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IS STONE RADIODENSITY A USEFUL PARAMETER FOR PREDICTING OUTCOME OF EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY FOR LOWER CALYCEAL STONES < 15 MM?

ETAFY, M.1, ABDALMALEK, G.2, SALEH, F.1, GAWISH, M.1
1UCI, Dept. of Urology, Orange, United States of America,
2Alazhar University, Dept. of Urology, Assiut, Egypt.


Introduction & Objectives:
We examined the outcome of SWL for solitary stones less than or equal 15mm located within the Lower calyx, based on their radiographic criteria in KUB.

Material & Methods:
216 patients with solitary lower calyx stones measuring less than or equal 15mm were treated on a Simens lithotriptor. Patients were stratified into 3 groups based on radiographic appearance of the calculus in pre-operative KUB according to homogeneity, smoothness and density. The stone radiodensity was determined relative to the ipsilateral 12th rib. (SFR) were determined at 3 months by (KUB). Patients requiring re-treatment or auxiliary procedures were considered failures in SWL.

Results:
Follow-up information was available in all 216 patients, there was a correlation between stone radiographic criteria and stone composition. The calculi in the SF series were predominantly rough (75%) and had a density less than or equal bone (74%), whereas calculi in the NSF series were most often smooth (56%) and denser than bone (50%).

Conclusions:
Our study suggests that for stones less than or equal 15mm within lower calyx there is tendency for a worse SWL outcome for stones that have a smooth shape or radio-density greater than the 12th rib in KUB than those with rough shape and radio-density less than or equal to the 12th rib in KUB.

BALOON DILATOR FOR NEPHROSTOMY TRACT DILATATION: EXPERIENCE with 28 cases & comparison with alkan dilator system

Tarek M.A El-Gammal, M.D.
National Institute of Urology and Nephrology, Cairo, Egypt

Objective:
We present our initial experience with the high-pressure balloon dilator in nephrostomy tract dilation for percutaneous renal access & Compare our results retrospectively with a group of patients in whom metal Alkan dilators were used.

Patient and Methods:
Our study population consists of twenty eight patients, who had undergone percutaneous nephrolithotomy (PCNL)   between Jan. 2007 & Jan. 2008 using high-pressure dilating balloon catheter.  Insertion time, total operative time, blood loss, tract dilatation failure, pelvi-calyceal system perforation and the balloon cost were recorded &compared retrospectively with the results of the same procedure using metal alkan dilators.

Results:
Among the study patients who underwent balloon dilatation, the average insertion time was shorter (5min.), compared with the Alkan dilatation group (20-25min.), while the average total operative time was 90min.for balloon dilation &120-140min.
For alkan dilation a difference that is statistically significant. There was no renal hypermobility or collecting system injury or significant blood loss as we have clearly shown during the sequential alkan dilatation. The disadvantages reported were the high balloon cost & some difficulties in performing access in patients with prior renal surgery.

Conclusion:
Our study have shown that in spite of some downsides of balloon dilation system like high cost & some insertion difficulties among patients with prior renal surgery, it can be regarded as the most safest (atraumatic), Efficacious (high performance single-step technique) & Faster (short total operative & Fluoroscopic time) dilation system for renal access with improved haemostasis, compared to other kinds of mechanical dilators such as metal alkan dilators.  Although metal alkan dilators are cost-effective; there was a significant problems during the dilation procedure including kidney hypermobility, pelvi-calyceal system perforation, blood loss,
& time consumption.

Key Words:
Balloon dilation, metal alkan dilation, percutaneous nephro-lithotomy, renal calculi.

Evaluation of the results of Dornier Lithotripter S II system in the treatment of renal calculi

Mohamed Ramadan, Mohamed Mabrouk, Ismail El-Helaly, Ali Gomaa.
Department of Urology, Al-Azhar university hospital, Cairo, Egypt


Objective:
The aim of work is to evaluate the efficacy and safety of the Dornier lithotripter S II system in the treatment of renal calculi.

