Direct percutaneous embolization of renal pseudoaneurysm

To describe and evaluate a novel method of direct ultrasound [US] guided percutaneous embolization of renal pseudoaneurysm. Elevn patients with severe hematuria were included in this study during the period from February 2005 to February 2006. They included five patients with penetrating renal trauma, two patients post-renal biopsy and four patients after percutaneous nephrolithotripsy. Diagnostic duplex US of the pseudoaneurysm was performed. The size of the pseudoaneurysm and its neck were determined. A solution of Gelfoam particles was prepared in sterile saline solution and under US guidance, the tip of the needle was inserted into the aneurysm and slowly Gelfoam particles solution was injected. During the injection of Gelfoam, the pseudoaneurysm initially filled with an echo genic thrombus, decreasing thereby the color flow detected by US. The needle was removed when no flow in the pseudoaneurysm was detectable. The patient was kept for 30 minutes in the department and then discharged home. Follow up by color Doppler US every 2 to 4 weeks. In 10 patients bleeding was effectively controlled with direct embolization in a single session and did not need any further intervention, while one patient needed endovascular embolization due to recurrent severe hematuria after 24 hours. The amount of the injected Gelfoamn particles [1-2 mm diameter] was from 1 to 3 ml, according to the size of the pseudoaneurysm. No complication was observed secondary to embolization procedure. Re-bleeding did not occur in any patient during their follow-up period that ranged from 3-12 months. Direct ultrasound guided percutaneous embolization of renal pseudoanureysm is a new method for treating renal pseudoaneurysm. It avoids the side effects of contrast media, hazards of irradiation and complications of angiographic catheterization. Moreover, it saves the patient the risk of surgical interference to control bleeding by partial or total nephrectomy specially in patients with solitary kidney. it has been proved to be a rapid, effective, feasible, tissue preserving, and likely to reduce morbidity and mortality. Therefore, it is recommended to be a first line of treatment of actively bleeding renal pseudoaneurysms

Modified supratrigonal bladder transection for the treatment of severe resistant detrusor instability

Detrusor instability causing severe urinary urge incontinence remains a complex problem for patients and clinicians. While standard treatment targets the bladder as the source of the problem, most of the patients with urge incontinence were not satisfied with those standard treatments. Bladder transection is another available surgical option for the treatment of severe resistant urge incontinence, which failed to respond to the standard conservative methods of treatment. Nine patients, six males and three females, aged 27 to 43 years [mean age 36 years] have undergone the procedure. All of them had symptoms of increased diurnal frequency, urgency, urge incontinence, nocturia and nocturnal eneuresis. None of the patients had evidence of neurological disease. All of them had urodynamically proven Detrusor Instability. The procedure was performed with undue difficulties in six patients. Operative time ranged between 105 and 165 minutes with a mean duration of 145 minutes. No major complication occured during or immidiatly after the procedure. All of the patients were followed for 6 to 24 months with a mean follow up of 18 months. Seven patients [77.7%] were either cured or improved initially. All of the seven patients [77.7%] had no nocturnal eneuresis, being invariably dry throughout the night. During daytime, six patients [66.6%] were dry. Another patient had more than 50% reduction in incontinence episodes. After one and half years of follow up, six patients [66.6%] maintained their good results. Modified Supra Trigonal bladder transaction offers a reasonable success rate of 67% after follow up period of 18 months. This result is comparable to other surgical procedures used in the treatment of severe resistant Detrusor Instability. Still, long-term follow up of such patients is required in larger group of patients to confirm the reasonable success rate of this procedure

Percutaneous nephrolithotripsy [PCNL] in morbidly obese patients: a special experience

Morbidly obese patients have an increased risk of morbidity with open stone surgery. ESWL failure rates have been recorded in obese patients in many centers. This study is designed to evaluate the feasibility of PCNL in this group of patients. Purpose to evaluate the role of PCNL in the management of uorinary stones in morbidly obese patients. Material and Thirty-eight [38] PCNLs were performed on 35 patients. Their age ranged from 40-70 years with a mean age of 50 +/- 13.7 years. BMI [body mass index] ranged from 40-58.6 Kg/m2 with a mean of 45.15 +/- 6.4 Kg/m2. PCNL was done equally on both sides [19 each]. Four patients presented with ureteric stones [upper 1/3rd], 9 patients with staghorn stones, 1 patient with multiple stones in a solitory kidney, and 24 patients with single renal stone. All patients were treated in the prone position. In most cases, the upper or the middle posterior calyceal approach was preferred. A specially designed Amplatz sheath was used. A Pneumatic Lithoclast was used in all the procedures. Residual stones were found in only 4 cases [10.6%] while the remaining 34 cases were stone free [89.4%]. None of patients had significant bleeding and no blood transfusion was required. No major intraoperative anesthetic problems occured. Operative time ranged from 100-185 minutes with a mean of 145 +/- 19.3 minutes. All patients were discharged in the first post-operative day. PCNL is a feasible procedure for treating urinary stones in morbidly obese patients. This option should be offered even in small renal stones in this group of patients

