Does primary urethral realignment improve the outcome of pediatric pelvic fracture urethral injury? A randomized controlled trial.

OBJECTIVE: To assess the efficacy of primary urethral realignment in the prevention of urethral stenosis and in simplifying delayed urethroplasty after complete pelvic fracture urethral injury in male children. METHODS: This randomized comparative trial included 40 boys <18 years with complete pelvic fracture urethral injury. The initial management was a primary urethral realignment in 20 boys and suprapubic cystostomy alone in the remaining 20 boys. The boys who underwent primary urethral realignment were assessed regarding the development of urethral stenosis. Boys who needed to be delayed urethroplasty in the two groups were compared regarding urethral defect length, intraoperative details, postoperative outcomes, number of procedures, and time to achieve normal voiding. RESULTS: Although 14 (70%) patients were able to void after primary urethral realignment, all of them developed urethral stenosis and needed delayed urethroplasty. No statistically significant difference between the two groups was found regarding urethral defect length, intraoperative details, and postoperative outcomes. Patients in the primary urethral realignment group underwent significantly more procedures (p < 0.001) and took a significantly longer time to achieve normal voiding (p = 0.002). CONCLUSION: Primary urethral realignment is neither able to prevent urethral stenosis nor effective in simplifying later urethroplasty after complete pelvic fracture urethral injury in male children. It exposes the patients to more surgical procedures and a prolonged clinical course.

Evaluation of early endoscopic realignment of post-traumatic complete posterior urethral rupture.

INTRODUCTION: to report our experience with 41 patients treated by early endoscopic realignment of complete post-traumatic rupture urethra. MATERIALS AND METHODS: The study includes patients presented to our institute, between May 2004 and April 2009, with post-traumatic complete posterior urethral disruption. Preoperative retrograde urethrography, voiding cystourethrography and abdominopelvic CT were performed to evaluate the urethral defect length, the bladder neck competence, the prostate position, and the extent of the pelvic hematoma. Within the first week after trauma, antegrade and retrograde urethroscopy were performed to identify both urethral ends and insert urethral catheter. Patients were followed up by pericatheter retrograde urethrogram monthly postoperatively till catheter removal on disappearance of extravasation. Retrograde urethrography, voiding cystourethrography and urethroscopy were performed 1 month after the removal of the catheter. Follow-up abdominal ultrasound and uroflowmetry monthly till 6 months, bimonthly till 1 year, and every 3 months thereafter were encouraged. Urinary continence and postoperative erectile dysfunction were assessed by direct patient interview. RESULTS: Forty one patients in the age group 17-61 years (mean 37.9) were treated. Patients were followed up for. CONCLUSIONS: Early endoscopic realignment for complete posterior urethral rupture is a feasible technique with no or minimal intraoperative complications. The technique is successful as the definitive line of therapy in reasonable number of patients and seems to render further future interventions for inevitable urethral stricture easier.

Extracorporeal shock wave lithotripsy as first line treatment for urinary tract stones in children: outcome of 500 cases.

