[Percutaneous lithotripsy]

Extra-corporeal shock wave lithotripsy [ESWL] has failed to manage renal stones > 2cm in diameter. Percutaneous nephrolothotomy lithotripsy [PCNL] has proved to be a very effective alternative. This study is the first study in Syria about PCNL, reflecting our own experience. To review and to evaluate the results of percutaneous lithotripsy [PCNL] for kidney stones, especially in regard of indications, steps of the procedures and possible complications. Between 2002 and 2009, 105 patients underwent PCNL. Mean age 37 years [20-68 yr.]. 72 patients were males and 33 were females. Mean stone volume was 3,2cm [2-4.5cm]. In 87 patients [82.8%], stones were located in the lower calyx and pelvis, the rest in the middle and upper calyx and in one case only in the uretero-pelvic junction. In 60 cases [57.1%] the stones were in the right kidney and in 45 [42.8%] in the left kidney. The ultrasonic lithotripter was used to disintegrate the stones in 95 cases [90.4%] and laser was used for the rest [9.5%]. Failure of extracorporeal lithotripsy [ESWL] represented the indication for PCNL in 84 patients [80%], stone volume and location represented the indication in the rest of cases. Puncturing of the kidney was performed in 96 cases [91.4%] under fluoroscopy control in the operating room. In the rest of cases this puncturing was done in the outpatient office under ultrasonic control. The lower calyx was the site of puncture in 99 patients [94.2%], the middle calyx in and the upper calyx in only one case. The disintegration was complete in 77cases [73.3%], while the rest of stones needed further treatment with ESWL. We faced only 2 major complications that treated successfully. It is to consider that PCNL is a very effective method to treat high volume stones and stones located in the lower calyx, with acceptable rate of complications. Experience in proper puncturing of calyx under fluoroscopy and ultrasound control is crucial. In addition, equipments and experience to manage any complication that may happen, should be available

Inguinal optic loupe varicocelectomy

Microsurgical loupe inguinal varicocelectomy has been associated with relatively high success rates and minimal postoperative complications. The aim of this study is to analyze the results of a group of patients who underwent inguinal microsurgical varicocelectomy using optic loupe magnifications. From April 2003 to April 2007, 72 patients underwent loupe-assisted inguinal varicocelectomy. In 68 patients [94.3%][the varicoceles were left sided, in 1 patient [1.3%] it was right sided and they were bilateral in 3 patients [4.1%]. The mean age was 26.9 years [range: 16.42]. Fifty four patients [75%] were infertile and 18 patients [25%] had painful scrotal sensation, in 6 of them oligoasthenospermia [OAT] was detected. The diagnosis was based on clinical features namely testicular pain and, or scrotal hypersensation and physical examination. Color duplex ultrasonogrphy [CDUS] was performed in persistent cases. The majority of varicoceles were stage II and III, of them 5 [6.9%] were persistent cases. In 10 patients [13.9] OAT was mild [sperm number 10-20 millions], In 30 patients [41.6%] was moderate [5.10 millions] and in 18 [25%] was severe [less than 5 millions]. Azoospermia was detected in 2 patients [2.7%]. Furthermore, 12 patients [16.6%] had normal spermiogram. The loupe-assisted microsurgical inguinal "artery-and lymphatic-sparing" technique of dissection was performed under general anesthesia. All operations were performed as outpatient procedures [postoperative stay 3.7 hours] and the mean operating time was 45 minutes [30.55]. Follow up was performed by physical examination and semen analysis. Color duplex ultrasonogrpahy [CDUS] was done only if persistence was suspected. Immediate and long-term complications were hydrocele in 1 patient [1.3%], palpable persistence in 4 patients [5.2%] and found abscess in 1 patient [1.3%]. Forty four out of sixty [73.3%] patients showed an improvement of semen analysis and from the 30 patients who continued follow up, 14 [47%] have conception. Finally 6 out of 18 patients [33.3%] who presented with scrotal pain have their pain disappeared. Loupe-assisted inguinal varico-celectomy is a safe and effective method. It preserves spermatic artery and lymphatics and minimizes the risk of complications and persistence. In our experience this technique of varicocelectomy showed an improvement of semen analysis and the results are comparable to those obtained by the standard microsurgical technique using the microscope

Management of erectile dysfunction in diabetic patients

Diabetes is one of the major risk factors for erectile dysfunction [ED]. The aim of this study is to review all flies of our impotent diabetic patients in order to assess the role of diabetes and other concomitant risk factors in causing impotency and to discuss the role of major diagnostic and therapeutic tools. Patients and From June 2000 to June 2002, 275 male patients were referred to our andrological clinic, where 136 patients [49%] suffered from ED. Of those patients 58 [43%] were diabetic. The mean age of the diabetic patients was 47 years and mean duration of illness 7 years. Only 4 patients suffered from insulin-dependent diabetes. In 16 patients [31%] hypercholesterolemia and hyperlipidemia were registered, Eleven patients [19%] were smokers and 23 patients [39%] suffered from cardiovascular diseases CVD. Organogenic ED could be diagnosed in 48 patients [83%]. Four patients underwent nocturnal penile tumescence NPT, 40 intracavernous injection ICI of vasoactive drugs, 24 of them with color Doppler ultrasonography. Veno-occlusive dysfunction merely due to autonomic neuropathy, could be diagnosed as a major pathology. In non-diabetic patients the mean age was 57 years, in only half of the patients ED was of organic origin and only 20% of patients suffered from CVD. We treated 43 patients [72%] conservatively, only 24 patients [39%] responded to sildenafil. In the non-diabetic group about two- third of the patients responded to sildenafil. Vacuum device was adopted by 14 patients and only 3 patients rejected this treatment and choose the implantation of penile prostheses PP, with other 12 patients. Only 4 patients were treated successfully by ICI of vasoactive drugs. ED represents a major health problem especially in diabetics. Special attempts should be made at early diagnosis and treatment of diabetes and other risk factors and to diagnose this disease early and treat it appropriately. As only less than half of the patients responded well to sildenafil, more efforts should be done to discover new oral treatment for ED in order to avoid other invasive treatment such as vacuum device, ICI of vasoactive drugs and especially implantation of PP. Unfortunatly the new drug apomorphine proved to be less effective than sildenafil, tadalafil and vardenafil are promising drugs, still not yet in clinical use