Long-Term Outcomes of Two Ipsilateral vs Single Double-J Stent After Laser Endoureterotomy for Bilharzial Ureteral Strictures

Background: Laser endoureterotomy became a preferable choice for managing benign ureteral strictures. Ureteral stricture caused by bilharzias is characterized by focal destruction of ureteral musculature, ending by fibrosis, making it poor responder to endoureterotomy. There is no consensus about the ideal ureteral stent size after endoureterotomy. However, many researches recommend larger stents caliber (12-14F). We assess long-term efficacy of insertion of two ipsilateral Double-J stents vs single Double-J stent after laser endoureterotomy for bilharzial ureteral stricture. Materials and Methods: Within 4 years, 70 patients underwent retrograde laser endoureterotomy for bilharzial ureteral stricture (diagnosed by positive history of bilharziasis, positive serology test, and/or bilharzial cystoscopic finding). Patients with history of stone, urologic or pelvic surgery were excluded. Patients were randomized into two groups: the first group (35 patients) received ipsilateral two Double-J (7F each) postendoureterotomy, whereas the second group (35 patients) received one Double-J (7F). Double-Js were removed after 8 weeks. Follow-up was done regularly by clinical interpretation and imaging studies. Patients' characteristics, operative data, and postoperative outcomes (subjectively and objectively) were compared in both groups. Results: Sixty-three patients completed follow-up >18 months, mean follow-up 30 ± 4 months [19-41], and mean stricture length 1.4 ± 0.6 cm [0.5-3.0], with no statistical significance between both groups. Success proved by relief of symptoms and radiographic resolution of obstruction. The overall success rate was significantly better in 2-Double-J group than in 1-Double-J group (83.9% vs 53.1%) p = 0.009, and also for stricture >1.5 cm (85.7% vs 38.5%) p = 0.018, respectively. Conclusions: Insertion of two ipsilateral Double-J, after laser endoureterotomy for bilharzial ureteral stricture associated with long-term success rate better than insertion of 1-Double-J, especially for stricture segment >1.5 cm.

Urinary biomarkers for early detection of platinum based drugs induced nephrotoxicity

BACKGROUND

Nephrotoxicity is a major hazard complicating the use of platinum based drugs (PBD), which can hinder using higher doses protocols to maximize the therapeutic gain. Shortage of serum creatinine level as an accurate biomarker for acute kidney injuries (AKI) necessitates searching for novel biomarkers with better sensitivity and specificity in patients on PBD.

METHODS

In a prospective cohort design, 132 patients receiving PBD were selected for the study. AKI was diagnosed by continuous follow up of serum creatinine level according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines 2012. Serum creatinine and urinary biomarkers (KIM-1, NGAL and cystatin C) was measured in the day of treatment and for 3 days after PBD cycle.

RESULTS

AKI occurred in 35 patients (26.52% of patients). KIM-1, Cystatin C, and NGAL showed significant increase in samples collected in the day of AKI in comparison to their corresponding basal levels (P <  0.0001). In addition, significant increase in urinary levels of the biomarkers in samples collected 1 day before AKI in comparison to their basal levels (P <  0.0001, P <  0.0001, and P = 0.013 for KIM-1, NGAL and Cystatin C respectively). Furthermore KIM-1 data showed a significant increase 2 days before serum creatinine rise in comparison to the corresponding KIM-1 levels in patients who developed AKI (P = 0.001).

CONCLUSIONS

Urinary KIM-1, Cystatin C and NGAL can predict PBD induced AKI in earlier stages than serum createnine. KIM-1 is the most sensitive biomarker for early detection of AKI in patients receiving PBD.

Transperineal repair of complex rectourethral fistula using gracilis muscle flap interposition--can urinary and bowel functions be preserved?

PURPOSE

Rectourethral fistula developing after prostate cancer treatment is usually complex and difficult to repair. We present our experience with 25 cases of complex rectourethral fistula using gracilis muscle interposition, addressing the efficacy of this technique as well as the postoperative urinary and fecal outcome.