PURPOSE: The continued evolution of stone treatment modalities, such as endourologic procedures, open surgery and shock wave lithotripsy, makes the assessment of continuous outcomes are essential. Pediatric urolithiasis are an important health problem allover the world, especially in Middle East region. We evaluate the safety, efficacy and factors affecting success rate and clearance of stones in children treated with shock wave lithotripsy. PATIENT AND METHODS: Between 2005 and 2010, a total of 500 children with stones in the upper urinary tract at different locations were treated by Extracorporeal shock wave lithotripsy (ESWL) in our department, Sohag University, Egypt. We have used the Siemn's Lithostar Modularis machine, Germany. A total of 371 boys and 129 girls with the average age of 8.63 ± 5 years, and a range from 9 months to 17 years were included in this study. Diagnosis of their urinary calculi was established either by the use of abdominal ultrasound, plain X-ray, intravenous urography, or CT scan. The stones were located in the kidney in 450 (90%) patients; 298 (66%) pelvic, 26 (5.7%) upper calices, 57 (12.6%) mid calices, and lower calices in 69 (15.3%) patients. The average of their stone sizes was 12.5 ± 7.2 mm. The other 50 children their stone were located in the proximal ureteral stones in 35 patients (70%); middle third in 5 (10%) patients and in the distal ureter in 10 (20%) patients. The average ureteral stone size was 7.5 ± 3.2 mm. All children were treated under general anesthesia with adequate lung and testes shielding using air foam. We treated the distal ureteral stones of young children in the supine position through greater sciatic foramen and lesser sciatic foramen as the path of shockwave instead of prone position, which is not a comfortable or natural position and could adversely affect cardiopulmonary function especially under general anesthesia. Localization was mainly done by ultrasound, and X-ray was only used to localize ureteral calculi. For follow-up, we have used abdominal ultrasound, plain X-ray, and CT scan if needed to confirm stone disintegration and clearance. RESULTS: The overall success rate for renal and ureteral calculi was 83.4 and 58.46%, respectively. The re-treatment rate was 4% in renal group and 28% for the ureteral group. No serious complications were recorded in our patients. Minor complications occurred in 15% of our patients; renal colic was reported in 10% of our treated patients, and repeated vomiting was reported in 5% that respond to antiemetics. In the renal group; children with history of pervious urologic surgical procedures had low success rate of stone clearance after ESWL. In the ureteral group stone burden, stone location, had a significant impact on stone clearance outcome. CONCLUSION: This study showed that SWL in pediatric age group for both renal and ureteral stone is cost effective, safe with an acceptable re-treatment rate; however children with large stone burden or previous urologic surgery have low success rate.

Expression of integrin proteins in non-muscle-invasive bladder cancer: significance of intravesical recurrence after transurethral resection.

OBJECTIVES: • To evaluate the expression of integrin proteins, a family of transmembrane heterodimers, in non-muscle-invasive bladder cancer (NMIBC). • To assess the significance of these proteins as prognostic indicators in patients undergoing transurethral resection (TUR). PATIENTS AND METHODS: • The present study comprised 161 patients diagnosed as having NMIBC after TUR. • Expression levels of six subunits of integrin proteins, including α2, α3, α5, α6, ß1 and ß4, were measured in TUR specimens by immunohistochemical staining. RESULTS: • Of the six proteins, expression levels of α2-, α3-, α6- and ß4-subunits were significantly associated with the incidence of intravesical recurrence. Univariate analysis identified expression levels of α3-, α6- and ß4-subunits as important predictors of intravesical recurrence, while tumour size, pathological T stage and concomitant carcinoma in situ (CIS) were also important. • Multivariate analysis showed that the expression level of the ß4 subunit, pathological T stage and concomitant CIS are independently related to intravesical recurrence. • There were significant differences in intravesical recurrence-free survival for patients who were positive for the three independent risk factors; intravesical recurrence occurred in 10 of 49 (20.4%) patients who were negative for all risk factors, 31 of 68 who were positive for one risk factor (45.6%), and 30 of 44 who were positive for two or three risk factors (68.2%). CONCLUSIONS: • Consideration of the expression levels of integrins, particularly those of the ß4 subunit, in TUR specimens, in addition to conventional variables, would contribute to accurate prediction of intravesical recurrence after TUR for NMIBC patients.

Expression of cell cycle-associated proteins in non-muscle-invasive bladder cancer: correlation with intravesical recurrence following transurethral resection.

The objective of this study was to evaluate the expression patterns of cell cycle-associated proteins in newly diagnosed non-muscle-invasive bladder cancer (NMIBC) to clarify the significance of these proteins as prognostic predictors in 161 consecutive patients undergoing transurethral resection (TUR). Expression levels of 7 cell cycle-associated proteins, including Aurora-A, c-erbB2, cyclin-D1, Ki-67, p21, p27, and p53, in TUR specimens were measured by immunohistochemical staining. Of the 7 proteins, weak expression of p21 was significantly associated with the incidence of intravesical recurrence (P = 0.012). Univariate analysis identified expression level of p21, tumor size, T stage, and concomitant carcinoma in situ (CIS) as significant predictors for intravesical recurrence (P = 0.0053, 0.0014, 0.024, and 0.035, respectively). Of these, p21 expression, tumor size, and concomitant CIS appeared to be independently related to intravesical recurrence (P = 0.029, 0.025, and 0.016, respectively). Furthermore, there were significant differences in intravesical recurrence-free survival according to positive patterns of these 3 independent factors; that is, intravesical recurrence occurred in 17 of 72 patients who were negative for risk factor (23.6%), 30 of 57 positive for a single risk factor (52.6%), and 24 of 32 positive for 2 or 3 risk factors (75.0%). These findings suggest that consideration of expression levels of cell cycle-associated proteins, in addition to conventional parameters, would contribute to accurate prediction of intravesical recurrence following TUR of NMIBC. Moreover, combined evaluation of p21 expression, tumor size, and concomitant CIS might be particularly useful for further refinement of the outcome in predicting intravesical recurrence following TUR of NMIBC.

