The effect of stone size on the results of extracorporeal shockwave lithotripsy versus semi-rigid ureteroscopic lithotripsy in the management of upper ureteric stones.

OBJECTIVES: To evaluate the role of stone size on the efficacy and safety of extracorporeal shockwave lithotripsy (ESWL) monotherapy vs ureteroscopy (URS) for managing upper ureteric stones. PATIENTS AND METHODS: The study design was a randomised prospective study of a total cohort of 180 patients with upper ureteric single stones of 0.5-1.5 cm. Half of the patients were managed by ESWL monotherapy, while the other half underwent URS with stone fragmentation using an ultrasound lithotripter (URSL). The success rate, re-treatment rate, auxiliary procedure (AP) rate, efficacy quotient, and complications were compared between the two groups. RESULTS: After single URSL and ESWL procedures 70/90 (77.8%) and 35/90 (38.9%) of the stones were successfully cleared, respectively (P < 0.001). The re-treatment rate after ESWL was significantly higher than in the URSL group (38.9% vs 11.1%, P < 0.001). Requiring an AP was not significantly different following ESWL (22.2%) and URSL (24.4%) treatment. The overall stone-free rate (SFR) at 3 months was significantly superior in the URSL group (88.9% vs 77.8%); however, both procedures had excellent results with no significant difference for stones of <1 cm (95.5% vs 92.9%, P > 0.05), compared to better results following URSL for stones of >1 cm (82.6% vs 64.6%, P < 0.05). CONCLUSION: Our present study supports that ESWL is recommended as a first-line non-invasive monotherapy for upper ureteric opaque stones of <1 cm, while URSL is recommended as a first-line treatment for stones of >1 cm. The results for URSL were superior with lower a re-treatment rate, rapid stone clearance in a very short time, and less radiation exposure. Therefore, stone size is an important factor for the final decision of the initial management of upper ureteric stones because it has a direct relation to the efficacy of ESWL, but it has no effect on the results of URSL.

Mirabegron versus Solifenacin in Children with Overactive Bladder: Prospective Randomized Single-Blind Controlled Trial.

PURPOSE: The purpose of this study is to investigate the efficacy and safety of mirabegron versus solifenacin in the treatment of newly diagnosed overactive bladder (OAB) in children. METHODS: We conducted a prospective randomized controlled study on pediatric patients with newly diagnosed OAB. Patients were randomized into 3 groups: mirabegron (50 mg once daily) in group I, solifenacin (5 mg) in group II, and placebo in group III. Before starting our treatment and at the end of the 3 months course, we obtained a 3-day voiding diary. This diary included incontinence episode per day, mean voided volume per micturition, mean number of micturition per day, and post-void residual urine. Moreover, the parents/patients were asked to rate symptom relief, and the adverse events were recorded throughout the study period. RESULTS: A total of 190 patients aged from 5 to 14 years completed this study. At the end of this trial, both groups I and II showed significant improvement versus placebo regarding our efficacy parameters with no significant difference between group I and II. The overall success rate based on assessment of symptom relief was significantly higher in the treated groups (87.5% in I and 90.2% in II) versus placebo (55.8%). Dry mouth was reported in 2.8, 10, and 0% and constipation in 2.8, 11.4, and 1.4% in group I, II, and III, respectively, without statistically significant difference between group I and placebo. However, there was a significant difference between group II and placebo regarding these side effects. CONCLUSION: Both mirabegron and solifenacin have comparable efficacy regarding the control of OAB symptoms in the newly diagnosed children, but mirabegrone seems to have less side effects.

Efficacy and safety of mirabegron versus solifenacin as additional therapy for persistent OAB symptoms after tamsulosin monotherapy in men with probable BPO.

