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The role of emergency shockwave lithotripsy (SWL) in persistent pain control in patients with ureteral stones is not well established. The aim of this study is to evaluate efficacy as well as the predicting variables for successful early SWL patients with symptomatic ureteral stones. Eighty-six patients with a persistent renal colic secondary to single ureteral stone (6–12 mm) were prospectively enrolled in this study. SWL was performed within 24 h of the onset of flank pain. Pain control and stone-free rate after emergency SWL session were 58.1% and 44.2%, respectively. Seven patients required post-SWL ureteroscopy and ureteral stent placement for uncontrolled pain. The overall 3-month stone-free rate after SWL monotherapy was 83.7%. On multivariate analysis, predictors for pain relief after emergency SWL were lower Hounsfield (HU) stone density, mild hydronephrosis (HN) at presentation and presentation during the first colic episode. Lower HU stone density was the single predictor of successful stone clearance after single emergency SWL session on multivariate analysis. In conclusion, early SWL is feasible and effective in management of ureteral stones presented by renal colic with low HU.

To compare the efficacy and morbidity of transurethral cystolithotripsy (TUCL) and percutaneous CL (PCCL) in the management of bladder stones in male children.A total of 100 boys, aged14 years with a single bladder or urethral stone of30 mm, were randomised into two equal groups. Initial diagnostic urethro-cystoscopy and push back of urethral stones were done for patients in both groups. Patients in Group A had TUCL, while those in Group B had PCCL through a 20-F sheath using a 12-F nephroscope. The two groups were compared regarding preoperative criteria, intraoperative details, and postoperative outcomes.The patients in this study had a median (range) age of 36 (4-144) months and stone size of 10 (5-26) mm. There was no statistically significant difference between the two groups for preoperative criteria. The assigned procedure was successful in 48 (96%) patients in Group A and 49 (98%) in Group B (P = 1). Complications were encountered in 11 (22%) patients in Group A and five (10%) in Group B (P = 0.171). The median (range) operative time was 21.5 (4-90) min in Group A and 13 (5-70) min in Group B (P0.001). In all, 47 (94%) stones needed disintegration in Group A vs 22 (44%) in Group B (P0.001).Both techniques have comparable success and complications rates. However, PCCL has a shorter operative time and less need for stone disintegration.

Context: The management of renal stones of high density (>1000 Hounsfield units) on non-contrast computed tomography (NCCT), and moderate sized (15-25 mm) is still debatable. Aims: The aim of this study was to compare the outcomes of percutaneous nephrolithotomy (PCNL) and shock wave lithotripsy (SWL) for the high-density and moderate-sized renal stones regarding the stone-free rate (SFR), morbidity, and patients' quality of life. Settings and Design: This is a prospective randomized study. Patients and Methods: Eighty consecutive patients with renal stones, excluding those with lower calyceal stones, were randomized to receive either PCNL or SWL (40 in each arm). Patients were followed up by abdominal ultrasound and plain X-ray (NCCT if indicated) till clearance of stone. Outcomes, complications, costs, and SF-8 Health Survey scoring were recorded for each group. Statistical Analysis: We used Stata software, version 9.2 (Intercooled STATA®; StataCorp LP College Station, Texas, USA). Comparison of the two groups was made with regard to patient and stone criteria and the procedure details. Continuous variables were compared using the Mann–Whitney U-test with values shown as the median and interquartile range. Categorical variables were compared using the Pearson's Chi-square/Fisher's exact test. Multivariate logistic regression analysis was used to identify variables independently associated with the stone clearance after two sessions of SWL. P < 0.05 was considered statistically significant. Results: The basic characteristics of both groups were comparable. After a single treatment session, the SFR was 80% and 27.5% for PCNL and SWL, respectively (P < 0.001). The overall 3-month SFR was 87.5% versus 90%, respectively (P = 0.723). The median number of the required maneuvers was 1 (range: 1–3) for PCNL versus 2 (range: 1–4) for SWL (P < 0.001). The complication rate was 10% and 7.5%, respectively (P = 0.692). The cost of SWL was significantly lower (P < 0.001). On multivariate analysis, a single stone was an independent predictor for stone clearance after two sessions of SWL (odds ratio: 7.26, 95% confidence interval: 1.13–46.62, P = 0.037). Conclusions: PCNL for the dense, and moderate-sized renal stone provides higher initial success and lower re-treatment rates compared with SWL with comparable outcome after 3 months of therapy. However, SWL is an alternative, especially for a single stone.

