Holmium Laser En-bloc Resection Versus Conventional Transurethral Resection of Bladder Tumors for Treatment of Non-muscle-invasive Bladder Cancer: A Randomized Clinical Trial.

BACKGROUND: En-bloc resection of bladder tumors achieves complete tumor removal, improves the quality of resection, decreases perioperative complication, and potentially improves recurrence rates. OBJECTIVE: To assess the efficacy and safety of holmium laser en-bloc resection (HolERBT) versus conventional transurethral resection of bladder tumor (cTURBT). DESIGN, SETTING, AND PARTICIPANTS: Between September 2015 and September 2018, 100 patients with non-muscle-invasive bladder cancer were randomly allocated to cTURBT or HolERBT. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary endpoint was detection of residual tumor in reTURBT specimens at 4 wk after the primary resection. Operative parameters, specimen quality, perioperative complications, and recurrence-free survival (RFS) were compared. Independent sample t tests, χ2 tests, and Kaplan-Meier curves were used, as appropriate. RESULTS AND LIMITATIONS: The patient and tumor baseline characteristics were comparable between the groups. Residual tumors were detected in 7% and 27.7% of cases after HolERBT and cTURBT, respectively (p=0.01). Detrusor muscle was sampled in 98% of HolERBT and 62% of cTURBT cases (p<0.001). Lamina propria invasion substaging was feasible in only 68.2% of HolERBT and 18.4% of cTURBT cases (p<0.001). Following HolERBT, catheterization time (p<0.001) and hospital stay (p=0.001) were shorter when compared to cTURBT. Immediate postoperative instillation of chemotherapy in indicated cases was feasible for 100% of the HolERBT group and 91.5% of the cTURBT group (p=0.04). After follow-up of 20 ± 9.9 mo (13-36), RFS was 31.76 mo (95% confidence interval [CI] 28.67-34.86) in the HolERBT group and 28.25 mo (95% CI 24.87-31.64) in the cTURBT group (hazard ratio 0.43, 95% CI 0.17-1.1; p=0.07). However, this study was not powered to detect a difference in RFS. CONCLUSIONS: Compared to cTURBT, HolERBT is a safer procedure for bladder tumor resection. It fulfills the oncological criteria of optimized resection with less residual tumor and better specimen quality. PATIENT SUMMARY: En-bloc resection of bladder cancer tumors using a holmium laser is safer than the conventional technique. It has the advantages of less residual tumor and better specimen quality, with a similar tumor recurrence rate. This study is registered at ClinicalTrials.gov as NCT02555163.

Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo-enucleation of the prostate for treatment of large benign prostate obstruction: 3-years outcomes.

OBJECTIVE: To compare transurethral resection in saline (TURIS), Greenlight laser vapo-enucleation of the prostate (GL.PVEP), and holmium laser enucleation of the prostate (HoLEP), for controlling lower urinary tract symptoms secondary to large benign prostatic hyperplasia (BPH) and to assess non-inferiority of 3-year re-treatment rates. PATIENTS AND METHODS: Eligible patients with BPH (prostate size 80-150 mL) were randomly assigned to one of the intervention groups. Non-inferiority of re-treatment rate was evaluated using a one-sided test at 5% level of significance. RESULTS: At the time of analysis, 60 GL.PVEP, 60 HoLEP and 62 TURIS procedures were included. Perioperative parameters were comparable between groups; however, the operative time was longer in GL.PVEP vs HoLEP and TURIS, at a mean (SD) of 92 (32) vs 73 (30) and 83 (28) min (P = 0.005); and was less effective with a mean (SD) removal of 1.2 (0.4) vs 1.7 (0.7) and 1.4 (0.6) g/min (P < 0.001), respectively. Perioperative complications and need for auxiliary procedures were similar in the three groups; however, there was a significantly higher rate of capsular perforation in TURIS group (five, 8%) compared to one (1.6%) in the GL.PVEP group and none in the HoLEP group (P = 0.01). There was a significantly longer hospital stay, catheter-time and higher rate of blood transfusion in the TURIS group. There was significant but comparable improvements in the International Prostate Symptom Score in three groups at different follow-up points. At 3 years, re-treatment for recurrent bladder outlet obstruction was required more after GL.PVEP and TURIS. More re-do surgeries for recurrent obstructing prostate adenoma was reported after GL.PVEP (four, 6.7%) and TURIS (six, 9.7%) than for HoLEP (none) (P = 0.04). CONCLUSION: The perioperative outcomes of GL.PVEP and HoLEP surpassed that of TURIS for the treatment of large prostates, but with a significantly prolonged operative time with GL.PVEP. The three techniques achieve good functional outcomes; however, 3-year re-treatment rates following TURIS and GL.PVEP were inferior to HoLEP.