PURPOSE: To investigate the efficacy and safety of mirabegron versus solifenacin as add-on for persistent OAB symptoms after tamsulosin monotherapy in men with probable BPO. PATIENTS AND METHODS: This prospective randomized single-blind study was conducted on patients with persistent OAB symptoms after at least 12 weeks of tamsulosin 0.4 mg. The patients were randomized into group A in which mirabegron (50 mg once daily) was added and group B in which solifenacin (5 mg once daily) was added. Before and 12 weeks after addition of either drugs, we assessed the efficacy of the treatment using the OABSS, IPSS, Q max, MVV/mic and PVR. RESULTS: Ninety two men were included in this study (46 patients in each group). All the study parameters were significantly improved after the 12-week treatment period in both groups except mean PVR which showed non-significant change in group A and a significant change in group B despite of being clinically irrelevant with only one case of acute urine retention. Overall, no significant difference has been observed between both groups after 12 weeks of treatment regarding all studied parameters except PVR. The incidence of side effects in group A was 10.9% versus 26.1% in group B. Main side effects included dry mouth in 2.2% and 8.7% and constipation in 2.2% and 6.5% in group A and B, respectively. CONCLUSION: Our results indicate that the addition of either mirabegron or solifenacin to patients with persistent OAB symptoms after tamsulosin monotherapy has significant efficacy in controlling these symptoms. The adequate balance between efficacy and tolerability reported in this study with mirabegron may result in better QOL and overall patient satisfaction if compared with antimuscarinics.

Management of 'forgotten' encrusted JJ stents using extracorporeal shockwave lithotripsy: A single-centre experience.

Objective: To evaluate the role of extracorporeal shockwave lithotripsy (ESWL) for the management of 'forgotten' encrusted stents. Patients and Method: This is a retrospective study of 133 patients with forgotten JJ stents, treated between January 2015 and January 2018. Encrustation was mainly found in the renal coil of the stent with distal concomitant encrustation in the vesical and/or ureteric segment. After laboratory and radiological assessment, treatment started with ESWL for the renal encrustation before successful extraction. Auxiliary endourological procedures were used for the encrusted vesical or ureteric segments. Failed cases underwent open surgery. Results: The mean (SD; range) JJ stent indwelling time was 25.84 (10; 14-70) months. In all, 96 (72.2%) patients were seen after treatment for stone disease. In total, 94 patients (70.7%) were managed by ESWL monotherapy, whilst in 36 (27%) additional endourological procedures were required before successful extraction including: cystolithotripsy 19 patients (52.8%), ureteroscopic lithotripsy eight (22.2%), and percutaneous nephrolithotomy nine (25%). Open surgery was required in only three patients (2.3%). A mean of 0.28 procedures per patient was required before smooth stent extraction. The encrusted stents were removed after the first, second, third, and fourth ESWL sessions in 44 patients (33.1%), 43 (32.3%), 26 (19.5%), and 17 (12.8%), respectively. Patients with forgotten indwelling JJ stents for >2 years had significantly larger and harder encrustation at both JJ coils. Conclusion: ESWL proved a feasible first-line treatment for forgotten encrusted JJ stents. The indwelling time of forgotten stents in the urinary tract is associated with greater encrustation burden, density and multiple sites of encrustation. Abbreviations: CLT: cystolithotripsy; ESWL: extracorporeal shockwave lithotripsy; HU: Hounsfield unit; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; PCNL: percutaneous nephrolithotomy; URL: ureteroscopic lithotripsy.

Outcome of Modification of Dose and Time of Administration of Tamsulosin in Men with Abnormal Ejaculation.