Patients and methods:
One hundred patients having renal stones who are candidates for  SWL treatment at Bab El-shaa’rya university Hospital, from Apr. 2010 to Mar. 2011, including 54 males and 46 females, ranging in age from 2.5 years to 67 years old (mean age: 40.2 years).

Results:
The initial fragmentation rate was 96%. The stone-free rate for stones of < 10 mm was 100%, for 11–20 mm was 87.6% and for > 20 mm was 75%. The overall stone-free rate 3 months after lithotripsy was 87%. After single session of lithotripsy, 48 patients (48%) became stone-free. Additional procedures to render patients stone-free after lithotripsy were needed in only 6 cases (6%). The stone-free rates for lower, upper, middle calyceal and renal pelvic calculi were 84%, 83.3%, 85.7% and 88.7%, respectively. Post SWL Complications, renal colic in (42%), Transient gross haematuria lasting 24 hours or less occurred in (33%) steinstrasse in (4%) of cases.

Conclusions:
The size, position, and number of calculi had a significant impact on the outcome after SWL, Significant stone clearance was achieved in patients with single, pelvic stone (10-20 mm), Dornier lithotripter S II system is one of the  effective and safe means of stone disintegration.

Flexible Uretero-renoscopy: Comparison between Basket Extraction and Spontaneous Passage Following Laser Disintegration of Renal and Upper Ureteral Stones

Yasser M. Eldemerdash, Ahmed R. EL-Nahas and Ahmed M. Shoma
Urology and Nephrology Center, Mansoura University, Egypt


Objectives:
To compare basket extraction and spontaneous passage of stone fragments following laser disintegration of renal and upper ureteral stones using the flexible uretero-renoscopy (F-URS).

Patients and Methods:

Retrospective study of the data of 52 patients who were managed by laser disintegration of renal and upper ureteral stones using F-URS between January 2009 and June 2011. In 25 patients (group A) the stone fragments were left for spontaneous passage and in 27 patients (group B) the stone fragments were extracted using tipless nitinol basket. Success was defined as being stone free or with residual stone <4 mm in the largest diameter on non-contrast computerized tomography at 3 months.

Results:

Table 1 summarizes patients’ demographics, stone and renal characteristics. Table 2 summarizes intraoperative and postoperative data comparing the two groups. Mean operative time was 78.95+33 minutes (group A) and 89.44+30 minutes (group B) (p=0.247). The success rate was 72% in group A and 77.8% in group B (p=0.631). All inta-operative and postoperative complications were comparable between the two groups (p=0.367 and p=0.510 respectively) and were successfully managed. Mean hospital stay was also comparable (3.1 and 2.9 days respectively, p=0.856). 

Conclusions:

There is no significant effect of basket extraction of the stone fragments following laser disintegration on the success of fragments clearance after flexible uretero-renoscopy of renal and ureteral stones.

 Table 1:  Patients’ demographics, stone and renal characteristics:                                       
Variable No retrieval
N (%)
Group A
Retrieval
N (%)
Group B
P value
Patients
        Male
        Femalee
17 (68)
8 (32)
13 (48.1)
14 (51.9)
0.148
Mean age: years (SD) 52.9 (11.1) 49.1( 16.1) 0.326
Side
       Right
       Leftt
6 (24)
19 (76)
18 (66.7)
9 (33.3)
0.002
Stone Number
      Single
      Multiple
13 (52)
12 (48)
12 (44.4)
15 (55.6)
0.586
Mean stone length: mm (SD) 9.4 (9) 11.3 (8) 0.419
Renal Morphology
      Normal
      Hydronephrosis
      Pyelonephretic
7 (28)
16 (64)
2 (8)
6 (22.2)
18 (66.7)
3 (11.1)
0.853
Previous stone treatment
      Denovo
      Recurrent
16 (64)
9 (36)
18 (66.7)
9 (33.3)
0.84
UTI (Positive culture)
      No  
      Yes
20 (80)
5 (20)
16 (59.3)
11 (40.7)
0.105
Stone nature
     Radio-opaque
     Radio-lucent
15 (60)
10 (40)
20 (74.1)
7 (25.9)
0.28
Pre-operative ureteric stent
      No
      Yes
9 (36)
16 (64)
14 (51.9)
13 (48.1)
0.25

