients (51.7%), PUV ablation in nine patients (31%) and ileocystoplasty in four patients (13.7%). The mean ± sd follow-up was 4.52 ± 1.55 and 4.07 ± 1.27 years in groups A and B, respectively. There was no significant difference in creatinine and eGFR between the groups at different points of follow-up. The GSRs at the end of the study were 93.1 and 91.1% in groups A and B, respectively (P = 1.00). According to Kaplan-Meier survival curves, there was no significant difference in the GSR between the groups using the log-rank test (P = 0.503). No graft was lost as a result of urological complications. In group B, one child died from septicaemia. The rate of urinary tract infections was 24 and 12% in groups A and B, respectively, but was not significant. No significant difference was found between the groups with regard to the incidence of post-transplantation hydronephrosis. Of the 22 patients who had hydronephrosis after transplantation, three were complicated by UTI. Injection of bulking agents was required in two patients for treatment of grade 3 VUR. In the third patient, augmentation cystoplasty was needed. CONCLUSION: Acceptable graft function, survival and UTI rates can be achieved in children with ESRD attributable to LUTD. Thorough assessment and optimization of LUT, together with close follow-up, are key for successful RTx.

Caudal extradural catheterization in pediatric renal transplant and its effect on perioperative hemodynamics and pain scoring: a prospective randomized study.

PURPOSE: 'Hockey stick incision' used in renal transplant is large enough to cause severe postoperative morbidity especially in pediatric recipients. Although epidural analgesia is known to be effective in pain control, the resulting sympathectomy might affect hemodynamics interfering with the transplant process. In our study, we evaluated the feasibility and safety of inserting an epidural catheter to the thoracic level via the caudal route, and the effect of using epidural local anesthetics at low concentrations on hemodynamics. METHODS: After approval from the ethical committee at Kasr Al Ainy University Hospital and consent from parents/legal guardians, sixty patients aged 3-12 years who were scheduled for renal transplant were randomly divided into two equal groups. Group I (epidural group) received continuous caudal epidural bupivacaine 0.125 % with fentanyl together with intravenous (IV) fentanyl and paracetamol. Group II (control group) received only IV fentanyl and paracetamol. Intraoperative data included heart rate (HR), mean arterial blood pressure (MAP) and central venous pressure (CVP). Postoperative variables included HR, MAP, CVP, pain score and complications. RESULTS: Threading failure via the caudal route occurred in 6.67 % of cases. Intraoperative differences in hemodynamics and CVP were not clinically significant between groups. Postoperative HR, MAP, and CVP were generally higher in the control group. Pain control was more satisfactory and postoperative complications were less in the epidural group. CONCLUSION: Caudal epidural anesthesia in pediatric renal transplant is a valuable addition to general anesthesia as it provides stable perioperative hemodynamics, excellent postoperative analgesia and is associated with fewer complications than narcotic-dependent analgesia. CLINICAL TRIAL REGISTRATION NUMBER: NCT02037802.

Use of surgeon-tailored polypropylene mesh as a needle-less single-incision sling for treating female stress urinary incontinence: Preliminary results.

OBJECTIVE: To evaluate the safety and efficacy of a procedure using surgeon-tailored polypropylene mesh (STM) through a needle-less single-incision technique for treating stress urinary incontinence (SUI), aiming to decrease the cost of treatment, which is important in developing countries. PATIENTS AND METHODS: In all, 43 women diagnosed using a cough stress test were treated from January 2011 to June 2013 at the Urology and Gynaecology Departments (dual-centre), Cairo University Hospitals. Previous surgery was not a contra-indication. Patients with a postvoid residual urine volume of >100 mL, a bladder capacity of <300 mL, impaired compliance or neurological lesions were excluded. The Stress and Urge incontinence Quality of life Questionnaire (SUIQQ) and urodynamic variables were compared before and after surgery. The variables were compared between the baseline and postoperative follow-up values using a paired t-test, a Wilcoxon signed-rank test or McNemar's test. RESULTS: The mean age was 42.7 years and 20 (47%) patients had associated urgency UI (UUI), whilst 21 (49%) had intrinsic sphincter deficiency. The median (range) operative duration was 14 (5-35) min. There were no complications during surgery. The mean (SD, range) follow-up was 28.1 (5.1, 18-36) months. Postoperative complications were vaginal discharge (5%), failure of wound healing (5%), dyspareunia (5%) and UTI (5%). The sling was removed in one case. SUI, UUI and quality-of-life indices improved significantly after surgery. There were no significant differences in pressure-flow studies before and after surgery. In all, 38 (88%) patients were cured, four (9%) improved and in one only the treatment failed (2%). CONCLUSION: This technique is simple, safe, effective, reproducible and economical for treating SUI. The STM was easy to insert in a short operation.

Outcome of Mini-percutaneous Nephrolithotomy for Renal Stones in Infants and Preschool Children: A Prospective Study.

