Ahmed Aly Hussein Aly

OBJECTIVE: To investigate the role of cognitive and mental workload assessment may play a critical role in defining successful mentorship MATERIALS AND METHODS: "Mind Maps" project aims at evaluating cognitive function of surgeon's expertise and trainee's skills. The study included electroencephalogram (EEG) recordings of the mentor observing trainee surgeons in 20 procedures during extended lymph node dissection (e-LND) and urethro-vesical anastomosis (UVA), with simultaneous assessment of trainees using NASA-TLX questionnaire. We also compared the brain activity of the mentor during this study to his own brain activity while actually performing the same surgical steps from previous procedures populated in the "Mind Maps" project..

RESULTS: During LND and UVA, when the mentor thought the trainee's mental demand and effort were low based on his NASA-TLX (not satisfied with his performance), his EEG-based mental workload increased (reflecting more concern and attention). The mentor was mentally engaged and concerned while he was engrossed in observing the surgery. This was further supported by the finding that there was no significant difference in the mental demands and workload between observing and operating for the expert surgeon.

CONCLUSION: This study objectively evaluated cognitive engagement of a surgical mentor teaching technical skills during surgery. Our study provides a deeper understanding of how surgical teaching actually works and opens new horizons for assessment and teaching of surgery. Further research is needed to study the feasibility of this novel concept in assessment and guidance of surgical performance. This article is protected by copyright. All rights reserved.

OBJECTIVES: To develop a scoring tool, Pelvic Lymphadenectomy Appropriateness and Completion Evaluation (PLACE), to assess the intraoperative completeness and appropriateness of pelvic lymph node dissection (PLND) following robot-assisted radical cystectomy (RARC).

PATIENTS, SUBJECTS AND METHODS: A panel of 11 open and robotic surgeons developed the content and structure of PLACE. The PLND template was divided into three zones. In all, 21 de-identified videos of bilateral robot-assisted PLNDs were assessed by the 11 experts using PLACE to determine inter-rater reliability. Lymph node (LN) clearance was defined as the proportion of cleared LNs from all PLACE zones. We investigated the correlation between LN clearance and LN count. Then, we compared the LN count of 18 prospective PLNDs using PLACE with our retrospective series performed using the extended template (No PLACE).

RESULTS: A significant reliability was achieved for all PLACE zones among the 11 raters for the 21 bilateral PLND videos. The median (interquartile range) for LN clearance was 468 (431-545). There was a significant positive correlation between LN clearance and LN count (R(2) = 0.70, P < 0.01). The PLACE group yielded similar LN counts when compared to the No PLACE group.

CONCLUSIONS: Pelvic Lymphadenectomy Appropriateness and Completion Evaluation is a structured intraoperative scoring system that can be used intraoperatively to measure and quantify PLND for quality control and to facilitate training during RARC.

BACKGROUND: We sought to investigate the prevalence and variables associated with Early Oncologic Failure (EOF).

METHODS: Retrospective review of the IRCC database of patients who underwent robot-assisted radical cystectomy (RARC) since 2003. The final cohort comprised 1894 patients (23 institutions from 11 countries). EOF was defined as any disease relapse within 3 months of RARC. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncological surgical principles and technique of specimen and lymph node removal. Multivariate model was fit to evaluate predictors of EOF. The Kaplan Meier method was used to depict disease-specific (DSS) and overall survival (OS) and Cox proportional regression analysis to evaluate predictors of DSS and OS.

RESULTS: 305 patients (22%) experienced disease relapse, 220 (16%) distant, 154 (11%) local recurrence, 17 (1%) peritoneal carcinomatosis and 5 (0.4%) port-site recurrences. Seventy-one patients (5%) from 10 institutions developed EOF, and the incidence of EOF decreased from 10% in 2006 to 6% in 2015. On multivariate analysis, presence of any complication (OR 2.87; 95% CI 1.38-5.96; p=0.004), ≥pT3 disease (OR 3.73, 95% CI 2.00-6.97, p<0.001), and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p=0.008) were significant predictors of EOF. Patients with EOF demonstrated worse DSS and OS (23% and 13%) at 1 and 3 years when compared to patients who experienced later or no recurrences (log rank p<0.001) CONCLUSION: The incidence of EOF following RARC has decreased with time. Disease-related rather than technical-related factors play a major role in occurrence of EOF after RARC.

