Role of pretreatment Doppler ultrasound in the prediction of factors affecting stone-clearance post-shockwave lithotripsy for ureteral stones: a prospective study.

PURPOSE: To identify the role of Doppler US (DUS) in the prediction of factors affecting stone-clearance post-SWL for ureteral stones in addition to its role in prediction of pretreatment stone impaction. METHODS: We prospectively included patients with ureteric stone for SWL between October 2018 and September 2019. Patient's demographics were collected. Using DUS, resistive index (RI), Δ RI, and ureteric jets were evaluated in both kidneys. Also, stone site, volume, density, skin to stone distance, degree of hydronephrosis, ureteral wall thickness (UWT) were evaluated by NCCT. Univariate and multivariate logistic regression analyses were performed to identify factors that contribute to treatment success. Correlation between ipsilateral RI with other radiological findings predicting stone impaction was done. RESULTS: A total of 93 patients were finally included (61 males and 32 females). The mean age was 31.4 ± 7.7 years. The success rate (absence of significant residuals post 1 month by NCCT) was 51.6%. In multivariate analysis, the presence of ureteric jet, ipsilateral lower RI, and ipsilateral lower UWT were independent factors for treatment success (P = 0.0001, 0.002, and 0.03, respectively). Also, ipsilateral absence of ureteric jet, increased hydronephrosis, and increased UWT were correlated with higher ipsilateral RI in prediction of stone impaction. Ipsilateral higher RI was found to achieve higher accuracy in stone impaction prediction (PPV of 94.8%). CONCLUSION: Pretreatment DUS is a useful, non-invasive with a less irradiative tool for prediction of stone impaction and stone-free rate post-SWL for ureteric stones.

Assessment of Anticholinergic Use After Fading of BTX-A Effects in Refractory Idiopathic Overactive Bladder: A Prospective Blinded Randomized Trial.

PURPOSE: To evaluate the efficacy and safety of re-treatment with anticholinergics on refractory idiopathic overactive bladder (OAB) previously treated with intravesical botulinum neurotoxin type A (BTX-A) injections. METHODS: One hundred patients were initially managed by intravesical injections of 100 IU of BTX-A. After the effects of BTX-A faded, patients were randomized into 2 groups: group A patients received solifenacin (10 mg) for 12 weeks (study group), while group B patients received placebo treatment for 12 weeks (control group), then subsequently received solifenacin (10 mg) for another 6 weeks. All patients underwent preoperative urodynamic testing. Patients were asked to complete the validated overactive bladder symptoms score (OABSS) and incontinence quality of life (I-QoL) instruments after the effects of intravesical BTX-A faded and at 12 weeks of follow-up. Univariate and multivariate analyses of the factors affecting treatment response were conducted. RESULTS: At 12 weeks of follow-up, in group A, all OABSS items, including the total score, had improved significantly (P<0.0001). Group A had lower frequency and amplitude of detrusor overactivity and detrusor leak point pressure (P<0.0001, P=0.03, and P=0.01, respectively). Cystometric capacity also increased significantly (P=0.007), as did all I-QoL parameters. In a comparison of patients with failed treatment and patients with successful treatment, female sex, repeated intravesical BTX-A injections, and increased bladder capacity were statistically significant (P=0.001, P=0.0001, and P=0.002, respectively). Repeated intravesical BTX-A injections and increased bladder capacity were independent factors predicting treatment success. CONCLUSION: In patients with refractory idiopathic OAB, reuse of anticholinergics could be an effective treatment option in patients after the effects of BTX-A fade. Repeated intravesical BTX-A injections and increased cystometric capacity could affect treatment response.

Activation of Nrf2 by ischemic preconditioning and sulforaphane in renal ischemia/reperfusion injury: a comparative experimental study.

