Outcome and quality of life in obese patients underwent laparoscopic vs. open appendectomy

Background

Although obesity is a popular reason for choosing laparoscopic appendectomy (LA) versus open appendectomy (OA), however, the question of whether there is a difference remains. Our goal is to investigate if there is a difference between OA and LA in obese patients.

Methods

Fifty-eight obese patients diagnosed with acute appendicitis according to ALVARDO score at department of surgery at Suez Canal university hospitals from March 2020 till August 2021 were included. The study participants were assigned in two groups LA and OA. This study aimed to comparing between LA and OA regarding intraoperative complications, length of hospital stays, post -operative pain, and rate of post-operative complications. Meanwhile, using SF-36 scoring questionnaire, the quality of life was compared between both groups.

Results

A total of 58 patients were included in the present study (LG = 29 patients and OG = 29 patients). The early post-operative complications (within 30 days after surgery) were significantly lower in the LA group (5 patients out of 29) than the OA (11 patients out of 29). Additionally, lower incidence of complications was noticed in the LA group (2 out of 29 patients) compared to OA (6 patients out of 29) beyond 30 days after operation. Patients with laparoscopic surgery had statistically significant higher overall quality of life scores (SF-36) (72 ± 32) compared to open surgery patients (66 ± 35) 2 weeks after operation.

Conclusion

The laparoscopic procedure was associated with lower incidence of post operative complications. However, open appendectomy was superior for a shorter operative time. Laparoscopic approach is not only used for therapeutic purposes, but also it has a diagnostic role.

Deep Neural Network for the Prediction of KRAS Genotype in Rectal Cancer

BACKGROUND

KRAS mutation can alter the treatment plan after resection of colorectal cancer. Despite its importance, the KRAS status of several patients remains unchecked because of the high cost and limited resources. This study developed a deep neural network (DNN) to predict the KRAS genotype using hematoxylin and eosin (H&E)-stained histopathological images.

STUDY DESIGN

Three DNNs were created (KRAS_Mob, KRAS_Shuff, and KRAS_Ince) using the structural backbone of the MobileNet, ShuffleNet, and Inception networks, respectively. The Cancer Genome Atlas was screened to extract 49,684 image tiles that were used for deep learning and internal validation. An independent cohort of 43,032 image tiles was used for external validation. The performance was compared with humans, and a virtual cost-saving analysis was done.

RESULTS

The KRAS_Mob network (area under the receiver operating curve [AUC] 0.8, 95% CI 0.71 to 0.89) was the best-performing model for predicting the KRAS genotype, followed by the KRAS_Shuff (AUC 0.73, 95% CI 0.62 to 0.84) and KRAS_Ince (AUC 0.71, 95% CI 0.6 to 0.82) networks. Combing the KRAS_Mob and KRAS_Shuff networks as a double prediction approach showed improved performance. KRAS_Mob network accuracy surpassed that of two independent pathologists (AUC 0.79 [95% CI 0.64 to 0.93], 0.51 [95% CI 0.34 to 0.69], and 0.51 (95% CI 0.34 to 0.69]; p < 0.001 for all comparisons).

CONCLUSION

The DNN has the potential to predict the KRAS genotype directly from H&E-stained histopathological slide images. As an algorithmic screening method to prioritize patients for laboratory confirmation, such a model might possibly reduce the number of patients screened, resulting in significant test-related time and economic savings.

Role of the triad of procalcitonin, C-reactive protein, and white blood cell count in the prediction of anastomotic leak following colorectal resections

Purpose

The enhanced recovery after surgery (ERAS) program expedites patient recovery after major surgery. This study aimed to investigate the role of the triad of procalcitonin (PCT), C-reactive protein (CRP), and white blood cells (WBC) trajectories as a predictive biomarker for the anastomotic leak (AL) after colorectal surgery.

Method

Patients who had colorectal anastomosis were prospectively included. Postoperative clinical and laboratory parameters and outcomes were collected and analyzed. The 5-day trajectories of PCT, CRP, and WBC were evaluated. Based on the trajectory of the three biomarkers, we compared patients with and without AL as detected during the first 30 days after surgery using the area under receiver operator characteristic curves (AUC) for logistic estimation.

Results

This study included 205 patients, of whom 56% were men and 43.9% were women with a mean age of 56.4 ± 13.1 years. Twenty-two patients (10.7%) had AL; 77.3% underwent surgery, and 22.7% were treated with drainage and antibiotics. Procalcitonin was the best predictor for AL compared to CRP and WBC at three days postoperatively (AUC: 0.84, 0.76, 0.66, respectively). On day 5, a cutoff value of 4.93 ng/mL for PCT had the highest sensitivity, specificity, and negative predictive value. The predictive power of PCT was substantially improved when combined with either CRP or WBC, or both (AUC: 0.92, 0.92, 0.93, respectively).

Conclusion

The 5-day trajectories of combined CRP, PCT, and WBC had a better predictive power for AL than the isolated daily measurements. Combining the three parameters may be a reliable predictor of early patient discharge, which would be highly beneficial to ERAS programs.

Prevalence and awareness of varicocele among athletes in Riyadh, Saudi Arabia

Purpose

To evaluate the prevalence and awareness about symptoms, and complications of varicocele among athletes (bodybuilding and aerobics exercises) in Riyadh, Saudi Arabia.

Patients and methods

A cross-sectional study of male athletes aged between 18 and 48 years old was carried out in multiple branches of fitness centers over a period of 13 months in Riyadh, Saudi Arabia. A total of 382 face-to-face interviews using a predesigned questionnaire were conducted to identify the levels of knowledge, attitude, and practice. A randomly selected 48 subjects were examined. Varicocele was diagnosed and graded based on clinical examination and Doppler ultrasonography.

Results

Of the participants, 157 (41%) lacked knowledge and awareness regarding varicocele, its symptoms and complications. Of the examined participants, 22 (46%) were found to have varicocele. No difference in varicocele was found among bodybuilders and aerobic athletes (P=0.249). Similarly, no difference was related to duration of exercise session whether for 1 hour or more (P=0.131). However, our study revealed a higher rate of varicocele among athletes who exercised more than three times per week (P=0.009). Testicular volume was neither significantly different among respondents with and without varicocele nor between the left or right sides within each group.

Conclusion

Knowledge about varicocele, its symptoms and complications is poor among male athletes in Riyadh, Saudi Arabia. Varicocele is more common in athletic men who are frequently exercising. Efforts to increase knowledge and enhance awareness of varicocele in young males, in general, are strongly warranted.

Association of the modified frailty index with adverse outcomes after penile prosthesis implantation

OBJECTIVES

To investigate frailty as a predictor of surgical outcome in elderly patients undergoing penile prosthesis implantation.