Objective To present our experience with concealed epispadias and to estimate its actual share in the isolated male epispadias cases and its effect on the surgical outcome. Materials and Methods Consecutive patients with isolated male epispadias treated in our center between 2008 and 2015 were classified into concealed and classic epispadias. The 2 groups were compared regarding age at presentation, meatal location, incontinence, dorsal curvature, success rate, and complications. Results Out of 51 patients with isolated male epispadias, 11 (21.6%) were concealed: 7 balanic and 4 penile shaft epispadias. Concealed epispadias cases were found to have significantly delayed age at presentation, more distal meatal location, and less incontinence rate than classic epispadias cases. None of the surgical outcome parameters showed significant difference between the 2 groups. Conclusion Concealed epispadias represents about one-fifth of isolated male epispadias cases. Impediment and delay of diagnosis are its main clinical impacts, with insignificant effect on the surgical outcome.

AIM We studied the functional polymorphisms of intercellular adhesion molecule-1 (ICAM-1) and toll-like receptor-4 (TLR-4) genes and risk of acute pyelonephritis (APN) in children attending Assiut University Children's Hospitals, Egypt, from 2011 to 2015. METHODS Urinary tract infections (UTIs) were diagnosed in 380 children: 98 had APN and 282 had lower UTIs. Four single-nucleotide polymorphisms in ICAM-1 and TLR-4 genes were genotyped in all subjects: ICAM-1 rs1799969 Gly241Arg, ICAM-1 rs5498 Glu469Lys, TLR-4 rs4896791 Thr399Ile and TLR-4 rs4896790 Asp299Gly. RESULTS Patients with APN were significantly more likely to have AA genotype of the ICAM-1 rs5498 (1462 A/G) polymorphism (p = 0.04) than children with lower UTIs and the TLR-4 Asp299Gly GG genotype (p = 0.002) and G allele (p = 0.006) than healthy controls. The association with the ICAM-1 Glu469Lys (1462A/G) was less evident. The GG genotype was associated with a modest relative risk of 1.4 (p = 0.1) of developing APN, but was not an independent odds ratio, at 1.2 (p = 0.48). CONCLUSION Functional variants in ICAM-1 and TLR-4 genes were increasingly common in children with febrile UTIs with renal parenchymal involvement, but the ICAM-1 Glu469Lys (1462A/G) association was less evident. TLR4 Asp299Gly might independently increase renal parenchymal infection rather than renal scarring.

Background mTOR signaling pathway is commonly activated in cancer. PTEN, a tumor suppressor gene, is a potent inhibitor of this pathway. To date the expression pattern of mTOR and PTEN in schistosomal bladder squamous cell carcinoma and urothelial carcinoma was not investigated. Also, whether alterations of these proteins are associated with pathological parameters was not established. Hypothesis We hypothesize that “expression of mTOR and/or PTEN will be altered in schistosomal-related urothelial and squamous cell carcinomas”. Patients and methods To test our hypothesis we examined the expression pattern of mTOR and PTEN in normal and hyperplastic urothelium, squamous metaplasia, schistosomal urothelial carcinomas (70 cases) and squamous cell carcinomas (47 cases) using immunohistochemical methods. Results mTOR protein expression was absent in the normal, hyperplastic urothelium and metaplastic squamous epithelium. mTOR was over-expressed in muscle invasive urothelial and high grade squamous cell carcinomas. In contrast, PTEN protein expression was seen in the normal and hyperplastic urothelium. The expression was reduced (metaplastic squamous epithelium) or lost in muscle invasive urothelial and high grade squamous carcinomas. Alterations of these proteins were associated with some clinicopathological features. mTOR expression was negatively correlated with PTEN expression in urothelial carcinoma only. Conclusions We report, for the first time, altered expression of mTOR and PTEN proteins in schistosomal urothelial and squamous cell carcinomas. Alterations of these proteins may contribute to the progression and aggressive behavior of schistosomal bladder carcinoma. Targeting mTOR, may be a promising therapeutic strategy in these tumors.

We assessed the effect of tamsulosin as an adjunctive therapy after shock wave lithotripsy for pediatric single renal pelvic stones.A total of 120 children with a unilateral single renal pelvic stone were included in a prospective randomized, controlled study. All children were randomized to 2 equal groups. Group 1 received tamsulosin (0.01 mg/kg once daily) as adjunctive therapy after shock wave lithotripsy in addition to paracetamol while group 2 received paracetamol only. Stone clearance was defined as no renal stone fragments or fragments less than 3 mm and no pelvicalyceal system dilatation.Our study included 69 boys and 51 girls with a median age of 3.5 years and a median stone size of 1.2 cm. There was no statistically significant difference between groups 1 and 2 in stone or patient criteria. Of the children 99 (82.5%) achieved stone clearance after the first session, including 50 in group 1 and 49 in group 2. All children in each group were cleared of stones after the second session. The overall complication rate was 14.2%. There was no statistically significant difference between single session stone clearance rates (p = 0.81) and complications rates (p = 0.432) in either group. On multivariate analysis using logistic regression smaller stone size (p = 0.016) and radiopaque stones (p = 0.019) were the only predictors of stone clearance at a single shock wave lithotripsy session. Tamsulosin therapy did not affect stone clearance (p = 0.649).Tamsulosin does not seem to improve renal stone clearance. Smaller and radiopaque renal stones have more chance of clearance after shock wave lithotripsy for pediatric single renal pelvic stones.

