Saturday, June 30, 2012

Snod Grass technique of hypospadias repair (pics) (step-by-step operative urology)

Snod Grass technique of hypospadias repair (pics) (step-by-step operative urology)

5–0 polypropylene suture in glans for traction
artificial erection exclude curvature
Circumcising (subcoronal) incision

Degloving of penis
2 longitudinal incisions between urethral plate & glanular wings

midline incision of the urethral plate.
This manoeuvre is facilitated by counter-traction maintained by the surgeon and assistan

the urethral plate is tubularized (as Thiersch duplay principle) beginning at the neomeatus, using 6-0 or 7–0 polyglactin suture.
The first suture is placed through the epithelium at a point just distal to the midglans, so that the meatus has an oval, not rounded, configuration

Dartos pedicle flap (2nd layer) is dissected from the  preputial hood and dorsal skin
then either Rotated from side or button-holed and transposed ventrally to cover the entire neourethra (2nd layer to prevent fistulation)

Glansplasty by:
polyglactin suture through ventral lip of the meatus.
sutures placed subepithelially to complete glansplasty
No attempt is made to secure the glans to the underlying neourethra.  

Skin closures
also use subepithelial polyglactin sutures to minimize the risk of suture tracks.

Note: Snod grass repair can be used in more proximal hypospadias. 

Friday, June 29, 2012

Wednesday, June 27, 2012

inguinoscrotal lumps

Inguinoscrotal lumps

nice presentation from net
hope you like it

Inguino-scrotal lumps

View more presentations from Wadood Aref.

Tuesday, June 26, 2012

Outcomes of pT0N0 at radical cystectomy: The Canadian Bladder Cancer Network experience

Imported data are updated from this paper

In 2012, there will be an estimated 73,510 people diagnosed  with bladder cancer and approximately 14,880 deaths due to this disease.”
Bladder cancer is the fourth most common cancer in men and eighth most common in women.
While most patients presenting with bladder cancer have superficial disease (<cT2), about 25% of these individuals will have at least muscle invasive (≥cT2) or node positive (N+) disease.
Currently, radical cystectomy (RC) is the standard of care for the management of organ-confined muscle invasive or high-risk superficial disease.
About 10% of patients (range: 5-20) will have no evidence of tumour at pathological examination of the cystectomy specimen; such patients are designated stage pT0.
The clinical outcomes and significance of patients with stage pT0 disease at cystectomy is unclear. Thrasher and colleagues reviewed survival outcomes in these patients and found that survival in this population was determined by the presenting clinical stage. However, Palapattu and colleagues found that survival in patients with pT0 is similar to those with pTa and pTis (in situ) and Cho and colleagues found survival to be similar to those with pTis and T1 disease. In an effort to help clarify the clinical significance of  patients with stage pT0N0 disease at cystectomy, we assessed clinical outcomes of these patients following RC using a contemporary series of bladder cancer patients treated by urologic oncologists from multiple Canadian academic centres. 

Cystectomy specimens were processed and evaluated by staff pathologists with genitourinary expertise. Pathologic staging was in accordance with the 1997 TNM classification.
Postoperative surveillance consisted of routine history and physical examination, blood chemistry analysis, abdominal/pelvic imaging, urinary cytology and chest x-ray. All assessments were repeated every three to six months for the first five years and at increasing intervals thereafter. Any additional evaluation was done on an individual basis at the discretion of the treating physician.
Measured survival outcomes included recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OS). Time to recurrence was calculated as the time interval from surgery to evidence of clinical recurrence or last follow-up in the absence of any recurrence. Time to DSS was determined as the time interval from surgery to the date of death from bladder cancer or last follow-up if the patients had not died of bladder cancer. Time to OS was assessed as the time from surgery to the date of death, regardless of cause of death.
Patient and clinical characteristics
The entire study cohort consisted of 2287 patients, of which 135 (5.9%) patients had pT0N0 disease and 25 (1.1%) patients had pT0N+ disease. No patients with pT0 had metastatic disease. Of the 135 patients with pT0N0, TCC was the primary histology in 68.9% (83), and 80% (108) were male. Median age was 66 years (range: 39-72) and median follow-up of living patients was 42 months (range: 3-180). Most patients had either clinical T1 or T2 stage disease (65.9% of 135 patients). There was a history of concomitant CIS in 24% and a history of previous superficial TCC in 35% of patients. Very few patients did not receive a lymph node dissection (7.4%). Neoadjuvant chemotherapy was offered to 11 (8.1%) of 135 patients with pT0N0, and 71 (3.1%) patients in the entire study cohort. Adjuvant chemotherapy was not offered to any patients in the pT0N0 group.
Clinical outcomes with pT0N0 pathology
The five- and 10-year RFS for pT0N0 was 83% and 66%, respectively; moreover, the five- and 10-year DSS for pT0N0 was 96% and 92%, respectively. The five- and 10-year OS was 88% and 70%, respectively. The five-year RFS, DSS and OS for the entire study population (2287) were 57%, 48% and 67%, respectively.
The frequency of pT0 pathology at RC has been reported to range from 5% to 20%.
The frequency of 5.9% of pT0 disease from the Canadian Bladder Cancer Network is in keeping with the published range.
There are a number of causes of a pT0 RC specimen, including effective neoadjuvant therapy, complete endoscopic resection prior to cystectomy, residual tumour that is too small to be detected, and misdiagnosis at TURBT.

