Holmium laser versus cold knife visual internal urethrotomy for management of short segment urethral stricture: a prospective randomized clinical trial.

OBJECTIVES: To report the safety and efficacy of holmium laser and compare its results with cold knife visual internal urethrotomy (VIU) in the management of short segment urethral stricture. METHODS: This prospective randomized study included 66 male patients aged more than 18 years, with short segment bulbar urethral strictures < 2 cm from March 2020 to March 2022. The patients were randomized into two groups each containing 33 patients. In group A (Cold knife group), Sachse cold knife was used for stricture treatment. In group B (Holmium group), internal urethrotomy was done with Ho:YAG laser. Patients were evaluated before the operation and followed up after the operation at 1, 3, 6 and 12 months by physical examination, IPSS, PVR, Qmax and retrograde urethrography. RESULTS: There was significant improvement in the mean values of IPSS, PVR and Qmax in both groups. There was no significant difference between both groups in the mean values of IPSS, PVR and Qmax during follow-up visits. However, at the end of follow-up at one year there was statistically significant difference between both groups in the mean values of IPSS, PVR and Qmax due to higher recurrence rate in cold knife group than laser group. The overall complication rate is significantly lower in laser group (p = 0.014). CONCLUSION: Holmium laser VIU is an effective and safe treatment option for short segment urethral stricture with shorter operative time, less complication rate and less recurrence than cold knife VIU.

Simplified biplanar (0-90°) versus monoplanar renal puncture technique in flank free modified supine percutaneous nephrolithotomy regarding outcomes and learning curve: Randomized clinical trial.

Objective: To evaluate the learning curve and the success rate of the biplanar (0-90°) puncture technique in the flank-free modified supine position in comparison to the monoplanar puncture technique. Methods: Randomized controlled study included 68 patients more than 18 years with renal stones more than 2 cm from August 2021 to August 2022 were randomly classified by closed envelope method into group A (34 patients) scheduled for monoplanar renal puncture technique in flank-free modified supine PCN. Meanwhile, group B (34 patients) was scheduled for the 0-90° simplified fluoroscopic puncture technique. Morbid obese patients and patients with contraindications for PNL were omitted from the study. Results: There was no significant difference between both groups regarding stone distribution and patients' demographic data. There was a significant difference between both groups regarding puncture attempts. In 88.2% of patients in group B (Biplanar group), the success of renal puncture occurred from the 1st puncture attempt while in 11.2% of patients in group A (monoplanar group). There was a statistically significant difference between both groups in fluoroscopy time and total operation time (p-value <0.001 & p-value: 0.001), respectively. The stone-free rate was 85.2% vs. 88.2% in both groups, respectively, without significant difference. In this study puncture, attempt trials and puncture time were used as indicators for the easiness and rapid educability of the biplanar (0-90°) fluoroscopic guided renal puncture technique. In the biplanar (0-90°) group after 24 cases, the learning curve had reached the plateau. Conclusion: Biplanar (0-90°) puncture technique in flank-free modified supine position allows an easy puncture technique with an easy learning curve without affecting the success rate or complication rate.

Outcomes and clinical predictors of extracorporeal shock wave therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome: a prospective randomized double-blind placebo-controlled clinical trial.

OBJECTIVES: To report the one-year results of ESWT on CPPS patients and the possible clinical characteristics that may affect its efficacy. PATIENTS & METHODS: A prospective randomized clinical study between January 2017 and January 2021 on 155 adult patients with chronic pelvic pain syndrome. All patients were initially evaluated with a thorough history and physical examination. Baseline symptoms evaluation of each participant was assessed using NIH-CPSI score, IPSS, VAS, and IIEF-5 score. Patients were randomized into two groups: a verum treatment group and a placebo treatment group. Patients of verum group in the lithotomy position received a perineally applied ESWT treatment once a week for four weeks with 3000 impulses each. Patients of placebo group received the same therapy head of the same device with a layer of air-filled microspheres to absorb the shock waves. The previously mentioned validated scores were reassessed on regular follow-up visits at one, three, six, and 12 months after the completion of ESWT. RESULTS: A statistically significant improvement was noticed in the mean values of NIH-CPSI, IPSS, VAS, and IIEF-5 of the patients of verum group over the follow-up period with also statistically significant difference between both groups. At the first visit of follow-up after ESWT, 63 (82.8%) patients had ≥6 points decrease in the NIH-CPSI total score, while 13 (17.2%) patients did not. Univariate and multivariate analyses of the clinical characteristics between the responders and non-responders showed that those patients with history of psychological disorders or had higher initial NIH-CPSI score had a significantly lower response rate to ESWT (p = 0.005, 0.02 & p = 0.002, 0.004 respectively). ROC curve of NIH-CPSI score showed that a score of 32 was the cut-off point above which the response to ESWT decreased. CONCLUSION: ESWT is an effective treatment option for CPPS. Its efficacy remained throughout long-term follow up. High initial NIH-CPSI score and history of psychological problems are significant predictors for it.