MATERIALS AND METHODS

After receiving institutional review board approval we performed a retrospective chart review of patients with prostate cancer who had undergone gracilis muscle interposition for complex rectourethral fistula. A 1-page questionnaire was then mailed to all patients to assess urinary and bowel function.

RESULTS

At mean followup of 28 months all patients had successful fistula closure with no recurrence. Of the 18 patients (72%) with urinary continence 5 were continent after artificial urinary sphincter implantation. Three patients (12%) were totally incontinent and lost to followup. Four patients (16%) had permanent urinary diversion due to a devastated urinary outlet, while a urethral stricture was found in 5 and bladder neck contracture was noted in 3. Regarding bowel control, 19 patients (76%) were continent, 2 (8%) had fecal incontinence and 4 (16%) required permanent colostomy due to a devastated fecal outlet. A total of 17 patients replied to the mailed questionnaire for a 68% response rate and all had significant improvement in all parameters. Factors predisposing to a suboptimal outcome were large fistula size, surgery followed by radiation and cryotherapy.

CONCLUSIONS

Gracilis muscle transposition is an excellent procedure for treating complex rectourethral fistula. Several other local factors may affect the postoperative urinary and fecal outcome. The collaboration of colorectal and urological surgeons is necessary to achieve optimal results.

Modeling rear-end collisions including the role of driver's visibility and light truck vehicles using a nested logit structure

This paper presents an analysis of the effect of the geometric incompatibility of light truck vehicles (LTV)--light-duty trucks, vans, and sport utility vehicles--on drivers' visibility of other passenger cars involved in rear-end collisions. The geometric incompatibility arises from the fact that most LTVs ride higher and are wider than regular passenger cars. The objective of this paper is to explore the effect of the lead vehicle's size on the rear-end crash configuration. Four rear-end crash configurations are defined based on the type of the two involved vehicles (lead and following vehicles). Nested logit models were calibrated to estimate the probabilities of the four rear-end crash configurations as a function of driver's age, gender, vehicle type, vehicle maneuver, light conditions, driver's visibility and speed. Results showed that driver's visibility and inattention in the following (striker) vehicle have the largest effect on being involved in a rear-end collision of configuration CarTrk (a regular passenger car striking an LTV). Possibly, indicating a sight distance problem. A driver of a smaller car following an LTV, have a problem seeing the roadway beyond the LTV, and therefore would not be able to adjust his/her speed accordingly, increasing the probability of a rear-end collision. Also, the probability of a CarTrk rear-end crash increases in the case that the lead vehicle stops suddenly.

Analysis and prediction of traffic fatalities resulting from angle collisions including the effect of vehicles' configuration and compatibility

Although the rapid growth in light truck vehicle (LTV) sales, including minivans, sports utility vehicles (SUVs), and light-duty trucks, has not been associated with an overall increase in collisions or traffic deaths in the US, there is a need for a research program to determine whether particular types of collisions have become more frequent or injurious because of the increase in the percent of LTVs in traffic. This paper presents an analysis of the effect of the increasing number of LTV registrations on fatal angle collision trends in the US. The analysis investigates the number of annual fatalities that result from angle collisions as well as collision configuration (car-car, car-LTV, LTV-car, and LTV-LTV). The analysis uses the Fatality Analysis Reporting System (FARS) crash databases covering the period 1975-2000. Results showed that death rates differ based on the collision configuration. Time series modeling results showed that fatalities in angle collisions will increase in the next 10 years, and that they are affected by the expected increase in the percentage of LTVs in traffic. Forecast showed that the total number of annual deaths is expected to reach 6300 deaths by the year 2010 (an increase of 12% over 2000). Analysis into the configuration of the collision indicated the seriousness of angle collisions involving an LTV striking a common passenger car (LTV-car). A time series model illustrated the significance of time lag and percent of LTVs in traffic on the increase of this type of fatal collisions. Forecasts from the time series model indicated a 32% increase in deaths due to this type of collisions in the next 10 years.