Urology Journal

Purpose: To report the results of bilateral same-session ureteroscopy in patients with bilateral pathologies in urinary system.

Materials and Methods: From among nearly 3000 patients who had undergone diagnostic or therapeutic ureteroscopy in our center, 23 (13 females and 10 males) were treated with bilateral same-session ureteroscopy. Pathologies included bilateral ureteral stone in 19, hematuria of unknown etiology in 3, and bilateral obstructive uropathy in 1. Hospital and follow-up records of the patients were reviewed in this study.

Results: Of 19 patients with bilateral ureteral stone, 11 had anuria and increased serum creatinine. Ureteroscopy was successful in 9, and the stones were fragmented. Ureteroscopy insertion was not successful in 1, and in 1 another, upper ureteral stone was pushed into the Kidney. Six patients had normal urine output and normal serum creatinine. In 5 of them, ureteroscopy was done and the stones were fragmented, but due to ureteral stricture, ureteroscopy was impossible in 1. In 2 patients with oliguria and increased serum creatinine, bilateral ureteral stones were extracted successfully. Of 3 patients with hematuria of unknown origin, 2 had normal ureteroscopy, and 1 had a small non-opaque stone that was extracted successfully. In 1 patient with obstructive uropathy and the diagnosis of obstructive megaureter, bilateral ureteroscopy was done and bilateral ureteral stents were placed. Finally, from 23 patients, 21 had successful bilateral same-session ureteroscopy. Postoperative complications included pyrogenic infection in 2 and gross hematuria in 4, all of which were resolved with medical treatment.

Conclusion: Bilateral same-session ureteroscopy is an appropriate therapeutic and diagnostic option, with its own specific indications. It can reduce hospital stay, prevent multiple anesthesias, and alleviate the costs. We recommend this approach in patients with bilateral ureteral pathologies, provided that they are amenable to ureteroscopy.

Purpose: It is believed that extracorporeal shock wave lithotripsy (ESWL) may be less effective than other modalities for treating stones in complex calculi. In this study, we investigated the efficacy of ESWL for treatment of complex stones.

Materials and Methods: Between September 2002 and October 2003, 250 complex cases of urolithiasis, including ureteral stones, staghorn stones, and stones in children, high risk patients, single kidneys, steinstrasse, and horseshoe kidneys were selected to be treated with Siemens Lithostar (Siemens AG, Munich, Germany) on an outpatient basis. Data were collected prospectively and the results of ESWL monotherapy on these complex patients were reviewed.

Results: The overall success rate was 91.2% for children and 77.7% for patients with single kidneys. Also, ESWL was efficient in the treatment of ureteral stones at the rate of 70.5% to 83.3%, depending on the location of the stone in the ureter and its size. The success rate of ESWL for patients with horseshoe kidneys, staghorn stones, and steinstrasse were marginal (66.6%, 66.0% and 33.3%, respectively). All of the cases were managed on outpatient basis and hospital admission was not required.

Conclusion: Outpatient ESWL can be safely performed as a minimally invasive treatment after proper patient selection, even for complex patients. Its successfulness in children, patients with solitary kidney, and for almost all of ureteral stones is quite acceptable. However, its usage in patients with horseshoe kidneys or steinstrasse, and those with staghorn stones is questionable and should be done only in carefully selected cases. Thus, with appropriate patient selection, significant improvements in stone-free rates may also be achieved in these cases.

Purpose: Prevalence of ureter and kidney duplication is roughly 1 per 125 people, and is associated with vesicoureteral reflux to lower pole in about 45% of cases. From antireflux surgical principles viewpoint, standard antireflux surgeries can be performed in these kidneys without releasing ureters from each other. We studied the results of Gil-Vernet antireflux surgery in 12 patients with duplicated collecting system and lower pole reflux.

Materials and Methods: Between 1996 and 2000, 12 patients with unilateral duplicated system underwent Gil-Vernet antireflux surgery. There were 8 (67%) females and 4 (33%) males with a median age of 5.6 years. Of the patients, 50% had unilateral lower pole reflux in duplex system and 50% had bilateral reflux.

Results: Twelve patients with lower pole reflux in duplicated system, and overall, 18 refluxing renal units were treated, using Gil-Vernet antireflux surgery. In 11 (92%) patients, upper pole orifices were non-refluxing and without ureterocele. One (8%) patient had upper pole ureterocele that was treated by a small medial incision in the same session. Median hospital stay was 4 days, and median follow-up was 10 months, in 10 patients who were followed. Of patients, 80% and of refluxing units, 94% improved. Overall, success rate was 88%.