Introduction Obstructive anuria can be managed by primary ureteroscopy (URS) or deferred URS after initial ureteral stenting. We want to compare the primary URS and deferred URS in the management of calculus anuria regarding the feasibility and clinical outcome. Material and methods Between January 2012 and December 2014, 150 patients with anuria due to ureteral calculi were prospectively randomized according to the timing of ureteroscopic intervention into two groups; deferred URS group (69 patients who were treated initially by ureteral stenting) and primary URS group (81 patients who were treated by emergency URS). Follow-up was at least 6 months postoperatively. Results Complete stone clearance was 87 % and 75.3% for deferred and primary URS groups, respectively (p = 0.097). Renal function normalized in 94.2% of deferred URS vs. 97.5% of primary URS (p = 0.414). Deferred URS group had a 2.9 % overall complication rate in comparison to 9.9 % for the primary URS group (p = 0.109). Ureteral perforation/pyelonephritis was noted in 6.2% of the primary URS group only (p = 0.043). The median number of maneuvers required until stone clearance was one (range 1–5) for primary URS vs. two (range 2–3) for deferred URS (p

Introduction: Possible approaches for postoperative analgesia after pediatric inguinoscrotal surgery are caudal block by bupivacaine/ketamine (BK) and bupivacaine/magnesium sulfate (BM). Aim: The purpose of the following study is to compare the analgesic efficacy and safety of ketamine and magnesium sulfate in combination with bupivacaine for caudal blockade in pediatric patients after inguinoscrotal operations. Materials and Methods: Patients randomly received one of the two solutions for caudal epidural injection after induction of general anesthesia. Group-BK: Were given a mixture of 0.25% bupivacaine and 0.5 mg/kg of ketamine. Group-BM: Were given a mixture of 0.25% bupivacaine and 50 mg magnesium sulfate. Postoperatively, a blinded post-anesthesia care unit nurse assessed the quality of analgesia with a visual pain analog scale (VPAS). Significant pain is defined as one that has a VAPS of ≥3. Results: Forty American Society of Anesthesiologists I-II children (20 in each group) completed the study. The two groups were comparable regards age, sex, body mass index, anesthesia and surgery durations, recovery time and sevoflurane concentration. The mean duration of caudal analgesia ± standard deviation was 462 ± 17.2 min versus 398.05 ± 12.9 min for BK and BM groups, receptively (P < 0.001). Supplemental rectal paracetamol within 12 h postoperatively were 15% for BK group versus 25% for BM (P = 0.05). Four patients in BK group only experienced postoperative nausea and vomiting (P = 0.053). Conclusion: Caudal administration of BK is efficient and safe for pediatric inguinoscrotal operations with longer postoperative analgesia than BM sulfate.

The aim of this study was to report the functional outcome after endoscopic management of neobladder complications.Out of 197 patients who underwent radical cystectomy and orthotopic ileal neobladder reconstruction between 2007 and 2013, 30 patients with delayed postoperative complications were enrolled in this study. Complications were in the form of: eight patients with outflow obstruction, 12 with ureteroenteric stricture, nine with neobladder calculi and one with an isolated recurrent papillary tumor inside the neobladder. Patients were followed up regularly to assess the outcomes of endoscopic treatment.The mean maximum flow rate and postvoiding residual urine after endoscopic treatment of outflow obstruction were 18.2 ± 3.9 ml/s and 28.7 ± 11 ml, respectively. Ten patients with ureteroenteric stricture showed resolution of hydronephrosis after antegrade dilatation and JJ-stent fixation, with two patients requiring open surgery owing to impassable strictures. Complete clearance of neobladder calculi occurred after endoscopic neocystolithotripsy, with two patients requiring two sessions owing to large calculi. Transurethral resection of the neobladder for isolated tumor recurrence was performed in one patient over two sessions, followed by adjuvant chemoirradiation.Endourological management of orthotopic neobladder problems is the safest choice. It avoids the difficulties and complications of open surgery and has durable results.

