Continent cutaneous urinary diversion versus ileal conduit post-radical cystectomy: a comparative study

Objectives: to evaluate the efficacy and outcome of continent cutanuous urinary diversion using the extramural serous lined tunnel [CCD] and compare it with the standard ileal conduit procedure [ICD] after radical cystectomy due to bladder cancer

Patients and Methods: Between 1998 and 2002, 68 patients were underwent radical cystectomy and were not candidates for orthotopic diversion. Of these patients, 24 underwent CCD as described by Abo-Enein and Ghoneim in 1995 and 44 patients underwent ICD. Outcome analysis included operative time, hospital stay, early postoperative complications, quality of life and cosmetic appearance

Results: Overall, mean age at surgery and follow up was 55, 3 years, respectively. Mean operative time was 8.3 and 6.8 hours for CCD and ICD, respectively. Sixty cm of ileum was used to fashion the CCD pouch compared to 1520 cm used in ICD. Mean capacity of the pouch was 450 in CCD. Of CCD patients, 23 were continent and only one patient had cutaneous incontinence, one had stoma1 stenosis and one had pouchoureteral reflux associated with continence. Serum creatinine, Na, K acid acid-base profile were within normal. Most of the patients had better quality of life than ICD group. Eady postoperative complications were comparable. No intraoperative or postoperative mortality was encountered

Conclusion: Continent Cutaneous diversion is technkally feasible, aapplnce free, applicable for urinary diversion with low complication rate and good quality of life with cosmetically accepted stoma for this selected group of patients. It is considered an alfemative diversion when orthotopic type is not feasible

Evaluation of transurethral vaporesection versus standard transurethral resection in the treatment of BPH

The aim of this study is to evaluate the safety and the efficacy of transurethral vaporesection of the prostate [TUVRP] in comparison to the standard transurethral resection [TURP] in the treatment of benign prostatic hyperplasia with especial emphasis on electrolytes and haemodynamic changes. Eighty patients with BPH requiring surgery were included in the study. They were prospectively randomized into two equal groups. The first group was subjected to [TUVRP] and the second group to [TURP]. All the patients were subjected to complete preoperative evaluation by clinical examination, laboratory and radiological investigations. Intraoperative and early postoperative evaluation of the resection time, resected volume, serum Na, blood loss, complications, catheterization period and hospital stay. Also they are re-evaluated 6 months postoperatively for improvement in the symptoms, uroflowmetry, US findings and late complications. The mean age of patients was 59.5 +/- 6 and 61.3 +/- 5.55 years for TUVRP group and TURP group respectively. The preoperative baseline data were statistically insignificant Patients after TURP had significantly lower levels of serum sodium, hemoglobin and hematocrit at 1 and 24 hours postoperatively than in group underwent TUVRP [p < 0.05]. None of the patients required blood transfusion and no cases of transurethral resection syndrome was occurred. There was no significant difference in operative time between the 2 groups. The resected weight is significantly lesser in the TUVRP group than that of TURP. The mean postoperative catheterization time was [3.5 +/- 0.51 and 6.5 +/- 0.99 days] in TUVRP and TURP respectively [p < 0.05] which is statistically significant. Patients were followed up for six months post-operatively. Symptomatic improvement was noted for both groups after six months of surgery with no significant difference. None of the patients developed sphincteric incontinence, bladder neck contracture or urethral stricture. TUVRP is as effective as TURP in the treatment of BPH. It is more safe than TURP as it causes less bleeding and less electrolytes disturbance and also ensures shorter post-operative catheterization and hospital stay

Evaluation of different modalities for surgical management of renal stones

There is no single method suitable for the removal of all renal stones. The goal of surgical stone management is to achieve maximal stone clearance with minimal morbidity to the patient. The aim of the work is to evaluate different modalities as extracorporeal shock wave lithotripsy [ESWL], percutaneous nephrolithotomy [PNL] and open stone surgery [OSS] in the management of renal stones in patients attending our department in one year. This study was conducted on 200 patients with renal calculi. The patients were divided into three groups: group A [100 patients] underwent ESWL, group B [50 patients] had PNL and group C [50 patients] had OSS. They were completely evaluated by histor, physical examination, laboratory and radiological investigation. Patients were evaluated postoperatively by KUB, US and urinalysis at 1 day, 2 week up to 3 months. Comparing the results in the three groups revealed that the total stone free rate [SFR] in them is nearly equal 90%, 88% and 88% in group A, B and C respectively. On the other hand comparing the results in the three groups in relation to the stone characteristics [burden, number and fresh or recurrent] revealed that the SFR in them is nearly equal in single and small burden stone either fresh or recurrent. While with multiple and large stone burden [> 3 cm] PNL gives the best results [72.2 - 87.5%] especially with recurrent cases as a monotherapy, followed by open surgery [66.6- 80%] especially with fresh cases, then ESWL as it gives the least SFR [33.3-60%]. Stones less than 1 cm, ESWL is usually the primary approach. For stones between 1 - 2 cm, ESWL is still the first-line treatment unless factors of stone composition, location, or renal anatomy shift the balance toward more invasive but definitive treatment modalities [PNL or OSS]. Stones > 2 cm should primarily be treated by PNL, unless specific indications for OSS are present. Stones >3cm, multiple or staghorn better managed by sandwich technique [PNL and ESWL]

