Translation and Validation of the Ureteral Stent Symptoms Questionnaire in Urdu.

Introduction In endourology, ureteric stenting is a common procedure, and stent placement is not without adverse health consequences. A ureteric stent symptoms questionnaire (USSQ) was devised to objectively evaluate the symptoms related to it. The original questionnaire is in English and translated into various languages worldwide. We translated the questionnaire into Urdu and validated it in an Urdu-speaking population with a stent in situ. Materials and methods The English version of USSQ was translated and back-translated by experts in both languages. Content validity was checked by sending Urdu version to five experts, and their scores were used to calculate the content validity index. The final version was filled by patients with stents on three different occasions, two with stents in situ at one and two weeks post stent placement, and a third time two weeks after stent removal. Discriminant validity was checked by filling of USSQ by 64 healthy individuals. Statistical analysis was done with mean and standard deviation, Cronbach's alpha, Spearman's coefficient, and paired sample t-test. Results A total of 64 patients filled the complete questionnaire at all times with mean age of 35.31 ± 8.853. All subdomains of USSQ have significant drop in scores with stent in situ in comparison to post stent removal. Reliability was checked by Cronbach's alpha in all subdomains (71.5-91.1) and test-retest reliability by Spearman's coefficient (80.5-94.7). Symptoms change in stent in situ with post stent removal checked with paired sample t-test with a p-value of <0.005 in all domains, except body pain. Discriminant validity was checked with healthy controls, and a p-value of <0.005 was found in all subdomains of USSQ, except pain.  Conclusion The Urdu version of the USSQ is a reliable and valid instrument that can be used in clinical practice and future research in an Urdu-speaking population.

Vision for the future on urolithiasis: research, management, education and training-some personal views.

The field of urolithiasis has undergone many rapid changes in the last 3 decades. In this article, three eminent experts in various fields of urolithiasis research describe their respective visions for the future in stone research, stone treatment and surgical training. Many stone researchers have seen and regretted that there has not been a real breakthrough for decades now. Exceptions are the application of citrate prophylaxis and the abandonment of calcium-avoiding diet in stone formers. Certain areas of stone research have been exhausted and the body of literature available should suffice as background knowledge in those. Yet, to find meaningful mechanisms of clinically applicable stone prevention, the limited funds which are currently available should be used to research priority areas, of which crystal-cell interaction is envisioned by one of the present authors as being a crucial direction in future stone research. In the opinion of the second author, surgical stone treatment is very much technology-driven. This applies to the evolution of existing technologies and instruments. In addition, robotics, IT and communication software, and artificial intelligence are promising and are steadily making a meaningful impact in medicine in general, and endourology in particular. Finally, the third author believes that despite the exciting advances in technology, the role of the surgeon can never be replaced. The idea of a fully automated, artificially thinking and robotically performing system treating patients medically and surgically will not appeal to urologists or patients but may at least be a partial reality. His vision therefore is that surgical training will have to take on a new dimension, away from the patient and towards virtual reality, until the skill set is acceptably developed.

Does ureteral stenting prior to shock wave lithotripsy influence the need for intervention in steinstrasse and related complications?

OBJECTIVE: To analyze factors affecting steinstrasse (SS) and study the impact of pre-shock wave lithotripsy (SWL) stenting in the prevention of SS and related complications. PATIENTS AND METHODS: The cohort included 4,644 patients with renal stones treated by SWL. Three hundred and twenty-six (7%) developed SS. Initially, all patients were managed conservatively (group 1); interventions were reserved for those in whom conservative treatment failed (group 2). The 2 groups were further analyzed to identify factors influencing the need for intervention. The impact of pre-SWL stenting on the development of SS and the need for intervention was also assessed. RESULTS: Expectant management was successful in 176 (54%) patients, while 150 (46%) required intervention for SS. The size of the stones had a significant association with the number of sessions required (p < 0.01) and the development of SS. The placement of a stent prior to SWL decreased neither the sessions of SWL (p < 0.01) nor the interventions required for SS and related complications. CONCLUSIONS: SWL for larger stones is a potentially significant complication of SWL and is associated with significant morbidity. Ureteral stents decrease the acute presentations of patients with SS; however, it does not decrease the ultimate need for intervention in the management of SS.

Predictors of recurrence of urethral stricture disease following optical urethrotomy.

