impact of stone radiodensity on the outcome of extracorporeal shockwave lithotripsy for renal pelvic stones

To evaluate the outcome of extracorporeal shock wave lithotripsy [SWL] for solitary stones 12th rib compared to a SFR of 67.9% [19/28] if the stone radiodensity was < 12 th rib. Stone composition was available in 68.5% of treated patients [n=74], but no correlation was found between stone radiodensity and stone composition. On the Domier compact alpha machine, stone radiodensity alone does not predict lithotripsy treatment outcome for stones

Incidentally discovered adrenal masses: report on 20 cases and update of the literature

To report our experience with diagnosis and management of twenty cases of adrenal incidentaloma. Over a period of 7 years, adrenal masses were detected incidentally in 20 cases [13 males and 7 females] during imaging work-up performed for extra-adrenal complaints. Their ages ranged between 15-68 years [mean 48 years]. The reasons for an abdominal imaging procedure were vague abdominal pain in 8 cases [40%], renal colic in five cases [25%]; biliary colic in 4 cases [20%], post-surgery follow-up in two cases [10%] and acute abdomen in one case [5%]. The most common clinical abnormalities were hypertension [5 cases], obesity [4 cases] and diabetes mellitus [4 cases]. Diagnosis was made by ultrasound and confirmed by CT. The longest diameter of the masses ranged from 2 to 12 cms. The right side was affected in 16 cases and the left side in 4 cases. Biochemical work up included determinations of serum electrolytes, lipids and hormonal studies. Percutaneous adrenal biopsy was done in 5 cases under ultrasound guidance. Abnormal hormonal functions were detected in four cases. Seven cases had adrenal cysts, 6 cases had adrenal carcinomas, 3 had pheochromocytoma and 3 cases had adrenal metastases with, unknown primary tumors and one had subclinical Cushing disease. Surgical adrenalectomy was performed in 9p…tients [45%] for malignancy in 6 cases [one of them had adrenal metastasis] and for pheochromocytoma in 3 cases. Eight out of those nine cases who underwent adrenalectomy had masses with diameters greater than 5 cm and one had adrenal cyst 4 cm in diameter on CT proved to be pheochromocytoma. Imaging characteristics suggestive of malignancy were found in six cases. In two cases surgery was indicated but not performed because it was refused by one patient and was excluded for extensive metastases in another one. We concluded that, Every patient with an adrenal incidentaloma has to be investigated thoroughly to detect malignancy and subtle hormonal overproduction, to select the cases for surgical treatment. All cases of adrenocortical carcinomas were more than 5 cm in diameter. For prophylactic purposes, adrenal incidentalomas > 5 cm should be treated by surgery, while the smaller ones could be followed-up. Percutaneous adrenal biopsy was generally safe and accurate diagnostic procedure

Adrenal cystic masses: report of ten cases and suggested algorithm for therapy

Purpose: To report our experience in diagnosis and treatment of adrenal cysts in 10 cases. Patients and Over 7 years period adrenal cysts have been diagnosed in 10 patients [7 males and 3 females]. Their ages ranged between 25 n 68 years. Eight cases were between 50 and 68 years. Six cysts were detected incidentally during imaging work-up performed for extra-adrenal complaints. Three cases presented by flank pain and only one had severe hypertension. Diagnosis was made by ultrasound [US] in all cases and confirmed by computed tomography [CT] in six cases. The longest diameter of the cysts ranged from 3 to 12 centimeters. The right side was affected in 8 cases and the left side in 2 cases. All cases had unilateral cysts. Biochemical work up included determinations of serum electrolytes, lipids and hormonal study. Adrenal ultrasound-guided FNAB was performed in all cases. Six cases had simple non-functioning adrenal cysts, two had infected adrenal cysts one had cystic pheochromocytoma and one had adrenal carcinoma. Surgical adrenalectomy was performed in three patients [30%]. The indications for operation were pheochromocytoma in one patient, symptomatic adrenal cyst with diameter greater than 5 cm in another one, and adrenal carcinoma in a third patient. Imaging characteristics suggestive of malignancy were found in only one proved to have adrenal carcinoma. Cysts recurred in five cases after FNAB. Small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by US or CT. Symptomatic benign nonfunctioning adrenal cyst may be managed by aspiration alone. If the cyst recurs and is asymptomatic, it may observed. If a symptomatic cyst recurs, it may be reaspirated or excised. Malignant adrenal cysts should be treated by adrenalectomy

