Doppler-Assessed Ureteric Jet Frequency: A Valuable Predictor of Ureteric Obstruction.

OBJECTIVES: To compare ureterovesical jet frequency in non-obstructed versus obstructed ureter secondary to ureteric stone using ultrasonography in patients presenting with ureteral stones. STUDY DESIGN:  Cross-sectional prospective study. Place of study and duration: Urology Department, The Kidney Centre Post Graduate Training Institute from May 16 to November 15, 2019. METHODS: This study included 97 patients having presented in the emergency department with acute renal colic and were diagnosed as having ureteral stones on a non-contrast-enhanced computed tomography (NCCT). The ureteric jet frequency was measured by Doppler ultrasonography by our radiologist with the Hitachi Aloka F-37 ultrasound machine after they underwent CT. Patients were asked to drink 750-1000 ml of liquids 15-20 minutes before their ultrasonographic examination of both kidneys, ureters, and urinary bladder. The kidney size (length and width) and presence/absence of hydronephrosis were evaluated by grayscale ultrasound. Then, with the help of color Doppler ultrasonography, the frequency of the ureteric jet was recorded. RESULTS: The patient's mean age was 46.66 ± 3.21 years ranging from 37 to 56 years. There were 58 (59.8%) male and 39 (40.2%) female cases. The mean cumulative stone size was 9.77 ± 2.65 mm. According to stone location, 44 (45.4%) cases had upper ureteric, 24 (24.7%) cases had mid ureteric, and 29 (29.9%) cases had lower ureteric stone. The mean obstructive side jet frequency was 0.70/min ± 0.49, and the non-obstructive side jet frequency was 2.89/min ± 1.29 (P < 0.05). CONCLUSIONS: The mean obstructive side jet frequency was 0.70 ± 0.49/min, which, if we compare to the non-obstructed normal ureter, is significantly less. Hence, color Doppler ultrasonography can be helpful to patients who were previously diagnosed with ureteral stones on NCCT to see if their stone has passed. This can be a very cost-effective modality especially in resource-poor countries where repeat CT can be very expensive. The results from this study can also be used in a specific population (i.e., pregnancy) where the use of imaging modalities that involve ionizing radiation is prohibited.

Effects and outcome of Tamsulosin more than just stone clearance after extracorporeal shock wave lithotripsy for renal calculi.

OBJECTIVE: To determine the effect of Tamsulosin, as adjunctive medical therapy after Extracorporeal Shock Wave Lithotripsy for renal stones on rate of stone clearance, clearance time, pain intensity during stone clearance, steinstrasse formation and auxiliary surgical intervention required. METHOD: A prospective randomized controlled study was carried out in 120 patients who undeiwent ESWL for renal stones of 0.5-2.0 cm. They were randomized into study and control group in which Tamsulosin 0.4 mg/day was given in former as an adjunctive medical therapy. All patients underwent ESWL every 2 weeks until complete stone clearance for 8 weeks. The parameters assessed were stone clearance, clearance time, pain intensity and effect on steinstrasse. RESULTS: Of the 120 patients 60 were in each group. The stone clearance rate was greater in study than in control group, 58 (96.7%) vs. 48 (80%) respectively, (p < 0.004). The mean stone clearance time was observed earlier in study group as compared to control group with significant statistical difference in stone size between 0.6-1.Scm.The mean intensity of pain patients experienced according to Visual analogue scale (VAS) was significantly less in study group (p < 0.002). The rate of steinstrasse formation was observed to be higher in control than in study group 15 (25%) vs 6 (10%) respectively (p < 0.003), while its spontaneous clearance was higher in study group than in control group 83.3% vs 33.3% (p < 0.03). CONCLUSION: Tamsulosin significantly increases stone clearance after shock wave lithotripsy for renal stones. It also appeared to facilitate earlier stone clearance, reduces severity of pain, reduces the incidence of steinstrasse formation and tends to facilitate its spontaneous clearance.

Management of acute urinary retention: a worldwide survey of 6074 men with benign prostatic hyperplasia.

OBJECTIVES: To evaluate the management of acute urinary retention (AUR) associated with benign prostatic hyperplasia (BPH) in real-life practice. To identify predictors of successful trial without catheter (TWOC). MATERIALS AND METHODS: In all, 6074 men catheterized for painful AUR were enrolled in a prospective, cross-sectional survey conducted in public and private urology practices in France, Asia, Latin America, Algeria and the Middle East. Patient clinical characteristics, type of AUR and its management (type of catheterization, hospitalization, TWOC, use of α(1)-blockers, immediate or elective surgery) and adverse events observed during the catheterization period were recorded. Predictors of TWOC success were also analysed by multivariate regression analysis with stepwise procedure. RESULTS: Of the 6074 men, 4289 (71%) had a spontaneous AUR and 1785 (29%) had a precipitated AUR, mainly as the result of loco-regional/general anaesthesia (28.5%) and excessive alcohol intake (18.2%). Presence of BPH was revealed by AUR in 44% of men. Hospitalization for AUR varied between countries, ranging from 1.7% in Algeria to 100% in France. A urethral catheter was inserted in most cases (89.8%) usually followed by a TWOC (78.0%) after a median of 5 days. Overall TWOC success rate was 61%. Most men (86%) received an α(1)-blocker (mainly alfuzosin) before catheter removal with consistently higher TWOC success rates, regardless of age and type of AUR. Multivariate regression analysis confirmed that α(1)-blocker before TWOC doubled the chances of success (odds ratio 1.92, 95% CI 1.52-2.42, P < 0.001). Age ≥70 years, prostate size ≥50 g, severe lower urinary tract symptoms, drained volume at catheterization ≥1000 mL and spontaneous AUR favoured TWOC failure. Catheterization >3 days did not influence TWOC success but was associated with increased morbidity and prolonged hospitalization for adverse events. In the case of TWOC failure, 49% of men were recatheterized and had BPH surgery and 43.5% tried another TWOC with a success rate of 29.5%. Elective surgery was preferred to immediate surgery. CONCLUSIONS: TWOC has become a standard practice worldwide for men with BPH and AUR. In most cases, an α(1)-blocker is prescribed before TWOC and significantly increases the chance of success. Prolonged catheterization is associated with an increased morbidity.