OBJECTIVE: To assess the predictors of recurrence in Optical urethrotomy (OU) for male urethral strictures. METHODS: 148 male patients treated with OU with intent to treat during the period of January 2003-December 2008 were included in the study. Charts were reviewed for demographics, cause of stricture, stricture length and need for ancillary procedure following OU. The time to recurrence following OU was noted. All patients were evaluated postoperatively with uroflowmetry monthly for the first 3 months, every 3 months during year 1 and every 6 months during year 2. After year 2 most patients were followed annually. RESULTS: 139 patients were included in the study, 9 were excluded for inadequate follow up. Median age was 54 years (17-87). The etiology of stricture was iatrogenic in 35%, unknown in 32%, inflammatory in 17% and secondary to external trauma in 16%. Majority (61%) were bulbar or bulbo membranous in location. For a mean follow up of 8.9+/-11 months, the overall recurrence rate was 37%, with mean time to recurrence of 4.5 months. Stricture length (p=0.0001), etiology (p=0.001) and site (p=0.017) were significant factors of recurrence. CONCLUSIONS: Strictures of penile urethra, following transurethral resection of prostate and length greater than 20mm are significant causes of poor result for optical urethrotomy monotherapy. Patients with these predictors should preferably not be treated by OU.

Role of estrogens in the secondary hormonal manipulation of hormone refractory prostate cancer.

OBJECTIVE: To evaluate the role of Estrogens (Honvan) in the secondary hormonal manipulation of patients with hormone refractory prostate cancer (HRCP). METHODS: Twelve patients diagnosed as hormone refractory prostate cancer received intravenous estrogens for six days (Fosfestrol, a synthetic phosphorylated estrogen derivative), followed by a maintenance oral dose of 120 mg thrice daily as second line hormonal treatment. During the treatment they were given deep venous thrombosis prophylaxis. Their stage at initial presentation, primary treatment, mode of androgen ablation, prostate specific antigen (PSA) level, duration of remission prior of HRPC status, PSA doubling time before and after estrogen treatment were recorded. The morbidity and mortality of the treatment was also recorded. A drop in PSA of > 50% was classified as major responder. The drop of < 50% was defined as minor responders. Treatment failure was defined as a rise in PSA > the level prior to the start of treatment. RESULTS: The mean age at diagnosis of prostate cancer was 66.6 + 5.4 years (range 57-73). At the time of initial diagnosis only 3 patients (25%) had localized disease and 9 (75%) had metastatic prostate cancer. Six patients each opted for surgical or medical castration (LHRH analogs) as the mode of androgen ablation. The mean initial PSA at diagnosis was 340 + 728.1 ng/ml (range 4.1-2375, Median 94). After development of HRPC, six patients (50%) had major response, four (33%) had minor response to estrogen administration. Two patients (17%) did not respond to estrogens. The mean PSA before receiving Fosfestrol was 60.5 + 82 ng/ml (range 0.013-246). The PSA (nadir) after treatment was 24.3 +/- 33.2 ng/ml (range 0.9-81.3). One patient developed gynaecomastia and one had congestive cardiac failure. Two patients died of non cancer related deaths and one patient died of cancer related death. CONCLUSION: Synthetic estrogens are well tolerated, in-expensive agents and could be considered for palliative use against hormone resistant prostate cancer.

The effect of intracalyceal distribution on the clearance of renal stones of > or = 20 mm in children after extracorporeal lithotripsy.

OBJECTIVES: To determine the effect of the intracalyceal distribution of renal stones on clearance rates after treating paediatric nephrolithiasis with extracorporeal shock wave lithotripsy (ESWL). PATIENTS AND METHODS: We assessed a retrospective case series of children (aged < or = 14 years) undergoing lithotripsy on an MPL 9000 (Dornier GmbH, Germany) echo-guided lithotripter. Patients were identified using an international coding and indexing system and ESWL registry. In all, 125 children were treated during 1990-2003, but 21 had stones of > or = 20 mm. Stone clearance was assessed at 1 and 3 months, the stone-free state being defined as no radiological evidence of stone or fragments of < or = 3 mm. Failed treatments were analysed to identify any correlation with stone site. RESULTS: The overall stone-free rate was 81%; in four children the treatment failed (all girls) and subsequently they required ancillary procedures. Nineteen patients (90%) received up to three sessions of ESWL; two required four or more sessions. Of the four children in whom treatment failed, two had JJ stents; the stones were in the lower pole calyx in two, and the renal pelvis and lower pole calyx in two. The mean stone size in those where treatment failed was 25 mm, vs 21 mm in the stone-free group. The complication rate was 19%, but only one child required admission to hospital. CONCLUSIONS: ESWL is very effective for renal stones in children, with minimal morbidity. Lower pole and partial staghorn stones with a major component in the lower pole calyx should preferably be treated by a percutaneous approach.

Optimization of low pre-operative hemoglobin reduces transfusion requirement in patients undergoing transurethral resection of prostate.

