CT-Based Predictors of Spontaneous Ureteral Stone Passage.

OBJECTIVE: To assess CT-scan based parameters, particularly ureteral wall thickness (UWT), in predicting spontaneous ureteral stone passage. STUDY DESIGN: Cross-sectional, analytical study. PLACE AND DURATION OF THE STUDY: Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from June to November 2023. METHODOLOGY: Patients with symptomatic, single, radio-opaque, unilateral ureteral stones having size ≤10 mm with normal kidney functions, diagnosed by non-contrast CT-scan KUB, and treated by conservative option for four weeks were enrolled. Clinical and radiological predictors for stone passage (SP), including stone size, area, laterality, location, density, degree of hydronephrosis, maximal UWT at the stone site, and ureteral diameter and density above and below the stone, were evaluated. Binary logistic regression analysis was employed to identify predictors of stone passage. Receiver operating characteristic (ROC) curve was used to find the optimal cut-off for UWT. RESULTS: Among 34 eligible patients, 22 (64.7%) passed their stones spontaneously. Patients who passed had smaller stone size and area and lesser UWT. Stone location, laterality, degree of hydronephrosis, stone density, ureteral wall diameter, and density above and below stones were not associated with SP. Multivariate analysis revealed maximum UWT as the independent predictor of SP, with a cut-off of 1.95 mm and an accuracy of 0.94. CONCLUSION: UWT was the single most convincing factor for the spontaneous passage of ureteral stone in this study. By applying UWT's optimal cut-off value, it might be an extremely significant tool when taking decisions in daily practice. KEY WORDS: Ureteral wall thickness, Medical expulsive therapy, Non-contrast computed tomography.

Extracorporeal Shock Wave Lithotripsy (ESWL) Outcome Based on CT Scan and Patient Parameters Using ESWL Score.

OBJECTIVE: To prospectively evaluate ESWL (extracorporeal shock wave lithotripsy) outcomes and validate ESWL Score. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, from January 2021 to December 2021. METHODOLOGY: Patients with symptomatic, solitary, radio-opaque renal stone measuring <15 mm with normal renal functions were included in this study. Stone size <11mm, BMI <27 Kg/m2, and stone density <900 Hounsfield units (HU) were all given 1 point each to give a total ESWL Score between 0-3 to each patient. Patients were evaluated after 4-weeks for the outcome i.e. stone clearance and complications. RESULTS: A total of 146 patients were included in the study. Median values for age, stone size, BMI and stone density were 40 years, 8 mm, 27 Kg/m2, and 774 HU respectively. Post ESWL, 99 (68%) patients were stone-free while 47 (32%) patients had residual stones. The stone clearance increased with the increasing score: 50% for ESWL score 0, 55.6% for ESWL score 1, 66.1% for ESWL score 2, and 85.7% for ESWL score 3 (p=0.01). The area under the curve (AUC) of ESWL score was 0.655 with 95 % CI (p=0.001). CONCLUSION: ESWL Score is a useful predictor of the success of ESWL. It can help decide the individualised and appropriate modality of treatment and assist with patient counselling. KEY WORDS: Stone, Lithotripsy, Extracorporeal, Score, Shock wave, Outcome.

Stem cells in Urology.

Stem cell research is rapidly expanding and has provided novel concepts in understanding and managing various diseases. Recent progress in translational and experimental urology has given insight about their utilization in the treatment and regeneration of urological structures. Chronic degenerative and neurological conditions affecting the lower urinary tract (LUT) are excellent targets for stem cell therapy. Their role has been particularly studied in bladder dysfunction, painful bladder syndrome, bladder outflow obstruction, stress urinary incontinence, erectile dysfunction, and urethral regeneration. However, the translation of this research in clinical domain is slow. Furthermore, regeneration of kidney using stem cells has been explored but remains challenging due to complexities of nephrons. Stem cells research in uro-oncology, especially bladder and prostate cancer, provided significant insight in understanding of pathogenesis processes and expanded potential therapeutic options. This review is centered to discuss application of stem cells and regenerative medicine in urology particularly human subject clinical studies and trials published in recent years.

Stem cell research, regenerative medicine and challenges.

