Treatment of retained encrusted ureteral Double-J stent.

OBJECTIVES: We conducted this study to evaluate patients with retained encrusted ureteral stents, identify the predisposing factors and present our experience in the management of such challenging problem. MATERIALS AND METHODS: This prospective study was carried out in the period from May 2007 to February 2011 at the Urology and Nephrology Center, Al-Thawra General Hospital, Sana'a, Yemen. 40 patients with retained encrusted ureteric stents were treated at our center. All patients were initially evaluated with a radiographic imaging for assessment of stent encrustation and stone burden. Treatment decisions were based on the site and severity of encrustations in the renal pelvis, ureter and bladder and on our technical situation and availability of instrumentations. Multi-modal approaches ranging from extracorporeal shock wave lithotripsy (ESWL) to endourological and open urologic procedures were used to achieve stent removal. RESULTS: A total of 90 urological procedures were performed to render all 40 patients stent and stone free. The average duration of stent remained indwelling was 24.2 months (range 4 months -16 years). All patients were managed either by minimally or more invasive multi-modal endourological approaches. For upper coil encrustation percutaneous nephrolithotripsy was performed in eight patients, pyelolithotomy in two patients and ESWL in three patients. Encrustation of the body was treated initially by ESWL, followed by retrograde ureteroscopic manipulation in 12 patients. Lower coil encrustation was successfully managed by cystolitholapaxy in seven patients and one patient required cystolithotomy. Cystolithotomy, pyelolithotomy and ureterolithotomy were carried out in two patients. Two patients who had large burden bladder and kidney stones with loss of kidney function underwent nephrectomy and cystolithotomy. CONCLUSIONS: The retrieval of severely encrusted retained ureteral stent and its associated stone burden poses a real management challenge for urologists due to the need for multimodal procedures and the lack of standardized treatment plan.

Gunshot wound injuries to the male external genitalia.

OBJECTIVE: To identify the patterns of civilian gunshot wound (GSW) injuries to the male external genitalia, and to present our experience in the management of such injuries. METHODS: This descriptive study was carried out in the Urology and Nephrology Center, Al-Thawra Modern General and Teaching Hospital, Sanaa, Yemen from June 2005 to April 2008, and included 20 men that presented with GSW injuries to the external genitalia. After clinical and radiological evaluation with retrograde urethrography when indicated, early surgical repair was undertaken for all patients with evident, or suspected deep genito-urinary wounds. RESULTS: The mean age of the patients was 33.2 years. In 15 (75%) patients, injuries were inflicted by high-velocity weapons, and in 5 by low-velocity pistols, and 18 (90%) patients had other associated injuries. The penis was involved alone in 10 (50%), scrotum in 4 (20%), and the penis and scrotum in combination in 6 (30%) patients. In 5 patients, the lesions were superficial. Corporeal injuries were detected in 13 patients, and urethral injuries were detected in 6 patients. In post-repair, mild curvature during erection was experienced by 5 patients, severe angulation by one, and sexual dysfunction by 2 patients. We encountered 9 testicular ruptures, and our testicular salvage rate was 45.5%. CONCLUSION: Although the dominant inflicting weapons were high-velocity automatic rifles, the severity of injuries and their related outcomes were almost comparable to other low-velocity series. This is possibly due to the primary involvement of nearby bulky muscles in 90% of cases, which may absorb the blasts effect of the projectiles on the genitalia.

Urethral stricture Yemen experience.