Objectives of the study were to investigate impact of ischemic preconditioning (Ipre) and sulforaphane (SFN) and combination of them on nuclear factor 2 erythroid related factor 2 (Nrf2) gene and its dependent genes, heme oxygenase-1 (HO1) and NADPH-quinone oxidoreductase1 (NQO-1) and inflammatory cytokines TNF-alpha, IL1beta, and intercellular adhesion molecule-1 (ICAM1) and caspase-3 in renal ischemia/reperfusion (I/R) injury. Ninety male Sprague Dawely rats were classified into 5 groups (each consists of 18 rats): sham, control, Ipre, sulforaphane and Sulfo+Ipre. Each group was subdivided into 3 subgroups each containing 6 rats according to time of harvesting kidney and taking blood samples; 24 h, 48 h, and 7 days subgroups. Renal functions including serum creatinine, BUN were measured at basal conditions and by the end of experiment. Expression of Nrf2, HO-1, NQO-1, TNF-alpha, IL-1beta, and ICAM-1 was measured by real time PCR in kidney tissues by the end of experiment. Also, immunohistochemical localization of caspase-3 and chemical assay of malondialdehyde (MDA), GSH and SOD activity were measured in kidney tissues. Both Ipre and SFN improved kidney functions, enhanced the expression of Nrf2, HO-1, and NQO-1, attenuated the expression of inflammatory (TNF-alpha, IL-1, and ICAM-1) and apoptotic (caspase-3) markers. However, the effect of sulforaphane was more powerful than Ipre. Also, a combination of them caused more improvement in antioxidant genes expression and more attenuation in inflammatory genes but not caspase-3 than each one did separately. Sulforaphane showed more powerful effect in renoprotection against I/R injury than Ipre as well as there might be a synergism between them at the molecular but not at the function level.

Activation of nuclear factor erythroid 2-related factor 2 (Nrf2) and Nrf-2-dependent genes by ischaemic pre-conditioning and post-conditioning: new adaptive endogenous protective responses against renal ischaemia/reperfusion injury.

AIM: To investigate the impact of ischaemic pre-conditioning (Ipre) and post-conditioning (Ipost) on expression of nuclear factor erythroid 2-related factor 2 (Nrf2) gene and its dependent genes, haem oxygenase-1 (HO-1) and NADPH-quinone oxidoreductase-1 (NQO-1); inflammatory cytokines TNF-α, IL1ß and ICAM-1; and apoptotic markers such as caspase-3 in renal ischaemia/reperfusion (I/R) injury. METHODS: One hundred and fifty male Sprague Dawley rats were classified into five groups (each consisted of 30 rats): sham, control (I/R), Ipre + I/R, Ipre without I/R and Ipost + I/R. Serum creatinine and blood urea nitrogen (BUN) were measured at 2, 24 and 48 h after ischaemia. In kidney tissues, mRNA of Nrf2, HO-1, NQO-1, TNF-α, IL-1ß and ICAM-1 and immunohistochemical expression of Nrf2 and caspase-3 were assessed. RESULTS: Serum creatinine and BUN improved significantly in Pre + I/R group; however, they did not show any significant improvement in Post + I/R group. Also, Ipre-I/R group showed non-significant change in serum creatinine and BUN. The expression of Nrf2, HO-1 and NQO-1 is increased significantly in Pre + I/R and Pre - I/R groups, while the enhancement in Post + I/R group was non-significant. Moreover, the expression of proinflammatory cytokines (TNF-α, IL-1 and ICAM-1) and apoptotic (caspase-3) markers showed high significant attenuation in Pre + I/R group, but slight significant attenuation in Pre + I/R group. CONCLUSION: The renoprotective action of Ipre might include early activation and enhanced expression of Nrf2 gene and its dependent antioxidant genes, HO-1 and NOQ1, as endogenous adaptive renoprotective genes, as well as reduction in TNF-α, IL-1ß, ICAM-1 and caspase-3.

Fate of accessory renal arteries in grafts with multiple renal arteries during live-donor renal allo-transplantation.