Is it necessary to remove foleys catheter late after transurethral prostatectomy in patients who presented with acute urinary retention secondary to benign prostatic hyperplasia?

OBJECTIVE: To assess the influence of early versus late removal of catheter after Transurethral Prostatectomy (TURP) in patients who presented with Acute Urinary Retention (AUR), at our centre. METHODS: The records were reviewed of patients presenting to the Emergency Room (ER) or out patient department (OPD) with AUR, after TURP done between April 2004 to June 2008, at The Kidney Centre PGTI, Karachi. Total 60 patients were enrolled. Age, size of prostate, days catheterized before TURP, the post operative day of catheter removal and results after catheter removal were recorded. RESULTS: Fifty two (86.7%) patients had successful voiding while 8 (13.3%) patients, 4 from each group, went into retention again. There was no significant difference in the results of patients who had catheters for either shorter or longer periods prior to surgery. CONCLUSION: There is no difference in early versus late removal of catheter after TURP in patients who present with AUR.

Is ascending urethrogram mandatory for all urethral strictures?

OBJECTIVE: To determine the role of ascending urethrogram in decision making for patients with suspected urethral strictures. METHODS: Medical Records were reviewed of male patients presenting with lower urinary tract symptoms who were subjected to ascending urethrogram and selected cases for cystourethroscopy from January 2001 to December 2002. Cystourethroscopy was performed on those patients who complied with treatment for urethral stricture or who had persistent low flow of urine despite ascending urethrogram reporting no urethral stricture. Data was analyzed on SPSS 10.0. Sensitivity, specificity, positive and negative predictive values were calculated for ascending urethrogram as a measure to evaluate urethral stricture. RESULTS: Ascending urethrogram was done on 92 patients. Of whom 55 were reported to have urethral stricture. The mean age of patients was 42.8 +/- 13.2 years. Of the 92 patients who had ascending urethrogram, 62 were subjected to cystourethroscopy proceed optical internal urethrotomy (OIU) in cases of stricture. It was that out of 45 reported urethral strictures on ascending urethrogram, 5 did not have stricture on cystourethroscopy (P = 0.001). Likewise in the same group of 62 patients, 17 patients were reported to have no stricture on ascending urethrogram, whereas subsequent cystourethroscopy revealed stricture in 4 patients. The calculated sensitivity of ascending urethrogram was 91% and specificity 72%. The calculated positive and negative predictive values were 89% and 76% respectively. CONCLUSION: The study concluded that Ascending Urethrogram does not completely rule out urethral stricture (Negative Predictive Value 76%). It was also observed that urethral stricture may be non-existent even though suggested in Ascending Urethrogram (Positive Predictive Value 89%). With a sensitivity of 91% and a low specificity of 72% of the ascending urethrogram for diagnosing urethral stricture, it would be advisable to subject the patient to cystourethroscopy proceed Optical Internal Urethrotomy in cases of urethral stricture. This will save cost, avoid infection reduce risk of radiation and contrast related hypersensitivity reaction.

Single-center review of fluoroscopy-guided percutaneous nephrostomy performed by urologic surgeons.

PURPOSE: To review the success rate and complications of radiologically guided percutaneous nephrostomies (PCNs) performed by urologists and compare the complication rates with the standards recommended by the Society of Interventional Radiology (SIR) and the American College of Radiology (ACR). PATIENTS AND METHODS: From January 1996 to December 2005, 667 patients had 765 PCNs performed by three urologists, with 74 patients having simultaneous bilateral PCNs. The mean age of the patients was 29 years (range 8 months-95 years). The medical records were reviewed for underlying diseases, success rate, and complications of PCN; and the results were assessed in comparison with recommendations made by SIR and ACR. RESULTS: The PCN was successful in 742 renal units (97%). A total of 26 of the 667 patients (3.89%) had major complications: 12 (1.79%) had sepsis, 10 (1.49%) had hemorrhage sufficient to necessitate transfusion, 1 (0.14%) had pleural injury that was managed conservatively, and another patient had a vascular complication necessitating nephrectomy. None of the patients had bowel transgression. Minor complications occurred in 61 patients (9.1%): urinary-tract infection in 17, PCN tube dislodgement in 11, catheter obstruction by clot or debris in 12, urine leakage around the PCN site in 8, and loss of the PCN catheter in 13. CONCLUSION: Percutaneous nephrostomy is a relatively safe, minimally invasive, and effective procedure with a low rate of morbidity. Our overall results in term of success rate and major complications are within the threshold limits set by the SIR and ACR. Hence, trained urologists can produce results similar to those of interventional radiologists. Learning of PCN should be mandatory in the training curriculum for all urology residents.

Safety and efficacy of tubeless percutaneous nephrolithotomy.

OBJECTIVE: To determine the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL). METHODS: A quasi-experimental study conducted on 50 patients, at a specialized urology centre. RESULTS: The primary success rate of the procedure in terms of stone clearance was 70%. Mean length of hospital stay was 2.44 days. There were no significant complications during or after the surgery. CONCLUSION: Tubeless PCNL is a safe and effective modification of the conventional procedure. Absence of the nephrostomy tube may help in keeping the patient comfortable after the surgery and reduction in the length of hospital stay.