Delivery of intravesical botulinum toxin A using low-energy shockwaves in the treatment of overactive bladder: A preliminary clinical study.

Objective: To evaluate the efficacy and safety of botulinum toxin A (BoNT-A) instillation in the bladder under the effect of low-energy shockwaves (LESWs) for the treatment of refractory idiopathic overactive bladder (OAB). Patients and methods: A preliminary clinical study was conducted, including 15 patients with refractory OAB, between September 2016 and July 2017. Intravesical instillation of 100 IU of BoNT-A was done followed by LESWs (3000 shocks over 10 min) exposure to the supra-pubic area. Patients were followed-up by urine analysis, urine culture, post-void residual urine volume (PVR), and Overactive Bladder Symptom Score (OABSS) at 1, 2 and 3 months. Results: There were statistically significant improvements in all OABSS domains and the total score after 1 and 2 months of treatment (P < 0.05). Whereas, only the nocturia domain remained significantly improved after 3 months (P = 0.02). There was no significant increase in PVR throughout the study period (P > 0.05) and none of the patients required clean intermittent catheterisation. Two, two and three patients developed urinary tract infections after 1, 2 and 3 months, respectively. Conclusion: Intravesical instillation of BoNT-A and LESWs is safe and effective method for the treatment of refractory OAB with a durable response for 2 months. Abbreviations: BoNT-A: botulinum toxin A; CIC: clean intermittent catheterisation; DO: detrusor overactivity; LESWs: low-energy shockwaves; OAB: overactive bladder; OABSS: Overactive Bladder Symptom Score; Qmax: maximum urinary flow rate; QoL: quality of life; UUI: urgency urinary incontinence.

Acute kidney injury after percutaneous nephrolithotomy for stones in solitary kidneys.

OBJECTIVES: The aim of this study was to report the incidence, severity, outcome and risk factors of acute kidney injury (AKI) following percutaneous nephrolithotomy (PNL) in solitary kidneys. METHODS: The study included consecutive adult patients who underwent PNL for treatment of calculi in a solitary kidney between May 2012 and July 2015. Patients with congenital renal anomalies or with stages 4 and 5 chronic kidney disease (CKD) were excluded. Serum creatinine levels were measured the day before PNL, daily after PNL for 2-5 days and after 3 months. AKI was depicted according to changes in early postoperative serum creatinine levels and its severity was determined based on the Acute Kidney Injury Network (AKIN) classification. The outcome of AKI was evaluated after 3 months by changes in the stage of CKD. Univariate and multivariate statistical analyses were conducted to determine risk factors for developing AKI. RESULTS: The study included 100 patients (62 males) with a mean ± SD age of 50 ± 11.7 years. Complications were reported for 27 patients. AKI developed in 25 patients; at the 3 month follow-up, 23 of them (92%) had completely recovered from AKI and two (8%) had developed stage 4 CKD. Independent risk factors for developing AKI were multiple PNL tracts and postoperative ureteric obstruction (relative risks were 14 and 22, respectively). CONCLUSIONS: The incidence of AKI was 25% after PNL for a solitary kidney. The likelihood of renal function recovery was 92%. Multiple PNL tracts and postoperative ureteric obstruction were risk factors for developing AKI.