Ultra-Mini-Percutaneous Nephrolithotomy in Flank-Free Modified Supine Position vs Prone Position in Treatment of Pediatric Renal Pelvic and Lower Caliceal Stones.

Objectives: To report the safety and efficacy of ultra-mini-percutaneous nephrolithotomy (UMPCNL) in flank-free modified supine (FFMS) and prone positions in management of pediatric renal calculi. Patients and Methods: This prospective randomized study included 55 pediatric patients with symptomatic renal stones and suitable for UMPCNL. They were randomized into two groups. Group A included 28 patients who were treated by UMPCNL in FFMS position (with a pad below the ipsilateral shoulder and buttocks, putting ipsilateral upper limb over the chest, and crossing the extended ipsilateral lower limb over the flexed contralateral one) and Group B included 27 patients treated by UMPCNL in the prone position. In both groups dilatation was done to 13F sheath allowing the introduction of 6/7.5F semirigid ureteroscope and fragmentation of stones by Holmium: yttrium-aluminum-garnet laser with a 550-µm fiber laser lithotripter. Results: The operation time in FFMS position UMPCNL group was significantly shorter than prone position UMPCNL group (84.3 ± 9.87 vs 99.3 ± 8.75 minutes) with p = 0.022. There was no significant difference between both groups in terms of stone-free rate (89.3% vs 88.9%), overall complication rate (including transient fever; 21.4% vs 18.5%), postoperative pain (visual analog scale score; 3.4 ± 0.8 vs 3.3 ± 0.9), or hospital stay (3.53 ± 0.8 vs 4.1 ± 1.1 days). Conclusion: Both UMPCNL in FFMs and prone positions are feasible, safe, and effective in treatment of pediatric renal stones with relatively shorter operative time in FFMS position.

Miniature semi-rigid ureteroscopy with holmium-yttrium-aluminium-garnet laser vs shockwave lithotripsy in the management of upper urinary tract stones >1 cm in children.

OBJECTIVE: To compare the efficacy and safety of miniature semi-rigid ureteroscopy (URS) with holmium (Ho)-yttrium-aluminium-garnet (YAG) laser lithotripsy vs shockwave lithotripsy (SWL) for treating upper urinary tract (UUT) calculi >1 cm in children. PATIENTS AND METHODS: Children with unilateral single UUT ureteric stones of >1 cm were prospectively enrolled in this study. Patients were randomly divided into two groups: Group 1, treated with SWL; and Group 2, treated with URS (6/7.5 F) and laser lithotripsy. The patients' characteristics, stones demographics, operative time, adjunctive procedures, stone-free rate (SFR), re-treatment rate, and complications were statistically analysed and compared. Success was defined as stone-free status (no stone residual of ≥0.3 cm) at 1 month from the initial treatment without any auxiliary procedures. RESULTS: In all, 68 patients with UUT stones met our inclusion criteria. There were no significant differences between the two groups for patient or stone demographics. In Group 1, the SFR was 26/34 (76.4%) and in Group 2 it was 33/34 (97.1%) (P = 0.03). A total of 12 auxiliary procedures in Group 1 and two in Group 2 were needed to reach a 100% SFR (P = 0.014). There were no significant differences between the two groups for operative times, adjunctive procedures, number of complicated cases or complications of Grade ≥III (P = 0.65, P = 0.23, P = 0.77, and P = 0.62, respectively). CONCLUSION: Miniature semi-rigid URS with Ho-YAG laser lithotripsy for UUT ureteric stones of >1 cm in children was more effective than SWL in terms of SFR and re-treatment rate, with no significant difference in the rate or grade of complications. ABBREVIATIONS: EQ: efficiency quotient; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; RCT: randomised controlled trial; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy; US: ultrasonography/ultrasound; URS: ureteroscopy; UUT: upper urinary tract; YAG: yttrium-aluminium-garnet.

Renal protective effect of N-acetylcysteine with stepwise ramping voltage against extracorporeal shock wave lithotripsy-induced renal injury: a prospective randomized trial.