MATERIAL AND METHODS

A total of 54 elderly patients, above 60 years of age, underwent penile prosthesis implantation between 2012 and 2014. Their data were collected and retrospectively analyzed. A modified frailty index (mFI) was calculated for each patient based on 11 risk factors from the Canadian Study of Health and Aging Frailty Index. The 1-year adverse outcomes were correlated with mFI, patients' and procedure's risk factors.

RESULTS

Mean age was 64.9 ± 5.2 years. No mortality was reported in our patients, however, one-year adverse outcomes were encountered in 43 (79.6%) patients. Among all studied variables, the 1-year adverse outcomes was not significantly association with mFI, but with preoperative glycosylated hemoglobin A1c (HbA1c) (p = 0.031) and associated Peyronie's disease (PD) (p = 0.000). HbA1c, dyslipidemia, hypertension, PD and duration of the procedure were predictive of infection complications (p < 0.05). Only PD and HbA1c sustained an independent significant impact.

CONCLUSIONS

mFI is not a predictive of post-penile prosthesis implantation adverse outcomes in elderly patients with impotence. Degree of diabetic control and association with PD was associated with the 1-year adverse outcomes and infection complications.

Microdissection testicular sperm extraction in men with nonobstructive azoospermia: Experience of King Saud University Medical City, Riyadh, Saudi Arabia

Objectives:

Microdissection testicular sperm extraction (micro-TESE) is an optimal technique of sperm extraction for intracytoplasmic sperm injection. This study is to present our experience in micro-TESE and evaluate the relation of its sperm retrieval rate (SRR) with patients' characteristics, testicular functions, and histological parameters as well as previous sperm retrieval interventions.

Materials and Methods:

We retrospectively reviewed records of 255 patients with nonobstructive azoospermia who underwent micro-TESE between 2011 and 2014. Medical records were reviewed for the results of follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone levels, karyotype analysis, and testicular histology pattern. Testicular volume was measured with an ultrasound scale.

Results:

The mean patients' age was 35.8 ± 7.2 years, duration of infertility 7.7 ± 4.5 years, right testicular volume 13.1 ± 5 ml, and left testicular volume 12.9 ± 5 ml. The overall SRR was 43.9%. SRR was significantly higher in testes with hypospermatogenesis histology pattern (P = 0.011). Patients' age, testicular size, serum FSH, LH, prolactin, and testosterone or failed previous sperm retrieval interventions showed no significant impact on SRR. Eleven (4.3%) patients had nonmosaic Klinefelter syndrome with a mean age of 37.8 ± 3.3 years. Sperms were retrieved in 6 (54.5%) patients. Post micro-TESE androgens significantly deteriorated with near complete recovery after 1 year.

Conclusions:

Micro-TESE has a high SRR, minimal postoperative complications, and reversible long-term androgen deficiency. Sperm retrieval depends on the most advanced pattern of testicular histology. Hypospermatogenesis pattern has the highest SRR. We demonstrated a high SRR with micro-ESE in men with Klinefelter syndrome.

Gender differences in perception of psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia

The objective of the study was to evaluate the differences in psychosocial distress and coping mechanisms among infertile men and women in Saudi Arabia (SA). We performed a cross-sectional study of infertile patients (206 women and 200 men) attending infertility clinics in three referral hospitals in Riyadh, SA. A semi-structured questionnaire was developed to assess socio-demographic, clinical and psychosocial variables. Infertility-related psychosocial pressures were reported in 79 (39.7%) male and 97 (47.3%) female participants (p = 0.123). Males suffered more from intrusive questions and pressure to conceive, remarry or get divorced, while females were stressed more from psychological and emotional exhaustion, marital discord, attitudes of mothers-in-law or society, and persistent desire by the husband to have children. To cope with infertility, females engaged more in religious activities (p < 0.001) and spoke more to someone regarding their problems (p < 0.001). To solve their infertility problems, 50% tried to find solutions via the internet, and 38.5% of males and 51% of females reported using alternative medicines (p = 0.012). The patients with infertility in SA face multiple psychosocial stressors related to their infertility, and cope differently based on the gender and culture-specific knowledge of infertility. The female participants were significantly more affected from psychosocial stressors and the persistent desire by their spouse to have children.

Noninvasive treatments for iatrogenic priapism: Do they really work? A prospective multicenter study

Objectives:

Intracorporeal injections (ICIs) of vasoactive substances during penile Doppler ultrasound (PDU) are a common investigation for erectile dysfunction (ED) diagnosis. ICI can be responsible of priapism, a pathological condition of prolonged penile erection not related to sexual stimulation. The aim of our study is to investigate the effectiveness of physical exercise and medical treatment as noninvasive therapy to restore detumescence in prolonged erections after ICI.

Materials and Methods:

Data were prospectively collected on men undergoing PDU in three urological centers. Three hundred and sixty-nine patients underwent PDU for the investigation of ED. All the participants received an ICI of quadrimix; prostaglandine E1, papaverine, phentolamine, and atropine. The data of the patients have been analyzed to record their comorbidities, results of PDU, and the complications encountered.

Results:

Fifty-three patients (14.4%) developed prolonged erections. Physical exercise alone was successful in reversing prolonged erection within 30 min in 21 (39.6%) patients. Out of the remaining 32 patients, oral salbutamol induced detumescence in 18 (34%) within the observation period of 60 min. Nonresponders were managed successfully with aspiration and irrigation of corpora with saline (11 patients, 20.75%) or with Phenylephrine (three patients, 5.66%).

Conclusions:

Physical exercise and oral salbutamol are safe and effective in restoring detumescence of pharmacologically-induced priapism. Noninvasive therapy may save a significant number of these patients an invasive treatment.

Pfannenstiel incision for intact specimen extraction in laparoscopic transperitoneal radical nephrectomy: a longitudinal prospective outcome study

OBJECTIVES

To evaluate the intra- and postoperative outcomes of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel transverse suprapubic incision.

METHODS

Prospective follow-up of 26 laparoscopic transperitoneal radical nephrectomies for suspected renal tumors in which the kidneys were extracted via a Pfannenstiel lower abdominal transverse incision.

RESULTS

The mean operating time was 152.3 (80-255) minutes, and the mean blood loss was 90 (20-300) ml. The mean extraction time was 20.4 (12-35) minutes. The mean weight of the removed specimen was 631.5 (190-1505) grams, and the mean longest diameter of the extracted specimen was 17.4 (9-25) cm. The mean extraction incision size was 10.7 (7-16) cm. No open surgical conversions were necessary. Pain control was excellent, with minimal intravenous morphine equivalent narcotic use by patients: 15.7 (0-31) mg in the recovery room, 33.8 (0-127) mg on the first postoperative day and 8.7 (0-60) mg in the first week after discharge. The patients experienced a short duration to full ambulation and normal dietary intake. Postoperative follow-up visits were recorded for at least six months. The patients reported a high cosmetic satisfaction rate of 97.7% (60-100). No late postoperative complications were observed related to the extraction site.