Corrigendum to "Percutaneous nephrolithotomy for treating staghorn stones: 10 years of experience of a tertiary-care centre" [Arab J. Urol. 10 (2012) 324-329].

[This corrects the article DOI: 10.1016/j.aju.2012.03.002.].

Corrigendum to "Percutaneous nephrolithotomy vs. extracorporeal shockwave lithotripsy for treating a 20-30 mm single renal pelvic stone" [Arab J. Urol. 13(3) (2015) 212-216].

[This corrects the article DOI: 10.1016/j.aju.2015.04.002.].

Percutaneous nephrolithotomy for staghorn stones: a randomised trial comparing high-power holmium laser versus ultrasonic lithotripsy.

OBJECTIVE: To compare high-power holmium laser lithotripsy (HP-HLL) and ultrasonic lithotripsy (US-L) for disintegration of staghorn stones during percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: A non-inferiority randomised controlled trial was conducted between August 2011 and September 2014. Inclusion criteria were patients' aged >18 years who had complete staghorn stones (branching to the three major calyces), without contraindications to PCNL. Eligible patients were randomised between two groups: HP-HLL and US- . A standard PCNL in the prone position was performed for all patients. The only difference between the treatment groups was the method of stone disintegration. In the first group (HP-HLL), a laser power of 40-60 W (2 J, 20-30 Hz) was used to pulverise the staghorn stone into very small fragments, which could pass through the Amplatz sheath with the irrigation fluid. US-L,with suction of the fragments, was used in the second group. The primary outcome (stone-free rate) was evaluated with non-contrast computed tomography after 3 months. Secondary outcomes of complications, blood transfusion, operative time, and haemoglobin deficit were compared. The outcome assessor was 'blinded' to the treatment arm. RESULTS: The study included 70 patients (35 in each group). The baseline characteristics (age, sex, body mass index, side, stone volume, and density) and operative technique (number, size of tracts, and need for second PCNL session) were comparable for both groups. Operative time was significantly shorter in US-L group, at a mean (SD) of 130 (34) vs 148.7 (35) min (P = 0.028). The haemoglobin deficit was significantly more with in the US-L group, at a mean (SD) of 1.7 (0.9) vs 1.3 (0.6) g/dL (P = 0.037). The differences in blood transfusion (17% for US-L vs 11% for HP-HLL) and the complication rates (34% for US-L vs 23% for HP-HLL) were not significant (P = 0.495 and P = 0.290, respectively). The stone-free rates at 3 months were comparable (60% for US-L and 66% for HPL-L; P = 0.621). CONCLUSIONS: Compared with US-L for intracorporeal lithotripsy of staghorn stones during PCNL, HP-HLL showed comparable safety and efficacy with a lower haemoglobin deficit but longer operative time.

Percutaneous nephrolithotomy vs. extracorporeal shockwave lithotripsy for treating a 20-30 mm single renal pelvic stone.

OBJECTIVE: To compare the efficacy, safety and cost of extracorporeal shockwave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL) for treating a 20-30 mm single renal pelvic stone. PATIENTS AND METHODS: The computerised records of patients who underwent PNL or ESWL for a 20-30 mm single renal pelvic stone between January 2006 and December 2012 were reviewed retrospectively. Patients aged <18 years who had a branched stone, advanced hydronephrosis, a solitary kidney, anatomical renal abnormality, or had a surgical intervention within the past 6 months were excluded. The study included 337 patients with a mean (SD, range) age of 49.3 (12.2, 20-81) years. The patients' criteria (age, sex, body mass index) and the stone characteristics (side, stone length, surface area, attenuation value and skin-to-stone distance) were compared between the groups. The re-treatment rate, the need for secondary procedures, success rate, complications and the total costs were calculated and compared. RESULTS: In all, 167 patients were treated by ESWL and 170 by PNL. The re-treatment rate (75% vs. 5%), the need for secondary procedures (25% vs. 4.7%) and total number of procedures (three vs. one) were significantly higher in the ESWL group (P < 0.001). The success rate was significantly higher in the PNL group (95% vs. 75%, P < 0.001), as was the complication rate (13% vs. 6.6%, P = 0.050). The total costs of primary and secondary procedures were significantly higher for PNL (US$ 1120 vs. 490; P < 0.001). CONCLUSIONS: PNL was more effective than ESWL for treating a single renal pelvic stone of 20-30 mm. However, ESWL was associated with fewer complications and a lower cost.