Conclusion: Gil-Vernet antireflux surgery is a simple technique, associating with minimum ureteral manipulation for releasing them. Accordingly, we recommend Gil-Vernet antireflux surgery as the first line surgical modality for duplicated ureters with lower pole reflux, without upper pole ureterocele.

Purpose:  Acute urinary retention in children is a relatively rare entity. There are a variety of causes that are poorly defined in the literature. We review our cases of acute urinary retention in children at three major pediatrics centers in Iran.

Materials and Methods:  Between 1996 and 2003, children (up to 14 years old) who had been referred due to acute urinary retention were examined. Urinary retention was defined as inability to empty the bladder volitionally for more than 12 hours with a urine volume greater than expected for age or a palpably distended bladder. All data from the patients’ past medical history, physical examination, and laboratory and radiographic assessments were collected.  Also, cystourethroscopy and urodynamic procedures had been carried out according to patient’s conditions. Patients with secondary urinary retention, including those with surgical history, immobility or chronic neurological disorders, mental retardation, and drugs or narcotics consumption were excluded from study.

Results:  There were 86 patients meeting the inclusion criteria, consisting of 58 males with a median age of 4 years (range 1 month to 14 years) and 58 females with a median age of 4 years (range 4 month to 14 years). Etiologies were lower urinary tract stone in 27.9%, neurological disorders in 10.4%, trauma in 10.4%, local inflammatory causes in 9.1%, urinary tract infection in 7.4%, ureterocele in 7.4%, benign obstructing lesions in 5.8%, iatrogenic in 5.8%, constipation in 4.6%, imperforated hymen in 3.5%, and large prostate utricle, urethral foreign body, and rhabdomyosarcoma each in 1 case (1.1%).

Conclusion:  The most common cause of acute urinary retention was lower urinary tract stone in our pediatric cases. Ureterocele and stone were the main findings in girls and boys, respectively, and urinary retention in boys was twice as prevalent as that in girls.

Purpose: To compare the outcomes of Mathieu and Snodgrass techniques in the repair of anterior distal shaft hypospadias.

Materials and Methods: From 2001 to 2003, 33 patients with the mean age of 7.06 ± 3.44 (range 2 to 12) years suffering from anterior distal shaft hypospadias, were assessed. Inclusion criteria were anterior distal shaft hypospadias, and exclusion criteria were association with chordee, circumcision, and surgical repair history. Fifteen patients underwent surgical repair using Snodgrass technique and 18 patients, using Mathieu technique. Surgeries were performed by one single surgeon, acquainted with both techniques. Patients were examined 1 week, 1 month, and 6 months after discharge. Data including duration of the surgery, stenting time, duration of hospitalization, and any kind of complications such as break down, meatal stenosis, and fistula formation were collected. Also, success rate was calculated for every single patient and accordingly, the two groups were compared.

Results: Mean operative time, stenting duration, and hospital stay were 94 ± 26.06 minutes, 5.06 ± 1.31 days, and 3.93 ± 1.86 days in Mathieu group and 106.11 ± 23.04 minutes, 5.11 ± 1.56 days, and 4.55 ± 1.29 days in Snodgrass group, respectively (P > 0.05). The rate of break down, meatal stenosis, and fistula formation were 0%, 0%, and 5.55% in Mathieu group and 0%, 6.66%, and 13.32% in Snodgrass group, respectively (P > 0.05). Success rate was 80.02% in Snodgrass group and 94.45% in Mathieu group (P > 0.05).

Conclusion: In spite of some reports about preference for Snodgrass technique, we concluded that these techniques are as acceptable and as effective as each other for hypospodias repairing, regardless of cosmetic outcomes; however, we need further studies and larger sample sizes to determine which is the superior technique.

Purpose: Asymptomatic bacteriuria is a very common complication after kidney transplantation and the need for antibiotic therapy is controversial. The aim of this study was to evaluate the effect of antibiotic therapy on the clinical course of asymptomatic bacteriuria in renal transplant recipients.