CONCLUSIONS

The operative specimen can be extracted via a low transverse Pfannenstiel incision during radical laparoscopic nephrectomy. This incision ensures the extraction of large specimens while preserving the aesthetic and functional advantages of laparoscopy without increasing the cancer risk. The absence of muscle cutting maintains the integrity of the abdominal wall and elicits minimal pain. No postoperative incisional hernias or keloid formations were observed.

Attitude and perception of urology by medical students at the end of their medical school: An appraisal from Saudi Arabia

Objectives:

To evaluate the attitude and perception of the graduates of King Saud University (KSU) College of Medicine regarding the quality of their urology rotation, urology exposure during this rotation, confidence about managing common conditions, and career prospects.

Materials and Methods:

In 2013, a questionnaire regarding the students’ perceptions of urology rotation was developed and E-mailed to all final (5^th) year medical students and interns of KSU College of Medicine, Riyadh, Saudi Arabia. Individual responses were recorded, tabulated and compared using descriptive statistics.

Results:

The overall response rate was 67.7%. Respondents included 101 (49.8%) males and 102 (50.2%) females. All the respondents but 18 (8.9%) were enrolled in a urology rotation during undergraduate years. Only 27 (13.3%) were willing to choose urology specialty as a future career. Significant gender differences were found regarding choice of urology as a future career (P = 0.002) and the need for more urology exposure during surgical rotation (P = 0.002).

Conclusions:

Knowledge of medical school graduates is insufficient in many urologic subjects, and there is a need for more urology exposure. Social reasons and lack of knowledge about urology hinder the choice of urology specialty as a future career. Clearance of learning objectives, immediate and prompt feedback on performance and adequate emphasis of common problems and ambulatory care are some aspects that should be taken into account by curriculum planners as they consider improvements to urology rotation program.

Evaluation of the learning environment of urology residency training using the postgraduate hospital educational environment measure inventory

OBJECTIVES

The educational environment plays a crucial role in the learning process. We aimed to evaluate the educational-environment perceptions of Saudi urology residents using the postgraduate hospital educational environment measure (PHEEM) inventory, and to investigate associations of their perception with stages of residency program, regions of Saudi Arabia, and main sectors of the health care system.

METHODS

We used PHEEM to measure the educational environment of Saudi urology residents. Respondents' perception was compared regarding different levels of residency training, regions of Saudi Arabia, and sectors of the health care system. Internal reliability of the inventory was assessed using Cronbach's alpha coefficient.

RESULTS

Out of 72 registered residents, 38 (53%) completed the questionnaire. The residents did not perceive their environment positively (77.7±16.5). No significant differences in perception were found among residents of different program stages or Saudi regions. Residents from different health care sectors differed significantly regarding the total PHEEM score (P=0.024) and the teaching subscale (P=0.017). The inventory showed a high internal consistency with Cronbach's alpha of 0.892.

CONCLUSION

Saudi urology residents perceived the educational environment as less than satisfactory. Perception of the educational environment did not change significantly among different stages of the program or different regions of Saudi Arabia. However, some sectors of the health care system are doing better than others.

Evaluation of sperm DNA damage in men from infertile Saudi couples

OBJECTIVE

To evaluate sperm DNA quality of the male partner in Saudi infertile couples in order to establish prevalence of sperm DNA damage and to help future identification of responsible etiologies and possible treatments.

STUDY DESIGN

A retrospective study of semen analysis and sperm DNA integrity using the sperm chromatin dispersion (SCD) technique in male partners of infertile couples examined for infertility in a dedicated fertility clinic, King Khalid University Hospital, Riyadh, Saudi Arabia, from January 1, 2009-December 31, 2011.

RESULTS

Reports of semen and SCD analysis of 405 men were reviewed; 384 met the inclusion criteria. Normal semen parameters were demonstrated in 133 (34.6%) male subjects, while 251 (65.4%) had ≥ 1 abnormal semen parameters. Saudi male partners showed increasing level of sperm DNA fragmentation index (DFI) at 25.4 (range, 5-97). Men with normal semen parameters had a significantly lower DFI (17.5; range, 5-32) than did men with abnormal semen parameters (49; range, 21-97, p < 0.001). DFI > 30% was encountered in 59.1% of the study group. Teratospermia single abnormality was significantly associated with DFI > 30% (p < 0.00007).

CONCLUSION

This study demonstrates a high percentage of sperm DNA damage in the male partner in Saudi infertile couples, and the damage was more obvious in men with suboptimal semen parameters. Patients with abnormal sperm morphology showed a high rate of DNA fragmentation.

Evaluation of urology residents' perception of surgical theater educational environment

PURPOSE

To evaluate surgical theater learning environment perception in urology residents in Saudi Arabia and to investigate association of learning environment perception and stages of residency program, sectors of health care system, and regions of Saudi Arabia.

DESIGN

A cross-sectional survey using the surgical theater educational environment measure (STEEM) inventory.

SETTINGS AND PARTICIPANTS

The STEEM inventory was used to measure theater learning environment perception of urology residents in Saudi Arabia. Respondents' perception was compared regarding different residency stages, sectors of the health care system, and regions of Saudi Arabia. Internal reliability of the inventory was assessed using the Cronbach α coefficient. Correlation analysis was done using the Spearman ρ coefficient.

RESULTS

Of 72 registered residents, 33 (45.8%) completed the questionnaire. The residents perceived their environment less than acceptable (135.9 ± 16.7, 67.95%). No significant differences in perception were found among residents of different program stages, different sectors of health care system, or different regions in Saudi Arabia. Residents from the eastern region perceived the training and teaching domain better (p = 0.025). The inventory showed a high internal consistency with a Cronbach α of 0.862.

CONCLUSIONS

STEEM survey is an applicable and reliable instrument for assessing the learning environment and training skills of urology residency program in Saudi Arabia. Urology residents in Saudi Arabia perceived the theater learning environment as less than ideal. The perceptions of theater learning environment did not change significantly among different stages of the program, different sectors of health care system, or different training regions of Saudi Arabia assuring the uniformity of urology training all over Saudi Arabia. The training programs should address significant concerns and pay close attention to areas in surgical theater educational environment, which need development and enhancement, mainly planned fashion of training, supportive supervision and hospital environment, and proper coverage and management of workloads.

Ligation anopexy versus hemorrhoidectomy in the treatment of second- and third-degree hemorrhoids

BACKGROUND

The aim of the study was to compare ligation anopexy (LA) and conventional hemorrhoidectomy (CH) in treatment of second- and third-degree hemorrhoids.