Ureteroscopic versus cystoscopic introduction of ureteric guide wire

To evaluate the feasibility of the ureteroscope versus the use of cystoscope to introduce the ureteric guide wire. This study was conducted on 50 patients [100 units]. They were divided into two groups, group A [50 units] with normal ureters in one side as seen in IVU and group B [50 units] with pathology either stricture or stone ureter in the other side. After initial cystoscopic evaluation and identification of both ureteric orifices, the cystoscope and/or ureteroscope were used to introduce the guide wire in group A ureteroscopy was successful in 100% of the cases [25 units] as initial tool, while with the use of the cystoscope it is only 76% [18 out of 25] which increased to 96% after the use of ureteroscope to introduce the guide wire. In group B with the use of ureteroscope in 25 pathological ureters, it is successful in 92% of the cases [23/ 25] while with the use of cystoscope it is only 60% [15/ 25]. With the aid of the ureterpscope in the remaining failed cases the success rate was increased to 80% [20/25] and complete failure in 5 cases due to massive trauma to the ureter from multiple trials of blind introduction of the guide wire through the cystoscope. Introduction of the ureteric guide wire is essential step in ureteroscopy as with its failure all the procedure will fail. So, simple and easy introduction of the guide wire through the cystoscope was tried first, if failed, multiple trials is not recommended and it is better to use the ureteroscope to introduce it under vision better than blind trials avoiding trauma to the ureter

Z - plasty for the management of penoscrotal hypospadias

The aim of this study is to evaluate this new technique for the repair of cases with penoscortal hypospadias, associated with mild to moderate degree of chordee. This study included 15 cases with penoscortal hypospadias [3-8 years] old, 8 of them associated with mild degree of chordee, 7 with moderate degree of chordee. In all the cases a Z- shape incision was done with the two limbs parallel to the penile shaft along the proximal and distal halves of the shaft and the oblique line across the urethral plate. This oblique incision to the urethral plate with minimal dissection of the underlying surface of the plate can correct minimal degree of chordee, while in cases with moderate degree dorsal plication sutures were used to correct it. The two limbs of the Z incision were dissected to create long based flaps which can be rotated and sutured to the other side, this creates two tubes connected by the oblique line with the suture line of the tube in two different directions along the penile shaft. The glanular part is corrected as in snodgrass technique All the tube was covered with additional dartos layer as in the original snodgrass technique covering the suture line in two differently directed flaps, closure of the skin with the Byars flaps. All the patients were subjected to routine regular dilatation postoperatively. The over all success rate was 80% [12 out of 15]. Complete loss of the tube was encountered in 1 cases due to infection and compromised blood supply of the flap. Urinary fistula in 1 case at the site of junction between the two tubes, which repaired later-on in one session, and persistent mild degree of chordee in 1 case. Z plasty technique is a feasible and promising technique for repair of penoscrotal hypospadias associated with penile curvature. As it correct mild degree of chordee and the tube is formed and covered from two different directions on the penile shaft giving more blood supply to each flap with the suture line in two different directions

Alternating mitomycin C and Bacillus calmette-guerin instillations versus MMC or BCG monotherapy in treatment of superficial bladder cancer

To evaluate whether, in patients with superficial bladder cancer, alternating instillation therapy with mitomycin C [MMC] and bacillus Calmette-Guerin [BCG] was effective and less toxic than conventional BCG or MMC monotherapy. This study was conducted on 90 patients, their age ranged from 38-72 years [73 male and 17 female]. They were clinically evaluated and investigated by routine laboratory investigation, plain x-ray, IVU and US. Cystoscopic biopsy was done, and after confirmation of the pathology as superficial bladder cancer [Cis, Ta or T1] they were classified into three groups A,B and C each of them 30 patients in a random fashion. Transurethral resection was done for the pathological lesion. All the patients received the treatment in the first postoperative day, after the urine becomes clear. Group A received a full dose of BCG [120 mg] weekly for 6 weeks, group B received a full dose of MMC [40mg] weekly for 6 weeks and group C received weekly alternatively a reduced dose from BCG [75mg] and MMC [30 mg] for 12 weeks. All the patients were followed by cystoscopic biopsy every 3 months during a period of 18 months for recurrence or progression of the tumor and local toxicity of the drug. Comparing the results in group [C] with the other two groups [A and B] we found lower recurrence rate [6.7% versus 23.3% and 16.7% respectively] and progression rate [3.3% versus 16.7% and 13.3% respectively]. Also the regimen is well tolerated with less toxicity as compared with the two other groups [6.7% versus 23.3% and 13.3% in group C versus A and B respectively]. Alternating bacillus Calmette Guerin and mitomycin C instillations for treatment of superficial bladder cancer in low doses after transurethral resection in the early postoperative day is an effective regimen for prophylaxis against tumor recurrence and progression like monotherapy and even more effective with less toxicity and well tolerated by the patients. These results must be evaluated on a more large scale