OBJECTIVE: To identify factors that influence peri-operative hemorrhage in view of reducing the need for transfusions in patients undergoing trans uretheral resection of prostate (TURP). METHODS: All patients undergoing TURP between January 1997 and December 1999 were identified using ICD 9CM coding and indexing system. Overall 430 patients were identified, however, 384 charts were included and reviewed for demographics, pre and intra-operative data and post-operative morbidity. Patients were divided into two groups on the basis of presence of significant hemorrhage. RESULTS: Overall 384 patients were analyzed. Nineteen patients had hemorrhage--group I whereas 365 had no significant hemorrhage--group II. Mean age and co-morbidities in the two groups were similar. However, in group I, 58% presented with urinary retention compared to 33% in group II. In group I, factors that reached statistical significance include; operative time (p<0.05), mean resected tissue weight (p<0.02), and patient presentation (urinary retention) (p<0.032). There was no significant difference in the two groups with respect to type of anesthesia (regional versus general) and histology of the resected tissue. Patients with mean pre-operative hemoglobin of 10.6 % had a 37% transfusion rate. CONCLUSION: Operative time, weight of resected prostate tissue are inter related and are only partly controllable. Low pre-operative hemoglobin is the only reversible factor in reducing transfusion following TURP.

Improvement in serum creatinine following definite treatment of urolithiasis in patients with concurrent renal insufficiency.

OBJECTIVE: To assess whether definitive treatment of urolithiasis following relief of obstruction in patients with renal insufficiency results in further improvement in renal function as determined by serum creatinine. METHODS: In a review of 500 patients with urolithiasis, we identified 43 (12%) patients with serum creatinine level of > or =176 micromol/l at the time of presentation. Location and complexity of calculi, type of procedure required to render the patients stone free and effects of surgical intervention (following relief of obstruction) on renal function were evaluated. RESULTS: Mean serum creatinine at presentation was 555 micromol/l and after relief of obstruction was 361 micromol/l. Mean serum creatinine level after surgical intervention dropped to 193 micromol/l (p < 0.001). Complete or partial staghorn calculi were seen in 40% of patients. Two-thirds of patients required more than one procedure for complete stone clearance. CONCLUSIONS: Renal calculi and concurrent mild to moderate renal insufficiency warrants aggressive treatments. Patients demonstrate significant improvement in renal function independent of relief of obstruction.

A 10-year experience of managing ureteric calculi: changing trends towards endourological intervention--is there a role for open surgery?

OBJECTIVES: To study changing practices in the management of ureterolithiasis with the introduction of newer technologies, the efficacy and safety of endourology, extracorporeal shock wave lithotripsy (ESWL) and open surgery, and to determine if any indication remains for open ureterolithotomy in a tertiary endourology unit. PATIENTS AND METHODS: A 12-year retrospective review (1987-1998) was conducted of all primary ureteric stones treated by ESWL, endoscopy, intracorporeal shock wave lithotripsy (ISWL) administered via ureteroscopy, and open surgery. RESULTS: In all, 1195 patients were treated for primary ureteric stones, 44% by ESWL, 37% by ureteroscopy and ISWL, and 20% by open surgery. At the 3-month follow-up the stone-free rates for ESWL monotherapy, ureteroscopy and open surgery were 95%, 85% and 97%, giving an efficiency quotient of 73%, 64% and 94%, respectively. The overall complication rate for ESWL was 13%, for ISWL 32% and for open surgery 13%, but the complications of open surgery were often serious and potentially life-threatening. CONCLUSIONS: With recent advances in endourology the indications for open surgery have decreased considerably, from 26% in 1987-95 to 8% in 1996-98. However, the remaining indications for open ureterolithotomy include failure of less invasive modalities, the presence of medical/anatomical abnormalities, a concomitant open procedure, and the presence of large impacted calculi for which patients prefer to avoid multiple procedures.

Candidal infections as a cause of recurrent uretero-ileal anastomotic dehiscence.

Fungal infections are common in immunocompromised patients. The presentation is often subtle and therefore treatment is delayed. Uretero-ileal anastomotic dehiscence due to candidal infection has never been reported before. This case represents an uncommon but potentially life-threatening complication in reconstructive surgery; that is, anastomotic dehiscence due to a unique etiology.

Therapeutic efficacy of Dornier MPL 9000 for prevesical calculi as judged by efficiency quotient.