Perivesical collections: percutaneous ultrasound-guided drainage

Purpose: To report our experience in percutaneous drainage of postoperative perivesical collections under ultrasound guidance

Patients and methods: Between March 1997 and January 2004, fifty patients with perivesical collections were evaluated. Those collections were secondary to Cystolithotomy in 14, open transvesical prostatectomy in 12, repaired bladder injuries after gynecologic operations in 12, partial cystectomy in five, ureteroneocystostomy in four and augmentation cystoplasty in three cases. The presenting symptoms and signs included suprapubic pain in 21, urine leakage in 11, fever in 10, masses in the iliac fossa in eight. Ultrasound-guided drainage of those collections was done

Results: Ultrasound-guided single step drainage of the collections was done using 10 F Pigtail catheters in 32 cases while Seldinger technique [puncture and gradual dilatation of the track] was used in 18 cases. The aspirated fluid was clear urine in 23 cases and turbid in 27. The amount of fluid drained ranged from 140-300 mL immediately after the procedure. We used color Doppler sonography to map the site of puncture. Urethral catheters were refixed in all cases. No complications were encountered after drainage except for recollection in three cases. The period of drainage varied from I week to 25 days. Adjuvant Ultrasound guided single step Percutaneous nephrostomy was needed in four cases. Further intervention was needed in three cases for revision of the ureteroneocystostomy

Conclusion: Percutaneous ultrasound-guided drainage of post-operative perivesical collections is a safe, rapid, and easy method of treatment beside fixation of urethral catheter and should eliminate the need for exploration to drain those collections

Percutaneous nephrostomy of nondilated pelvicalyceal systems under ultrasound guidance: technique and outcomes

The aim of this study was to present our experience in using a modified double-puncture technique for percutaneous nephrostomy [PCN] of nondilated renal collecting systems under ultrasound [US] guidance without using fluoroscopy. Over a 6-years period, 35 patients [42 kidneys] without calyceal dilatation at US who required nephrostomy drainage were studied. Twenty-five patients [30 kidneys] had ureteral leaks or fistulas, six patients [7 kidneys] had ureteral injuries after gynaecologic surgery, two patients [3 kidneys] had acute nondilated renal failure and two cases had PCN for extraction of ureteral stents [2 kidneys]. Mean age was 47.5 years [range, 18-68 years]; 26 patients were men and nine were women. A modified double apuncture technique was used under ultrasound guidance. After intravenous administration of frusemide to allow visualization and distention of the nondependent calyces for definitive renal access, a 22-gauge needle was inserted into the renal pelvis, and an 18-gauge 5-F sheath-needle set was used to puncture the desired calyx and a hydrophilic wire was introduced. After serial dilation, a nephrostomy catheter was inserted. Success and major complication rates were studied. Catheter placement was successful in 40 [95.2%] of 42 kidneys. Five patients [14.3%] developed urinary tract infection after PCN. One patient [2.8%] developed septicaemia. Drainage catheter dislodgement occurred in six cases [17.2%]. Tube blockage occurred in two cases [5.7%]. Two patients [5.7%] developed peri-renal urinomas .One patient developed severe hematuria that required blood transfusion but no further intervention was performed. The modified double-puncture technique is a simple and relatively safe procedure to fix a nephrostomy tube in the nondilated renal collecting systems with few complications

Outcomes of extracorporeal shock wave lithotripsy [ESWL] for ureteric stones: experience with storyz modulith Sl20 and SLX