Long-term functional outcome of percutaneous nephrolithotomy in solitary kidney.

OBJECTIVE: To evaluate the long-term functional outcome of percutaneous nephrolithotomy (PNL) for calculi in solitary kidneys and to determine factors leading to renal function deterioration. MATERIALS AND METHODS: The computerized files of patients with solitary kidneys who underwent PNL between January 2002 and December 2009 were retrospectively reviewed. Patients with follow-up <2 years were excluded. Complications, secondary procedures, and stone-free rates were recorded. Changes in the renal function were judged by comparing preoperative and postoperative estimated glomerular filtration rates. Preoperative, intraoperative, and postoperative factors that may affect renal function were tested using univariate and multivariate analyses to define risk factors for deterioration of renal function on long-term follow-up. RESULTS: The study included 200 patients (133 men [66.5%] and 67 women [33.5%] with mean age 52.3 ± 11.7 years). Complications were reported in 34 patients (17%). Severe bleeding was noticed in 10 patients (5%). The overall stone-free rate was 89.5%. After a mean follow-up of 3 ± 1.4 years (range, 2-8), there was significant improvement of the estimated glomerular filtration rate from 57 to 64 mL/min (P <.001). Thirty-one patients (15.5%) showed deterioration of the renal function. Multiple punctures and postoperative bleeding were independent risk factors for renal function deterioration (odds ratio was 3.7 and 4.5, respectively). CONCLUSION: PNL for calculi in solitary kidneys provided significant improvement in renal function at long-term follow-up. Multiple punctures and severe bleeding are independent risk factors for deterioration of the kidney function.

Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone.

OBJECTIVE: To determine factors affecting the stone-free rate and complications of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. METHODS: The computerized database of patients who underwent PNL for treatment of staghorn stones between January 2003 and January 2011 was reviewed. All perioperative complications were recorded and classified according to modified Clavien classification system. The stone-free rate was evaluated with low-dose noncontrast computed tomography (CT). Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free and complication rates. RESULTS: The study included 241 patients (125 male and 116 female) with a mean age of 48.7 ±14.3 years. All patients underwent 251 PNL (10 patients had bilateral stones). The stone-free rate of PNL monotherapy was 56% (142 procedures). At 3 months, the stone-free rate increased to 73% (183 kidneys) after shock wave lithotripsy. Independent risk factors for residual stones were complete staghorn stone and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). The complication rate was 27% (68 PNL). Independent risk factors for development of complications were performance of the procedure by urologists other than experienced endourologist and positive preoperative urine culture (relative risks were 2.2 and 2.1, respectively). CONCLUSION: Factors affecting the incidence of residual stones after PNL are complete staghorn stones and the presence of secondary calyceal stones. Complications are significantly high if PNL is not performed by an experienced endourologist or if preoperative urine culture is positive.

Percutaneous nephrolithotomy for treating staghorn stones: 10 years of experience of a tertiary-care centre.