Stem cell research and regenerative medicine have exponentially evolved in the past two decades. With the ability of cell renewal, unlimited expression and differentiation, stem cell research can potentially transform medical practice. Stem cells have different sources of origin and a wide range of potency ranging from unipotent to totipotent. Stem cell therapy can modify behavior of cells, generate differentiated tissues, and be used as a pharmacological intervention. Regenerative medicine is an emerging medical endeavor dedicated to reconstructing and repairing of tissues and organs. Several challenges are to be addressed to allow transition of stem cell research from basic sciences to clinical practice. These obstacles include selection of appropriate stem cells with associated ethical concerns, manufacturing and processing of stem cells, genetic instability, lack of complete understanding of their mode of action at target sites, economic concerns, and lack of regulations of stem cell therapy.

Subcutaneous Leiomyosarcoma Of Supra-Pubic Region Managed With Wide Local Excision And Total Penectomy.

Subcutaneous leiomyosarcomas (LMS) are rare soft tissue sarcomas arising from small-to-medium-sized blood vessels. Involvement of the anterior abdominal wall is extremely rare. We present a case of a 72-year-old gentleman who presented with 3 months history of a progressively increasing mass in the supra-pubic region reaching the root of the penis without any regional lymphadenopathy. Magnetic resonance imaging (MRI) pelvis showed a large heterogeneous mass in the lower abdomen indenting the penile corpora. Complete pathological clearance was achieved by wide excision of the mass with total penectomy and cutaneous urethrostomy. The patient received adjuvant radiation therapy and is free of local recurrence or distant metastasis two years after the surgery.

Male Urethral Diverticulum with Stones Presenting as Acute Urinary Retention.

The urethral diverticulum is an outpouching of the urethral wall communicating with its lumen. Acquired male urethral diverticulum is a rare entity and arises secondary to intervention or distal urethral obstruction. Most patients present with lower urinary tract symptoms (LUTS). Development of calculi is seen in 4-10% of cases. We describe a case of a 63-year gentleman who presented with urinary tract infection (UTI) and acute urinary retention (AUR). He denied history of urolithiasis. Per-urethral catheterization failed, so a supra-pubic catheter was placed and UTI was managed with broad-spectrum parenteral antibiotics. On workup, he was found to have a large tubular urethral diverticulum in the anterior urethra with multiple stones and urethral strictures. The case was managed endoscopically with optical urethrotomy and fragmentation and retrieval of stones using a semi-rigid ureteroscope and pneumatic lithoclast. Key Words: Urethra, Diverticulum, Male, urethral calculus, Lithoclast.

Comparison Of Emergency And Elective Intervention With Semi-Rigid Ureteroscopic Lithotripsy For Patients With Ureteral Calculi.

BACKGROUND: Ureteroscopy (URS) is a safe and highly effective treatment option for treatment of ureteral calculi. With the advancement of technology, there is also expansion of its indications including use in early or emergency setting. This study aims to compare safety and efficacy of emergency ureteroscopy (EmURS) versus elective ureteroscopy (ElURS) for ureteral stones. METHODS: Patients with unilateral single radio-opaque ureteral stone who underwent semi-rigid URS from January 2008 till December 2019 were included. Patients with solitary kidney, uro-sepsis, pregnancy or pre-operative drainage with nephrostomy or JJ stent were excluded. EmURS was defined as URS being performed within 48 hours of presentation, while ElURS was defined as URS performed after failed medical expulsive therapy. Patient, stone and outcome related variables were compared in both groups. Stone free rate was defined as no evidence of stone on plain x-ray KUB after 1 week. RESULTS: We compared 132 patients in EmURS group against 264 in ElURS group. Age, gender, comorbidities, stone location, laterality and mean stone size were comparable in both groups. EmURS had a less median operative time (p=0.05). Stone free rate achieved was 90.2% in EmURS and 87.1% in ElURS, respectively (p=0.38). Double J stent was placed in 44.7% and 46.2% of EmURS and ElURS respectively (p=0.89). Ancillary procedures were performed in 9.8% of EmURS and 11.7% of ElURS (p=0.57). Overall complication rates were reported in 7.6% in EmURS and 11.7% in ElURS (p=0.22) and most were Clavien grade 1. CONCLUSIONS: Emergency URS for ureteral stones is a safe and effective one-stage definitive treatment option for patients with acute renal colic not responding to conservative management.

Surgeons and ethical challenges in operating room.