       
 

  Table 2:  Intraoperative and postoperative data:                                            

Variable No retrieval
N (%)
Group A
Retrieval
N (%)
Group B
P value
Access
      Guide wire
      Ureteral Access  Sheath
      No touch
16 (64)
8 (32)
1 (4)
12 (44.4)
15 (55.6)
0 (0)
0.163
Intra-operative complications:
      No       
      Perforation
      Mucosal injury
24 (96)
0 (0)
1 (4)
26 (96.3)
1 (3.7)
0 (0)
0.367
post-operative Complications:
      No      
      Fever
      Haematuria
      Obstruction after stent  removal
      Perinephric hematoma
      Pulmonary embolism
21 (84)
1 (4)
1 (4)
0 (0)
1 (4)
1 (4)
25 (92.6)
1 (3.7)
0 (0)
1 (3.7)
0 (0)
0 (0)
0.510
Number procedures: mean (SD)      1.4 (0.9) 1.2 (0.5) 0.383
Success       18 (72) 21 (77.8) 0.631
Operative time in min: mean (SD) 78.9 (33.2) 89.4 (30.1) 0.247
Post operative stent
     No stent
     Ureteric catheter
     Double JJ stent
0 (0)
14 (56)
11 (44)
1 (3.7)
18 (66.7)
8 (29.6)
0.387
Hospital stay in days: mean (SD) 3.1 (2.3) 2.9 (2.3) 0.856

Solo Ultrasonography-Guided Percutanous Nephrolithotomy for Single Stone Pelvis

Wael M. Gamal,  Mohamed Hussein, Mohamed Aldahshoury, Ahmed Hammady, Essam Moursy, and Abdelmonem Abuzeid,


Purpose:
To evaluate the success and outcomes of solo ultrasonography (US)-guided percutaneous nephrolithotomy (PCNL) for management of a single stone pelvis.

Patients and Methods:
From April 2008 to April 2010, the procedure was applied to 34 patients (22 men and 12 women) whose ages ranged from 25 to 55 years (mean 29.5 y) with unilateral single stone pelvis in a moderately to markedly dilated pelvicaliceal system (PCS). The stone size ranged from 20 to 30mm (mean 24 mm). Middle caliceal puncture and dilation were performed in all cases by an experienced urologist under US guidance with a needle-guided system attached to the side wall of the US probe. The evaluation of the procedure included the success of accessing the stones, the occurrence of intraoperative or postoperative complications, the stone-free
rate, and the need for auxiliary maneuver.

Results:
The access was successful in all cases. Minor intraoperative complications occurred in two cases where PCS perforation was detected and was managed conservatively by Double-J stent insertion for 4 weeks. The only reported postoperative complication was fever in five cases that responded to antibiotic treatment. Thirty-two (94%) patients were stone free on postoperative day 2; significant residual stones (8 and 10mm) were detected in two patients who underwent shockwave lithotripsy, and they became stone free within 10 days.

Conclusion:
Solo US-guided PCNL can be performed safely as an alternative to the fluoroscopy-guided PCNL for single stone pelvis in a moderately to markedly dilated PCS by an experienced urologist.

Tension-Free Vaginal Tape versus Trans-Obturator Vaginal Tape in management of female Stress Urinary Incontinence long term follow up: which to choose?

Mursi K1,  Elsheikh MG1,  Haitham M1,  Fayad A1,  Ghamrawy H1,  Aboumohamed A1.
1 Urology department, Faculty of Medicine, Cairo University.