OBJECTIVE: To present the results of percutaneous nephrolithotomy (PCNL) for treating staghorn stones. PATIENTS AND METHODS: A database was compiled from the computerised files of patients who underwent PCNL for staghorn stones between 1999 and 2009. The study included 238 patients (128 males and 110 females) with a mean (SD) age of 48.9 (14) years, who underwent 242 PCNLs, and included staghorn stones that were present in the renal pelvis and branched into two or more major calyces. PCNL was performed or supervised by an experienced endourologist. All perioperative complications were recorded. The stone-free status was evaluated after PCNL and again after 3 months. RESULTS: Multiple tracts were needed in 35.5% of the procedures, and several sessions of PCNL were needed in 30% of patients. There were perioperative complications in 54 procedures (22%); blood transfusion was needed in 34 patients (14%). The stone-free rate for PCNL monotherapy was 56.6% (137 patients). Secondary procedures were required for 51 patients (21%), and included shock-wave lithotripsy for 49 and ureteroscopy for two. The 3-month stone-free rate was 72.7% (176 patients). Multiple tracts resulted in an insignificantly higher overall complication rate than with a single tract (P = 0.219), but the reduction in the haemoglobin level was statistically significant with multiple tracts (P = 0.001). CONCLUSIONS: PCNL for staghorn stones must be done by an experienced endourologist in a specialised centre with all the facilities for stone management and treatment of possible complications. The patients must be informed about the range of stone-free and complication rates, and the possibility of multiple sessions or secondary procedures.

Long-term results of percutaneous nephrolithotomy for treatment of staghorn stones.

OBJECTIVE: • To study long-term results of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. PATIENTS AND METHODS: • The records of patients who underwent PNL for staghorn stones between January 1998 and January 2008 were retrospectively reviewed. • Patients who completed follow-up for one year or more were included. Follow-up with KUB and renal ultrasonography were performed every 3-6 months. • Renal radioisotopic scan was performed for patients who had already undergone this study before doing PNL. RESULTS: • The study included 122 patients (69 male and 53 female) with mean age 47.6 ± 14.5 years (5-74). They underwent 126 PNL. • Perioperative complications were encountered in 28 procedures (22%). The mean period of follow-up was 3.5 ± 2.3 years (1-11.3). Among 71 stone-free kidneys, 18 (25%) developed stone recurrence. Of 55 kidneys with residuals at the start of follow-up, 36 (65%) showed growth of these residuals. • Preoperative and postoperative renograms were performed for 71 patients. • At the last follow-up, differential GFR was stable in 53 (74.5%), improved in 12 (17%) and deteriorated in 6 (8.5%). Among patients with deteriorated renal function, 3 had undergone embolization to control severe bleeding, one developed secondary UPJO, and one had recurrent stone obstructing the kidney. CONCLUSION: • Long-term functional results of PNL for staghorn stones are satisfactory as 91.5% of kidneys showed stable or improved GFR. Long-term follow-up is mandatory especially for patients with residual stones.

Bilateral same-session ureteroscopy for treatment of ureteral calculi: critical analysis of risk factors.

OBJECTIVE: To determine factors affecting the success of bilateral same-session ureteroscopy (BSU) in the treatment of ureteral calculi. MATERIAL AND METHODS: From January 2003 to December 2008, BSU was carried out in 89 patients (178 renal units). A successful outcome was considered when both ureters were free of stones without intraoperative complications. Stone-free rate was evaluated with a kidney-ureter-bladder plain X-ray or non-contrast computed tomography. Factors interfering with successful completion of BSU were tested using univariate (chi-squared test and t test) and multivariate (logistic regression) analyses. Data on unilateral ureteroscopy for the treatment of multiple ureteral calculi carried out in 105 patients during the same period were compared with BSU. RESULTS: Intraoperative complications were recorded in 11 procedures (6.2%) in the form of ureteral perforation in three and mucosal injury in eight. After BSU, 153 renal units were stone free (86%) as 17 had residual fragments, stones migrated to the kidney in six and failure was encountered in two. A successful outcome was observed in 62 patients (70%). Stone impaction, stones located in the proximal ureter and stone surface area were the significant risk factors for unsuccessful BSU (relative risks 3.6, 3.3 and 1.47, respectively). Compared with unilateral ureteroscopy, no difference were found with regard to complication rate (6.7%, p = 0.5) or stone-free rate (80%, p = 0.2). CONCLUSIONS: Bilateral same-session ureteroscopy is a safe and effective procedure in the management of bilateral ureteral stones. Proximal ureteral calculi, large and impacted stones carry the highest risk of unsuccessful results.