Infertility is a common disease affecting 10-15% of reproductive couples with significant psychological and financial impacts to both patients and society. Approximately 80 million people worldwide are infertile, with an increasing incidence of male infertility. Semen cryopreservation in adults is a proven method of fertility preservation for male patients undergoing gonadal toxic therapies. Unlike adults who can cryopreserve sperm at any time prior to gonadal toxic treatments, there are no effective fertility preservation options for children undergoing cancer treatment, a time when semen cryopreservation is not feasible. Thus, most of the childhood cancer survivor will develop irreversible azoospermia due to the gonadal toxicity of the treatment on spermatogononial stem cells. This review will summarize the possible options and challenges of fertility preservation in this vulnerable population.

OBJECTIVE: To develop quality assessment tool to evaluate surgical performance for robot-assisted radical cystectomy (RARC) program.

METHODS: A prospectively maintained quality assurance database of 425 consecutive RARCs performed by a single surgeon between 2005 and 2015 was retrospectively reviewed. Potentially modifiable factors, related to the management and perioperative care of patients were used to evaluate patient care. Criteria included: Preoperative (administration of neoadjuvant chemotherapy); Operative (operative time <6.5 hours and estimated blood loss <500cc); Pathologic (negative soft tissue surgical margins and lymph node yield ≥20); and Postoperative (no high grade complications, readmission or non-cancer related mortality within 30 d).The Quality Cystectomy Score (QCS) was developed (1 star: achieving ≤2 criteria or mortality within 30 d; 2 stars: 3 or 4 criteria met; and 3 stars: 5 or 6 criteria met; 4 stars: 7 or all criteria met). Univariate and multivariate Cox proportional hazard regression models were fitted to test for the association between QCS and survival outcomes.

RESULTS: Most patients (85%) achieved at least 3 stars, and more patients achieved 4 stars with time. High QCS was associated with better recurrence free (RFS), cancer specific (CSS) and overall survival (OS) (p-values <0.05). None of the patients with 1-star were alive at 1 yr. Patients with 4 stars achieved the best survival rates (RFS 62%, CSS 70% and OS 53% at 5 yrs) (log rank p<0.0001).

CONCLUSION: Continuous assessment for quality improvement facilitated implementation and maintenance of robot-assisted program for bladder cancer.

OBJECTIVE: To develop quality assessment tool to evaluate surgical performance for robot-assisted radical cystectomy program.

METHODS: A prospectively maintained quality assurance database of 425 consecutive robot-assisted radical cystectomies performed by a single surgeon between 2005 and 2015 was retrospectively reviewed. Potentially modifiable factors, related to the management and perioperative care of patients, were used to evaluate patient care. Criteria included the following: preoperative (administration of neoadjuvant chemotherapy); operative (operative time <6.5 hours and estimated blood loss <500 cc); pathologic (negative soft tissue surgical margins and lymph node yield ≥20); and postoperative (no high-grade complications, readmission, or noncancer-related mortality within 30 days).The Quality Cystectomy Score (QCS) was developed (1 star: achieving ≤2 criteria or mortality within 30 days; 2 stars: 3 or 4 criteria met; 3 stars: 5 or 6 criteria met; and 4 stars: 7 or all criteria met). Univariate and multivariate Cox proportional hazard regression models were fitted to test for the association between QCS and survival outcomes.

RESULTS: Most patients (85%) achieved at least 3 stars, and more patients achieved 4 stars with time. High QCS was associated with better recurrence-free, cancer-specific, and overall survival (P values <.05). None of the patients with 1-star were alive at 1 year. Patients with 4 stars achieved the best survival rates (recurrence-free survival [62%], cancer-specific survival [70%], and overall survival [53%] at 5 years) (log rank P < .0001).