Objective To report our experience with hemospermia and its relation to hyperuricemia. Patients and Methods Between July 2005 and July 2012, 143 patients with hemospermia presented to the outpatient clinic in our hospital. History, examination, workup, treatment outcomes, and long-term follow-up were reported in a prospective database. Patients were followed up monthly by semen examination till disappearance of hemospermia, then every 3 months for 1 year. We identified 43 patients, who had 4-12 hemospermia attacks for 2-10 months before presentation with no identifiable cause for hemospermia. Of them, 22 had hyperuricemia. The association between hemospermia and hyperuricemia was examined by comparing such 22 hyperuricemic hemospermic patients with the other 21 idiopathic hemospermic patients. Results The commonest 5 findings identified as possible causes of hemospermia were bilharziasis (21.6%), hyperuricemia (15.4%), idiopathic (14.7%), tuberculosis (8.4%), and chronic prostatitis (8.4%). Hyperuricemic hemospermic patients were significantly of younger age (median of 31.5 vs 45 years), complaining of more painful ejaculation (68.2% vs 9.5%), and had higher serum uric acid (median, 9.3 vs 4.5 mg/dL) compared with those of idiopathic hemospermia. Hemospermia disappeared completely in all patients of the hyperuricemia group vs only 25% of the idiopathic group (P

To compare the safety, efficacy, and complications of percutaneous nephrolithotomy (PCNL) in the oblique supine lithotomy position vs the prone position in a randomized comparative study.The study included 101 and 102 patients in the oblique supine lithotomy position and prone position, respectively. Inclusion criteria were renal and upper ureteral stones. Exclusion criteria were uncorrectable bleeding disorders, active urinary tract infection, and pregnancy.Both the groups were comparable regarding the male/female ratio, stone size, and site. No significant differences were found in terms of the stone-free rate, blood transfusion rate, and complication rates. Significant differences were reported in mean hemoglobin loss (-1.03 and -2.18 g/dL), mean operative time (86.16 and 111.7 minutes), and mean hospital stay (49.88 and 81.2 hours) in the supine and prone positions, respectively, and anesthesiological parameters (the mean blood pressure decreased by 2 and 14.06 mm Hg, the mean heart rate changed by -0.82 and +13.28 beat/minute, and the peak air way pressure changed by +1.08 cm H2O and +7.56 cm H2O in the supine and prone positions, respectively).PCNL in both positions was equally successful with no significant differences in complications. PCNL in the oblique supine lithotomy position was superior to PCNL in the prone position regarding operative time, hospital stay, and effects on respiratory and cardiovascular status, making it more comfortable for patients and anesthesiologists. Morbidly obese patients, patients with cardiologic disorders, and patients with pulmonary obstructive airway disease need further studies to show if they would benefit from these differences. Additionally, it is more comfortable for the surgeon with little challenges added in the initial puncture.

Introduction: Penile fracture is the most common presentation of acute penis. Rupture of the superficial dorsal penile vein (s) may mimic penile fractures with similar clinical presentation but with intact corporeal bodies. Our aim of the study is to highlight superficial dorsal penile vein (s) injury as true emergency with better prognosis. Subjects and Methods: Sixty-eight patients with suspected penile fractures presented to our hospital between June 2007 and January 2013. Out of these, 11 patients showed intact tunica albuginea on exploration with injured dorsal penile vein (s) identified. Records of such 11 cases were reviewed regarding age, etiology, symptoms, physical signs, findings of surgical exploration and post-operative erectile function. Results: All 11 patients were injured during sexual intercourse and presented with penile swelling and ecchymosis and gradual detumescence. Mild penile pain was encountered in 5 cases and the "snap" sound was noted in 2 cases. Examination revealed no localized tenderness, or tunical defect. All the patients regained penile potency without deformity after surgical ligation of the severed vessels. One patient developed penile hypoesthesia. Conclusion: Although the classic "snap" sound and immediate detumescence are usually lacking in the symptomology of dorsal penile vein rupture, its clinical presentation can be indistinguishable from true penile fracture. Surgical exploration is still required to avoid missing tunical tear with possible future complications. The long-term outcome and prognosis are excellent.