PURPOSE: To evaluate the role of combination of N-acetylcysteine with stepwise ramping voltage in renal protection against the ischemic, vascular and oxidative effects of extracorporeal shock wave lithotripsy. PATIENTS AND METHODS: A prospective randomized trial on 164 adult patients scheduled for ESWL for single renal stones. Patients with radio-lucent stones, diabetes, hypertension, febrile UTI, and preoperative albuminuria were excluded from the study. Patients were randomized into one of four groups. Group A patients received maximal fixed voltage of ESWL. Group B patients received stepwise ramping voltage of ESWL. Group C patients received fixed maximal voltage with N-acetylcysteine (NAC) 600 mg/bid from 48 h before to 24 h after the procedure. Group D patients received gradual ramping voltage with NAC. Urinary ß2-microglobulin, 24 h albumin and N-acetyl-ß-D-glucosaminidase/creatinine ratio at 1 day and 5 days post-ESWL and the stone free rate at 2 weeks were measured. RESULTS: Group D was the only group that showed no significant difference pre and post ESWL in urinary albumin, ß2-microglobulin and N-acetyl-ß-D-glucosaminidase/creatinine ratio. Post hoc analysis revealed no significant difference between group B and group C in albumin, ß2-microglobulin N-acetyl-ß-D-glucosaminidase/creatinine ratio, but both of them had significantly lower levels than group A and significantly higher levels than group D. There was no statistically significant difference between all groups in the stone free rate at 2 weeks. CONCLUSION: N-acetylcysteine protects the kidney against ESWL-induced renal injuries especially if combined with stepwise ramping voltage.

Transrectal ultrasound-guided aspiration versus transurethral deroofing of prostatic abscess: A prospective randomized study.

AIMS: The aim of this study is to compare between transrectal ultrasound (TRUS)-guided aspiration and transurethral (TU) deroofing in the treatment of prostatic abscess regarding safety and efficacy. SETTINGS AND DESIGN: This prospective randomized study was done during the period between April 2009 and March 2015 and included 32 patients with prostatic abscess. SUBJECTS AND METHODS: All patients were enrolled in the study after obtaining a written informed consent and approval of the local ethical committee. The patients were randomly allocated into two groups; Group A treated by TRUS-guided aspiration, saline wash, and local injection of antibiotics and Group B treated by TU deroofing of the abscess. All patients received broad-spectrum antibiotics during the period of treatment, and the follow-up was done on the 5th day by TRUS to ensure complete resolution of the abscess. STATISTICAL ANALYSIS USED: Statistical analysis was done using online social science statistical calculators http://www.socscistatistics.com/Default.aspx using t-test for two independent means, Chi-square test, and Mann-Whitney U-test with P < 0.05 considered statistically significant. RESULTS: The mean age was 59 ± 11.46 and 60 ± 13.65 years for Groups A and B, respectively. Diabetes mellitus was detected in 9 (56.25%) and 6 (37.5%) patients in Groups A and B, respectively, hypertension in 7 (43.75%) and 6 (37.5%) patients in Groups A and B, respectively, and two patients (12.5%) with liver cirrhosis in each group. The mean size of the abscess was 3.36 ± 0.86 and 3.04 ± 0.86 cm in Groups A and B, respectively (P = 0.29). The abscess recurred in five patients (31.25%) and one patient (6.25%) in Groups A and B, respectively (P = 0.08). TRUS-guided aspiration was done for all recurrent cases except for two patients (12.5%) in Group A required trans urethral deroofing of the recurrent abscess. The mean hospital stay was 12.9 ± 4.05 and 7.25 ± 2.40 days for Groups A and B, respectively (P = 0.000). In Group A, one patient (6.25%) was complicated by urethrorectal fistula, whereas in Group B, one patient (6.25%) was complicated by septic shock, three patients (13.75%) with epididymo-orchitis and two patients (12.5%) with urethral stricture. CONCLUSION: Patients with prostatic abscess treated with TRUS-guided aspiration show less morbidity, higher recurrence rate, and longer hospital stay than those treated with TU deroofing.

The role of neural precursor cell-expressed developmentally down-regulated protein 9 in predicting bacillus Calmette-Guerin response in nonmuscle invasive bladder cancer.

OBJECTIVE: To report the sensitivity and specificity of neural precursor cell-expressed developmentally down-regulated protein 9 (NEDD9) protein high expression in predicting BCG response and its effect on recurrence or progression free survivals. PATIENTS AND METHODS: Between May 2014 and April 2017, a prospective cohort study was conducted on 105 patients with intermediate or high-risk nonmuscle invasive bladder cancer. Immunohistochemical staining with mouse monoclonal anti-NEDD9 antibody was done. Examination of the slides was done to detect NEDD9 cytoplasmic expression. Intravesical induction bacillus Calmette-Guerin (BCG) instillation therapy was started for all patients 2 to 4 weeks after endoscopy with once weekly instillation for 6 weeks. Intravesical maintenance BCG instillation was then continued every 3 months for at least 1 year. Follow up with cystoscopy every 3 months for 2 years and every 6 months after that. RESULTS: The mean age ± SD of the patients was 57 ± 4.5 years. The median follow-up period was 25 (12-36) months. NEDD9 protein was highly expressed in 61 (58.1%) patients, whereas low expression was in 44 (41.9%) patients. Sensitivity and specificity of NEDD9 high expression in predicting recurrence were 83.6% and 64.2%, respectively. Its sensitivity and specificity in predicting progression to muscle invasion or distant metastases were 91.3% and 51.2%, respectively. Its sensitivity and specificity in predicting complete response to BCG therapy were 84.1% and 80.9%. Kaplan-Meier test showed highly significant difference (P<0.0001) in survival without recurrence or progression between patients showing high expression and those showing low expression. CONCLUSION: NEDD9 protein tissue marker could be used as a predictive marker for BCG response in nonmuscle invasive bladder cancer with reasonable sensitivity and specificity.

