Archive for the Oral

Evaluation of the Results of Laparoscopic pyeloplasty in The Treatment of Ureteropelvic Junction Obstruction

Etafy, M.1 ,   and  Abdalmalek, G.2
1UCI, Dept. of Urology, Orange, United States of America, 2Alazhar University, Dept. of Urology, Assiut, Egypt


OBJECTIVE:
In the treatment of ureteropelvic junction obstruction (UPJO), laparoscopic dismembered pyeloplasty and open pyeloplasty have been shown to have similar outcomes. We present our experience with laparoscopic dismembered pyeloplasty (LDP).

METHODS:
A retrospective review of all adult LDP procedures was performed at our institution between November 2002 and July 2005. Preoperative evaluation included an abdominal CT angiogram to assess for crossing vessels and a diuretic renal scan to quantify the degree of obstruction. Follow-up with diuretic renal scan and patient pain analogue scale was performed at 3, 6, and 12 months after surgery. If the study is normal at 12 months then the patient is followed with ultrasonography of the kidneys and bladder looking for ureteral jets. The absence of ureteral jets, worsening of the hydronephrosis or patient complaint of pain then necessitates repeat diuretic renography.

RESULTS:
Eighteen LDP were performed on 7 men and 11 women .(Follow up was available for all patients) with an average age of 35  + 16 and average follow up of 11months. Mean operative time was 230 + 124 minutes and estimated blood loss was 61 + 40 ml. Average length of hospitalization and post­operative analgesia required was 2+1 days and 19+12 mg morphine sulfate equivalents. The overall success rate was 89% based on a normal diuretic renogram and lack of pain using a validated pain scale. There were no major complications.

CONCLUSION:
In this study, LP resulted in a durable success rate of 89% in patients with PUJO over a mean follow up of 11months. These results were comparable to those from open pyeloplasty, but with less morbidity. Based on our experience and that of others, LP is gaining acceptance as the new standard for patients with PUJO, especially if there are crossing vessels.

Key Words:
laparoscopy,  ureteral obstruction, ureteropelvic junction obstruction

MANAGEMENT ENT OF 12 UNUSUAL CASES OF URETHRAL OBSTRUCTION SECONDARY TO PELVIC FRACTURE

M.A. Al-Rifaei and A.A. Al-Rifaei
From the Department of Urology, Faculty of Medicine, Alexandria, Egypt.


Patients and Methods:

2 children had obstruction between the bladder and prostate, and one patient had an obstruction at prostate, were managed by bladder tubes.
One patient had destruction of the prostate and membranous urethra, was managed by bladder tube. One child had separation of both edges of the prostate, was managed by suturing both edges together.  2 patients had double membranous urethral strictures were managed by visual dialation.
One infant with marked displacement of the prostate could be managed by the transpubic route.
One child whose torned membranous urethra was fixed to the pubic bone was managed by pubectomy.
One adult had a long defect between the prostate and the bulbar urethra was managed by a vascuarlised skin tube.

Result:
were satisfactory.

Stentless pediatric ureteroscopic holmium: YAG laser stone disintegration: is gravels retrieval an issue?


W. Gamal • M. Aldahshoury • A. Hammady • Mohamed Hussein • Ahmed Mmdouh and A. Abouzeid


Purpose:
To evaluate the safety and efficacy of stentless pediatric ureteroscopic holmium laser stone disintegration without gravels retrieval.

Patients and methods:  
From Feb 2007 to Feb 2010, 21 children (12 boys and 9 girls) with unilateral single stone ureter, with an average age of 8.5 years (range 4–12 years), were treated with 6.9 Fr semirigid ureteroscope for a stone size ranged from 5 to 10 mm (mean 6.5 mm). All the stones were radioopaque, located in the upper ureter in 2 cases (9.5%), in the middle ureter in 5 cases (24%), and in the lower ureter in 14 cases (66.5%). Complete holmium laser stone disintegration was applied in all cases without gravels removal. No postoperative ureteral
stent was inserted in any case.

Results:
The stones were successfully approached and completely disintegrated in a single session in 20 cases (95.2%). All the procedures were done without ureteral orifice dilatation apart from 3 cases where
another working guide wire was applied. No intraoperative complications were recorded in the form of mucosal injury, ureteral perforation, or urinary extravasation. There is no early postoperative complication in the form of urinary tract infection or colic apart from single case of hematuria which was successfully treated conservatively. Two weeks postoperatively, KUB (kidney, ureter, and bladder) films were completely free from any significant gravel (3 mm) and US showed no hydronephrosis.

Conclusion:
Stentless ureteroscopic holmium laser disintegration without gravels removal is a safe and effective method for pediatric ureteral stone less than 10 mm in diameter.