INTRODUCTION AND OBJECTIVES: The role of ureteroscopy (URS) in management of acute renal failure caused by ureteral calculi could be primary or deferred after ureteral stenting. In this study we evaluate both approaches as regards the feasibility and clinical outcome. METHODS: Between January 2012 and December 2014, 150 patients with anuria / oliguria with a significant increase in serum creatinine due to ureteral stones (114 men and 36 women); including 72 solitary functioning kidney. Patients were prospectively randomized according to timing of ureteroscopic intervention into two groups; deferred URS group (69 patients who were treated initially by ureteral stenting then URS in another session) and primary URS group (81 patients who were treated by emergency URS). Follow up was at least 6 months postoperatively. RESULTS: Stone distribution was: 56% lower ureteral, 32% mid ureteral, and 12% upper ureteral. Both groups were comparable at presentation. Complete ureteroscopic stone clearance was 87 % and 75.3% for deferred and primary URS groups respectively (p1⁄40.097). Normal renal function returned in 94.2% of deferred URS vs. 97.5% of primary URS (p1⁄40.414). Deferred URS group had 2.9 % overall complication rate in comparison to 9.9 % for primary URS group (p1⁄40.109). Ureteral perforation/pyelonephritis was noted in 6.2% of primary URS group only (p1⁄40.043). Median number of maneuvers required till stone clearance was one (range 1-5) for primary URS vs. two (range 2-3) for deferred URS (p < 0.001). The cost of primary URS was significantly lower (p < 0.001). On multivariate analysis, lower ureteral calculi (OR 13.03, 95% CI 4.0741.7, p

Adenine phosphoribosyltransferase (APRT) deficiency is a rare under-recognized disorder of adenine metabolism. It has a familial tendency and is inherited as autosomal recessive. APRT deficiency eventually leads to increased production of 2,8-dihydroxyadenine (DHA) which has a low solubility at normal range of urine PH resulting in the formation of DHA crystals and recurrent kidney stones as the main presenting feature [1]. Deposition of Dihydroxyadenine crystals in the renal tubules can lead to permanent renal damage with significant morbidity.

Summary Background Acute pyelonephritis is associated with renal scarring in up to 30% of patients. Renal scarring may cause significant long-term morbidity. The pathogenesis of acute pyelonephritis remains unclear, although it involves interaction among uroepithelium, the immune system cells, and the locally produced cytokines. That some UTI-prone children develop acute pyelonephritis, and eventually renal parenchymal scarring, suggests a genetic role. Interleukin-6, interleukin-8, chemokine receptor-1 (CXCR1), and tumor necrosis factor-alpha (TNFα), the key regulators of the host immune responses, are proteins whose secretion is controlled by genes. We postulated that functional polymorphic variants of their genes might have a role in APN susceptibility. Objectives We sought to investigate a possible association of the common functional polymorphisms in genes encoding IL-6, IL-8, CXCR1, and TNFα with the risk of APN in children. Methods Urine culture was used to diagnose 300 children with UTI, of mean age of 51.31 ± 37.4 months (2–180 months). 99Tc-DMSA scans diagnosed 86 children with APN. Follow-up scans identified new renal scars in 18 children. Six functional single-nucleotide polymorphisms (SNPs) in genes encoding IL-6, IL-8, CXCR1, and TNFα were genotyped in all subjects (IL-6 rs1800795 (−174G/C), IL-6 rs1800796 (−572G/C), IL-8 rs2227306 (781C/T), IL8 rs4073 (−251A/T), CXCR1 rs2234671 (2607G/C), and TNFα rs1800629 (−308G/A)). Results TT genotype of IL-8 −251A/T polymorphism was significantly higher in APN patients (26.7%) than those with lower UTI (11.7%, p = 0.01) and control individuals (12.2%, p = 0.002). T allele was significantly more common in APN than in lower UTI (p = 0.025) and was significantly more common in APN (46%) than in the controls (p = 0.001). Similarly, TT genotype of IL-8 781C/T polymorphism was significantly more common in APN patients (31.4%) than those with lower UTI (17.3%, p = 0.003) and the controls (14.3%, p = 0.001). T allele was significantly more common in APN (55%) than lower UTI (40%, p = 0.005) and controls (37%, p = 0.001). However, IL-8 −251A/T and +781C/T SNPs did not qualify as an independent risk for parenchymal infection (OR 1.9, 95% CI 0.68–2.6, p = 0.13 and OR 2.3, 95% CI 0.89–3.7, p = 0.091, respectively). Lower UTI did not differ from the controls. The frequency of the genotypes and alleles of IL-6, CXCR1, and TNFα SNPs did not differ significantly among the different groups of the study. Conclusion IL-8 −251A/T and +781C/T SNPs are associated with susceptibility to renal parenchymal infection in children and could be implicated in APN risk. However, none of these variants could clearly and independently predict this risk.