CONCLUSION: Continuous assessment for quality improvement facilitated implementation and maintenance of robot-assisted program for bladder cancer.

OBJECTIVE: To understand cognitive function of an expert surgeon in various surgical scenarios while performing robot-assisted surgery.

MATERIALS AND METHODS: In an Internal Review Board approved study, National Aeronautics and Space Administration-Task Load Index (NASA-TLX) questionnaire with surgical field notes were simultaneously completed. A wireless electroencephalography (EEG) headset was used to monitor brain activity during all procedures. Three key portions were evaluated: lysis of adhesions, extended lymph node dissection, and urethro-vesical anastomosis (UVA). Cognitive metrics extracted were distraction, mental workload, and mental state.

RESULTS: In evaluating lysis of adhesions, mental state (EEG) was associated with better performance (NASA-TLX). Utilizing more mental resources resulted in better performance as self-reported. Outcomes of lysis were highly dependent on cognitive function and decision-making skills. In evaluating extended lymph node dissection, there was a negative correlation between distraction level (EEG) and mental demand, physical demand and effort (NASA-TLX). Similar to lysis of adhesion, utilizing more mental resources resulted in better performance (NASA-TLX). Lastly, with UVA, workload (EEG) negatively correlated with mental and temporal demand and was associated with better performance (NASA-TLX). The EEG recorded workload as seen here was a combination of both cognitive performance (finding solution) and motor workload (execution). Majority of workload was contributed by motor workload of an expert surgeon. During UVA, muscle memory and motor skills of expert are keys to completing the UVA.

CONCLUSION: Cognitive analysis shows that expert surgeons utilized different mental resources based on their need.

PURPOSE: There is paucity of data regarding the operative management of complications after robot-assisted radical cystectomy. We reviewed operative management of robot-assisted radical cystectomy specific complications during our 10-year experience with this procedure and assessed the feasibility, safety and outcomes of robot-assisted reoperations.

MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent surgical interventions for robot-assisted radical cystectomy specific complications between 2005 and 2015. Univariable and multivariable logistic regression models were fit to evaluate predictors of surgical intervention after robot-assisted radical cystectomy. Kaplan-Meier curves were used to describe time to surgical interventions.

RESULTS: A total of 92 patients (23%) underwent surgical intervention after robot-assisted radical cystectomy. Mean followup was 27 months. Average time to any surgical intervention after cystectomy was 14 months. The reoperation rate was 5%, 2% and 16% at 30, 30 to 90 and greater than 90 days, respectively. Using the Kaplan-Meier method surgical interventions occurred at a rate of 30% at 2 years and 46% at 5 years. Interventions for ureteroileal complications were the most common (48 cases) followed by interventions for bowel obstruction, fistulas and abdominal wall related complications (11 cases). Clavien 3 or greater complications and neoadjuvant chemotherapy were associated with surgical intervention.

CONCLUSIONS: Even in experienced hands the long-term complications of robot-assisted radical cystectomy are notable. Of our patients 23% required surgical interventions after the procedure. Our initial experience with robot-assisted management of robot-assisted radical cystectomy complications appears safe and feasible, although the decision to proceed is determined primarily by surgeon experience.

OBJECTIVES: To compare percutaneous nephrostomy (PCN) tube vs JJ ureteric stenting as the initial urinary drainage method in children with obstructive calcular anuria (OCA) and post-renal acute renal failure (ARF) due to bilateral ureteric calculi, to identify the selection criteria for the initial urinary drainage method that will improve urinary drainage, decrease complications and facilitate the subsequent definitive clearance of stones, as this comparison is lacking in the literature.