Ethics lie in the heart of professionalism. In surgery, it represents an essential element, with surgeons facing ethical challenges in their routine practice. The rapid expansion of surgical technology and innovation along with the use of resources and consideration of conflict of interest have brought up the need for the development of current surgical code of ethics. Operating room represents a stressful environment where patients' lives depend upon careful preparation, planning and execution. The progression of surgery within the operating room must be done in harmony and in line with the ethical principles of autonomy, beneficence, non-maleficence and justice. Discussion of ethical problems arising in the operating room is not a common subject in surgical literature. The current narrative review was planned to cover ethical concerns related to patients' safety and privacy in the operating room and some of the evolving topics, like ethics of overlapping surgery, live surgical broadcast and 'do not resuscitate' policy in the operating room.

Simulation based team training in surgery - a review.

The healthcare environment in surgery is complex, dynamic and often ambiguous. Besides subject knowledge and technical skills, other competencies, such as team work, communication skills and situation awareness, are required to ensure better patient-related outcome. Teams that demonstrate poor non-technical skills make more technical errors, often resulting in patient morbidity or mortality. Different hospital-based locations, such as operating rooms, intensive care units, emergency rooms and surgical wards, are the areas where poor team dynamics prevail. Simulation-based team training is a strategy to provide inter-professional training and experiential learning opportunities for surgeons, anaesthetists and allied health professionals. It helps them to effectively respond in complex situations in complex surgical environment. Simulation-based team training has 3 components; didactics, simulation itself, and debriefing. Literature has shown that simulation-based team training in surgery improves identification of team-based behaviours, improves team performance and overall patient safety.

Primary diffuse large B cell lymphoma (DLBCL) of the prostate presenting with lower urinary tract symptoms (LUTS).

Malignant lymphomas of the prostate are very rare tumours and are generally not considered in the clinical or pathological diagnosis of prostatic enlargement. We report a case of a 56-year-old man who presented with long-standing history of low back pain and a 2-month history of voiding lower urinary tract symptoms. He denied any history of urinary retention, trauma, catheterisation or any constitutional symptoms. Examination revealed no lymphadenopathy and hepatosplenomegaly. Digital rectal examination showed an irregular, moderately enlarged nodular prostate. His prostate-specific antigen was 1.54 ng/mL. MRI of the pelvis did not show any focal lesion apart from abnormal signal intensity in the central zone. Bone scan was negative. Transrectal ultrasound-guided prostate biopsy revealed diffuse large B cell lymphoma. Bone marrow biopsy and whole body positron emission tomography/CT were unremarkable. The patient achieved complete remission after receiving six cycles of R-CHOP chemotherapy.

Efficacy and Safety of Semi-rigid Ureteroscopic Lithotripsy (URS) for Proximal Ureteral Stone ≥10 mm.

OBJECTIVE: To evaluate the efficacy and safety of the semi-rigid URS with pneumatic lithotripsy for the treatment of large (>10 mm) proximal ureteral calculi. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2018. METHODOLOGY: All patients with single, radio-opaque unilateral proximal ureteral stones >10 mm were included in the study. Patients with urosepsis, pregnancy, solitary kidney, and indwelling JJ stent or prior percutaneous nephrostomy drainage were excluded. Patients without any visualisation of stone on abdominal X-Ray done at 4 weeks of the procedure were labelled as stone-free. RESULTS: One hundred and three cases with stones >10 mm and fulfilling the selection criteria were included. The mean age was 40.83 + 14.92 years. The mean stones size was 13.33 + 4.64 mm. The mean procedure time was 41.50 + 15.60 minutes. Indwelling JJ stents were placed in 49 (47.6 %) cases. The stone-free rate was 83.5% at four weeks with calculated efficiency quotient (EQ) of 0.72, using a standard equation. The overall complication rate was 27% with the majority being minor (Clavian-Dindo grade 1). Only one patient had urosepsis (MCG IV). Ancillary procedures were performed in 17 (16.5%) cases, most commonly the extracorporeal shock wave lithotripsy (ESWL) in 14 (13.5%) cases, followed by the secondary URS in 3 (2.9%) cases. CONCLUSION: Semi-rigid URS is an effective and safe procedure for the large proximal ureteral stones, with limited access to flexible instruments. Key Words: Ureteroscopy, Semi-rigid, Stone, Proximal, Clearance, Safety.

Nephron sparing surgery for renal tumors-comparison of off-clamp partial nephrectomy with hilar clamping.