INTRODUCTION: To determine risk factors for and the effects of impaired perfusion (IP)-"reduced or non-perfusion"-of graft areas supplied by an accessory artery on allograft function. OBJECTIVES: One hundred five consecutive grafts with multiple renal arteries were prospectively evaluated using Doppler ultrasound (US) to detect the perfusion of allograft segments supplied by the accessory artery. We studied factors predicting and the effects of IP on graft function. RESULTS: Doppler US diagnosed IP of allograft accessory arteries in 11 (10.5%) allografts. Mean values ± standard deviations and median (range) of renographic clearance of grafts with IP were 50.5 ± 26 and 40 (range, 21-92) mL/min, while those of grafts with patent accessory arteries were 68.6 ± 18.9 and 67.2 (range 21-117; P < .01). The percentage change in renographic clearance before versus after transplantation increased among grafts with patent arteries and decreased for those with IP (P = .03). On multivariate analysis, factors predicting IP of the accessory artery were delayed graft function (odds ratio [OR] = 9.9; 95% confidence interval [CI] = 1.6-58.6; P = .01) and upper polar arteries (OR = 8.9; 95% CI = 1.8-43.4; P < .01). CONCLUSION: When considering transplants with accessory arteries, greatest attention and efforts should be exerted on upper polar arteries to avoid delayed graft function.

MRI in patients with chronic obstructive uropathy and compromised renal function: a sole method for morphological and functional assessment.

The aim of this study was to assess the role of MRI as a single modality for anatomical and functional evaluation of obstructed kidneys in patients with compromised renal function. The study included 96 adults with unilateral or bilateral chronic obstructive hydronephrosis and compromised renal function (serum creatinine >or=1.8 mg dl(-1)). Patients were subjected to gadolinium-enhanced MRI (Gd-MRI), which determined the anatomy of both renoureteral units, as well as their function, through selective calculation of the glomerular filtration rate (GFR) of each kidney. All patients underwent a technetium-99m diethylenetriamine-pentaacetic acid renal scan. Moreover, a correlation was made between the GFR determined by Gd-MRI and the isotope GFR. The study comprised 59 males and 37 females. A comprehensive MRI study detected the cause of obstruction in all kidneys with non-calcular obstruction (sensitivity of 100%) and in 21 kidneys with calcular obstruction (sensitivity of 70%). The overall sensitivity of MRI combined with plain X-ray of the abdomen and ultrasound in the detection of various causes of obstruction was 97%. A comparison between the isotope GFR of the obstructed kidneys and the corresponding magnetic resonance urography (MRU) GFR showed perfect correlation. In conclusion, combined static and dynamic MRU is a promising technique that allows anatomical and functional evaluation of obstructed kidneys in patients with impaired renal function but, owing to the possible risk of nephrogenic systemic fibrosis in patients with a GFR <30 ml min(-1), the lowest possible dose of the most stable Gd-macrocyclic chelates should be used if a functional MRI study is required.

Sexual life in Pharaonic Egypt: towards a urological view.

Sex is a basic human need, common to all people at all times. It is evident that the ancient Egyptians were real human beings, not only a people who built massive pyramids and made mummies of their dead. The ancient Egyptians had a rich and varied sexual life, which they found an opportunity to describe in words and pictures. As in the other early primitive civilizations, erotic matters were of prime importance and became an integral part of life. In Pharaonic times, the Egyptians described impotence and recorded several methods to increase the sexual power. In the present paper, we will shed light on some aspects of the sexual life in ancient Egypt that may be interesting to the urologists, including ancient Egyptian concepts of sex and erotic matters, their own way of treatment of impotence and Min, the Egyptian fertility God.

Sliding hernia containing the ureter--a rare cause of graft hydroureteronephrosis: a case report.