PURPOSE: In order to evaluate the etiology of urethral stricture in our society and outcome of different types of surgical reconstruction used to treat them. PATIENTS AND METHODS: This prospective study was carried out in the Urology and Nephrology Center, at Al-Thawra Modern General and Teaching Hospital, Sana'a, Yemen from July 2003 to July 2007 and included 62 male patients with complete urethral stricture whom underwent Urethral reconstructive surgery. The patients were evaluated by history, local and systemic physical examination, and radiological assessment according to each case. RESULTS: Patient's age ranged between 3 and 70 years (mean 25.31). Of 55 patients presented to the GER, 31 patients had car accident, 14 patients had gun shot injury, 9 patients fell from high, and one patient had bomb explosion. Five patients had history of traumatized catheterization and urethrocystoscopy, while two patients had history of urethritis. The site of the stricture was at the bulbomembranous area in 43 patients, in the penile urethra in 14 patients, and in bulbous urethra in 5 patients. The length of the urethral stricture was 10-30 mm in 39 patients (63%), <10 mm in 13 patients (21%) and of 30-70 mm in 10 patients (16%). A total of 15 patients (24%) with posterior urethral stricture of 10 mm or less (+2 patients with 1.2 and 1.5 cm), subjected to endoscopic treatment, 37 patients (60%) with stricture >10-30 mm, were underwent anastomotic urethral reconstruction and 10 patients (15%) with stricture >30 mm, were repaired utilizing tissue transfer technique. Follow-up period ranged from 3 months to 2 years (median 15 months), in which recurrent stricture was found in 11 patients (18%), wound dehiscence in 4 patients (6%) and fistula formation in 1 patient (1.5%), while no patient came with erectile dysfunction. CONCLUSION: Trauma is the commonest cause of urethral stricture in our country, therefore the control of it will decrease extremely the urethral stricture disease. No one technique is suitable for all types of the stricture, and the surgeon should be familiar with the different techniques and choose the most suitable one according to the case he deals with.

Management of penile fractures.

OBJECTIVE: To present our experience with surgical and conservative management of penile fracture. METHODS: This prospective study was carried out in the Urology and Nephrology Center, at Al-Thawra Modern General and Teaching Hospital, Sana'a, Yemen from June 2003 to September 2007, and included 30 patients presenting with penile fracture. Diagnosis was made clinically in all our patients. Six patients with simple fracture were treated conservatively while 24 patients with more severe injuries were operated upon. RESULTS: Patients' ages ranged from 24-52 years (mean 31.3 years), 46.7% of patients were under the age of 30 years and 56.7% were unmarried. Hard manipulation of the erect penis for example during masturbation was the most frequent mechanism of fracture in 53.3% of patients. Solitary tear was found in 22 patients and bilateral corporal tears associated with urethral injury were found in 2 patients. Corporal tears were sutured with synthetic absorbable sutures and urethral injury was repaired primarily. All operated patients described full erection with straight penis except 3 of the 8 patients who were managed by direct longitudinal incision, in whom mild curvature during erection was observed. The conservatively treated patients described satisfactory penile straightness and erection. CONCLUSION: The optimal functional and cosmetic results are achieved following immediate surgical repair of penis fracture. Good results can also be obtained in some selected patients with conservative management.

Whether post-ureteroscopy stenting is necessary or not?

OBJECTIVE: To verify if post-ureteroscopy (URS) stenting is still necessary as a routine strategy, or if some cases can be treated without. METHODS: Between August 2004 and April 2005, 85 patients were admitted to the Urology Department at the Nephrology and Urology Center, Al-Thawra Hospital, Yemen with ureteric stones of different size and site. All were scheduled and treated by the ureteroscopy method. According to prospective pure randomization, 45 patients were left non-stented at the end of the operation (non-stented group), while 40 patients were left with stent (stented group). RESULTS: The ages of the non-stented group ranged between 6-70 years (mean 34.36 +/- 15.53), while the size of the stones ranged between 5-20 mm (mean 8.4 +/- 3.1). They were 33 males and 12 females. Regarding the site, 26 stones were in the right, and 19 in the left ureter. In the stented group, the ages ranged between 14-70 years (mean 39.35 +/- 13.36), while the size of the stones ranged between 6-16 mm (mean 9.9 +/- 3.2). They were 34 males and 6 females. Twenty-five stones were in the right ureter, and 15 in the left. Success was 100% in the non-stented group, while it was 39 out of 40 in the stented group. The 2 groups were compared statistically for postoperative analgesia, color clearance of urine and hospital stay, and found significantly different. However, for operative time, the difference was insignificant. CONCLUSION: When treating ureteric stones by ureteroscopy, postoperative stenting should not be used as routine, but should be limited to those with ureteric injury, bigger sizes and prolonged operative time. The non-stenting method decreases the need for postoperative analgesia, time of color clearance and hospital stay.