BACKGROUND AND OBJECTIVE: Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function. METHODS: This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. Non clamping technique was used in 43 while clamp was applied in 22 patients. Variables studied were patients' demographics, clinical variables, the laterality, tumors size and location, R.E.N.A.L nephrometry score, blood loss, tumor histology and surgical margins. Patients' renal function (serum creatinine and eGFR) were determined pre-operatively, at 3 and 12 months follow up. Data was analyzed on SPSS v. 22. RESULTS: Both the groups were comparable with regards to pre-operative renal function. Mean radiological size of tumor was 4.71±1.31 and 3.81±1.0 (0.003) in two groups respectively. Mean R.E.N.A.L nephrometry score was 6.1±1.5 in off-clamp group compared to 7.05 ± 1.7 in clamp group (p=0.04). No statistically significant difference was found in operative duration, blood loss, positive surgical margins and intra/ peri-operative complications. At three months and one year, renal function was better preserved in non-clamp group compared to clamp group (p=0.001 and 0.007 respectively). CONCLUSION: Off clamp open partial nephrectomy is safe and feasible option leading to less decline in renal function.

Validation of S.T.O.N.E nephrolithometry and Guy's stone score for predicting surgical outcome after percutaneous nephrolithotomy.

BACKGROUND: The aim of this study was to validate and compare Guy's and S.T.O.N.E. scoring systems in predicting perioperative and postoperative outcome following percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: From November 2015 to June 2017, 190 patients with renal stones who underwent single tract unilateral PCNL in the prone position were included in our study. Guy's and S.T.O.N.E. nephrolithometry scores were calculated in each case based on preoperative computed tomography images. The association of these scoring systems with stone-free status, length of hospital stay, operative time, and postoperative complications was studied. Regression analysis was done, and receiver operating characteristic curves were plotted. RESULTS: Mean S.T.O.N.E. and Guy's stone scores were 8.76 ± 2.29 and 2.70 ± 1.0, respectively. When compared with patients with residual stones, stone-free (SF) patients had significantly lower mean Guy's score (2.58 ± 1.01 vs. 3.23 ± 0.77 [P < 0.001]) and S.T.O.N.E. scores (8.44 ± 2.24 and 10.17 ± 2.0 [P < 0.001]), respectively. On logistic regression analysis, both Guy's score (odds ratio [OR] = 0.48, P = 0.001) and S.T.O.N.E score (OR = 0.78, P = 0.001) were found to be significantly associated with SF status. Both of these scoring systems were also significantly associated with longer operative time (>90 min), prolonged hospital stay (>3 days) and overall complications. No significant difference was found in the area under curve for both scoring systems for stone clearance. CONCLUSION: Both the S.T.O.N.E and Guy's scoring systems were found to predict the outcome of PCNL, either of these could be used in the routine clinical practice for patients' counseling.

Assessing clinical reasoning skills using Script Concordance Test (SCT) and extended matching questions (EMQs): A pilot for urology trainees.

INTRODUCTION: Clinical reasoning skill is the core of medical competence. Commonly used assessment methods for medical competence have limited ability to evaluate critical thinking and reasoning skills. Script Concordance Test (SCT) and Extended Matching Questions (EMQs) are the evolving tests which are considered to be valid and reliable tools for assessing clinical reasoning and judgment. We performed this pilot study to determine whether SCT and EMQs can differentiate clinical reasoning ability among urology residents, interns and medical students. METHODS: This was a cross-sectional study in which an examination with 48 SCT-based items on eleven clinical scenarios and four themed EMQs with 21 items were administered to a total of 27 learners at three differing levels of experience i.e. 9 urology residents, 6 interns and 12 fifth year medical students. A non-probability convenience sampling was done. The SCTs and EMQs were developed from clinical situations representative of urological practice by 5 content experts (urologists) and assessed by a medical education expert. Learners' responses were scored using the standard and the graduated key. A one way analysis of variance (ANOVA) was conducted to compare the mean scores across the level of experience. A p-value of < 0.05 was considered statistically significant. Test reliability was estimated by Cronbach α. A focused group discussion with candidates was done to assess their perception of test. RESULTS: Both SCT and EMQs successfully differentiated residents from interns and students. Statistically significant difference in mean score was found for both SCT and EMQs among the 3 groups using both the standard and the graduated key. The mean scores were higher for all groups as measured by the graduated key compared to the standard key. The internal consistency (Cronbach's α) was 0.53 and 0.6 for EMQs and SCT, respectively. Majority of the participants were satisfied with regard to time, environment, instructions provided and the content covered and nearly all felt that the test helped them in thinking process particularly clinical reasoning. CONCLUSIONS: Our data suggest that both SCT and EMQs are capable of discriminating between learners according to their clinical experience in urology. As there is a wide acceptability by all candidates, these tests could be used to assess and enhance clinical reasoning skills. More research is needed to prove validity of these tests.