Objective Peeping testis is an inconsistently palpable/seen undescended testis that migrates back and forth at the internal inguinal ring. Both open and laparoscopic orchiopexy are effective forms of management. The present study aimed to evaluate the efficacy and safety of both approaches. Patients and methods Between September 2007 and January 2012, 46 peeping inguinal testes were randomly treated with either open (25 cases) or laparoscopic (21 cases) orchiopexy procedures. Spermatic vessels were preserved for all cases. Operative details, postoperative morbidity and final testicular site and size were recorded. Results The median age of the children was 2.5 years (range 0.5–12.0). The follow-up period ranged from 1.0 to 5.5 years. Of these testes, 20 in the open surgery group and 19 in the laparoscopic group maintained correct intrascrotal position (P = 0.428). Re-do orchiopexy was indicated for two cases in the surgical group (P = 0.493). No cases of testicular atrophy or hernia were encountered. Conclusion Open and laparoscopic orchiopexy procedures for peeping testes are fairly comparable. However, laparoscopy is relatively more effective, as two re-do orchiopexies were required in the open surgical group.

Objective To evaluate the outcome of primary versus secondary ureteroscopy for pediatric ureteral stones. Patients and methods A retrospective chart review study that included 66 children aged less than 12 years, who were subdivided into two groups: Group A, which included 42 children who had undergone primary ureteroscopy without pre-stenting; and Group B, which included 24 children who had undergone ureteroscopy after ureteric stenting. Kidneys, ureters and bladder radiographs were done on the first postoperative day to assess the degree of stone clearance and stent position. Results Age, gender, stone location and stone size were not significantly different between both groups. In Group A, 31 (73.8%) children required ureteric dilation, 13 (31%) had a tight ureter that failed to respond to dilation, 25 (59.5%) displayed complete stone clearance, and of these, 13 (52%) needed postoperative stenting. One child experienced ureteric injury during stone disintegration and was stented for two weeks. Children in Group B experienced a 95.8% complete stone clearance rate, with no ureteric injury reported; postoperative stenting was performed in three (12.5%) children.. Conclusion Secondary ureteroscopy is preferable over primary ureteroscopy in pediatric populations because of a significantly lower need for ureteric dilation, shorter procedure time and better stone clearance rate..

We prospectively evaluated the efficacy of dissolution therapy and standard shock wave lithotripsy as a noninvasive modality for radiolucent renal stones in children.A total of 87 children with radiolucent renal calculi were included in study. Median age was 2.5 years (range 0.5 to 13). Computerized tomography was done to confirm a stone density of less than 500 HU. Median stone length was 12 mm (range 7 to 24). Patients were randomly divided into 2 groups. The medical group of 48 patients received potassium sodium hydrogen citrate at a dose of 1 mEq/kg per day for 1 to 3 months. The shock wave lithotripsy group of 39 patients were treated with a Lithotripter S (Dornier Medtech, Kennesaw, Georgia) while under general anesthesia. Complications in each group were recorded. Patients were considered stone free when imaging within 3 months showed no evidence of stones.The stone-free rate was 72.9% for dissolution therapy vs 82.1% after a single session of shock wave lithotripsy (p = 0.314). One patient per group experienced a pyelonephritis episode during followup (p = 0.698). Three of the 13 patients in whom medical regimens failed were noncompliant and 5 ingested the medication sporadically.Medical dissolution therapy is a well tolerated, effective treatment for radiolucent renal stones in children. It eliminates the need for shock wave lithotripsy in up to 73% of cases.

INTRODUCTION AND OBJECTIVES: Tamsulosin is proved to promote spontaneous passage of distal ureteral and juxtavesical calculi. Our aim is to prospectively evaluate the role of neoadjuvant tamsulosin during ureteroscopic treatment of lower ureteric stone. METHODS: One hundred thirty-eight adult patients with lower ureteral calculi underwent ureteroscopic management. Stone length varied from 7 to 12 mm. Before treatment, the patients were randomly divided into 2 groups; the study group (n 70) received tamsulosin 0.4 mg once daily for 3-6 weeks and the control group (n 68) received standard analgesia only. Preoperative medications were blinded to the endourologists. The primary endpoint was the need for intraoperative ureteral dilatation. Postoperative complications were recorded for both groups. RESULTS: Of the 120 patients available for follow up, the need for intraoperative ureteral dilatation was 30% in the study group, compared with 86.7% in the control group (p 0.001). Of the control group, 5% had postoperative pyelonephritis episodes, in contrast to only 1.7% of the study group (p 0.619). CONCLUSIONS: Preopertive tamsulosin simplifies ureteroscopic management of lower ureteric calculi. To the best of our knowledge, this is the first study to show the value of neoadjuvant tamsulosin in ureteroscopic management of distal ureteric calculi.