OBJECTIVE: To assess the safety and efficacy of Miniperc for renal stones in preschool-age patients. To the best of our knowledge, this may be the first prospective study on this subject. Reports on Miniperc are still few and mostly retrospective using a sheath size of ≥ 18Fr, which is still relatively large for young children. PATIENTS AND METHODS: From January 2012 to May 2013, Miniperc was performed for 26 children (≤ 6 years old) with renal calculi <5 cm through 14Fr sheath using a 9.5Fr semirigid ureteroscope with Holmium:yttrium-aluminum-garnet laser lithotripsy. Effects of different factors on operative time, complications, and stone-free rate (SFR) were compared using chi-square, Fischer exact, or Mann-Whitney tests as appropriate using SPSS v15.0. RESULTS: Primary SFR, SFR after retreatment, and SFR after auxiliary extracorporeal shock wave lithotripsy (ESWL) were 77%, 85%, and 92%, respectively. Retreatment rate was 8%. Auxiliary ESWL was done in 11%. Complications were bleeding (8%), hematuria and blood transfusion (4%), renal pelvis perforation (4%), leakage (8%), and fever (15%). Operative time was significantly prolonged in multiple (>2) stones (P = .006), calyceal stones (P = .002), or stone size ≥ 30 mm (P = .022). SFR was significantly lower in children with >2 stones (P = .028) and increased stone size ≥ 30 mm (P = .014). CONCLUSION: Miniperc is a safe and effective minimally invasive procedure for pediatric renal stones using 14Fr access sheath. SFR was significantly lower in children with >2 stones or increased stone size ≥ 30 mm. This was overcome by retreatment and auxiliary ESWL.

Surgeon-tailored polypropylene mesh as a tension-free vaginal tape-obturator versus original TVT-O for the treatment of female stress urinary incontinence: a long-term comparative study.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to compare the safety and efficacy of surgeon-tailored polypropylene mesh (STM) through tension-free vaginal tape-obturator (TVT-O) versus original TVT-O in the treatment of stress urinary incontinence (SUI) aiming to decrease the cost of treatment. This is important in developing countries due to limited health care resources. METHODS: A retrospective cohort study was done at the Urology and Gynecology Departments (dual-center), Cairo University from May 2007 to June 2010. Women evaluated by cough stress test, Stress and Urge Incontinence and Quality of Life Questionnaire (SUIQQ), maximum flow rate (Qmax), and abdominal leak point pressure (ALPP) with follow-up for at least 48 months were included. Patients with post-void residual urine > 100 ml, bladder capacity < 300 ml, or impaired compliance were excluded. The effect of different factors on outcome was compared between both groups pre- and postoperatively using the paired t, Wilcoxon signed rank, McNemar, chi-square, Fisher's exact, independent t, or Mann-Whitney tests. RESULTS: STM and TVT-O were inserted in 79 and 66 women, respectively. Intrinsic sphincter deficiency, ALPP, previous surgeries, associated urgency, urgency urinary incontinence (UUI), and prolapse were comparable in both groups. Operative duration was longer in STM by 10 min. No significant difference was found between both groups in complications (p = 0.462), cure (p = 0.654), and different indices of SUIQQ. In STM, 74 (93 %) were cured and 3 (4 %) improved, while SUI persisted in 2 (2 %) patients. In TVT-O, 59 (89 %) were cured and 4 (6 %) improved, while failure was detected in 3 (4 %) patients. CONCLUSIONS: The 5-year outcome is comparable between STM and TVT-O. Furthermore, STM is more economical due to our resterilizable modified helical passers and the cheap polypropylene mesh.

Surgeon-tailored polypropylene mesh as a needleless single-incision sling versus TVT-O for the treatment of female stress urinary incontinence: a comparative study.

PURPOSE: To compare safety and efficacy of surgeon-tailored polypropylene mesh through needleless single-incision technique (STM) versus tension-free vaginal tape-obturator (TVT-O) aiming to decrease cost of treatment of stress urinary incontinence (SUI). This is important in developing countries due to limited healthcare resources. PATIENTS AND METHODS: A retrospective cohort study was done at Urology and Gynecology Departments (dual-center), Cairo University, from January 2011 to August 2013. STM was inserted in 72 females, while TVT-O was inserted in 48 females. Females evaluated by cough stress test, stress and urge incontinence quality of life questionnaire (SUIQQ), Q max and abdominal leak point pressure (ALPP) were included. Different factors were compared between both groups using paired t, Wilcoxon's signed rank, McNemar, Chi-square, Fisher's exact, independent t or Mann-Whitney tests. RESULTS: Age, parity, previous surgeries, ALPP, intrinsic sphincter deficiency (ISD), associated prolapse and associated prolapse repair were comparable in both groups. No significant difference was found between both groups in postoperative complications (except groin pain), cure, SUIQQ indices improvement and Q max decline. In total, 65 (90 %) cured, 6 (8 %) improved while failure was detected in one (1 %) patient in STM group, while 42 (87 %) cured, 4 (8 %) improved and failure was detected in two (4 %) patients in TVT-O group. Presence of ISD (p = 0.565), urgency (p = 0.496), UUI (p = 0.531), previous surgeries (p = 0.345), associated urogenital prolapse (p = 0.218) or associated prolapse repair (p = 0.592) did not lead to any significant difference in outcome between both groups. Cost of mesh decreased from US$500 (TVT-O) to US$10 (STM). CONCLUSION: Outcome of STM is comparable to TVT-O. Furthermore, STM is more economic.