Long-term effects of anatrophic nephrolithotomy on selective renal function.

To evaluate the long-term changes of selective renal function after anatrophic nephrolithotomy (ANL). A retrospective study was conducted for patients who underwent ANL between January 1995 and December 2016. Inclusion criteria were availability of preoperative and follow-up (1 year or more) radio-isotopic renal scans. Stone-free status was evaluated after 1 month with KUB and ultrasonography or NCCT. Renal isotope scans using 99mTc MAG3 were performed to measure the changes in selective function of the affected kidney (GFR%). Eligible patients were classified into two groups, group 1 patients with stable or improved function and group 2 patients with deteriorated function (> 5% decrease in GFR%). Univariate and multivariate analyses were performed to determine risk factors for deterioration of renal function. The cutoff value for any significant variable was determined using ROC curve. The study included 50 patients with mean age 43.8 + 13.9 years. Complications developed in 26 patients (52%), and stone-free status was documented in 42 patients (84%). After a median follow-up of 2.7 years (range 1-11), mean GFR% of all cases significantly decreased from preoperative value of 52.7% + SD 20 to 45.4% + SD 25% during follow-up (P < 0.001). Deterioration of GFR% was documented in 21 kidneys (42%). Cold ischemia time with a cutoff value 50 min was the independent risk factor (RR 3.986, 95% CI 1.069-14.869, P 0.039). The results of this study support limiting ANL to a selected group of patients and taking all the possible efforts to minimize cold ischemia time below 50 min.

A randomized controlled trial evaluating sildenafil citrate in relieving ureteral stent-related symptoms.

PURPOSE: To evaluate the role of sildenafil in relieving ureteral stent symptoms. PATIENTS AND METHODS: A randomized controlled trial was conducted between March 2014 and November 2016. It included adult men who underwent unilateral ureteric stent after ureteroscopy. Patients who were taking PDE5-Is, alpha-blockers or anticholinergics, had contraindication to sildenafil or developed postoperative complications were not included. Eligible patients were randomized using sealed closed envelops to one of two groups (S and C). Patients in group S received sildenafil citrate 50 mg tablet once daily. Patients in group C were the control. All patients answered the ureteral stent symptom questionnaire (USSQ) after 2 weeks of stenting. Primary outcome was the difference in total USSQ score between both groups. Secondary outcomes were tolerability of the treatment and the difference in each domain of USSQ score. RESULTS: After randomization, four patients (7.3%) in group C withdraw their consent because of severe symptoms and two patients (3.6%) in group S discontinued treatment because of headache and dizziness. Final analysis was performed for 46 and 48 patients in groups C and S, respectively. Total USSQ score and all domains (except work performance) were significantly lower in group S (P < 0.001). Dysuria and urgency were significantly more in group C (P = 0.012 and 0.007, respectively). Three patients in groups S (6.25%) experienced transient mild adverse effects (dyspepsia, flushing and rhinitis in one patient for each) but they continued sildenafil. CONCLUSIONS: Sildenafil is an effective and well-tolerated treatment option for relieving ureteral stent-related symptoms in men. CLINICALTRIAL. GOV IDENTIFIER: NCT02345980.

Hospital admission for treatment of complications after extracorporeal shock wave lithotripsy for renal stones: a study of risk factors.

The objective of this study was to determine risk factors of hospital admission for treatment of complications after extracorporeal shock wave lithotripsy (SWL). The electronic files and images of all patients who underwent SWL for treatment of renal stones between January 2011 and December 2015 were retrospectively reviewed. All patients underwent SWL with the same electromagnetic lithotripter (Dornier Lithotripot S). The data of those who needed hospital admission for treatment of complications within 30 days after SWL were compared with patients who did not require hospital admission. Compared data included patients' demographics (age, gender, BMI, ASA score, and pre-SWL stenting), renal characters (side, hydronephrosis, and solitary kidney), and stone characters (site, length, density, and previous treatment). Univariate and multivariate statistical analyses were used to identify risk factors. The study included 1179 patients. Complications that required hospital admission were observed in 108 patients (9.2%). They included obstructing steinstrasse in 91 (7.7%), peri-renal hematoma in 3 (0.25%), and fever (>38.0 °C) in 14 (1.2%). Independent risk factors on multivariate analysis were solitary kidney (OR 2.855, P = 0.017), pre-SWL stenting (RR 2.03, P = 0.044), ASA II (OR 1.965, P = 0.007), hydronephrosis (RR 1.639, P = 0.024), and stone length (RR 1.083, P < 0.001). Patients with medical co-morbidities, pre-SWL ureteral stents, large stones and those with obstructed and/or solitary renal unit are more liable to post-SWL complications that need hospital admission. The probability of hospital admission has to be explained to patients with these risk factors.