Objectives: We'd like to present our experience in treating long (>5 cm) anterior urethral stricture by penile skin flap as dorsal on-lay in one-stage procedure. Patient and Methods: Between January 1998 and December 2010, 18 patients (aged from 28-65 years) presented with long urethral stricture, 5.6-13.2 cm, (penile in 6, bulbar in 2, and combined in 10 cases), those were repaired utilizing long penile skin flaps placed as dorsal on-lay flap in one-stage (Orandi flap 6 cm in 6 cases, circular flaps 7-10 cm in 8, and spiral flaps 10-15 cm in 4). Uroflowmetry and RUG were done following catheter removal and at 6 and 12 months. Results: The urethral patency was achieved in 77% of patients. The complications were fistula in 1 patient (5.5%), re-stricture occurred in 3 patients (16.6%) that required visual internal urethrotomy (VIU), and 2 patients (11%) showed curvature on erection that did not interfere with sexual intercourse. Diverticulum (penile urethra) was seen in 1 patient (5.5%) containing stones and was excised surgically. There was penile skin loss in 3 patients (16.6%). All patients completed at least one year follow-up period. Conclusion: Free penile skin flaps offer good results (functional and cosmetic) in long anterior urethral stricture. Meticulously fashioned longitudinal, circular or spiral penile skin flaps could bridge urethral defects up to 15 cm long.

Background Pathogenesis of renal parenchymal scarring (RPS) after acute pyelonephritis (APN) is unclear. The risk of RPS varies markedly among individuals, suggesting a genetic role. Objective To investigate a possible role of common polymorphisms in renin angiotensin system genes in APN-associated RPS in children. Patients and methods This study included 104 APN children and 300 controls. APN was diagnosed by urine culture and typical findings on 99Tc-DMSA scans. Voiding cystourethrogram tested the presence of vesicoureteral reflux (VUR). Follow-up DMSA scans were performed 4–6 months later to identify new RPS. Angiotensin converting enzyme gene I/D, angiotensin II receptor type-1 A1166C and angiotensinogen M235T polymorphisms were genotyped. Results New RPS developed in 44.2% (46/104) of children with APN. VUR was diagnosed in 35.6% (37/104) of APN cases. RPS developed in 73% of cases of VUR. The D allele of ACE gene I/D polymorphism was significantly more common in APN cases with RPS (73.91%) than non-RPS (58.6%) and controls (54.5%) (p = 0.021, p = 0.002, respectively). The AGTR-1 A1166C A allele was significantly more common in VUR than the non-reflux children (91.9% versus 76.1%; p = 0.005). VUR, in contrast to the D allele (OR 6.1, 95% CI 0.878–19.7; p = 0.05), was an independent risk factor for RPS. Discussion ACE gene D allele is associated with a twofold increase in RPS risk, which could be a result of a functional effect to increase tissue levels and activity of ACE during APN. However, D allele failed to qualify as an independent risk and its RPS association could be dependent on other co-factors, such as TGFβ1 activation, or the D-allele might link with recently discovered functional polymorphisms at the 5′ end of the ACE gene. Although VUR is an independent risk for RPS, it is not clear whether this is due to exposure of the kidneys to infected urine, or VUR-associated dysplasia. In contrast with published literature, we noted higher rates of RPS and high-grade VUR, suggesting a more aggressive VUR course or local unawareness of APN. Our study has its limitations; the small number of VUR children, and the clinical and ethical difficulties of testing VCUG and DMSA in controls. Conclusions ACE gene D allele is associated with, but cannot independently predict, RPS in children. VUR is an independent risk for post-pyelonephritic scarring. AGTR-1 1166A/C polymorphism is associated with occurrence, but not progression, of VUR. Figure options Download full-size image Download high-quality image (174 K) Download as PowerPoint slide