Validation of Epstein criteria of insignificant prostate cancer in Middle East patients.

BACKGROUND: Since introduction of Contemporary Epstein criteria, it has been studied and validated in many countries and nations. However, they were not validated in Middle East patients up till now. AIM OF THE WORK: To validate the Contemporary Epstein criteria in Middle East patients. MATERIALS AND METHODS: On past 8 years, 70 cases underwent radical prostatectomy for T1c prostate cancer. Contemporary Epstein criteria were applied retrospectively on prostatic biopsies. Among our patients, 35 cases met the criteria for clinically insignificant prostate cancer. Pathological revision of the prostatic biopsies, definitive prostatectomy specimens and re-staging were done by single pathologist. Assessment of recurrence rate was done. Up and down grading of the Gleason scoring was studied. RESULTS: The preoperative data and biopsy results using the Contemporary Epstein criteria were fulfilled on 35 cases. On definitive pathology; 16 cases (45.7%) had Gleason score >6, while 8.6% of cases are non-organ confined (2 cases and 1 case with extra- capsular and Seminal vesicles infiltrations, respectively). Both lobes were involved in 20 cases. Moreover, 40% (14 cases) showed upgrading of the score. Lymphatic permeation could be recognized in four cases. Mean follow-up time 88.1 months, 8.6% cases develop metastasis. CONCLUSION: Whenever Epstein criteria are applied in Middle East patients, the decision of active surveillance based for clinically insignificant prostate cancer (who met the Epstein criteria) will miss nearly 46% of unfavorable prostate cancer. As well as a risk of later metastasis could be in 8.6% of them.

Shock wave lithotripsy versus semirigid ureteroscopy for proximal ureteral calculi (<20 mm): a comparative matched-pair study.

OBJECTIVES: To use a matched-pair analysis design to compare the safety and efficacy of shock wave lithotripsy (SWL) and ureteroscopy (URS). Controversy still exists regarding whether SWL or URS is the best management of upper ureteral calculi. METHODS: We reviewed the records of patients with a single radiopaque upper ureteral stone treated by URS or SWL from January 2003 to December 2005. SWL was performed as an outpatient procedure using the electromagnetic lithotripter (Dornier Lithotripter S). URS was performed using an 8F or 8.5F semirigid ureteroscope. Intracorporeal lithotripsy with pneumatic or holmium laser energy was used when needed. A matched-pair analysis was performed using 3 parameters (sex, stone size, and degree of hydronephrosis). The success rates, retreatment rates, auxiliary procedures, and complications were compared in each group. RESULTS: A total of 427 patients were treated for upper ureteral stones. Forty-three matched pairs were identified and compared. The success rate was 83.7% for SWL vs 88.4% for URS (P = .8). The retreatment rate was significantly greater in the SWL group than in the URS group (65% vs 2.3%, respectively; P < .001). The need for auxiliary procedures was equal in both groups (16.3%). The complication rate was 14% in the URS group and 4.7% in the SWL group (P = .1). CONCLUSIONS: SWL and semirigid URS are highly effective in the treatment of proximal ureteral stones <20 mm. The results of our study showed that SWL was safer and less invasive, but that URS was more effective and resulted in a lower retreatment rate.

Semirigid ureteroscopy for ureteral stones: a multivariate analysis of unfavorable results.

PURPOSE: We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi. MATERIALS AND METHODS: We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results. RESULTS: The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively). CONCLUSIONS: Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

Combination of laparoscopy and nephroscopy for treatment of stones in pelvic ectopic kidneys.