INTRODUCTION: Alpha-adrenergic blockers are now the cornerstone medication in management of lower urinary tract symptom (LUTS); however, the associated treatment-related abnormal ejaculation could be a bothersome event. This is a comparative study among different methods of tamsulosin administration in terms of efficacy, recoverability of ejaculatory function, and quality of life (QoL) in men with tamsulosin-related abnormal ejaculation. PATIENTS AND METHODS: Sexually active men receiving tamsulosin for LUTS who were bothered by treatment-related abnormal ejaculation following initiation of tamsulosin were randomized into 3 groups; group A received intermittent-full-standard-dose, group B received low-dose-tamsulosin, and group C received full-standard-dose tamsulosin The status of ejaculatory function, IPSS, QoL score, and Q-Max were measured at baseline and 3 months later. RESULTS: A total of 93 men with mean age of 53.1 years were included in the study, 3-months after randomization, statistically significant improvements in IPSS, QoL index, and Q-Max in comparison to pre-treatment levels were noted. Restoration of normal ejaculation was reported by 74.1 and 90.3% of patients in group A and B, respectively, versus none in group C. The QoL score was significant when comparing group A to the other groups; finally, the Q-Max was significant when comparing group C to the other groups. CONCLUSION: For patients bothered by tamsulosin-related abnormal ejaculation, a significant improvement in the QoL, without deviation from the therapeutic purpose of treatment, can be achieved by administration of 0.4 mg tamsulosin every other day.

Goserelin acetate before transurethral resection of moderately enlarged benign prostatic hyperplasia: Prospective randomised-controlled clinical trial.

OBJECTIVE: To evaluate the impact of a luteinising hormone-releasing hormone (LHRH) agonist, goserelin acetate (GA), on surgical blood loss during transurethral resection of the prostate (TURP), as well as its histopathological effect on prostatic microvessel density (MVD). PATIENTS AND METHODS: Patients who underwent TURP due to benign prostatic enlargement (60-100 mL) were randomly subdivided into two equal groups according to whether they received preoperative GA administration (3.6 mg; group A) or not (group B). Evaluation parameters were operative time, weight of resected prostatic tissue, perioperative haematocrit (HCT) changes, estimation of intraoperative blood loss, and suburethral and stromal prostatic MVD. Effects of GA on prostate weight and any possible side-effects were also monitored. RESULTS: In all, 35 and 33 patients were included in groups A and B, respectively. Operative time and HCT values' changes were significantly less in group A (P < 0.05). Also, operative blood loss (both total and adjusted per weight of resected tissue) was lower in group A, at a mean (SD) of 178.13 (77.71) mL and 3.74 (1.52) mL/g vs 371.75 (91.09) mL and 8.59 (2.42) mL/g (P < 0.001). The median MVD in both suburethral [8 vs 11 vessels/high-power field (HPF)] and stromal tissues (9 vs 17 vessels/HPF) were significantly lower in group A (P < 0.001). Side-effects were minimal. CONCLUSION: A single dose of GA, a LHRH agonist, before TURP is safe and effective in reducing surgical blood loss. It significantly reduced MVD in both suburethral and stromal nodular prostatic tissues without regional discrepancy.

Immediate and late management of iatrogenic ureteric injuries: 28 years of experience.

OBJECTIVE: To evaluate the long-term results after managing intraoperative and late-diagnosed cases of iatrogenic ureteric injury (IUI), treated endoscopically or by open surgery. PATIENTS AND METHODS: Patients immediately diagnosed with IUI were managed under the same anaesthetic, while those referred late had a radiological assessment of the site of injury, and endoscopic management. Open surgical procedures were used only for the failed cases with previous diversion. RESULTS: In all, 98 patients who were followed had IUI after gynaecological, abdominopelvic and ureteroscopic procedures in 60.2%, 14.3% and 25.5%, respectively. The 27 patients diagnosed during surgery were managed immediately, while in the late-referred 71 patients ureteroscopic ureteric realignment with stenting was successful in 26 (36.6%). Complex open reconstruction with re-implantation or ureteric substitution, using bladder-tube or intestinal-loop procedures, was used in 27 (60%), 16 (35.5%) and two (4.5%) patients of the late group, respectively. A long-term radiological follow-up with a mean (range) of 46.6 (24.5-144) months showed recurrent obstruction in 16 (16.3%) patients managed endoscopically and reflux in six (8.3%) patients. Three renal units only (3%) were lost in the late-presenting patients. CONCLUSION: Patients managed immediately had better long-term results. More than a third of the late-diagnosed patients were successfully managed endoscopically with minimal morbidity. Open reconstruction by an experienced urologist who can perform a complex substitutional procedure was mandatory to preserve renal units in the long-term.