A randomised controlled trial evaluating renal protective effects of selenium with vitamins A, C, E, verapamil, and losartan against extracorporeal shockwave lithotripsy-induced renal injury.

OBJECTIVE: To evaluate the protective effects of selenium with vitamins A, C and E (selenium ACE, i.e. antioxidants), verapamil (calcium channel blocker), and losartan (angiotensin receptor blocker) against extracorporeal shockwave lithotripsy (ESWL)-induced renal injury. PATIENTS AND METHODS: A randomised controlled trial was conducted between August 2012 and February 2015. Inclusion criteria were adult patients with a single renal stone (<2 cm) suitable for ESWL. Patients with diabetes, hypertension, congenital renal anomalies, moderate or marked hydronephrosis, or preoperative albuminuria (>300 mg/L) were excluded. ESWL was performed using the electromagnetic DoLiS lithotripter. Eligible patients were randomised into one of four groups using sealed closed envelopes: Group1, control; Group 2, selenium ACE; Group 3, losartan; and Group 4, verapamil. Albuminuria and urinary neutrophil gelatinase-associated lipocalin (uNGAL) were estimated after 2-4 h and 1 week after ESWL. The primary outcome was differences between albuminuria and uNGAL. Dynamic contrast-enhanced magnetic resonance imaging was performed before ESWL, and at 2-4 h and 1 week after ESWL to compare changes in renal perfusion. RESULTS: Of 329 patients assessed for eligibility, the final analysis comprised 160 patients (40 in each group). Losartan was the only medication that showed significantly lower levels of albuminuria after 1 week (P < 0.001). For perfusion changes, there was a statistically significant decrease in the renal perfusion in patients with obstructed kidneys in comparison to before ESWL (P = 0.003). These significant changes were present in the control or antioxidant group, whilst in the losartan and verapamil groups renal perfusion was not significantly decreased. CONCLUSIONS: Losartan was found to protect the kidney against ESWL-induced renal injury by significantly decreasing post-ESWL albuminuria. Verapamil and losartan maintained renal perfusion in patients with post-ESWL renal obstruction.

Holmium laser enucleation of the prostate for treatment for large-sized benign prostate hyperplasia; is it a realistic endourologic alternative in developing country?

OBJECTIVES: To assess the functional outcome and cumulative health-resource-related cost of holmium laser enucleation of the prostate (HoLEP) in comparison with transvesical open prostatectomy (TVOP) in a developing country. METHODS: Matching of 92 HoLEP and 91 TVOP procedures was performed using resected prostate tissue weight as a sole matching criterion. Safety, efficacy, and accordingly health-related cost-efficiency of both procedures were statistically compared. RESULTS: Preoperative criteria and mean prostate size (166.7 ± 49.7, 161.4 ± 35.7 ml) were similar in HoLEP and TVOP, respectively; however, HoLEP treated more comorbid patients. Blood transfusion was 2.1 and 26.1 % after HoLEP and TVOP, respectively (P = 0.001). Median time to catheter removal and hospital stay was 2 days after HoLEP and 5 and 9 days, respectively, after TVOP (P < 0.001). On modified Clavien scale, grade per grade, there was no statistically significant difference between the two groups apart from local wound complications in TVOP group. High-grade complications (≥ grade 3) were reported in 3.2 and 6.5 % in HoLEP and TVOP, respectively (P = 0.49). Resected prostate tissue weight was independently associated with high-grade periprocedure complications (OR[95 %CI] 1.22[1.02:1.49], P = 0.03). Last follow-up symptom score, peak urine flow rate, residual urine, % PSA reduction, and need for reoperation were comparable between the two groups. HoLEP costs the hospital in the first 3 months 4111.8EP (575US$) versus 4305.4EP (602US$) for TVOP (P = 0.09). CONCLUSION: In high-volume hospital, HoLEP procedure seems to be equally safe and effective as TVOP with the advantages of minimally invasive procedures. Two years after adopting the technique, HoLEP equally costs the hospital as TVOP. Significant hospital cost savings are anticipated in subsequent cases.