PURPOSE: To study the efficacy and safety of the Dornier MPL 9000 lithotripter in the treatment of prevesical calculi using real-time ultrasound monitoring and to see if efficacy is adequately judged by the efficiency quotient (EQ). PATIENTS AND METHODS: Seventy-six patients underwent ultrasound-guided extracorporeal shockwave lithotripsy (SWL) for prevesical calculi over a period of 43 months. Their age ranged from 8 to 68 (mean 37.6) years, and the male:female ratio was 2.6:1. The size of the stones, measured in two dimensions, ranged from 4 to 25 mm (mean 9.3 mm) and 2 to 15 mm (mean 6.0 mm). No general or regional anesthesia or ureteral stents were used, and all patients were treated in the prone position. The EQ was calculated using the formula: Stone free (%) x 100/(100 + retreatment rate (%) + auxiliary procedures (%). RESULTS: Seventy patients were stone free in a mean time of 15 +/- 14.11 days. The average number of shockwaves used was 2,831 +/- 1,612, and the average number of sessions per patient was 1.7. About 92% of the patients were rendered stone free using in situ SWL alone. No major complication was encountered, and none of the patients required an inpatient stay after SWL. The EQ was 65. Five patients with failed SWL subsequently were rendered stone free, four with salvage ureteroscopy and pneumatic lithotripsy and one with cystolitholapaxy for a symptomatic fragment in the bladder. One patient was lost to follow-up. CONCLUSION: In situ SWL is a safe and effective treatment for prevesical calculi. It should be used as a first-line treatment for most such stones. Efficiency can be assessed objectively by the EQ.

Physician responsibility for removal of implants: the case for a computerized program for tracking overdue double-J stents.

PURPOSE: Ureteral stents are used in various modern urologic procedures. Although forgotten double-J (JJ) stents are an infrequent problem, they are associated with significant medical problems. Encrustation from excessive indwelling time increases morbidity and may require extracorporeal shock wave lithotripsy to free the coils of the cementing calcerous material. An effective system should be in place to ensure timely removal. The previously used "card" system not only is difficult to manage but has proved unreliable. We describe a computerized program that tracks JJ stents and alerts physicians about stents that need removal. MATERIALS AND METHODS: Two hundred eighteen patients who were stented between January 1997 and December 1998 were tracked through an integrated computerized program. This program keeps a log of all patients who received a JJ stent and determines the last date by which it should be removed. Patients are reminded if they have not returned for removal of the implant 2 weeks before it is overdue. RESULTS: Two hundred twenty-five JJ stents were placed in 218 patients. Comparison of data between the periods before and after computer program inception showed that the incidence of stents retained longer than their expiration time decreased from 12.5% to 1.2% in the first year of the program and 1.5% in the second year of the program. CONCLUSIONS: Forgotten implants pose a significant management dilemma for physicians. Our tracking program significantly lowered the incidence of overdue JJ stents from 12.5% to 1.2% and 1.5% in the first and second years, of the program respectively (p = .00039). We propose that this technically simple program should be in place for all implants placed in patients. The problems we encountered in the smooth running of this system could be averted by incorporating several recommendations.

Three techniques for simpler, safer, and cost-effective rigid ureteroscopy.

Postureteroscopy colic, accumulation of irrigant fluid in the bladder, and advancement of the ureteroscope through narrow ureters are some of the problems commonly encountered during ureteroscopy. Three methods to overcome these problems and to make ureteroscopy technically easy, safe and cost-effective are described.

Use of residual fraction instead of residual volume in the evaluation of lower urinary tract symptoms.

Assessment of postvoid residual volume (PVR) has become a valuable routine investigation in the evaluation of bladder outlet obstruction. PVR has been shown to have interindividual and intraindividual variation and dependence on prevoid urinary volume, thus raising a question about its significance. The aim of this study was to investigate an alternate parameter more reliable than PVR, described as residual fraction (RF) and calculated as (PVR x 100)/prevoid volume. Ninety-three adult patients with lower urinary tract symptoms (LUTS) presenting to the urology outpatient clinic were evaluated for bladder outlet obstruction. Patients with urinary retention and neurological disorders were excluded. Evaluation was by clinical assessment, uroflowmetry, and ultrasound bladder for prevoid and postvoid urine volume estimation. The latter was compared with RF. Results were statistically analyzed using bivariate analysis and Spearman's test. In 93 evaluable patients, there were 87 (94%) males and 6 (6%) females. Residual volume ranged from 4 to 450 mL (mean 91.4+/-92.7 mL). Peak flow rate (Qmax) varied from 3 to 49 mL/s (mean 9+/-15 mLis). Two-tailed correlation between PVR and Qmax was significant at the .05 level, whereas a more significant R value at .01 was observed between RF and Qmax. There was a strong positive correlation between RF and PVR with Qmax. RF statistically correlated better with Qmax than PVR. It is recommended that RF be used instead of PVR in the routine noninvasive evaluation of LUTS.