Materials and Methods: In the present study, 88 kidney transplant recipients with asymptomatic bacteriuria were divided into two groups of cases and controls. The patients had been selected from among those with at least 1 year follow-up. In the case group, asymptomatic bacteriuric episodes were treated with antibiotics, and in control group, they were followed without antibiotic therapy. The follow-up period was 9 to 12 months. Bacteriuric episodes, symptomatic urinary tract infection (UTI) episodes, and changes in plasma creatinine level were recorded and compared between the two groups.

Results: The rate of bacteriuric episodes and symptomatic UTIs were not significantly different between the two groups (P > 0.05). In addition, level of plasma creatinine did not increase significantly in neither of the groups during the study (P > 0.05).

Conclusion: It seems that treatment of asymptomatic bacteriuria in kidney recipients does not decrease the rate of UTI episodes afterwards. Asymptomatic bacteriuria does not affect renal function in short term. Thus, we can abandon antibiotic therapy, subject to careful follow-up.

Purpose: Cigarette smoking contributes to a number of health-related problems, but its impact on allograft survival in kidney recipients is not clear. This study was performed to evaluate the relationship between smoking and graft survival.

Materials and Methods: A total of 199 adult kidney recipients were enrolled in this study. All transplantations had been done in our center and all grafts had been taken from living donors. The patients were asked about their cigarette smoking behavior before transplantation and assessed for diabetes mellitus, hypertension, and hyperlipidemia, pre- and post-operatively.

Results: Of 199 recipients, 142 (71.4%) were male and 57 (28.6%) were female. They were 40.45 (range 18 to 65) years old. Forty-one recipients (20.6%) were smokers before kidney transplantation that 87.7% of them continued smoking after transplantation. Mean pack-year smoking was 13.2. Of the patients, 32.7% and 33.7% had hypertension, 19.3% and 23.1% had diabetes mellitus, and 46.2% and 42.2% had hyperlipidemia, before and after transplantation, respectively, showing no significant difference. Pretransplant smoking was significantly associated with reduced overall graft survival (P = 0.01), but no correlation between smoking cessation after transplantation with survival graft was found.

Conclusion: Cigarette smoking before kidney transplantation contributes significantly to allograft loss. However, smoking is not associated with increase in rejection episodes. Although we could not prove it, smoking cessation after renal transplantation may have beneficial effects on graft survival. These effects should be emphasized for patients with end-stage renal disease who are candidates for kidney transplantation.

Purpose: To evaluate the relationship between serum lipids including cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglyceride and erectile dysfunction (ED).

Materials and Methods: From January 2000 to June 2003, 100 patients with organic ED, who were referred to our center, were selected and their lipid profile (Cholesterol, Triglyceride, HDL, LDL) were assessed. The results were compared with those in 100 healthy individuals.

Results: Mean age of men in the study and control groups were 43.72 ± 9.76 and 43.59 ± 10.51 years, respectively. Mean plasma cholesterol and LDL levels in individuals suffering from erectile dysfunction were significantly higher than controls (P = 0.04 and P = 0.02, respectively). However, no difference in the mean plasma triglyceride and HDL levels was seen. Odds Ratios for high plasma cholesterol level (> 240 mg/dl) and high plasma LDL level (> 160 mg/dl) were 1.74 and 1.97, respectively (r² = 0.04 and r² = 0.04). Using linear regression analysis, the regression coefficient for cholesterol and LDL versus the International Index of Erectile Dysfunction Questionnaire (IIEF) score were -0.036 and -0.035, respectively (95% confidence interval: 0.98 - 2.5 for cholesterol and 1.13 - 2.81 for LDL).

Conclusion: The impact of total cholesterol and particularly LDL on men’s erectile function underlines the role of hyperlipidemia treatment in prevention of ED and emerges a holistic management in ED patients.

Purpose: To evaluate the reported outcomes of multimodality therapy with organ preservation in invasive bladder cancer and assess it as an alternative for radical cystectomy in selected cases.

Materials and Methods: All the articles on multimodality therapy with organ preservation in invasive bladder cancer, published from 1974 to 2004, were reviewed and the results were compared with the outcome of radical cystectomy in cases with invasive bladder cancer.

Results: Multimodality therapy is transurethral resection of the bladder tumor (TURBT) combined with chemoradiation therapy. It yields a 36% to 48% 5-year survival rate, when the bladder is preserved, and an overall rate of 48% to 63%. This method takes a long time for treatment and is accompanied by significant morbidity and mortality. Cystectomy will be required in 34% to 45% of the patients, during the treatment course, and in 28%, repeat TURBT will be performed due to recurrence of superficial tumors.