PATIENTS AND METHODS: A series of 90 children aged ≤12 years presenting with OCA and ARF due to bilateral ureteric calculi were included from March 2011 to September 2013 at Cairo University Pediatric Hospital in this randomised comparative study. Patients with grade 0-1 hydronephrosis, fever or pyonephrosis were excluded. No patient had any contraindication for either method of drainage. Stable patients (or patients stabilised by dialysis) were randomised (non-blinded, block randomisation, sealed envelope method) into PCN-tube or bilateral JJ-stent groups (45 patients for each group). Initial urinary drainage was performed under general anaesthesia and fluoroscopic guidance. We used 4.8-6 F JJ stents or 6-8 F PCN tubes. The primary outcomes were the safety and efficacy of both groups for the recovery of renal functions. Both groups were compared for operative and imaging times, complications, and the period required for a return to normal serum creatinine levels. The secondary outcomes included the number of subsequent interventions needed for clearance of stones. Additional analysis was done for factors affecting outcome within each group.

RESULTS: All presented patients completed the study with intention-to-treat analysis. There was no significant difference between the PCN-tube and JJ-stent groups for the operative and imaging times, period for return to a normal creatinine level and failure of insertion. There were significantly more complications in the PCN-tube group. The stone size (>2 cm) was the only factor affecting the rates of mucosal complications, operative time and failure of insertion in the JJ-stent group. The degree of hydronephrosis significantly affected the operative time for PCN-tube insertion. Grade 2 hydronephrosis was associated with all cases of insertion failure in the PCN-tube group. The total number of subsequent interventions needed to clear stones was significantly higher in the PCN-tube group, especially in patients with bilateral stones destined for chemolytic dissolution (alkalinisation) or extracorporeal shockwave lithotripsy (ESWL).

CONCLUSION: We recommend the use of JJ stents for initial urinary drainage for stones that will be subsequently treated with chemolytic dissolution or ESWL, as this will lower the total number of subsequent interventions needed to clear the stones. This is also true for stones destined for ureteroscopy (URS), as JJ-stent insertion will facilitate subsequent URS due to previous ureteric stenting. Mild hydronephrosis will prolong the operative time for PCN-tube insertion and may increase the incidence of insertion failure. We recommend the use of PCN tube if the stone size is >2 cm, as there was a greater risk of possible iatrogenic ureteric injury during stenting with these larger ureteric stones in addition to prolongation of operative time with an increased incidence of failure.

PURPOSE: Data are limited on imaging after primary treatment of localized prostate cancer.

MATERIALS AND METHODS: We identified 8,435 men newly diagnosed with nonmetastatic prostate cancer in 1995 to 2012 who were enrolled in CaPSURE™. Patients were followed after primary treatment with radical prostatectomy, cryosurgery, brachytherapy, external beam radiation therapy or androgen deprivation therapy. We assessed the use of bone scan, computerized tomography and magnetic resonance imaging after primary treatment. Factors associated with posttreatment outcomes (number of imaging tests, and time to first imaging and salvage treatment) were evaluated with multivariate Poisson regression and Cox proportional hazards regression.

RESULTS: The incidence of posttreatment bone scan, computerized tomography and magnetic resonance imaging was 20% or less. Last posttreatment log(prostate specific antigen) was associated with multiple posttreatment imaging. Management by radical prostatectomy, cryosurgery, external beam radiation therapy or brachytherapy vs androgen deprivation therapy was associated with a lower likelihood of posttreatment imaging. Of patients who were imaged after treatment 25% with radical prostatectomy and 9% with radiation underwent imaging before prostate specific antigen failure. The 5-year salvage treatment-free survival rate was 81%. Positive findings on posttreatment imaging were associated with a higher risk of salvage treatment.

CONCLUSIONS: Patients treated with androgen deprivation therapy for localized disease were most likely to be imaged, primarily by bone scan. Men treated with other therapies were less likely to be imaged and tended to undergo computerized tomography. Imaging may add value to posttreatment prostate specific antigen monitoring to identify disease recurrence and progression. Further studies are needed to establish guidelines for the optimal frequency and imaging type to monitor the treatment response.