Intraprostatic injection of botulinum toxin-A in patients with refractory chronic pelvic pain syndrome: The transurethral vs. transrectal approach.

OBJECTIVE: To evaluate the outcome of an intraprostatic injection of botulinum toxin-A (BTX-A) in men with refractory chronic prostatitis-associated chronic pelvic-pain syndrome (CP/CPPS) and to compare the efficacy of the transurethral and transrectal routes. PATIENTS AND METHODS: In an uncontrolled randomised clinical trial conducted in men with refractory CP/CPPS, the patients were classified into two groups according to the route of BTX-A injection; transurethral (group 1, 28 patients) and transrectal ultrasonography-guided (group 2, 35 patients). The chronic prostatitis symptom index (CPSI), maximum urinary flow rate (Q max) and white blood cell (WBC) count in expressed prostatic secretion (EPS) were measured before and at 3, 6 and 12 months after the injection. A significant clinical improvement (SCI, defined as a reduction of 4 points or a 25% decrease in total CPSI score) was correlated with patient age, prostate volume and symptom duration. RESULTS: In group 1, the pain and quality-of-life domain scores improved, but statistically significantly only at 6 months. The voiding score improved at all follow-up visits. In group 2 there was a significant improvement in all the CPSI domain scores at all follow-up visits, except for pain, which was insignificantly improved by 12 months. The SCI ratings in groups 1 and 2 were 36%, 79% and 57%, and 49%, 89% and 74% in group 2 at the three follow-up visits, respectively. The Q max was significantly improved in both groups during the follow-up (except at 12 months in group 1). There was a significant reduction in the mean WBC count in the EPS in patients with inflammatory prostatitis. Both prostate volume and symptom duration were significantly associated with a lower SCI rating. CONCLUSION: BTX-A is an available treatment option for patients with refractory CP/CPPS. It is more effective in patients with a small prostate and short symptom duration. The transrectal route provided better results than the transurethral route. More prospective longer term studies are needed.

The development of ureteric strictures after ureteroscopic treatment for ureteric calculi: A long-term study at two academic centres.

OBJECTIVE: To determine the incidence of symptomatic and 'silent' obstruction after ureteroscopic procedures. PATIENTS AND METHODS: In all, 1980 patients underwent ureteroscopy for ureteric calculi in two large centres. The methods of disintegration, auxiliary procedures used and type of stenting were considered. Intraoperative complications, in addition to the size and site of the stone, were assessed in relation to postoperative obstruction. The mean (range) follow-up was 42 (12-68) months, with patients assessed after 3-6 months and yearly thereafter. The postoperative evaluation included an assessment of pain, renal ultrasonography, a plain abdominal film, intravenous urography, and a diuretic renal scan in some cases to confirm obstruction. RESULTS: The success rate of stone removal was 98.5%. The failures were related to the size of the stone (>2 cm; P < 0.001). In eight patients there was a ureteric perforation, and six of these developed a ureteric stricture. A stricture also occurred in 12 patients (0.6%) during the follow-up; these included nine of 204 with stones of >2 cm (4.4%), compared to three (0.17%) of 1746 patients with stones of <2 cm (P < 0.001). Fourteen patients presented with pain (0.7%), and five had no obstruction, while in nine (0.46%) the pain was associated with obstruction. There was silent obstruction in three cases (0.15%). The negative and positive predictive values for pain were 99.8% and 64.3%, respectively. CONCLUSIONS: Radiographic surveillance for stricture formation and obstruction is mandatory in patients who are symptomatic after ureteroscopy, and for up to 18 months in patients with intraoperative complications or with a stone of >2 cm in the proximal ureter.