The results of this large multicentre study suggest that patients with pT0N0 have excellent outcomes from cystectomy with high five- and 10-year RFS, DSS and OS; however, there still remains a risk of tumour recurrence in this patient population. Given that patients with pT0N0 pathology are a heterogeneous group, ongoing postoperative surveillance is required for these patients.

Saturday, June 23, 2012

Imaging in urology: part 2 other conventional imaging

Imaging in urology: part 2 other conventional imaging

by Ahmad Al-Sabbagh and revised by M.A.Wadood

Imaging in urology: part 1 KUB & IVP

Imaging in urology: part 1  KUB & IVP

by Ahmad Al-Sabbagh & revised by M.A.Wadood
 sorry, previous upload was unsuccessful

Sunday, June 17, 2012

The Cohen procedure (step by step operations series)

The Cohen procedure (step by step operations series)


If the patient has recurrent breakthrough infections, or if there are signs of continued deterioration of the renal substance, radical treatment should be offered. Surgery consists of re-implanting the ureters into the bladder.

The aim of these treatments is to stop the VUR; this does not necessarily mean that the progression of renal damage is halted, or that further UTIs are prevented. In cases where the reflux has caused severe damage to the kidney (relative function <10%), a nephroureterectomy may be the best option. The choice between surgical or endoscopic correction of reflux is an individual matter, each technique having its protagonists.

Figure 1

The patient lies supine on the operating table; a small sheet placed under the sacrum is useful to flatten the abdomen. A right-handed surgeon should stand on the left side of the patient, with the scrub nurse on the left of the surgeon. The two assistants should stand on the right side of the patient. A transverse suprapubic incision is made, 2 cm above the pubic symphysis, in the lower abdominal crease.

Figure 2

The subcutaneous tissues are incised, exposing the rectus sheath, which is opened vertically in the midline (dotted line). Both recti are separated and the peritoneum gently pushed upwards.

Figure 3

A Dennis-Browne retractor is inserted. The lateral blades retract the recti and the upper and lower blades retract the skin and subcutaneous tissues.

Figure 4

The anterior wall of the bladder is incised vertically and two or three stay sutures placed on each side to expose the bladder. To expose the trigone, one or several swabs are put inside the bladder and retracted upwards with a Deaver retractor held by the second assistant. A 3/0 or 4/0 absorbable suture isplaced at the lowest point of the vesicotomy, to prevent splitting of the incision downwards into the bladder neck and the urethra.The blades of the Dennis-Browne retractor should not be placed within the bladder for three reasons: (i) retraction is vigorous and may damage the bladder; (ii) access to the laterovesical spaces may be difficult; and (iii) the bladder wall loses its natural mobility, rendering the procedure more difficult. It is essential to avoid rigid retraction and to maintain the natural suppleness of the tissues.The trigone is now well exposed and an infant-feeding tube (usually 4 F) is inserted into each ureter. A stay suture is placed around each ureteric orifice and tied over the feeding tube. The first assistant holds this staysuture with mild traction.

Figure 5

The ureteric orifice is circumcised with diathermy (cutting and coagulation current should be very low) and the distal 2 cm of ureter can be mobilised with diathermy alone (these 2 cm will be excised later).