Obstructive uropathy following renal transplantation is frequently reported. However, ureteral obstruction due to its incorporation in a sliding hernia is a rare event. Herein, we report a case of late graft hydroureteronephrosis secondary to a sliding hernia containing the transplanted ureter. The diagnosis was confirmed with the aid of magnetic resonance urography and antegrade urography. Following hernioplasty, a decrease of serum creatinine level was achieved with significant decompression of the system.

Squamous cell carcinoma of the bladder: pathology, diagnosis and treatment.

Squamous cell carcinoma (SCC) can occur in both nonbilharzial and bilharzial bladders; the two subtypes differ in epidemiology, pathogenesis and clinicopathological features. The nonbilharzial type occurs in Western countries and represents < 5% of all vesical tumours; it occurs most often in the seventh decade with a slight male predominance. The principal predisposing factor is prolonged indwelling urethral catheterization in patients with spinal cord injury and the main symptom is haematuria. Patients are usually diagnosed at an advanced stage and most of the tumours are of moderate and high grades. At cystoscopy tumours are predominantly ulcerative and commonly involve the trigone and lateral walls. Although distant metastasis is infrequent (8-10%) the prognosis is grave and most patients die after failure of locoregional control; radical cystectomy provides the best therapy. To avoid nonbilharzial SCC, patients with spinal cord injury should be free of catheterization if possible. The outcome can be improved by early detection with frequent cytology, cystoscopy and biopsy. Bilharzial SCC occurs commonly in the Middle East, South-east Asia and South America where schistosomiasis is endemic. In an Egyptian series SCC represented 59% of 1026 cystectomy specimens. The tumour is diagnosed in the fifth decade, and five times more common in men than women. Bladder carcinogenesis is probably related to bacterial and viral infections, commonly associated with bilharzial infestation rather than the parasite itself. The presentation is often with irritative bladder symptoms and haematuria, and many patients present at an advanced stage, although most tumours are of low and moderate grades. At cystoscopy tumours are predominantly nodular and usually arise from the upper vesical hemisphere. Lymph-node metastasis occurs in approximately 19% and significantly decreases survival; radical cystectomy remains the main treatment, giving a 5-year survival rate of 50%. Early detection improves the therapeutic yield and prevention is possible by combining snail control and mass therapy of the infested rural population by oral antibilharzial drugs.

Role of urinary transforming growth factor-beta1 concentration in the diagnosis of upper urinary tract obstruction in children.

PURPOSE: We evaluate the role of transforming growth factor-beta1 (TGF-beta1) in the diagnosis and followup of children with pelviureteral junction obstruction. MATERIALS AND METHODS: TGF-beta1 concentration was measured in renal pelvic and bladder urine samples obtained from 15 children who underwent surgery for symptomatic unilateral pelviureteral junction obstruction. Bladder urine TGF-beta1 was also measured in 11 age matched patients with dilated nonobstructed kidneys as documented by nonobstructed washout curve and half-time drainage less than 10 minutes on diuretic renography. In the obstructed group bladder urine TGF-beta1 was measured 3 months after surgery. RESULTS: In the obstructed group mean TGF-beta1 plus or minus SD in the renal pelvic urine was 285 +/- 191 pg./mg. creatinine, or 4-fold that of bladder urine (p >0.001). Mean bladder urine TGF-beta1 was 3-fold higher in patients with upper tract obstruction than in controls (68 +/- 59 versus 22 +/- 18 pg./mg. creatinine, p <0.003). Mean bladder TGF-beta1 3 months after surgery showed a trend towards a decrease, albeit still insignificant (68 +/- 59 versus 39 +/- 31 pg./mg. creatinine for preoperatively versus postoperatively, p <0.08). Using a bladder urine concentration of 29 pg./mg. creatinine as a cutoff between obstruction and no obstruction, TGF-beta1 was 80% sensitive, 82% specific and 81% accurate for the diagnosis of obstruction. CONCLUSIONS: Bladder urine TGF-beta1 is a useful noninvasive tool for diagnosis of upper urinary tract obstruction. At 3 months following corrective surgery there is a trend towards decrease in bladder TGF-beta1 concentration in comparison to the preoperative value.