Endoscopic urethroplasty using small intestinal submucosal patch in cases of recurrent urethral stricture: a preliminary study.

OBJECTIVES: The objective of this study was to evaluate the results of internal urethrotomy with endoscopically placed small intestinal submucosa (SIS) graft for treatment of selected cases of recurrent urethral stricture. PATIENTS AND METHODS: This prospective study included 10 patients with recurrent inflammatory bulbar urethral stricture of 0.5-2 cm in length with no dense spongiofibrosis. Following the 12 o'clock visual internal urethrotomy, a prepared 12F Foley's silicon catheter with the SIS patch was introduced into the urethra over a preplaced super-stiff guidewire. The advancement of this catheter was monitored via a 15F urethroscope to enable us to put its balloon with the overlying SIS patch at the site of the urethral incision. Thereafter, the balloon was inflated with saline and the catheter was secured with a silk suture to the glans. In addition, a suprapubic cystostomy was fixed for bladder drainage. These catheters were kept in place for 2 weeks. The patients were followed up at regular intervals using uroflowmetry and ascending urethrography. RESULTS: At 3-month follow-up, only two cases showed mild recurrent stricture and the rest of cases had a normally patent functional urethra. The subsequent follow-up studies of all the eight successful cases for 12-18 months revealed no evidence of recurrent stricture in all of them and no more interventions were required for any of them. On the other hand, the two cases with recurrent stricture showed a satisfactory response to regular monthly urethral dilatation. CONCLUSION: Endoscopic urethroplasty using SIS patch can be considered as a minimally invasive solution for cases with recurrent, short urethral stricture that are associated with mild spongiofibrosis.

Ureteroscopic management of lower ureteric calculi: a 15-year single-centre experience.

OBJECTIVE: To review our 15-year experience with ureteroscopic treatment of distal ureteric calculi and to determine the impact of improved technology and techniques on the efficacy, success and complications of the procedure. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 4512 patients who underwent 5133 ureteroscopic procedures for the treatment of distal ureteric calculi at our institution from January 1991 to December 2005. The patient and stone characteristics, treatment variables and clinical outcomes were assessed. Factors such as type of ureteroscope, procedure duration, procedure success, complication rate and hospital stay were evaluated. Data obtained from a cohort of patients that underwent the procedure from 1991 to 1995 (group 1) were statistical compared with those obtained from a cohort of patients from 1996 to 2005 (group 2). Logistic regression analysis was used to identify associated factors with the major complications of ureteroscopy. RESULTS: Overall, the stone-free rate after the procedure was 94.6%, the mean (sd; range) operative duration was 43 (15.0; 25-120) min, the intraoperative complication rate was 6.67%, the postoperative complication rate was 9.9%, and the mean (sd) hospital stay was 1.7 (1.1) days. The clinical and radiological follow-up (mean 36.8 months) for 71.3% of eligible patients detected only 12 ureteric strictures (0.23%). On comparing group 1 with group 2, the overall success of ureteroscopic stone extraction improved from 85.7% to 97.3% (P < 0.001), significant ureteric perforation decreased from 3.3% to 0.5% (P = 0.05), ureteric avulsion decreased from 1.3 to 0.1% (P < 0.05), ureteric stricture decreased from 0.7% to 0.1% (P < 0.007), the mean (sd) procedure time significantly decreased from 75 (42.9) min to 36.5 (12.5) min (P < 0.001), and the mean hospital stay significantly decreased from 2.5 (1.6) days to 0.5 (1.2) days, with a trend toward outpatient treatment. Logistic regression analysis showed a significant association of the major ureteroscopic complications with increased operative duration, type of ureteroscope used, stone impaction, stone size and surgeon experience. CONCLUSION: The present series shows the high success rate, with minor complications, that can be achieved with ureteroscopic treatment of distal ureteric calculi. Improvements in ureteroscope design, accessories, technique and experience have led to a significant increase in the success rate and decrease in the complication rate.