Effect of a two-day extensive continuing medical education course on participants' knowledge of clinical and operative urology.

OBJECTIVE: Continuing Medical Education (CME) is an established method for facilitating the lifelong learning and developing knowledge, skills and attitudes to ensure delivery of a medical care which is up-to-date, evidence based, safe and patient-centered. An extensive 2 day urology course was conducted to meet the needs of learners. The purpose of the current study was to measure the effect of this CME activity on the knowledge of the participants. MATERIAL AND METHODS: This quasi-experimental, single group pre-, and post-test study measured the gain in learning as a result of the two-day extensive CME course conducted by the section of Urology at Department of Surgery, the Aga Khan University, Karachi-Pakistan. Gain in knowledge, defined as the difference between the pre-test and the post-test scores, was taken as a measure of course effectiveness. The test comprised of 40 one-best type carefully constructed multiple choice questions (MCQs). Item analyses were also performed. RESULTS: Forty-five out of a total of 70 participants from within and outside the city completed both pre and post-tests and were included in the study. The mean age of the subjects was 33.3+6.7 years. Of these 45 participants, 68.9% (n=31) of them were trainees at different levels. Mean gain in knowledge was 12.7±6.8% (p<0.01; 95% CI: 4.17-5.79). Mean test scores improved significantly from 37.8±11.3% to 50.3±10.8%. Difference in pre and post scores due to age, gender, practice type or years since start of training was not significant. The reliability of the test using Cronbach's α was 0.634. CONCLUSION: CME sessions when designed and delivered carefully are effective means of increasing the knowledge significantly. Pre- and post-test is a reliable and valid strategy to measure gain in participants' knowledge.

Fibrous Pseudotumor of Tunica Albuginea Testis Mimicking Testicular Neoplasm in a Young Man.

Intrascrotal lesions are common findings with a majority occurring in paratesticular tissue. Fibrous pseudotumors are rare, benign lesions of the testicular tunics and present with mass lesion(s) in the scrotum. Preoperative clinical and radiological diagnosis is challenging. We report a case of a 34-year-old man who presented with a 3-year history of left testicular swelling and was advised left radical orchidectomy by another surgeon. Physical examination revealed a firm, nontender mass attached to the lower pole of the testis. Testicular tumor markers were all negative, and ultrasound scan showed a relatively hypoechoic lesion closely associated with the left testis and suspicious for neoplastic process. The patient underwent a testicular sparing surgery. An intraoperative frozen section biopsy confirmed the lesion to be benign and this was reported on permanent section to be fibrous pseudotumor of the tunica albuginea. We also present the clinical, sonographic, and histopathological findings of this condition along with the literature review.

Role of multi-parametric (mp) MRI in prostate cancer.

Multi-parametric magnetic resonance imaging is increasingly being recommended as standard imaging modality for prostate cancer diagnosis and staging. It comprises structural T2 and T1 sequences supplemented by functional imaging techniques, i.e. diffusion-weighted, dynamic contrast enhanced and spectroscopic imaging. Pre-biopsy multi-parametric magnetic resonance imaging is recommended for both detection and staging as it avoids biopsy artefact, and when normal, has a negative predictive value of 95% for significant cancer. Magnetic resonance imaging-guided prostate biopsy targets only area(s) considered to be suspicious for prostate cancer, hence resulting in improved accuracy. Dynamic contrast enhancing helps in the detection of cancer and for the assessment of extra-capsular extension, distal urethral sphincter and seminal vesicles involvement. The role of multi-parametric magnetic resonance imaging in follow-up of patients on active surveillance is also increasingly recognised. Its role is now further expanded to facilitate targeted therapies. This review focuses on the evolving role of multi-parametric magnetic resonance imaging in diagnosis and management of prostate cancer.