METHODS

A prospective controlled randomized clinical trial included 100 patients who underwent CH (CH group) and 100 patients who underwent LA (LA group). A detailed history was taken from all the patients. The effectiveness, safety, postoperative complications, operative time, length of hospital stay, time until first bowel movement, time until return to work, and postoperative pain score were assessed.

RESULTS

There was no significant difference between groups regarding age, sex, and preoperative symptoms. The LA group had significantly shorter operative times, earlier first bowel movement, and an earlier return to work/activities. The postoperative pain score in the LA group was significantly lower than that in the CH group on days 1, 3, 7, and 14 after surgery. There was no significant difference between groups as regards postoperative complications.

CONCLUSIONS

LA is safe, and as effective as CH in the treatment of grade II and grade III hemorrhoids, with shorter operative times, earlier mobilization, and lower postoperative pain scores.

Pattern of semen fluid abnormalities in male partners of infertile couples in Riyadh, Saudi Arabia

INTRODUCTION

A decline in semen quality in men with increasing percentage of male factor abnormalities in infertile couples has been reported. The pattern of abnormalities differs from one part of the world to another, and it is probably multifactorial. Our objectives were to review the pattern of semen fluid abnormalities in Saudi male partners of infertile couples, to establish prevalence and help future identification of responsible etiologies and possible treatments.

MATERIALS AND METHODS

A retrospective study of semen analysis results of male partners of infertile couples examined in a dedicated infertility clinic, King Khalid University Hospital, Riyadh, Saudi Arabia from January 2009 through December 2011.

RESULTS

A total of 1485 male semen analysis reports were reviewed. According to 1999 WHO reference values for normal semen analysis, 61 (4.1%) of patients had normal semen parameters while 149 (10%) had azoospermia. Half of the samples (783, 52.7%) had single factor abnormality; the majority (97%) being teratospermia. Oligo-teratospermia was evident in 133 (9%) of the samples constituting nearly half of those who had 2 factor abnormality. Oligo-astheno-teratospermia was encountered in 191 (12.9%) patients. Oligospermia was evident in 403 (27.2%) patients; 52% of them had sperm concentrations of more than 10 million/mL. Twelve patients had only low volume ejaculate.

CONCLUSION

A high percentage of semen fluid and sperm morphology abnormalities were found in males of infertile couples in Riyadh, Saudi Arabia which may contribute to subfertility. Further studies are needed to address possible etiologies and treatment of oligospermia and teratospermia in our region in order to improve fertility rates.

Clinical, endocrinological and histopathological patterns of infertile Saudi men subjected to testicular biopsy: A retrospective study from a single center

PURPOSE

To evaluate the outcome of testicular biopsies as well as the etiology of azoospermia and severe oligospermia in Saudi men referred for tertiary care. To correlate testicular histology with patients' clinical and hormonal profiles.

MATERIALS AND METHODS

Charts of men subjected to testicular biopsies in the last 10-year period were retrospectively reviewed. Relative history and physical examination findings were reported. Results of male fertility profile tests and semen analysis of at least two ejaculates were collected. Reported histopathology was obtained.

RESULTS

Reports of 229 patients were included; 199 (86.9%) with azoospermia and 30 (13.1%) with severe oligospermia. The mean (SD) age was 30.6 (6.4) years. A small right or left testis was reported in 88 (38.4%) and 87 (38%) of the patients, respectively. The mean (SD) testosterone and follicle stimulating hormone (FSH) values were 17.2 (7.2) nmol/L and 13.1 (10.9) IU/L, respectively. Hypospermatogenesis was the most common histology encountered (36.5%), followed by Sertoli cell-only (SCO) histology (31.5%). Low testicular volume (P = 0.000), high FSH (P = 0.001) and high leutenizing hormone (LH) (P = 0.001) were found to be of significantly adverse effect on spermatogenesis. Despite having bilateral small testes, high serum FSH and LH, 24.3% of our patients showed active spermatogenesis.

CONCLUSIONS

Hypospermatogenesis was the most common pattern of spermatogenic defect in our patients. SCO histology was the most common pattern in patients with small testes, primary testicular failure, primary infertility and azoospermia. Low testicular volume, high FSH and LH are significantly associated with impaired spermatogenesis. Even with severe male factor infertility disorders, infertile men can have some spermatogenesis.

Large orthotopic reservoir stone burden: Role of open surgery

PURPOSE

To present our experience in open poucholithotomy as a primary management of large orthotopic reservoir stone burden and discuss different management options.

MATERIALS AND METHODS

Records of men underwent radical cystectomy and orthotopic urinary diversion were retrospectively reviewed as regards pouch stone formation. Patients with large reservoir stone burden managed by open poucholithotomy were further selected.

RESULTS

Large reservoir stone burden was encountered in 12 post radical cystectomy men. All underwent open poucholithotomy as a primary management of their reservoir stones. Median age at cystectomy was 46 (range: 32-55) years with a median total follow up period of 214.15 (range: 147-257) months and a median interval to stone detection of 99 (range: 63-132) months. The median stone burden was 5260 (range: 3179-20410) mm(2). All patients were continent during the day while 5 showed nocturnal enuresis; 2 of them became continent after removal of the stones. Post poucholithotomy, all patients had sterile urine cultures except one who showed occasional colonization. None of the 12 patients showed stone recurrence after poucholithotomy. Two patients underwent revision of a dessuscepted nipple valve in association with stone removal.

CONCLUSIONS

Open poucholithotomy for large reservoir stone burden is a feasible and safe option. It saves the reservoir mesentery and adjacent bowel. It allows complete removal of the stone(s) leaving no residual fragments. Furthermore, it permits correction of concomitant reservoir abnormalities.

Penile abscess and necrotizing fasciitis secondary to neglected false penile fracture

Penile infection and abscess formation have been described in association with priapism, cavernosography, intracavernosal injection therapy, trauma and penile prosthesis. We report a case of penile abscess and necrotizing fasciitis of penile skin in a 37-year-old male, presented 3 weeks after neglected false penile fracture.

Efficacy of local subcutaneous anesthesia versus intramuscular opioid sedation in extracorporeal shockwave lithotripsy: a randomized study

PURPOSE

To evaluate the analgesic efficacy of local subcutaneous (SC) anesthesia compared with intramuscular (IM) opioid sedation during extracorporeal shockwave lithotripsy (SWL) in a randomized study.

PATIENTS AND METHODS

After informed consent was obtained, 125 patients with urolithiasis who were scheduled for SWL were included in the study. The patients in each treatment session were randomized to receive either IM meperidine (group A) or SC infiltration of 10 mL 2% lidocaine and 10 mL 0.5% bupivacaine at the area of shockwave entry (group B). Degree of pain was rated by the patient using a five-point visual analogue scale (VAS).