Introduction and objective:
Tension-free vaginal tape (TVT) and trans-obturator vaginal tape (TVTO) are simple techniques that can be done under local anesthesia with minimal dissection, short hospital stay and minimal post-operative complications. Comparison of both techniques was made in a prospective randomized trial stressing on success rate, durability, operative time, and complications.

Materials and methods
:
Between September 2000 and December 2006; 110 patients with genuine SUI were randomized between TVT and TVTO for treatment. Mean age of our patients was 42.5 ± 8.5years (range 22- 64 years). Patients were divided into 2 groups; group (A) included 60 patients managed by TVT and group (B) included 50 patients managed by TVTO. Characteristics of the study population as well as the results, complications and outcome are illustrated in table 1.

Results
:
Results of both groups in terms of operative time and bleeding were comparable. Patients of group A suffered from a significantly higher rate of de-novo incontinence, while patients in group B suffered from a significantly higher rate of urine retention. Differences in other complications such as thigh pain, UTI, urgency and urge incontinence were not statistically significant. Similarly, success rate was comparable in both groups; with 93.3% in group A and 96% in group B (p= 0.8).

Conclusion:

Both techniques are effective with sustained success rates and minimal complications. TVT has significantly higher incidence of post-operative de novo urge incontinence while TVTO is has significantly higher incidence of post-operative urinary retention and thigh pain.

Table (1); Characteristics, results, complications and outcome

Group A (TVT)
(n=60)
Group B (TVTO)
(n=50)
P-value
Median age (yrs) 43 (36.5-49) 42 (37-47) 0.3
Premenopausal
Postmenopausal
44 (73.3%)
16 (26.7%)
42 (84%)
8 (16%)
0.3
First time
Recurrent case
54 (90%)
6 (10%)
47 (94%)
3 (6%)
0.7
Grade I cystocele
Grade II cystocele
54 (90%)
0 (0%)
38 (72%)
2 (4%)
0.2
Degree of SUI
        Grade I SUI
        Grade II SUI
       Grade III SUI
55 (91.7%)
5 (8.3%)
0 (0%)
42 (84%)
6 (12%)
2 (4%)

0.2

Pure SUI
Mixed incontinence
50 (83.3%)
10 (16.7%)
35 (70%)
15 (30%)
0.2
Median ALPP (cm water) 100 (90-120) 100 (90-110) 0.03*
Median operative time (min) 22 (21-24) 26 (25-28) <0.001*
Median operative bleeding (ml) 50 (50-100) 100 (50-100) 0.3
Post operative complications:
    Urine retention
    Thigh pain
    UTI
    Urgency &urge incontinence
    De-novo incontinence
0 (0%)
0 (0%)
5(8.3%)
12 (20%)
5(8.3%)
5 (10%)
3 (6%)
3 (6%)
9 (18%)
0 (0%)
0.04*
0.2
0.9
0.98
0.045*
Outcome of the procedure
     Cured
     Improvement
     Failure
54 (90%)
2 (3.3%)
4 (6.7%)
45 (90%)
3 (6%)
2 (4%)
0.7

*P- value is significant if <0.05

Evaluation of the need for transuretheral biopsy at first follow up after intravesical B C G therapy for superficial bladder cancer

Mursi K1, El-Sheikh MG1, AbdelRaouf H1, Aboumohamed AA1, Ramadan Y2,  Lotfi A1.
1Urology Department, Faculty of Medicine, Cairo University; 2 Urology Department Nasser Institute.


Introduction & Objective:
High risk non-muscle invasive superficial bladder cancer patients have lifelong risk of progression and require particular attention. Bacille calmette-guerin (BCG) instillation is recommended as first-choice treatment to reduce the risk of progression of high-grade bladder cancer and carcinoma in situ (CIS). We tried to evaluate the need for routine transuretheral biopsy from the previous resection site at 3 months, after BCG instillation therapy, even if post-treatment urine cytology and cystoscopy were free.