Summary Introduction Secondary vesicoureteric reflux (VUR) is a common problem associated with non-compliant bladders. Management of this disorder is debatable in literature. Many authors reported high resolution rate of VUR with augmentation cystoplasty (ACP) alone. Others showed significant residual VUR after ACP and recommend ureteric re-implantation (UR) at time of augmentation. Objective Studying efficacy of endoscopic correction of persistent high-grade VUR (ECVUR) post successful ACP. Design Patients with non-compliant bladders and high-grade VUR are enrolled in the program of our institute, where they are initially managed conservatively. Those not responding are managed endoscopically using intravesical botulinum toxin A and ECVUR. Patients who are not candidates or failed this approach undergo ACP without UR. A total of 82 patients with non-compliant bladder underwent ACP between 2001 and 2011. Of those, 24 patients had high-grade VUR with 44 refluxing units (RU), 20 bilateral and 4 unilateral. The mean age at intervention was 7.62 years with a mean follow-up of 5.6 years. Patients with persistent high-grade VUR and recurrent breakthrough febrile UTI despite antibiotic prophylaxis following ACP were identified and enrolled in our prospective trial of interval ECVUR. Statistical analyses was performed to identify predictors of high-grade VUR resolution after ACP and ECVUR. A p value Results Of the 24 patients, 17 underwent ileocystoplasty and 7 underwent ureterocystoplasty. One of the patients that underwent ileocystoplasty found to have a blind ending RU that was excised. Of the 36 remaining RU, 21/36 (58.3%) showed complete resolution in the first follow-up cystogram, and 1 showed complete resolution after 1 year. Two patients, each with single RU, received repeat ACP because of poor compliance and/or inadequate bladder capacity post ureterocystoplasty and showed complete resolution of reflux post-operatively, which increased the resolution rate post ACP to 66.6% (24/36) (Table 2). Of the remaining 12 RU in 7 patients, 10 underwent trial of ECVUR. VUR resolved in 8 RU after the first trial and in another 2 after the second trial (Table 3). Parents of 1 patient with the remaining 2 RU preferred to continue with conservative management (Table 2). Discussion VUR in patients with non-compliant bladder is usually secondary to high detrusor pressure, low compliance and small capacity. Whereas some investigators showed high resolution rate of VUR post augmentation without UR, claiming that by successfully augmenting the bladder, compliance will increase, detrusor pressure will decrease, and as a result, VUR will spontaneously resolve. Others showed high incidence of persistent VUR (47–57%) and recommend UR at time of ACP. In our study, the incidence of spontaneous resolution was 66.6% (24/36). In cases where VUR persists, ECVUR was performed. With this approach, VUR resolution increased to 94% (34/36). This study is limited by the small number of patients, lack of randomization and lack of comparison group in which patients undergo ACP with UR. Conclusion ACP without UR with interval endoscopic management seems to be an effective and adequate treatment for high pressure, non-compliant bladder as well as high-grade VUR when conservative management fails.

Objectives: The objective of this study is to assess the dose-related effects of tramadol on a group of patients with premature ejaculation (PE). Subjects and Methods: During the period of months between June 2010 and July 2012, 180 PE patients presented to outpatient clinic of our hospital. Patients were randomized in a 1:1:1 fashion to receive different sequences of the three medications: placebo, 50 mg of tramadol and 100 mg of tramadol. Every patient received 10 doses of each medication for 2 months. Intra-vaginal ejaculatory latency time (IELT) was recorded in seconds initially and for each arm. Successful treatment of PE is defined if IELT exceeded 120 s. Side-effects of medications were reported. Results: Of patients enrolled, 125 (69.4%) continued the study. Patients′ age range was 20-55 years with PE complaint of 1 to 10 years duration. Mean IELT was 72 at presentation, 82 for placebo, 150 for tramadol 50 mg, and 272 for tramadol 100 mg (P < 0.001 for all comparisons). PE was successfully treated in only 2.4% of patients with placebo, in contrast to 53.6% and 85.6% with 50 and 100 mg tramadol, respectively (P < 0.001 for all comparisons). On multivariate logistic regression analysis, baseline IELT was the only predictor of successful treatment of PE with both tramadol 50 mg (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.03-1.07, P < 0.001) and tramadol 100 mg (OR: 1.07, 95% CI: 1.04-1.11, P < 0.001). Postmicturition dribble annoyed 12.8% of those who received 50 mg tramadol and 33.6% of those who received 100 mg tramadol (P < 0.001). Weak scanty ejaculation was the main complaint in 7.2% versus 21.6% of those using 50 and 100 mg tramadol, respectively (P = 0.002). Two patients discontinued tramadol 100 mg due to side-effects. Conclusion: Tramadol hydrochloride exhibits a significant dose-related efficacy and side-effects over placebo for treatment of PE.

Purpose: To present our experience in the management of symptomatic ureteral calculi during pregnancy. Materials and Methods: Twenty-three pregnant women, aged between 19 and 28 years presented to the obstetric and urology departments with renal colic (17 cases, 73.9%) and fever and renal pain (6 cases, 26.1%); suggesting ureteric stones. The diagnosis was established by ultrasonography (abdominal and transvaginal). Outpatient follow-up consisted of clinical assessment and abdominal ultrasonography. Follow-up by X-ray of the kidneys, ureter, and bladder (KUB), or intravenous urography (IVU) was done in the postpartum period. Results: Double J (DJ) stent was inserted in six women (26%) with persistent fever followed by extracorporeal shock wave lithotripsy (ESWL) one month post-partum. Ureteroscopic procedure and pneumatic lithotripsy were performed for 17 women (distal ureteric stone in 10, middle ureter in 5, and upper ureteric stone in 2). Stone-free rate was 100%. No urologic, anesthetic, or obstetric complications were encountered. Conclusions: Ureteroscopy, pneumatic lithotripsy, and DJ insertion could be a definitive and safe option for the treatment of obstructive ureteric stones during pregnancy.