RESULTS

The study included 88 (70.4%) men and 37 (29.6%) women with a mean age of 47.6 ± 12.5 years and a mean body mass index (BMI) of 28.16 ± 4.67 kg/m2. Of the patients, 89, 26, and 10 received a single, two, or more than two treatment sessions, respectively (176 sessions). Maximum stone length was 10.68 ± 5.12 mm. Pretreatment stent placement was performed in 17 (13.6%) patients (28 sessions). Group A comprised 89 treatment sessions while 87 were involved in group B. Both groups were similar. Supplemental intrvenous sedation was needed in two (2.5%) and four (4.6%) sessions in groups A and B, respectively. VAS was not different between both groups (P = 0.063). Patients with pretreatment stent placement had significantly lower VAS score compared with patients without stents (P = 0.012). Sex and BMI had no impact on the VAS score.

CONCLUSIONS

Local SC anesthesia alone is effective for analgesic purposes during extracorporeal SWL. Sex, age, and BMI have no relation to analgesia requirement.

Urinary bladder catheter drainage following pelvic surgery--is it necessary for that long?

PURPOSE

Urinary bladder drainage for several days after pelvic surgery is a common surgical practice, despite insufficient evidence supporting its routine use. The aim of this study was to prospectively evaluate the utility of urinary bladder drainage after pelvic colorectal surgery.

METHODS

Patients undergoing pelvic surgery were prospectively randomly assigned to 3 groups. In group A, the Foley catheter was removed on postoperative day 1, and in groups B and C it was removed on postoperative days 3 and 5, respectively. Male patients with severe prostatic symptoms were excluded from the study. The main outcome criterion was acute urinary retention requiring reinsertion of the Foley catheter.

RESULTS

A total of 118 patients (68 males) at a mean age of 55 years were included in this study (group A, 41 patients; group B, 38; and group C, 39). Overall, urinary retention after removal of the Foley catheter occurred in 12 (10%) of the patients: 6 (14.6%) in group A, 2 (5.3%) in group B, and 4 (10.5%) in group C (P = .39). Symptomatic urinary tract infection was diagnosed in 5 patients in group A, 3 in group B, and 9 in group C, but this difference did not reach statistical significance. Likewise, there were no significant differences in anastomotic leak and intra-abdominal abscess rates among the 3 groups.

CONCLUSIONS

Routine prolonged urinary bladder catheterization after pelvic surgery may not be required, and the Foley catheter may be safely removed on postoperative day 1. Larger studies are needed to confirm the findings of this study.

Microvascular Tumor Invasion: Prognostic Significance in Low-Stage Renal Cell Carcinoma

OBJECTIVES

To evaluate the role of microvascular tumor invasion (MVI) in clinical behavior and prognosis of low-stage renal cell carcinoma.

METHODS

We retrospectively reviewed the records of patients who had undergone radical nephrectomy from 1990 to 2004 for clinically confined kidney tumors (Stage T1-T2N0M0) with a minimal follow-up period of 1 year. The pathology slides were reviewed regarding tumor diameter, pathologic tumor stage, histologic cell type, nuclear grade, macroscopic or MVI, perirenal fat invasion, and neoplastic lymph node involvement.

RESULTS

A total of 48 patients, 22 men and 26 women (mean +/- SD age 50.73 +/- 13.03 years, range 20-80) were included in the study. The patients were followed up for a mean +/- SD of 37.65 +/- 18.19 months (range 12-60). MVI was encountered in 8 patients (16.7%); 50% developed treatment failure in the form of distant metastases. Of the 40 patients without MVI, only 2 (5%) had treatment failure. MVI had a statistically significant association with sex (P = 0.017) and stage (P = 0.039). On comparing treatment failure with different patient and histologic parameters, a statistically significant association was noted with sex (P = 0.006) and MVI (P = 0.005). The 5-year disease-free survival rate was estimated at 45% and 90% when MVI was and was not present. Only MVI showed an independent statistically significant impact (P = 0.007) on multivariate analysis considering the impact of MVI, stage, grade, cell type, perirenal fat invasion, tumor size, and patient age on disease-free survival.

CONCLUSIONS

The results of our study have shown that MVI is an independent and relevant prognostic parameter for clinically low-stage renal cell carcinoma.

Extracorporeal shock-wave lithotripsy monotherapy of partial staghorn calculi. Prognostic factors and long-term results

OBJECTIVE

To define factors affecting the success and long-term outcome of extracorporeal shock-wave lithotripsy (ESWL) monotherapy of partial staghorn calculi.

MATERIAL AND METHODS

We retrospectively reviewed 92 patients with partial staghorn calculi who were treated with ESWL monotherapy. The outcome of the treatment was evaluated after 3 months. Long-term follow-up data (>24 months) were available for 49 patients. These data were further analyzed to determine long-term outcome.

RESULTS

At 3 months, the overall stone-free rate was 59.8%. Multiple ESWL sessions were required in 85.8% of patients. Stone surface area>500 mm2 was the only factor that significantly decreased the stone-free rate. Post-ESWL complications occurred in 12 patients (13%), among whom renal obstruction was observed in 10.8%. Secondary procedures were needed in 17 cases (18.4%). After a mean follow-up period of 7.5 years, the stone-free rate was 59.2% (29/49) and one-third of patients developed recurrence. In the long term, clinically insignificant residual fragments (CIRFs) passed spontaneously in 23% of patients, remained stable in 38.5% and became bigger in 38.5%. Regrowth of CIRFs was related to a history of stone recurrence. No patients showed deterioration of kidney function on the treated side and an improvement in pre-ESWL hydronephrosis was observed in 73.3% of patients.

CONCLUSIONS

ESWL is suitable for staghorn stones<or=500 mm2. In the long term, CIRFs became bigger and required secondary intervention in one-third of patients. A history of stone recurrence is a significant predictor of regrowth of CIRFs. ESWL provides long-term preservation of function of the treated kidneys; however, one-third of patients develop recurrence.

Predictors of Clinical Significance of Residual Fragments after Extracorporeal Shockwave Lithotripsy for Renal Stones

PURPOSE

To determine the predictors of the clinical outcome of residual fragments after extracorporeal shockwave lithotripsy (SWL).

PATIENTS AND METHODS

During the last 10 years, residual fragments < or =5 mm were present in 99 male and 55 female patients (mean age 43.1 years) for >3 months after SWL for renal stones. Follow-up with history, urine examination, and non-contrast CT scanning was carried out every 6 months or when symptoms developed. Clinically insignificant residual fragments were diagnosed in patients who became stone free or had asymptomatic fragments of the same size during follow-up. A clinically significant outcome was considered to have occurred in patients requiring secondary intervention for regrowth of the fragments or medical treatment for frequent symptomatic episodes. Univariate (Kaplan-Meier) and multivariate (Cox-regression) analyses were performed to determine significant predictors of the outcome. The mean follow-up was 31 months (range 6-80 months).