Between March 2000 and November 2003, 544 patient [374 males and 170 females] with ureteral stones were treated by ESWL using Storz Modulith SL-20 and Storz Modulith SL-X lithotriptors. Stones were located in the upper ureter in 308 cases, in the lower ureter in 204 cases and middle ureter in 32 cases. Stone sizes were 5-10 mm in 294 cases, 11-15 mm in 182 cases and 16-20 mm in 68 cases. The majority of the patients had single stones, while 43 cases had two or three stones. Pre-ESWL fixation of double-J stents was needed in 15.6%. The treatment voltage ranged between 15 and 18 kV. Mean duration of treatment was 35 minutes with average 3500 shocks. Patients required 2.2 sessions per stone. The overall stone free rate after six months was 73.6% [332 cases]. Stone size was the only statistically significant factor in the results of stone clearance. The stone free rates in patients with stones less than 10 mm, between 11-15 mm and 16-20 mm were 78%, 69.9% and 59.7%, respectively. There was no statistical significance for stone number or stone site in the results of stone fragmentation and clearance. Also, there was no significant statistical difference concerning the machine used. In conclusion, both Storz Modulith SL-20 and SL-X ESWL machines were equally effective. Stone size was the only statistically significant factor in the results of stone clearance

Transurethral repair of symptomatic distal female urethral diverticulum

To present our experience in the treatment of distal urethral diverticula using a novel surgical transurethral approach. Sixteen women with distal urethral diverticula were studied. Their ages ranged from 26 to 52 years [mean 36 years]. Clinical presentation included chronic intermittent pelvic pain, dysuria, dyspareunia, urgency and post void dribbling of urine. Clinical examination revealed tender anterior vaginal mass or fullness in all cases. Diagnosis of urethral diverticula was based on voiding cystourethrogram [VCUG] and Cystourethrocopy. Patients with proximal, multiple diverticula and those having stress urinary incontinence were excluded from the study. Transurethral diverticulectomy was performed successfully in all cases. The urethral defect was closed transversely with vicryl 3/0 and a Foley's catheter was fixed for two weeks. Follow up VCUG was performed two weeks after surgery to exclude extravasation. The diverticula were posterior in 14 cases and posterolateral in two cases. The average operating time was about 30 minutes. All patients reported subjective relief of pain after surgery. Complications included a urinary tract infection in four patients. One patient had persistent signs of a small, residual diverticulum on VCUG on the 15th day. There were no recurrences or urethrovaginal fistulae. Transurethral diverticulectomy is a simple, safe and effective procedure for treatment of distal urethral diverticula

Endoscopic treatment of ejaculatory duct obstruction: value of intraoperative transrectal ultrasound guidance

To report our experience in the use of intraoperative transrectal ultrasound [TRUS] guidance for endoscopic treatment of patients with ejaculatory duct obstruction [EDO]. A total of 200 infertile men were evaluated for azoospermia with normal palpable testes, and 35 patients were found to have EDO. Diagnostic criteria included a history, physical examination, semen analyses, semen fructose measurement, hormonal study, testicular biopsy and TRUS. Twenty-five patients underwent endoscopic management or treatment of their EDO under TRUS guidance in the form of resection in 20 cases and endoscopic extraction of calculi in five patients. In all of the 35 men, semen analyses showed the typical characteristics of complete EDO. TRUS revealed distended seminal vesicles [SV] and dilated ejaculatory ducts in 24 cases, fibrosed ejaculatory ducts in six cases, calculi obstructing ejaculatory ducts in five cases. Normal serum hormones, normal testicular biopsy and low ejaculate volume were found in all cases. The overall rates of improved semen values and paternity after endoscopic treatment were 52% [13/25] and 16% [4/25], respectively. Postoperative complications included urinary tract infection in 24%, haematuria in 16%, recurrent epididymitis in 12% and acute urinary retention in 8% of cases. TRUS provided useful information on the exact location of any cyst which was very helpful during transurethral resection of the ejaculatory ducts [TURED]. Intraoperative TRUS guidance facilitated and shortened operation time