PURPOSE: To present the combination of laparoscopy and nephroscopy for the treatment of stones in pelvic ectopic kidneys. PATIENTS AND METHODS: The series included seven male and four female patients (mean age 43 +/- 9 years). Laparoscopy-assisted percutaneous nephrolithotomy (PCNL) was performed for caliceal stones in five patients after failure of shockwave lithotripsy, while laparoscopic pyelolithotomy was performed for large or branched renal pelvic stones in six patients. RESULTS: The mean operative time was 164 +/- 30 minutes. There were neither complications nor conversions to open surgery. The stone-free rate was 91% (10 patients). One patient had a residual caliceal fragment that was treated with shockwave lithotripsy. The mean hospital stay was 3.5 +/- 0.7 days. CONCLUSION: The combination of laparoscopy and nephroscopy is feasible, safe, and effective for the treatment of stones in pelvic kidneys.

Urological trauma after gynecological and obstetric surgeries.

OBJECTIVE: Gynecological and obstetric surgeries are not uncommon causes of iatrogenic injury of the urinary tract. Herein, we retrospectively report our experience with these injuries over the last 18 years. MATERIAL AND METHODS: Between 1985 and 2003, 120 females (mean age 34.2+/-13.7 years) were included in this study. The types of injury were as follows: vesicovaginal fistula, n=90; ureterovaginal fistula, n=14, ureteric ligation, n=13, vesicouterine fistula, n=2; and ureterouterine fistula, n=1. Definitive repair of such injuries was performed in all cases, including 10 cases of recurrent vesicovaginal fistulae which were treated by means of augmentation cystoplasty or urinary diversion. All patients were evaluated regarding the time and type of surgical intervention and early and late postoperative complications, including failure of primary repair. RESULTS: Of the 80 cases of vesicovaginal fistulae treated with definitive repair, 12 (13.3%) showed recurrence of the fistula. Early ureteric deligation and early or delayed ureteroneocystostomy or ureteric replacement were successful in all cases with ureteric injury. There was no loss of kidney function following the trauma or its repair. CONCLUSIONS: It is mandatory for gynecologists and obstetricians to pay careful attention to the anatomy of the urinary tract in order to avoid its iatrogenic injury. Endourologic means were successful in enabling first aid management of some of these injuries. Early exploration is indicated in cases of ureteric obstruction that present early after trauma. Augmentation cystoplasty, urinary diversion or ileal replacement are indicated in only a few cases.

Laparoscopic adrenalectomy: a single-center experience of 43 cases.

PURPOSE: To evaluate the surgical feasibility of laparoscopic adrenalectomy and what laparoscopy offers for the surgeon and the patient. PATIENTS AND METHODS: From March 1996 to June 2004, 43 transperitoneal laparoscopic adrenalectomies were performed for various pathological states. Functioning adrenal masses and solid masses>5 cm were the most common indications. The mean size of the masses on abdominal CT was 6.8 cm in the largest diameter. All patients were assessed regarding the operative time, blood loss, complications, and conversion to open surgery. The postoperative course was reported with special attention to the complications and hospital stay. RESULTS: The mean operative time was 125 minutes with a mean blood loss of 60 mL. Intraoperative complications occurred in 3 cases (6.9%), necessitating conversion to open surgery in 2 to control bleeding from the avulsed right adrenal vein. A third case of conversion was elective because of difficult dissection of a large left pheochromocytoma from the renal hilum, so there was a 6.9% rate of conversion to open surgery. All patients showed early ambulation, early start of eating, and a short hospital stay (mean 2.6 days). CONCLUSION: Laparoscopic adrenalectomy is surgically feasible and can be applied for different adrenal pathologies. The procedure can be performed with a reasonable operative time, minimal blood loss, and an acceptable rate of complications. Laparoscopic adrenalectomy provides excellent postoperative recovery and convalescence with a short hospital stay.