RESULTS

Stone-free status, regrowth of fragments, and persistence of fragments of the same size were present in 21 (13.6%), 52 (33.8%), and 81 (52.6%) patients, respectively. A clinically significant outcome was documented in 75 patients (48.7%) as percutaneous nephrolithotomy was needed in 2, repeat SWL in 50, and medical treatment for symptomatic episodes in 23 patients. Significant independent predictors of a clinically significant outcome were fragment size > or =4 mm and history of recurrent stone disease (P < 0.001).

CONCLUSION

The term "clinically insignificant residual fragments" is not appropriate for all patients with post-SWL fragments, as 48.7% of patients had fragments that became clinically significant. Fragments of 4 to 5 mm and recurrent stone disease predicted clinical significance.

The outcome after restorative proctocolectomy with or without defunctioning ileostomy

PURPOSE

Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy.

METHODS

Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared.

RESULTS

Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes.

CONCLUSIONS

For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

Slow versus fast shock wave lithotripsy rate for urolithiasis: a prospective randomized study

PURPOSE

We determined the effect of shock wave lithotripsy (SWL) rate on treatment outcome in patients with renal and ureteral stones.

MATERIALS AND METHODS

A total of 156 patients were prospectively randomized to receive SWL using a slow (60 pulses per minute) or fast wave rate (120 pulses per minute). Inclusion criteria were patients with a single radiopaque renal or ureteral stone not exceeding 30 mm in maximum diameter. Patient characteristics, stone and therapy features were reviewed, and the relation to success rate and total number of shock waves required was assessed using the chi-square, Fisher exact and Mann-Whitney tests. Factors proven to be significant in univariate analysis were entered in a multivariate logistic regression analysis.

RESULTS

The study included 114 male (73.1%) and 42 female (26.9%) patients with a mean age +/- SD of 42.1 +/- 13.3 years. Stone length measured in maximum diameter was 13.2 +/- 5.9 mm (range 5 to 30). Renal stones were encountered in 94 (60.3%) patients and ureteral stones in 62 (39.7%). The slow SWL rate was used in 76 (48.7%) patients and the fast rate in 80 (51.3%). Baseline variables were comparable in both groups. However, the total number of shock waves required was statistically significantly lower in the slow rate group (p = 0.004) and the treatment time was significantly longer (p = 0.000). The rate of success, defined as being completely stone-free or having clinically insignificant gravel less than 2 mm, was significantly higher with the slow rate (p = 0.034), an increased number of sessions (p = 0.001), decreased stone length (p = 0.000) and greater total number of shock waves (p = 0.011). However, only the slow SWL rate and stone length maintained a statistically significant impact in multivariate analysis.

CONCLUSIONS

The slow SWL rate is associated with a significantly higher success rate at a lower number of total shock waves compared to the fast SWL rate.

Determination of the chemical composition of urinary calculi by noncontrast spiral computerized tomography

Various techniques for noncontrast spiral computerized tomography (NCCT) were utilized for the determination of the Hounsefield unit (HU) values of various types of urinary calculi with the aim of determining the best technique for distinguishing various stones compositions. A total of 130 urinary stones, obtained from patients who underwent open surgery, were scanned with a multidetector row scanner using 1.25 mm collimation at two energy levels of 100 and 120 kV at 240 mA. Two post-scanning protocols were used for the HU value assignment, tissue and bone windows, for both kV values. In both protocols, three transverse planes were defined in each stone, one near the top, one in the middle, and one near the bottom. Three regions of interest (ROI) were obtained in each plane. The absolute HU value was determined by three methods: the mean of the nine ROI, the mean of the central three ROI, and the central ROI in the middle plane. Determination of the stones' composition was performed using the absolute HU value measured at 120 kV, the dual CT values (HU values at 100 kV-HU values at 120 kV), and HU values/stone volume ratio (HU density). All stones were analyzed by x-ray diffraction to determine their chemical composition. After the exclusion of groups with few calculi, 47 pure stones [25 uric acid (UA), 15 calcium oxalate monohydrate (COM), seven struvite], and 60 mixed stones [15 COM 60-90%+hydroxyl apatite (HA), 14 COM 40-90%+UA, 21 UA+COM <40%, ten mixed struvite+COM+hydroxyl apatite] were included in the statistical analysis. From the least to the most dense, the pure stone types were UA, struvite, COM. Mixed UA+COM<40% calculi were less dense but insignificantly different from pure UA, while when the COM ratio was > or =40% their density became higher than and significantly different from pure UA, and less than but not significantly differentiated from pure COM. Mixed COM+HA were the most dense stones. Using the absolute HU values at 120 kV and HU density, we could distinguish, with statistical significance, all pure types from each other, pure UA from all mixed calculi except UA+COM <40%, pure COM from mixed UA+COM <40%, and pure struvite from all mixed stones except mixed struvite stones. Dual CT values were not as good as absolute HU values and HU density in the determination of stone composition. These results demonstrate that absolute HU values and HU density derived from CT scanning using a small collimation size could uncover statistically significant differences among all pure and most of the mixed urinary stones. This permits more accuracy in the prediction of stone composition. Moreover, this technique permits diagnostic conclusions on the basis of single CT evaluation.

Can we improve the prediction of stone-free status after extracorporeal shock wave lithotripsy for ureteral stones? A neural network or a statistical model?

PURPOSE

We evaluated whether an artificial neural network (ANN) can improve the prediction of stone-free status after extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for ureteral stones compared to a logistic regression (LR) model.

MATERIALS AND METHODS

Between February 1989 and December 1998, 984 patients with ureteral stones, including 780 males and 204 females with a mean age +/- SD of 40.85 +/- 10.33 years, were treated with ESWL. Stone-free status at 3 months was determined by urinary tract plain x-ray and excretory urography. Of all patients 919 (93.3%) were free of stones. The impact of 10 factors on stone-free status was studied using an LR model and ANN. These factors were patient age and sex, renal anatomy, stone location, side, number, length and width, whether stones were de novo or recurrent, and stent use. An LR model was constructed and ANN was trained on 688 randomly selected patients (70%) to predict stone-free status at 3 months. The 10 factors were used as covariates in the LR model and as input parameters to ANN. Performance of the trained net and developed logistic model was evaluated in the remaining 296 patients (30%), who served as the test set. The sensitivity (percent of correctly predicted stone-free cases), specificity (percent of correctly predicted nonstonefree cases), positive predictive value, overall accuracy and average classification rate of the 2 techniques were compared. Relevant variables influencing the construction of the 2 models were compared.