Comparison of the efficacy of topical diltiazem nd nitroglycerine before transrectal ultrasound guided biopsy of the prostate

Introduction and objectives:
Transrectal ultrasound biopsy of prostate is a painful procedure. The introduction of the rectal probe is one of the major contributors to the pain associated with this procedure. Drugs that relax the anal sphincter should theoretically decrease the pain of probe insertion. This study was done to compare the safety and efficacy of two topical medications, diltiazem and nitroglycerine to decrease pain associated with transrectal ultrasound guided prostate biopsy.

Methods:
66 patients who were to undergo their first prostate biopsy were randomized to receive either 2 ml of 2% topical diltiazem or 2 ml of 0.2% topical nitroglycerine or placebo 15 minutes before prostate biopsy. All the patients received 15 ml of intrarectal lignocaine. A 10-point visual analogue score was used to record the pain immediately after the insertion of the probe, during biopsy and at the end of the procedure. Any adverse effects reported by the patients were also recorded.

Results:
There was no significant difference in mean age and prostate volume between the groups. There was a significantly lower pain score due to probe insertion, during biopsy and at the end of the procedure in patients who received topical diltiazem or nitroglycerine as compared to the placebo group (p<0.001, Mann Whitney test). There were no significant differences between the pain scores between the patients receiving diltiazem as compared to those receiving nitroglycerine. Significantly higher incidence of headache and fall in blood pressure was noted in patients who received nitroglycerine as compared to those receiving diltiazem.

Conclusion:
Topical diltiazem and nitroglycerine are equally effective in reducing the pain associated with transrectal biopsy of the prostate. Diltiazem is safer as compared to nitroglycerine and should be preferred.

Dorsal Onlay  Urethroplasty Using Buccal Mucosa graft or  Penile Skin Flap for Management of Long Anterior Urethral Strictures: A Prospective Randomized Study

Samir El Gamal1, Hussein Abdel Hameed2, Mohamed Abo Farha1 and Mohamed Gaber1
Urology Department, Tanta University, Tanta, Egypt1
Urology Department, Fayoum University, Fayoum, Egypt2.


Objective:
The aim of this randomized study is  to compare the outcomes of  dorsal onlay urethroplasty using  buccal mucosa graft or penile skin flap in the repair of long anterior urethral strictures.
 
Patients and Methods:
In this prospective study 37 patients with anterior urethral strictures were randomized to undergo buccal mucosa dorsal onlay (19) or penile skin flap (18) urethroplasty. Operative time, hospital stay, short and long-term complications, recurrence rates, and patient satisfaction were compared between the 2 groups.

Results:

The number of patients with pendulous, bulbar and bulbopendulous strictures as well as mean stricture length and mean follow-up were comparable between the 2 groups.  Mean operative time was significantly higher in the penile flap vs. the buccal mucosa graft group. In the penile flap group 3 patients had superficial penile skin necrosis, 1 had extensive skin loss and required skin grafting, and 2 had penile torsion.  In the buccal mucosa group  6 patients had minor oral morbidity  in the form of perioral numbness and increased salivation which settled by 4 weeks after surgery. Troublesome post-voiding dribbling was significantly more in  penile flap group than in buccal mucosa graft group. In the buccal mucosa group 84.2% and in the penile flap group 66.7% said they would recommend this procedure to another patient (p = 0.001).  The success rate in the buccal mucosa (89.5%) and penile flap (83.3%) groups was similar (p > 0.05).

Conclusions:

Dorsal onlay buccal mucosa graft and  penile skin flap urethroplasty provide similar
success rates. Compared to buccal mucosa, penile flap procedures are technically complex, associated with higher morbidity and less preferred by patients.

Female sexual function after vaginal surgery using transobturator mesh for cystocele and rectocele repair

Hoda MR, Mohammad N, Fornara P
Clinic for Urology and Kidney Transplantation Centre
University Medical School of Halle/Wittenberg, Halle, Germany


Background
Although the use of transobturator mesh implants for cytocele/rectocele repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function. We evaluated prospectively the impact of transobturator mesh implants on sexual function using a validated questionnaire.
Materials and methods
A total of 82 women were included in this prospective study. The patients were evaluated with the Female Sexual Function Index (FSFI), a validated, 19-item questionnaire that assesses six domains of sexual function: desire, arousal, lubrication, orgasm, satisfaction, and pain. The questionnaire was administered preoperatively and at 6-month after the operation.