Figure 6

It is essential to enter the correct plane between the bladder and the transparietal ureter, commencing below the orifice. Sharp scissors should be avoided and Reynolds scissors make this procedure much easier. The tip of the Reynolds scissors elevates the muscle fibres that attach the ureter to the bladder musculature. These fibres are grasped with fine forceps, coagulated and divided. The fibres should be coagulated some distance from the ureter, to avoid damaging its blood supply.

Figure 7

The dissection continues progressively, circumferentially until the ureter is completely freed.

Figure 8

The peritoneum is visible at the end of this dissection and should be teased away from the ureter. In boys the vas deferens may lie close to the ureter at this point, and care must be taken to avoid damaging it. A similar procedure can be used for the opposite ureter. 

In cases of ureteric duplication, both ureters are dissected together and should not be separated, thus avoiding damage to their blood supply.In some cases the ureteric hiatus is wide and should be narrowed by one or two absorbable sutures, to prevent the formation of a bladder diverticulum. These sutures should narrow the hiatus, but still allow the free movement of the ureter and not restrict or constrict it.

Figure 9

The submucosal tunnel is then formed; it is usually a horizontal tunnel, crossing the midline of the posterior surface of the bladder, just above the trigone.

Figure 10

The length of the submucosal tunnel should be at least five times the ureteric diameter (Paquin’s rule) and, if this cannot be fulfilled, modelling of the ureter should be considered. In this case, the calibre of the ureter may be reduced by excising a strip of ureter (Hendren’s technique

Figure 11

The calibre of the ureter may also be reduced by infolding the ureter (Kalicinski’s technique and the length of the modelled segment should not exceed the length of the submucosal tunnel.

Figure 12

The site of the new ureteric orifice is selected and the bladder mucosa lifted from the underlying bladder muscles with a pair of Reynolds scissors, starting either from the hiatus or from the new ureteric orifice. Again, sharp scissors should be avoided; Reynolds scissors are ideal because their tips are blunt. 
The tunnel should be wide enough to allow easy insertion of the ureter, with no constriction.

A similar procedure can be used for the opposite ureter in case of bilateral reimplantation. The construction of the lowest tunnel which crosses the trigone can cause slight bleeding, and lifting the mucosa 
is slightly less easy.A pair of artery forceps or a right-angle is inserted through the tunnel, the stay suture grasped and gently pulled to draw the ureter into place, taking care not to twist or kink it.

Figure 13

The last 2 cm of ureter is excised and the ureteric opening spatulated with a pair of angled Potts scissors.

Figures 14 and 15

The 5/0 absorbable suture anchors the ureter to the bladder muscles and the ureterovesicostomy is completed with interrupted 6/0 absorbable sutures.

Figure 16

For some surgeons, an infant feeding tube or JJ stent or ‘Blue Stent’ is inserted into the reimplanted ureter and exteriorized through the bladder wall, the rectus muscle and the skin, using the punch of a suprapubic 
catheter. The feeding tube is left in position for 2 days, or for 10 days if the ureter has been re-modelled.There is no consensus on the efficacy of drainage of the reimplanted ureter and some authors do not leave any drainage. The bladder is drained either by a transurethral catheter for 5 days or by a suprapubic catheter.

Figure 17

The bladder is closed with a 3/0 or 4/0 suture (interrupted or continuous). The pre-vesical and subcutaneous spaces are drained by a suction drain. The abdominal wall, the subcutaneous tissues and the skin are then 


The child is usually hospitalized for 5 days; the ureteric stent is removed after 2 days (or 10 days if the ureter has been re-modelled). The bladder catheter is removed at 5 days. Both suction drains are usually removed on the second day. Bladder spasms are common and oral oxybutynin can be useful to reduce the
discomfort.The type of antibiotic prophylaxis varies widely among surgical 
teams. Pain is controlled with diclofenac suppositories.

Hypospadias 3 (ppt): MAGPI & snod grass (TIP) step by step oper series

Hypospadias 3 (ppt): MAGPI & snod grass (TIP)   
step by step operative series

MAGPI - step-by-step operative urology series

step-by-step operative urology series 
there is nothing much to say the name and the pics are much self- explanatory

Meatal advancement: Longitudinal incision closed by 3 sutures in transverse line.