RESULTS

Evaluating the performance of the LR and ANN models on the test set revealed a sensitivity of 100% and 77.9%, a specificity of 0.0% and 75%, a positive predictive value of 93.2% and 97.2%, an overall accuracy of 93.2% and 77.7%, and an average classification rate of 50% and 76.5%, respectively. LR failed to predict any nonstone free cases. LR and ANN identified stone location and stent use as important factors in determining the outcome, while ANN also identified stone length and width as influential factors.

CONCLUSIONS

ANN and LR could predict adequately those who would be stone-free after ESWL for ureteral stones. The neural network has a higher ability to predict those who fail to respond to ESWL.

The urethral Kock pouch: long-term functional and oncological results in men

OBJECTIVE

To evaluate our experience with men who underwent radical cystectomy and urethral Kock pouch construction between January 1986 and January 1996.

PATIENTS AND METHODS

Complications were classified as early (within the first 3 months after surgery) or late. Continence was assessed by interviewing the patient; they were considered continent if they were completely dry with no need of protection by pads, condom catheter or medication. The patients were followed oncologically and Kaplan-Meier survival curves constructed. Urodynamic studies were used to define the possible causes of enuresis.

RESULTS

Three patients died after surgery from pulmonary embolism. There were 67 early complications in 63 patients. The mean (SD) follow-up was 87.8 (49.1) months. There were 111 treatment failures from cancer; of these, four men only had an isolated local recurrence in the urethra. Late complications included 72 pouch stones in 55 patients, and 36 deteriorated renal units caused by reflux (17), uretero-ileal stricture (11), nipple valve eversion (four) or stenosis (four). Interestingly, 65 renal units that were dilated before surgery improved significantly afterward. Ileo-urethral strictures occurred in seven men and anterior urethral strictures in six. Nine patients were totally incontinent and two had chronic urinary retention. Daytime continence was complete in 94% of men, with nocturnal enuresis in 55; the latter had significantly more residual urine, and a higher amplitude and duration of phasic contractions.

CONCLUSIONS

Orthotopic bladder substitution after cystectomy for cancer is feasible, with good functional and oncological outcomes in properly selected patients. Nevertheless, the use of a hemi-Kock pouch is associated with many valve-related complications.

Prospective randomized comparative study of the effectiveness and safety of electrohydraulic and electromagnetic extracorporeal shock wave lithotriptors

PURPOSE

We compared the efficacy of 2 shock wave energy sources, electrohydraulic (Dornier MFL 5000, Dornier MedTech, Wessling, Germany) and electromagnetic (DLS, Dornier Lithotriptor S, Dornier MedTech), for the treatment of urinary calculi.

MATERIALS AND METHODS

A prospective randomized study of 694 patients with urinary stones was conducted during 12 months to compare the efficacy of the 2 machines. Entrance criteria were radiopaque single or multiple stones at any location within the kidney or the ureter, 25 mm or smaller that had not previously been treated by any means. Patients with congenital anomalies were excluded from this study with all other contraindications for extracorporeal shock wave lithotripsy. Following lithotripsy a plain abdominal film and tomograms were done 1 week after each session to determine if there were residual stones and assess the need for re-treatment. Patients were evaluated 4 weeks after lithotripsy by plane abdominal x-ray and spiral computerized tomography. Success was defined as no residual stones. Univariate and multivariate statistical analyses were performed for different variables that may have an impact on the success rate, including the type of lithotriptor. Comparisons of treatment parameters, complications and success rate for both lithotriptors were done.

RESULTS

Of 9 variables examined with univariate analysis 6 had a significant impact on the success rate. Of these 4 maintained their statistical impact on multivariate analysis. These were side, site of the stones, renal morphology and type of lithotriptor. Treatment time was significantly shortened for DLS (54 +/- 32.9 minutes compared to 65.7 +/- 44.7 for MFL, p <0.001). The re-treatment rate was lower for DLS at 34% versus 51.6% for the MFL (p <0.001). The overall success rate was 85.4%. It was 88.5% for DLS compared to 82.4% for MFL (p = 0.03). No statistically significant difference between the lithotriptors was noted for ureteral calculi (p >0.05). The success rate was higher in the DLS group for renal stones especially lower caliceal and pyelic stones (p <0.05). The success rate was higher in DLS group for stones 10 mm or smaller, 92.8% versus 85.3% for MFL (p = 0.03). The success rate was comparable in both groups for stones larger than 10 mm (81.8% for DLS versus 77.9% for MFL, p >0.05). No statistically significant difference was found in the complication rate for the groups. Steinstrasse were noted in 4% of patients treated with MFL and 3% of those treated with DLS. Subcapsular hematomas were noted in 2 patients in each group. No procedures after extracorporeal shock wave lithotripsy were needed in either group.

CONCLUSIONS

The electromagnetic lithotriptor (Dornier lithotriptor S) has significant clinical advantages over the electrohydraulic lithotriptor (Dornier MFL 5000) in terms of treatment time, re-treatment rate and success rate, although there is no difference in the complication rate.

Extracorporeal shock wave lithotripsy in anomalous kidneys: 11-year experience with two second-generation lithotripters

OBJECTIVES

To present our experience with extracorporeal shock wave lithotripsy (ESWL) in patients with anomalous kidneys and to determine the factors that may influence the stone-free rate in such patients.

METHODS

From February 1989 to February 2000, 198 patients were treated for urolithiasis in anomalous kidneys using ESWL. The mean patient age (SD) was 40.48 (11.53) years. The kidneys were horseshoe in 49 (24.7%), malrotated in 120 (60.6%), and duplex in 29 (14.7%). All patients were treated on an outpatient basis using two second-generation lithotripters (Dornier MFL 5000 and Toshiba Echolith). Pretreatment auxiliary measures were required in 6 patients (3%). Follow-up data were recorded at 3 months. The statistical analysis was performed using the chi-square and Mann-Whitney U tests, with differences considered statistically significant if P <0.05.

RESULTS

The mean stone length (SD) was 13.54 (5.49) mm. The stones were single in 148 (74.7%), of new onset in 155 (78.3%), and on the right side in 82 (41.4%). All stones, but 5 (2.5%), were radiopaque. The overall stone-free rate was 72.2%. Neither the type of renal anomaly nor the type of lithotripter had any impact on the stone-free rate (P >0.05). Stone burden (length and number) had a significant influence on the stone-free rate (P <0.05). No extraordinary complications were recorded. Steinstrasse developed in 7 patients (3.5%). No deterioration of renal function or configuration was detected.