The Prognostic Role of NEDD9 and P38 Protein Expression Levels in Urinary Bladder Transitional Cell Carcinoma.

Background. The most common malignant tumor of the urinary bladder is transitional cell carcinoma (TCC). Neural precursor cell-expressed developmentally downregulated protein 9 (NEDD9) is found to be a cell adhesion mediator. P38 Mitogen-Activated Protein Kinase is a serine/threonine kinases member which can mediate carcinogenesis through intracellular signaling. Methods. To assess their prognostic role; NEDD9 and p38 protein were evaluated in sections from 50 paraffin blocks of TCC. Results. The high expressions of NEDD9 and p38 protein were significantly associated with grade, stage, distant metastasis (p < 0.001), number of tumors, lymph node metastasis, and tumor size (p < 0.001, 0.002; 0.018, <0.001; and 0.004, 0.007, respectively). High NEDD9 and p38 detection had a worse 3-year OS (p = 0.041 and <0.001, respectively). By multivariate analysis the NEDD9 and p38 protein expression levels and various clinicopathological criteria including gender, grade, stage of the tumor, and regional lymph node involvement were independent prognostic parameters of TCC of the urinary bladder patients' outcome. Conclusion. NEDD9 and p38 protein expressions were poor prognostic markers of TCC.

Role of Preoperative Testicular Shear Wave Elastography in Predicting Improvement of Semen Parameters After Varicocelectomy for Male Patients With Primary Infertility.

OBJECTIVE: To evaluate the role of preoperative testicular shear wave elastography (SWE) in the prediction of improvement of semen analysis parameters after subinguinal microsurgical varicocele ligation in patients with primary infertility and clinically detectable varicocele. PATIENTS AND METHODS: Testicular SWE before the surgical intervention was done. Forty-eight patients were scheduled for subinguinal microsurgical varicocele ligation as a treatment option. Computer-assisted semen analysis was repeated 6 months after the intervention. RESULTS: At a cutoff value of 4.5 kPa, the stiffness index had a sensitivity of 86.4% and a specificity of 84.2% for semen parameter improvement after varicocelectomy. Correlation between different parameters of semen analysis and SWE showed a statistically significant negative correlation between SWE stiffness index and both sperm count (million/mL) and total motility. On the other hand, a nonsignificant negative correlation was found between SWE stiffness index and percentage of normal form. CONCLUSION: Testicular SWE is a good test that can be used in the assessment of male infertility with clinically detectable varicocele, and its results may predict semen parameter improvement after varicocelectomy. Further studies on a larger number of patients are needed to verify our results.

W-pouch With Modified Non-isolated Extra Limb for Continence in Cutaneous Diversion After Radical Cystectomy.

OBJECTIVE: To report the functional results of continent cutaneous ileal urinary diversion using modified W-pouch with non-isolated extra limb for continence. PATIENTS AND METHODS: From January 2013 to January 2016, 21 patients with muscle-invasive bladder cancer with median (interquartile range) of 59 (56.5-62.5) years old underwent radical cystectomy with pelvic lymphadenectomy; they then had an ileal continent cutaneous pouch constructed from W-pouch with non-isolated extra limb for continence. The technique entails the creation of a detubularized ileal W-pouch with extra limb fashioned from 59 cm of the terminal ileum. This extra limb is not isolated from the pouch. The proximal part of this limb is tailored and fixed in a subserous extramural tunnel for continence, whereas the distal part is left continuous with the pouch. The median (interquartile range) of follow up was 12 (8-17) months. Evaluation of the technique included operative time, continence efficiency, overall complications, and quality of life questionnaire for the patients. RESULTS: The median (interquartile range) of operative time of the operation was 4.7 (3.9-5.4) hours. The median (interquartile range) of operative time of the cutaneous pouch creation was 39 (33-43) minutes. No perioperative mortality had occurred. The incidence of continence was 95.2%. The overall complications were 42.8%, and most of them were grade 1 or 2 on Clavien-Dindo classification system. CONCLUSION: Modification of W-pouch with non-isolated extra limb as continent cutaneous pouch can simplify the technique and shorten the operative time with efficient continence, less side effects, and good quality of life.