PURPOSE: We describe the outcomes of patients with low risk localized prostate cancer who were upgraded on a surveillance biopsy while on active surveillance and evaluated whether delayed treatment was associated with adverse outcome.

MATERIALS AND METHODS: We included men in the study with lower risk disease managed initially with active surveillance and upgraded to Gleason score 3+4 or greater. Patient demographics and disease characteristics were compared. Kaplan-Meier curve was used to estimate the treatment-free probability stratified by initial upgrade (3+4 vs 4+3 or greater), Cox regression analysis was used to examine factors associated with treatment and multivariate logistic regression analysis was used to evaluate the factors associated with adverse outcome at surgery.

RESULTS: The final cohort comprised 219 men, with 150 (68%) upgraded to 3+4 and 69 (32%) to 4+3 or greater. Median time to upgrade was 23 months (IQR 11-49). A total of 163 men (74%) sought treatment, the majority (69%) with radical prostatectomy. The treatment-free survival rate at 5 years was 22% for 3+4 and 10% for 4+3 or greater upgrade. Upgrade to 4+3 or greater, higher prostate specific antigen density at diagnosis and shorter time to initial upgrade were associated with treatment. At surgical pathology 34% of cancers were downgraded while 6% were upgraded. Cancer volume at initial upgrade was associated with adverse pathological outcome at surgery (OR 3.33, 95% CI 1.19-9.29, p=0.02).

CONCLUSIONS: After Gleason score upgrade most patients elected treatment with radical prostatectomy. Among men who deferred definitive intervention, few experienced additional upgrading. At radical prostatectomy only 6% of cases were upgraded further and only tumor volume at initial upgrade was significantly associated with adverse pathological outcome.

INTRODUCTION: Across all specialties, economic pressure is driving increased utilization of outpatient surgery when feasible.

AIMS: Our aims were to analyze national trends of penile prosthesis (PP) surgery and to examine patient and hospital characteristics, and perioperative complications in the inpatient setting.

METHODS: We analyzed data from National Inpatient Sample. Patients in NIS who underwent PP insertion between 2000 and 2010 were included.

MAIN OUTCOME MEASURES: Our main outcomes were the number of inpatient PP procedures, type of prosthesis, patient demographics, comorbidities, hospital characteristics, and immediate perioperative complications.

RESULTS: There was a progressive and dramatic decline by nearly half in the number of both inflatable (IPP) and noninflatable (NIPP) inpatient insertions performed from 2000 to 2010 (P = 0.0001). The overall rate of inpatient complications for PP insertion was 13.5%. Patients with three or more comorbidities were found to have a higher risk of complications than patients with no comorbidities (OR = 1.45, 95% CI = 1.18-1.78) (P = 0.0001). Surgeries performed in high-volume hospitals (10 or more PP cases per year) were associated with reduced risk of complications (OR = 0.6) (P < 0.0001). There was a dramatic decrease in inpatient setting for PP placement in high-volume hospitals (32% in 2000 compared with 6% in 2010; P < 0.0001), and when compared with lower volume hospitals. NIPP was more likely performed in younger patients and in community hospitals, and less likely in white patients. Medicaid health insurance was associated with much higher rate of NIPP insertion than other types of insurance.

CONCLUSIONS: The number of PP procedures performed in the inpatient setting declined between 2000 and 2010, likely reflecting a shift toward increasing outpatient procedures. Our data also suggest a better outcome for patients having the procedure done at a high-volume center in terms of inpatient complications. Alwaal A, Harris CR, Hussein AA, Sanford TH, McCulloch CE, Shindel AW, and Breyer BN. The decline of inpatient penile prosthesis over the 10-year period, 2000-2010. Sex Med 2015;3:280-286.

INTRODUCTION: The management of urethral strictures is very challenging and requires the wide expertise of different treatment modalities ranging from endoscopic procedures to open surgical interventions.