Significance of rectal pressure changes during urodynamic testing

Rectal pressure is accepted as a means to determine the abdominal pressure. However, rectal pressure artifacts have been noticed in many urodynamic studies, but their significance and incidence were not adequately studied yet. Significance of rectal pressure changes was studied on 110 multichannel-urodynamic studies performed on 71 patients with benign prostatic hyperplasia. Multichannel-urodynamic studies were performed with a 6-channel Life Tech M-1406 Urovision machine, printed at 0.5 mm/sec paper speed and using a Bard, 8 F, 3-port, water filled, 2-marker urodynamic catheter. The bladder was filled with saline at a filling rate of 50 ml per minute. Urodynamic study included total vesical pressure measured by a urethral catheter, total abdominal pressure measured by a rectal balloon catheter, subtracted detrusor pressure [vesical minus abdominal], EMG [electromyography] recording of the external urethral sphincter and uroflow measurement. Twenty five patients [35%] had normal rectal pressure recording studies. Nineteen patients [27%] had rectal contractions Abnormal rectal pressure increase was present in 6 patients [8%], while rectal pressure decrease was present in 21 patients [30%]. There was good association between detrusor instability and rectal contractions. Rectal contractions occurred at high frequency in patients with detrusor instability [45.5%]. Rectal pressure changes observed in multichannel urodynamics are not randomly occurring events but their incidence and significance should be further studied. The association of rectal contractions with detrusor instability may indicate an underlying neurogenic pelvic floor dysfunction

Evaluation of BCL-2 expression in prostatic carcinoma. A fine-needle aspiration study

Bcl-2 expression was evaluated in a series of twenty cytologically positive prostatic carcinoma and was correlated with the cytologic grade of the tumor. In aspirated cells, the intensity of immunostaining was more frequent in high grade tumors [5 cases, 25%] than in intermediate grade [6 cases, 30%] or low grade tumors [9 cases, 45%]. There was a significant correlation [p = 0.027] between Bcl-2 expression and cytologic tumor grade. One patient was misdiagnosed as benign prostatic hyperplasia on histopathology but the diagnosis was proven to be well differentiated low grade prostatic carcinoma on application of Bcl-2 immunostaining. Bcl-2 immunostaining of specimens taken by FNAs of prostatic carcinoma is a potential tool to confirm or correct conflicting diagnosis. Bcl-2 is beneficial for diagnosis and grading of prostatic carcinoma. In addition, Bcl-2 can be used as a diagnostic marker of hormone refractory prostatic carcinoma and can be a very beneficial prognostic factor in metastatic prostate carcinoma

Is rectal pressure a true measurement of abdominal pressure?

In current urodynamic practice, rectal pressure measurement is accepted as a means to determine the abdominal pressure. Urifortunately, reclal pressure measurement can be erroneous secondary to hydrostatic pressure of the abdominal organs, pressure secondary to the intrinsic activity of the rectal wall and the tone of the abdominal muscles. The accuracy of the rectal pressure measuremenl was tested in seven rhesus monkeys [Macaca mulatta]. A total of 250 urodynamic experimenta were performed to compare the abdominal pressure measured by a freely implanted transducer and the rectal pressure measured by a water filled balloon catheler infroduced in the rectum and connected to an external pressure transducer. The comparison was made during sudden increase in intraabdornina! pressure indueed by either cough or rnanual abdominal compression and during bladder filling in cystometry. During stress [cough and manual abdominal compression], there was good correlalion between the true abdominal pressure and the rectal pressure. During cystometry, agreement of the rectal pressure with the implanted abdominal transducer [true abdominal pressure] was only present in 7.6%. The rest of the readings showed: increased rectal pressure with bladder filling in 72.8%, rectal contractions in 16%, while a sudden decrease of rectal pressure was present in 3.6% of the experiments. In monkeys, these findings suggest that rectal pressure measurement is only reliable during sudden increases of abdominal pressure. So, determining the outlet resistance in stress urinary incontinence using rectal pressure to measure the stress leak pressure is acceptable. However, determining detrusor forces by subtracting rectal pressure is subject to artifacls. Similar observations are found in humans. however, its significance, incidence and associaled diseases need further studies

Effect of low serum androgen level on bladder contractility in male rats

To study the effect of low androgens on bladder contractility. An in-vitro study was conducted on twelve Wistar male rats [six cryptorchid and six sham controls]. Field stimulation [FS] was applied at various frequencies and the blocking effects of propranolol, atropine and tetrodotoxin were determined. The contractile response to bethanechol, phenylephrine, adenosine triphosphate [ATP], and KCI was measured. Significantly greater response to FS and bethanechol was obtained from control bladder strips than from cryptorchid strips. There was no significant difference in the blocking action of atropine in both groups. Our data show that hormonal alterations associated with cryptorchidism decrease bladder contractility in male rats. There was no evidence of neurotransmitteR changes