Evaluation of acute post-shock wave lithotripsy renal changes by dynamic magnetic resonance imaging: a prospective clinical study.

PURPOSE: We studied acute renal morphological and hemodynamic changes after shock wave lithotripsy of renal stones. MATERIALS AND METHODS: A total of 60 adult patients with a single renal stone 25 mm or less in a radiologically normal urinary tract were eligible for shock wave lithotripsy and included in analysis. Study exclusion criteria were hypertension, diabetes mellitus, previous recent stone management and other contraindications to shock wave lithotripsy. Renal perfusion and morphological changes were evaluated by dynamic magnetic resonance imaging before, and 2 to 4 hours and 1 week after lithotripsy. RESULTS: In all cases there was a statistically significant decrease in renal perfusion 1 week after shock wave lithotripsy compared to before and 2 to 4 hours after lithotripsy (66% vs 71% and 72% of the aortic blood flow, respectively, p <0.05). At 1-week followup 39 unobstructed renal units (65%) showed no significant difference in renal perfusion at any time while 21 (35%) obstructed renal units showed a significant decrease in renal perfusion compared to before and 2 to 4 hours after lithotripsy (63% vs 76% and 75%, p = 0.003 and 0.005, respectively). Hematomas were observed in 7 cases (12%) 2 to 4 hours after lithotripsy, of which 5 were subcapsular and 2 were intrarenal. Three subcapsular hematomas resolved after 1 week. Localized loss of corticomedullary differentiation was observed in 2 patients (3.3%) with intrarenal hematoma 2 to 4 hours after treatment. Generalized loss of corticomedullary differentiation was observed 1 week after lithotripsy in 5 cases (8.3%). CONCLUSIONS: Shock wave lithotripsy alone induces minimal, reversible acute renal morphological changes and does not induce significant changes in renal perfusion. Posttreatment obstruction has a major effect on renal perfusion on the treated side and must be managed urgently.

Predicting the resected tissue weight from a digital rectal examination and total prostate specific antigen level before transurethral resection of the prostate.

OBJECTIVE: To determine the use of the prostate specific antigen (PSA) level and digital rectal examination (DRE) findings to estimate the resected tissue weight (RTW) before transurethral resection of the prostate (TURP). PATIENTS AND METHODS: We retrospectively analysed 983 patients who underwent TURP between December 2006 and December 2012. The primary outcome was the RTW required for clinical improvement, and was not associated with re-intervention. Age, PSA level, body mass index (BMI) and DRE findings were correlated and modelled with the RTW. The DRE result was defined as DREa (small vs. large) or DREb (small vs. moderate vs. large) according to the surgeon's report. Equations to calculate RTW were developed and tested using receiver operating characteristic (ROC) curve analyses. RESULTS: There were significant correlations between PSA level (r = 0.4, P < 0.001) and RTW, whilst BMI and age showed weak correlations. The median (range) RTW was 45 (7-60) vs. 15 (6-60) g for small vs. large prostates (DREa) (P < 0.001), respectively. Similarly, the median (range) RTW was 11 (6-59) vs. 26.2 (6-60) vs. 42 (7-60) g in small vs. moderate vs. large prostates (DREb) (P < 0.001), respectively. Using PSA level and DREb (model 3) there was a significantly better ability to estimate RTW than using PSA and DREa (model 2) or PSA alone (model 1) based on ROC curve analyses. The equation developed by model 3 (RTW = 1.2 + (1.13 × PSA) + (DREb × 9.5)) had a sensitivity and specificity of 82% and 71% for estimating a RTW of >30 g, and 84% and 63% for estimating a RTW of >40 g, respectively. CONCLUSIONS: The PSA level and DRE findings can be used to predict the RTW before TURP.

Validation of the Arabic linguistic version of the Ureteral Stent Symptoms Questionnaire.