OBJECTIVE: To assess the effectiveness and complications of retrograde endoscopic holmium: yttrium-aluminum-garnet laser (Ho: YAG) urethrotomy (HLU) for the treatment of pediatric urethral strictures.

PATIENTS AND METHODS: From January 2010 to January 2013, 29 male pediatric patients with a mean age of 5.9 years and primary urethral strictures 0.5-2 cm long were treated using HLU. The stricture length was <1 cm in 16 (55%) patients and >1 cm in 13 (45%). Fifteen (51.7%) patients had an anterior urethral stricture, while 14 (48.3%) had a posterior urethral stricture. No positive history was found in 14 (48.3%) patients for the stricture disease, while six (20.7%) had straddle trauma and nine (31%) had an iatrogenic stricture. All of the patients were pre-operatively investigated and at 3 and 6 months postoperation by uroflowmetry and voiding cystourethrography (VCUG). If there were suspicious voiding symptoms, selective uroflowmetry and VCUG were performed at 12 months postoperation.

RESULTS: The mean operation time was 31.7 min (20-45 min). Twenty-three (79.3%) and 18 (62.1%) patients showed normal urethra on VCUG with improvement of symptoms at 3 and 6 months, respectively. Thus, recurrence was 37.9% after 6 months of follow-up. The mean pre-operative peak urinary flow rate (Qmax) was 6.47 ml/s. The mean postoperative Qmax at 3 and 6 months was 17.17 ml/s and 15.35 ml/s, respectively. The success rate and flowmetry results did not show any statistical significance in relation to site, length and cause of the strictures. The other 11 patients who failed to improve underwent repeated HLU sessions: 4/11 (36.3%) achieved successful outcomes. Among the seven patients with failed HLU for the second time, a third session was conducted. However, only one patient (14.2%) was cured, while open repair was needed for the remaining six.

DISCUSSION: One study has previously been published on the management of pediatric urethral strictures using HLU. The present results are similar to short-term studies after a single session of visual internal urethrotomy using cold knife (VIU). In the present study, the length, location and cause of strictures did not significantly affect the results. However, the outcomes with strictures <1 cm were better than strictures >1 cm, although patients with strictures >2 cm were excluded. In the present study, the success rates among patients with second and third sessions of HLU were 36.3% and 14.2%, respectively. This was similar to other studies, which reported low success rate with the second session of VIU. The present study was limited by the relatively short period of follow-up and the small number of patients. However, it was the first prospective study evaluating HLU for pediatric strictures. The use of flowmetry and VCUG for evaluation of all patients added to the strength of the study.

CONCLUSION: HLU can be safely used with good success rates for the treatment of primary urethral strictures (<2 cm) in children. Repeat HLU (more than twice) adds little to success.

Stem cells (SCs) are undifferentiated cells that are capable of self-renewal and differentiation and that therefore contribute to the renewal and repair of tissues. Their capacity for division, differentiation, and tissue regeneration is highly dependent on the surrounding environment. Several preclinical and clinical studies have utilized SCs in urological disorders. In this article, we review the current status of SC use in benign urological diseases (erectile dysfunction, Peyronie disease, infertility, and urinary incontinence), and we summarize the results of the preclinical and clinical trials that have been conducted.

Although the prevalence of Peyronie's disease (PD) is reported to be 3-9% in men, the true prevalence is likely higher due to under-reporting. Many treatment modalities have been described for PD with varying degrees of success. In this article, we review and summarize the current literature pertaining to all pharmacotherapies (oral, intralesional, iontophoresis, and topical) and minimally invasive treatments available for PD (vacuum, traction device, shock wave therapy, and radiation treatment). Additionally, we discuss emerging therapies for PD that are still in pre-clinical development, including stem cell therapy.