Single puncture percutaneous nephrolithomy for management of complex renal stones.

BACKGROUND: The purpose of this report is to assess the safety and efficacy of single lower pole access for multiple and branched renal calculi. A prospective non randomized clinical study included 26 patients with complex renal stones (9 patients had branched renal stones and the other 17 had multiple renal stones) in the period from May 2003 to May 2004. Mean patient age was 42 years +/- 13.2 (range 18 to 67 years). All patients underwent percutaneous nephrolithotomy (PCNL) via a single lower calyceal puncture. Small stones were intactly extracted by a range of stone graspers while large stones (smallest diameter more than 1 cm) were disintegrated using either the pneumatic EMS Swiss lithoclast or Holmium YAG laser. Flexible nephroscope was used for stones inaccessible by the rigid instruments. FINDINGS: Overall stone-free rate was 74.8%. Patients with residual stones were managed by one session of shock wave lithotripsy (SWL). Mean operative time was (80 minutes +/- 27.4) for branched stones and (49.1 minutes +/- 15.9) for multiple stones. No significant blood loss reported. Perforation of pelvicalyceal system occurred in 2 patients (11.5%) with no serious sequelae. Only 1 patient developed secondary hemorrhage which necessitated blood transfusion and selective angio-embolization. CONCLUSION: In our hands, the efficacy and safety of single lower calyceal puncture PCNL in management of complex renal stones are comparable to those of the general procedure stated in literature.

Ureteroscopic holmium laser lithotripsy in patients with renal impairment.

OBJECTIVES: In this study, we try to evaluate the efficacy and safety of holmium lasers for treatment of ureteric stones in patients with renal impairment or obstructive anuria. PATIENTS AND METHODS: Twenty-six patients were included in this study, of which 20 patients presented with elevated blood urea and serum creatinine (2.1-7.6 mg%), and six patients presented with calcular anuria (mean serum creatinine 22 mg%). None of the patients had a ureteric stent or nephrostomy tube before the ureteroscopy. All patients were treated with holmium laser. A stone basket or grasper was used to remove significant stone fragments at the end of the procedure in seven patients. In these seven patients, ureteric stents were placed at the end of the procedure. RESULTS: All patients were free of any stone fragments at 1 week and at 3 months postoperatively. In all patients, including the six with obstructive anuria, the renal impairment resolved or improved as evidenced by normalization or fall in blood urea and creatinine. Thus, in this small group of uremic patients, the success rate for treatment of ureteral stone was 100%. CONCLUSIONS: A holmium laser is a safe and effective modality of ureteroscopic lithotripsy in patients with significant renal impairment or even obstructive anuria. The use of holmium laser with ureteroscopy may be considered in this group of patients as long as the general condition of the patient permits the safe administration of anesthesia.

The management of penile fracture based on clinical and magnetic resonance imaging findings.

OBJECTIVE: To present our experience with repairing penile fracture, based on clinical and magnetic resonance imaging (MRI) findings. PATIENTS AND METHODS: Between December 2002 and October 2004, 14 men (19-64 years old) presented to our centre with a penile fracture. Two patients had urethral bleeding. MRI was used before surgery in all patients, and the repair comprised a localized longitudinal penile incision in 13 men. This incision was designed according to the tunical tear site and size already depicted by MRI. One case was managed conservatively, as MRI confirmed an intercavernosal haematoma with no tunical tear. The follow-up was 4-21 months. RESULTS: The tear involved one corpus cavernosum in 11 patients; two were associated with urethral injury. The course after repair was uneventful in all men; the follow-up showed no erectile dysfunction in any. The patients reported neither pain nor penile curvature during erection. CONCLUSION: MRI is a simple and informative investigation for evaluating and documenting a penile fracture, and it improves the management plan.