Posterior urethral valves: does young age at diagnosis correlate with poor renal function?

OBJECTIVES: To determine whether young age at presentation is associated with poor renal function in patients with posterior urethral valves (PUVs). Previous studies have indicated that a young age at diagnosis is an adverse prognostic factor for patients with PUVs. METHODS: Fifty-three children with PUVs were diagnosed between January 1998 and March 2000. The patients included 25 infants with a median age of 3 months (group 1) and 28 children with a median age of 3.5 years (group 2). No statistically significant difference was present between the two groups regarding presenting symptoms, incidence of hydronephrosis, bilateral vesicoureteral reflux, presence of popoff mechanisms, or number of positive urinary cultures at presentation. Primary valve ablation was carried out in all patients. The median follow-up period for groups 1 and 2 was 19 and 18.5 months, respectively (P <0.05). RESULTS: The percentage of serum creatinine deviation greater than the normal age-reference range was calculated for each patient at diagnosis and at the last follow-up visit. The median percentage of serum creatinine deviation at presentation was 190% for group 1 and 22% for group 2 (P >0.05). The median percentage of serum creatinine deviation at the last follow-up visit was nil for group 1 and 10% for group 2 (P <0.009). Persistently dilated upper tracts were noted in 48% and 86% of patients in groups 1 and 2, respectively (P <0.004). CONCLUSIONS: In contrast to the findings of previous studies, we provide evidence of a less favorable outcome with delayed presentation of PUVs relative to those diagnosed in the first year after birth in respect to renal function and upper tract dilation.

Impact of schistosomiasis on patient and graft outcome after renal transplantation: 10 years' follow-up.

BACKGROUND: Schistosomiasis is a major health problem in some areas of the world. Schistosomal-specific nephropathy is a well-known occurrence and eventually leads to end-stage renal failure. Patients with schistosomal infection were considered to be suitable recipients for renal transplantation. However, the long-term impact of schistosomiasis on kidney transplantation is not yet been reported. METHODS: The long-term impact of schistosomiasis on patient and graft outcomes was studied by comparing two groups of subjects from a total of 243 patients. Group I consisted of cases with schistosomal infections and group II consisted of schistosoma-free controls. Schistosomiasis was documented in group I by identifying schistosoma eggs in urine, stool or rectal mucosal biopsy. Also intra-operative biopsies from bladder mucosa of the graft recipients and from the lower end of the ureter of living donors were obtained to search for schistosoma eggs. RESULTS: Sixty-three cases of schistosomiasis were diagnosed in both recipients and donors, 65 cases in recipients only, and eight cases in donors only. Infected recipients and donors with active lesions were treated at least 1 month before transplantation by combined antischistosomal drugs (praziquantel and oxamniquine). The 243 patients (136 schistosoma-infected cases and 107 controls) were followed regularly for a period of 10 years after transplantation. We found that there was no significant difference in the incidence of acute and chronic rejection between the groups; however, higher cyclosporin doses were needed for the infected group with subsequent higher incidence of both acute and chronic cyclosporin nephrotoxicity. Moreover, the schistosomal group had a significantly higher incidence of urinary tract infection and urological complications with no evidence of schistosomal re-infection. CONCLUSIONS: Despite a higher incidence of schistosoma-related complications after renal transplantation, schistosomal infection is not a major risk factor for transplantation. Therefore, infected patients can be considered as suitable recipients if they have been properly treated before transplantation.

A novel technique of ureteroneocystostomy (extravesical seromuscular tunnel): a preliminary clinical study.