Materials and Methods:
This is a prospective study carried out on 45 patients of both gender presenting between December 2008 and Febrauary2010 with superficial urothelial bladder tumors who received intra-vesical BCG for 6 weeks. The ages of our patients ranged between 33 and 80 years (mean 59.34). At the end of their BCG course and 3 months after initial resection, all underwent urine cytology and was found negative. They underwent Cystoscopy which was negative for any suspicious lesions and routine biopsy from previous resection site was taken. 

Results:
The indication of BCG instillation was T1G1 in 20 (44.4%), T1G2 in 12 (26.6%), and TaG2 in 8 (17.7%) patients. Of the 45 patients, 3 (6.6%) patients had positive bladder biopsy for malignancy 3 months post resection despite their negative Cystoscopy and cytology. There was no statistically significant difference between patients with positive and negative biopsy as regard stage before resection, grade before resection and number of resected lesions. The original pathology of these 3 positive patients was T1G1 (2 patients), and T1G2 (1 patient). The pathology after BCG instillations was the same as before BCG instillation, T1G1 (2 patients) and T1G2 (1 patient).

Conclusion:
Routine biopsy from the resection site at the time of check cystoscopy improves the detection of tumor recurrence.

Table 1: T staging, grading, and number of lesions of the studied sample in relation to patients with positive biopsy and those with negative biopsy.

Group Total
Negative Positive
T stage CIS Count 1 0 1
% within Group 2.3% 0.0% 2.2%
T1 Count 31 3 34
% within Group 73.8% 100.0% 75.5%
T1 Count 10 0 10
% within Group 23.8% 0.0% 22.2%
Total Count 42 3 45
% within Group 100.0% 100.0% 45
Grade G1 Count 19 2 21
% within Group 46.34% 66.6% 47.7%
G2 Count 19 1 20
% within Group 46.34% 33.3% 45.45%
G3 Count 3 0 3
% within Group 7.31% 0.0% 6.8%
Total Count 41 3 44
% within Group 100.0% 100.0% 100.0%
No. of Lesions 1 Count 37 3 40
% within Group 88% 100.0% 88.8%
2 Count 5 0 5
% within Group 11.9% 0.0% 11.1%
3 Count 1 0 1
% within Group 2.3% 0.0% 2.22%
Total Count 42 3 45
% within Group 100.0% 100.0% 100.0%

ENDOSCOPIC TREATMENT OF A MIGRATED INTRA-UTERINE CONTRACEPTIVE DEVICE INTO THE BLADDER

TAREK ELMORSY ABO ALY
Department of Urology, El Mabara Hospital, Health Insurance, El Mahalla Al Kobra, Egypt


Background and Aims: 
Perforation of the uterus by an intra-uterine
Contraceptive device (IUCD) is not uncommon, intra-vesical migration of IUCD is a very rare complication and is a fact exceptionally reported in literature.

Patient and Methods:  
We report a 32 years old female in whom an IUCD had been placed six years previously .She had became pregnant one year later and had given birth without complications. The IUCD had not been recovered; it was assumed that it had fallen out.  This patient presented complaining of bladder irritative symptoms with recurrent urinary tract infections for nearly one year and she received antibiotic treatment several times without proper investigations. Intra-vesical migration of IUCD was confirmed by radiographic investigations (ultrasound, PUT, C.T.) and cystoscopy. Endoscopic trans-urethral extraction of the intra-vesical migrated loop was performed.

Results:
The migrated loop was successfully retrieved with no intraoperative or postoperative complications. In the present case no stone formation occurred on a migrated IUD.

Conclusion:
How and when the intra-vesical migration of an IUCD occurs is not clear .Findings suggest that uterine perforation may  be at insertion or delayed A migrated IUD loop may be missed even during delivery. Irritative voiding symptoms with recurrent urinary tract infections in the absence of the intra-uterine location of the IUD should be considered in the differential diagnosis. Endoscopic treatment of a migrated IUD into the bladder is possible.


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