CONCLUSIONS

ESWL is safe and reliable for treatment of urolithiasis in anomalous kidneys. It should be the primary therapy when the stones are less than 20 mm. The ESWL outcome is comparable for normal and anomalous kidneys when the calculus size is considered.

Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model

PURPOSE

We studied the various stone, renal and therapy factors that could affect steinstrasse formation after extracorporeal shock wave lithotripsy (ESWL), Dornier Medical Systems Inc., Marietta, Georgia to define the predictive factors for its formation. Thus, steinstrasse could be anticipated and prophylactically avoided.

MATERIALS AND METHODS

Between February 1989 and May 1999, 4,634 patients were treated with a Dornier MFL 5000 lithotriptor (Dornier Med Tech, GmbH, Germany). Renal stones were encountered in 3,403 patients and ureteral stones in 1,231. Steinstrasse were recorded in 184 patients, of whom 74 required intervention and formed the "complicated group." All patient data, stone and renal characteristics, and data of ESWL were reviewed. Univariate and multivariate statistical analyses of patients, stones and therapy characteristics in correlation with the incidence of steinstrasse formation were performed to assign the factors that had a significant impact on steinstrasse formation.

RESULTS

The overall incidence of steinstrasse was 3.97%. The steinstrasse was in the pelvic ureter in 74% of the cases, lumbar ureter in 21.7% and iliac ureter in 4.3%. Steinstrasse incidence significantly correlated with stone size and site, the power level (kV.) used during therapy and radiological renal features. Steinstrasse was more common with renal stones more than 2 cm. in diameter in a dilated system, especially with the use of high power (greater than 22 kV.) for disintegration. A statistical model was constructed to estimate the risk of steinstrasse formation accurately.

CONCLUSIONS

Stone size and site, renal morphology and shock wave energy are the significant predictive factors controlling steinstrasse formation. If a patient has a high probability of steinstrasse formation, close followup with early intervention or prophylactic pre-ESWL ureteral stenting is indicated.

Impact of lower pole renal anatomy on stone clearance after shock wave lithotripsy: fact or fiction?

PURPOSE

We determined whether there is a significant relationship between the spatial anatomy of the lower pole on preoperative excretory urography and stone fragment clearance after shock wave lithotripsy.

MATERIALS AND METHODS

The anatomical factors affecting lower pole stone clearance after shock wave lithotripsy were evaluated retrospectively in 108 patients. Stone-free status was assessed by renal computerized tomography with or without renal ultrasound. The stone-free rate at 3 months was correlated with lower pole infundibular length and width in mm. as well as with the lower pole infundibulopelvic angle in degrees. The statistical significance of each lower pole anatomical factor as well as other stone, renal and treatment factors were correlated with the stone-free rate using the Mann-Whitney and chi-square tests.

RESULTS

Three months after shock wave lithotripsy 79 patients (73.1%) were free of stones. Mean lower infundibular length plus or minus standard deviation was 20.9 +/- 6.56 mm., mean infundibular width was 5.65 +/- 2.34 mm. and the mean lower pole infundibulopelvic angle was 48.33 +/- 14.84 degrees. In 49 (45.4%) and 59 (54.6%) patients infundibular length was greater than 3 cm. and 3 cm. or less, respectively. Infundibular width was greater than 5 mm. and 5 mm. or less in 45 (41.7%) and 63 (58.3%) patients, respectively. No obtuse infundibulopelvic angles were noted. None of the 3 lower pole anatomical factors had any significant impact on the stone-free rate at 3 months. Renal morphology was the only factor significantly affecting the stone-free rate since stone clearance was significantly less in pyelonephritic kidneys (p = 0.0009).

CONCLUSIONS

Differences in the intrarenal anatomy of the lower pole have no significant impact on stone clearance after shock wave lithotripsy. Further examination of the lower pole renal anatomy with a search for other contributing factors is still warranted.

Extracorporeal shock wave lithotripsy in children: experience using two second-generation lithotripters

OBJECTIVES

To assess the value of extracorporeal shock wave lithotripsy (ESWL) in treating paediatric urolithiasis, and to determine factors that may affect the results.

PATIENTS AND METHODS

Using two types of lithotripters (MFL 5000, Dornier MedTech GmbH, Germany, and the Echolith, Toshiba Medical Systems, Japan), 148 children and adolescents (mean age 11.2 years, SD 4.7, range 1-18) were treated for urinary stones. Of these, 137 patients had renal stones and 11 had ureteric stones. The respective mean (SD) stone width and length were 10.2 (4.1) and 12.9 (5.6) mm for renal stones and 7.6 (2.7) and 9.1 (2.7) mm for ureteric stones. The patients were assessed 3 months after treatment and the results compared using the chi-square test to detect factors that might be associated with the stone-free rate.

RESULTS

For those with renal stones, the overall stone-free rate was 86% and the re-treatment rate 64%. The only significant factor associated with the stone-free rate was the transverse diameter of the stone (P = 0.012); there was no significant effect of the type of lithotripter but there was a significant difference in re-treatment rate (P = 0.016) in favour of the MFL 5000. All those with ureteric stones were rendered stone-free and only four required re-treatment. Only one child among those with renal stones developed steinstrasse; this was managed by ureteroscopy and otherwise no other complications were recorded in either group.

CONCLUSIONS

ESWL is a safe and effective treatment for paediatric urolithiasis. The stone-free rate is influenced significantly by stone size. The re-treatment rate differed significantly between the electrohydraulic and piezoelectric lithotripters, but the stone-free rate did not.

A prospective randomized study comparing absorbable and nonabsorbable staples in constructing antireflux valves of urethral hemi-Kock pouches

OBJECTIVE

To determine the long-term complications associated with constructing an antireflux nipple valve using absorbable or nonabsorbable staples in the urethral hemi-Kock pouch.

PATIENTS AND METHODS

Fifty patients (all men, median age 47 years, range 28-73) undergoing construction of a urethral hemi-Kock pouch were randomized prospectively into two equal groups. In group 1, absorbable (polyglyconate) staples were used for the construction, and in group 2 nonabsorbable (metal) staples were used but omitting the staples applied at the tip of nipple valve. Assessment during the follow-up of 6-88 months comprised urine analysis, culture and sensitivity, measurement of serum creatinine, electrolytes and blood gases, and plain abdominal radiography, intravenous urography and micturating pouchography.

RESULTS

In group 1, 21 patients were evaluable; a pouch stone was detected in one, extussusception of the valve in one and valve stenosis in one. In group 2, 20 patients were evaluable; pouch stones were detected in six, extussusception of the valve in three and valve stenosis in one.

CONCLUSION

Compared with nonabsorbable (metal) staples, the use of absorbable (polyglyconate) staples significantly decreased the incidence of pouch stone formation and improved valve stability in patients with a urethral hemi-Kock pouch.