OBJECTIVES: To present our initial clinical experience with the new technique of extravesical seromuscular tunnel ureteroneocystostomy. METHODS: The technique was performed in 21 patients for different indications; the most common was unilateral bilharzial stricture of the lower end of the ureter. The patients were regularly seen every 3 months during the first year, every 6 months during the second year, and annually thereafter during a follow-up period of 24.2 +/- 10.2 months. A chemical profile, urine culture, and renal ultrasound scan were performed at every visit. A technetium-99m diethylenetriaminepentaacetic acid renal scan was carried out at least once every 12 months. Ascending cystography and intravenous urography were done at least once during the entire follow-up period. RESULTS: The postoperative course was uneventful in all patients. Improvement in renal function was achieved in 16 patients and the remaining 5 experienced stabilization. Improvement of the configuration of the corresponding renoureteral unit was observed in all but 4 patients who had stabilization to almost that of the preoperative condition. None of the 21 patients demonstrated vesicoureteral reflux during the follow-up period. CONCLUSIONS: The new technique of extravesical seromuscular tunnel is suitable for reimplantation of the dilated ureters. Other studies with a larger number of patients and a longer duration of follow-up are necessary to confirm these results.

Prospective comparison of nonenhanced helical computerized tomography and Doppler ultrasonography for the diagnosis of renal colic.

PURPOSE: We evaluate the accuracy of nonenhanced helical computerized tomography (CT) and Doppler ultrasonography for the diagnosis of renal colic. MATERIALS AND METHODS: Our study includes 109 patients, with 218 kidneys, who presented with unilateral flank pain. All patients underwent nonenhanced helical CT, Doppler ultrasonography and excretory urography (IVP). CT was evaluated for the presence of ureteral stones and manifestation of ureteral obstruction. For Doppler ultrasonography the renal resistive index was measured for the left and right kidneys in each patient, and change in resistive index between ipsilateral and contralateral kidneys was calculated and considered positive for ureteral obstruction with values 0.04 or greater. As a reference standard, absence of obstruction was considered if IVP was negative and the cause of flank pain was confirmed not to be urological. Obstruction was diagnosed not only by positive IVP, but also by patient followup until passage or retrieval of ureteral stones. Results of CT and change in resistive index were compared with those of the reference standard. RESULTS: Unilateral ureteral obstruction was confirmed in 52 patients, while no obstruction was found in 57. Of the 57 patients without ureterolithiasis the change in resistive index results was negative in all patients with a specificity of 100%, while CT was negative in 55 with a specificity of 96%. Of the 52 patients with ureteral obstruction CT was positive in 50, and change in resistive index was positive in 47 with a sensitivity of 96% and 90%, respectively, with a difference of no significant value. CONCLUSIONS: Nonenhanced helical CT and change in resistive index are sensitive and specific tests that can contribute significantly to the diagnosis of acute unilateral renal obstruction. They can replace IVP, particularly in situations in which it is undesirable.

Live-donor renal transplantation at the Urology & Nephrology Center of Mansoura: 1976-1998.

Based on more than 1,200 living donor transplants performed at the Urology & Nephrology Center at Mansoura University between 1976-1998, we report: 1. The overall graft survival rate was 75.8% and 51.9% at 5 and 10 years, respectively, with a projected half-life of 10.7 years. 2. Three factors acted as independent variables that significantly influenced graft survival: the number of HLA mismatches, the number of acute rejection episodes and the presence of posttransplant hypertension. a. Grafts with 2 or fewer HLA-A, -B and -DR mismatches had a significantly better survival rate. b. The incidence and the number of early acute rejection episodes had a significant negative impact on graft survival. c. A significant reduction in graft survival was associated with hypertension uncontrolled by or newly developed after transplantation. 3. Bilharziasis had no impact on the outcome. 4. Despite improvements in tissue matching and immunosuppression, an important proportion of grafts is still lost following living-donor kidney transplantation. 5. Efforts must be directed to identify better regimens, which can provide adequate immunosuppression and minimal nephrotoxicity.