Results

The mean patient age was 53.2 years (range 46 to 68). No statistically significant difference was found in sexual function after placement of transobturator mesh implants. Of the 82 patients, 29% were not sexually active before or after surgery. No statistically significant difference was found between preoperative and postoperative desire, arousal, lubrication, orgasm, satisfaction, and pain.

Conclusion
No change was found in overall sexual function in women undergoing transobturator mesh implantation. Specifically, neither a deleterious effect nor statistically significant improvement was found in sexual desire, arousal, lubrication, orgasm, satisfaction, or pain compared with the preoperative baseline values.

Detection of circulating prostate cancer cells by means of an antibody-conjugated nanoparticular biosensor

M. Raschid Hoda, Gerit Theil, Ekkehard Weber, Klaus Lücke, Paolo Fornara
Clinic for Urology and Kidney Transplantation Centre
University Medical School of Halle/Wittenberg, Germany


Introduction:
Currently existing techniques for the isolation of circulating tumor cells in blood (CTC) have experimental approaches. Nanoparticles as biosensors could allow a refinement of the method and possible clinical applicability of the CTC-isolation in cancer patients.

Methods:
In a translational project will be tested at the clinic, the clinical application of a coated with anti-EpCAM antibody-nano-scaled detector for the isolation of CTCs from peripheral blood of patients with prostate cancer. We reported on the results of preclinical testing.

Results:
The Nanodetektor consists of a nano-gold particles loaded with steel wire (GILUPI GmbH, Potsdam). This was coated with anti-EpCAM-AK. At first, the characterization of EpCAM expression in established PCa cell lines DU 145, PC3 and LNCaP cells as a model for various tumor entities. Cytochemistry showed that all three established cell lines express EpCAM on the cell membrane. The next step was to determine the cell binding efficiency of an anti-EpCAM-functionalized Nanodetektors in the fluid-dynamic system (Figure 1). The cell-binding experiments with cell lines showed a sufficient covalent binding of cells to the detector. For the characterization of the bound CTC was the multiplex RT-PCR (AdnaTestProstateCancerDetect) is used, the tumor antigens, PSMA, PSA, and EGFR were detected. In another step, blood samples from 20 prostate cancer patients of different stages were studied. These blood samples were used in the fluid dynamic system (Fig. 2). The characterization of isolated cells was carried out on the RT-PCR with regard to the marker PSMA, PSA, EGFR and cytochemical level on the detection of EpCAM expression and the control CD45-staining (Fig. 3). These were isolated on average 42.92 and 3.41 CTC/7.5ml blood at hrPCA CTC/7.5ml in locally limited PCA.

Conclusion:
Isolation of CTC using an antibody-coated nano-detector from the blood of prostate cancer patients of different stages is possible with high efficiency. The first in-vivo use of this system is currently being tested clinically.

Pelvic reconstructive surgery in octogenarians: Are we pushing the limits too far?

M. Raschid Hoda, Mohammad N, Paolo Fornara
Clinic for Urology and Kidney Transplantation Center
University Medical School of Halle/Wittenberg, Germany


Purpose:
Although the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, little data exist on their efficacy and appreciation in elderly women. This report describes our experience with pelvic reconstructive surgery in women with ages around or above 80 years.

Material and Methods
Prospective non-randomised study including 73 female patients aged >75 years with pelvic organ prolapse with or without stress urinary incontinence. Transvaginal anterior or posterior wall repair using transobturator mesh implants and concomitant transobturator sling procedure (25 Patients) were performed. Intra- and postoperative outcome data, POP-Q measurements, PAD-count, and quality of life measurements were recorded prospectively. Patients were followed for up to 12 months.

Results:
Mean age at surgery was 82.8±3.1 years. A total of 10 anterior repairs, 4 posterior repairs and 8 posterior and anterior repairs were performed using transobturator mesh implants. Concomitant synthetic mid-urethral transobturator sling procedure was performed in 18 women (82%). Mean operating time was 47.2±22.3 minutes, and the mean hospitalization period was 5.9±1.6 days. There were no systemic complications related to anaesthesia or surgery. Two patients (9.1%) required intraoperative bladder suturing due to iatrogenic bladder lesion. There were no rectal injuries, no bleeding necessitating transfusion, voiding dysfunction or erosions of synthetic implants. Pelvic floor testing at 24 months postoperatively showed 15% of the patients presenting with stage II vaginal wall prolapse. Further, quality of life parameters, as measured by SF-36 questionnaire, were improved compared to baseline values.

Conclusions:

Results of our study demonstrate that pelvic reconstructive surgery using mesh implants is feasible for management of pelvic organ prolapse in patients around 80 years of age and results in improvement of quality of life. However, special caution should be paid to risks and benefits of such surgery in this patient population.


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