OBJECTIVE: To validate the Arabic version of the Ureteral Stent Symptoms Questionnaire (USSQ). PATIENTS AND METHODS: The English version of the USSQ was translated into Arabic using a multi-step process by three urologists and two independent translators. The Arabic version was validated by asking 37 patients with temporary unilateral ureteric stents to complete the questionnaire at 2 weeks after stent insertion. The second group included 53 healthy individuals who agreed to complete the Arabic version of the questionnaire. The reliability of the Arabic version was evaluated for internal consistency using Cronbach's α test. Domain structures were examined by interdomain (section) associations using Spearman's correlation coefficient (r). The discrimination validity was evaluated by comparing the scores of patients with those of healthy individuals, using the Mann-Whitney test. RESULTS: Internal consistency was high for the sexual index and intermediate for urinary, pain and general health indices. There were good correlations of urinary symptoms with body pain (r = 0.596) and general health (r = 0.690). There was also a good correlation between body pain and general health (r = 0.681). For discrimination validity, there were significant changes in all domain scores when comparing patients with ureteric stents and healthy individuals (P < 0.001). CONCLUSION: The Arabic version of the USSQ is a reliable and valid instrument that can be used to evaluate symptoms and health-related quality of life in Arabic patients with ureteric stents.

Detrusor after contractions in men with lower urinary tract symptoms: Myth or reality?

OBJECTIVES: To study after contractions in men with lower urinary tract symptoms (LUTS) related to bladder outlet obstruction (BOO), in the absence of neuropathy, and to verify whether it is associated with the severity of symptoms or certain filling and voiding variables. PATIENTS AND METHODS: Of 380 patients with LUTS and who were assessed using urodynamic studies, we retrospectively analysed those who had after contractions (ACs). Bladder overactivity was diagnosed as any increase in the detrusor pressure of <2-s duration during the filling phase, and an AC was diagnosed as any increase in the detrusor pressure of ⩾2 s after the end of the voiding phase and complete cessation of flow. The presence of ACs was then assessed in relation to different components of the International Prostate Symptom Score (IPSS), using a two-tailed Levene's test, and to filling and voiding cystometry variables, using Mann-Whitney-Wilcoxon Rank test. RESULTS: In all, 373 of the 380 patients were included (seven had invalid voiding cystometry); ACs were detected in 51 (13.9%). There was no statistical significance for associations between AC and any of the variables assessed, including individual questions of the IPSS, detrusor overactivity, cystometric capacity, compliance, maximum urinary flow rate (Qmax), detrusor pressure at Qmax or the maximum detrusor voiding pressure. CONCLUSION: ACs detected on voiding cystometry of men with LUTS attributed to BOO do not seem to be related to symptoms, or filling and voiding variables.

Transvesical open prostatectomy for benign prostatic hyperplasia in the era of minimally invasive surgery: Perioperative outcomes of a contemporary series.

OBJECTIVE: To assess the perioperative morbidity of transvesical open prostatectomy (OP) and its predictors as a treatment for benign prostatic hyperplasia (BPH), and to update knowledge about the morbidity of OP using a standardised morbidity scale (Clavien), thus providing a platform for comparison with the newly developed techniques. PATIENTS AND METHODS: We retrospectively review men with BPH who were treated with transvesical OP between April 2002 and December 2012. Preoperative patients' data were reviewed for relevant variables. Operative details, the postoperative course, and 30-day relevant data were assessed. The study cohort was stratified based on the resected prostate weight, with group 1 having a resected weight of ⩽120 g and group 2 >120 g. RESULTS: The review identified 163 patients. The mean (SD, range) duration of catheterisation after OP was 7.9 (2.2, 5-20) days and the duration of hospitalisation after OP was 8.1 (1.8, 5-15) days; both were significantly longer in group 2. All patients were able to void spontaneously by the first follow-up visit. Of 163 OP procedures, there were 106 perioperative complications in 69 (42.3%). Low-grade complications (grade ⩽2) included 38 (45.2%) and 53 (67%) in groups 1 and 2, respectively (P = 0.8). High-grade complications (⩾3) included 3 (3.5%) and 12 (15.1%) in groups 1 and 2, respectively (P = 0.02). The blood transfusion rate was 24.5%, the perioperative mortality rate was 1.2% and the re-admission rate within the first 30 days after OP was 1.2%. High-grade complications were significantly associated with a greater resected prostate weight (odds ratio 1.08, 95% CI 1.001-1.17, P = 0.046). CONCLUSION: The OP procedure is associated with a significant perioperative morbidity that correlated significantly with the resected prostate weight, especially for high-grade complications.