Improvements in childhood cancer survival have allowed boys and their families to increasingly focus on quality of life after therapy, particularly their future ability to father children. Treatments should maintain comprehensive cancer care goals and consider the long-term quality of life of these children. While semen cryopreservation is a well-established method of fertility preservation for post-pubertal children, the use of cryopreserved pre-treatment testicular tissue represents a promising, yet experimental method of fertility preservation for prepubertal males facing sterilizing therapy. Healthcare providers should counsel families about the fertility risks of therapy, discuss or refer patients for standard fertility preservation options, and consider experimental approaches to fertility preservation while being mindful of the ethical questions these treatments raise.

Improvements in childhood cancer survival have allowed boys and their families to increasingly focus on quality of life after therapy, particularly their future ability to father children. Treatments should maintain comprehensive cancer care goals and consider the long-term quality of life of these children. While semen cryopreservation is a well-established method of fertility preservation for post-pubertal children, the use of cryopreserved pre-treatment testicular tissue represents a promising, yet experimental method of fertility preservation for prepubertal males facing sterilizing therapy. Healthcare providers should counsel families about the fertility risks of therapy, discuss or refer patients for standard fertility preservation options, and consider experimental approaches to fertility preservation while being mindful of the ethical questions these treatments raise.

OBJECTIVES: To describe and evaluate our protocol for management of children≤4years old with obstructive calcular anuria (OCA) and acute renal failure (ARF) to improve selection of initial urinary drainage (ID) method and to facilitate subsequent definitive stone management (DSM) as studies discussing this special group of patients are still few.

PATIENTS AND METHODS: Patients with a contraindication to any method of ID were excluded. Decision (percutaneous nephrostomy (PCN) or double J (JJ) stent) was based on degree of hydronephrosis and planned DSM. We used 4.8-5Fr JJ or 6-8Fr PCN under general anesthesia and fluoroscopic guidance. According to our protocol, JJ is inserted for hydronephrosis≤grade 1. When the hydronephrosis is >grade 1, patients with radiolucent stones were treated by JJ whatever the site of the stone. When the stones were radiopaque, PCN was reserved for stones in a solitary functioning kidney and bilateral ureteric stones prepared for subsequent bilateral ureterolithotomy (or stone prepared for ureterolithotomy in a solitary kidney). After normalization of renal functions, DSM was staged attacking only one side before discharge. Both sides were cleared at the same session in cases with bilateral ureterolithotomy. Renal or ureteric stones suitable for SWL in a solitary kidney were treated with percutaneous nephrolithotripsy (PNL) or ureteroscopy. This was followed also in patients with bilateral stones suitable for SWL by clearing one side using ureteroscopy or PNL before discharge. Open surgery (OS) was reserved for cases with failed ureteroscopy or PNL, for ureteric stones>2.5 cm in size or very large volume complex renal stones. Stone free rate (SFR) was evaluated by CT. Our protocol was evaluated as regard recovery of renal functions, complications, and number of interventions to clear stones.

RESULTS: This study included 62 boys and 22 girls presented with anuria for 1-4 days. JJ and PCN were inserted in 105 and 30 ureterorenal units (URU), respectively. Creatinine returns normal within 72 h. JJ insertion formed a part of DSM in 78/159 (49%) URU (stones prepared for extracorporeal shockwave lithotripsy or oral chemolytic dissolution therapy). PCN was the ideal tract for subsequent PNL in 11/159 (6.9%) URU. Accordingly, ID participated by 55.97% in DSM. Both operative and imaging times were slightly longer with PCN than JJ. There was no statistically significant difference in the insertion success or mean period to return to normal chemistry. Complications of both methods were mild and without any significant difference. Endourologic procedures constituted the majority of our interventions. Open surgical and endoscopic interventions for clearance of stones (including ID, treatment conversion and 2ry procedures) were done once for 25 patients, twice for 43 patients while it was needed three times for 16 patients. Total number of interventions was 149 procedures. SFR was 94%.

CONCLUSION: Our protocol ensures adequate ID with minimal complications when using our selection criteria in children≤4 years in age with OCA and ARF. It also minimizes number of subsequent procedures to clear stones. Complications and success in insertion and drainage were equivalent in PCN and JJ groups.