Glanuloplasty: 2 stay sutures in midline & closure of lateral glanular wings in midline

Saturday, June 16, 2012

No Scalpel Vasectomy (part 1)


Vasectomy is the most popular form of permanent surgical birth control for men. In 2002, an estimated 526,501 vasectomies were performed in the United States, which is a rate of 10.2/1,000 in men aged 25-49 years. The no-scalpel vasectomy (NSV), originally developed in China in 1974 and first introduced in the United States in 1984, is an innovative approach to exposing the vas deferens using 2 specialized surgical instruments. A recent Cochrane Review concluded that the NSV, as compared to traditional incisional technique, resulted in less bleeding, hematoma, infection, and pain, and a shorter operative time. According to one study, 37.8% of physicians, including urologists, family practitioners, and general surgeons, were using the NSV technique by 2002.
·         Vasectomy is indicated for any fully informed man who does not want to father any children (or any additional children) and who desires an inexpensive outpatient method of voluntary permanent surgical sterilization.
·         Although less popular than other forms of sterilization, such as tubal ligation for the man’s sexual partner, the procedure offers the advantages of lower expense, lower level of invasiveness (ie, does not require general anesthesia or hospitalization), and quicker recovery time. Also, future checks of fertility are possible at any time with semen analysis, unlike with women who have undergone tubal ligation.

·         Contraindications to no-scalpel vasectomy (NSV) include the following:
·         Anatomic abnormalities, such as the inability to palpate and mobilize both vas deferens or large hydroceles or varicoceles
·         Past trauma and scarring of the scrotum
·         Acute local scrotal skin infections
·         Extreme care and consideration must be taken with patients who are taking anticoagulants or antiplatelet medications.
·         Provision and review of both written and verbal informed consent is paramount. Men and their spouses must understand that vasectomy should be considered a permanent sterilization procedure. Belief that reanastomosis microsurgery provides a good backup plan for fathering future children should be strongly discouraged.
·         Surgical complications, failure rates, alternative methods of birth control, and possible chronic postoperative pain should also be discussed, and all questions should be answered.
·         Emotional instability or equivocal feelings about permanent sterilization are contraindications to vasectomy.
·         Compliance with postoperative follow-up and postprocedure semen analysis is of utmost importance.

Hematuria in children ( part 10- final)

Medical Care

Asymptomatic (isolated) hematuria generally does not require treatment. In conditions associated with abnormal clinical, laboratory, or imaging studies, treatment may be necessary, as appropriate, with the primary diagnosis.

Surgical Care

Surgical intervention may be necessary in certain anatomical abnormalities, such as ureteropelvic junction obstruction, tumor, or significant urolithiasis.


Consultations are required in patients with urinary tract anomalies and in some patients with systemic diseases (eg, bleeding disorders, collagen vascular diseases, sickle cell nephropathy).


Dietary modification is usually not indicated except for children who may have a tendency to develop hypertension or edema as a result of their primary disease process (eg, nephritis). In these patients, a low sodium diet may be helpful. In addition, a diet containing the recommended daily amount (RDA) for calcium plus a low-salt diet may be beneficial in children with hypercalciuria and hematuria.


Activities of a child with asymptomatic, isolated hematuria should not be restricted. However, these children and their parents should be informed that strenuous exercise may aggravate hematuria. Restrictions in physical activities may be indicated in children with severe hypertension or cardiovascular disease.

Medication Summary

Hematuria is a sign and not a disease. Therapy should be directed at the process causing hematuria.

Further Outpatient Care

Patients with persistent microscopic hematuria should be monitored at 6-month to 12-month intervals for the appearance of signs or symptoms indicative of progressive renal disease. Prominent among them are proteinuria, hypertension, and a decrease in renal function.


The prognosis of patients with asymptomatic isolated hematuria is good. The ultimate prognosis for the various conditions associated with hematuria depends on the primary medical condition that caused the hematuria in the first place.

Patient Education

Inform children and their parents that strenuous exercise may aggravate hematuria; however, hematuria by itself should not prevent the child from participating in sports. Despite the sometimes alarming intensity or persistence of hematuria, parents must be informed that, by itself, hematuria rarely causes anemia.

Friday, June 15, 2012

Hematuria in children ( part 9)

Categorizing patients with hematuria into one of the following groups is helpful:
·         Gross hematuria
o    Gross hematuria is alarming for the child's parents and sometimes for their pediatricians.
o    Gross hematuria is an uncommon finding in an unselected population of children. The prevalence of gross hematuria was reported as 0.13%, based on a retrospective review of children seen in an emergency walk-in clinic.
o    Most children with gross hematuria (56%) have an easily recognizable and apparent cause. The most common diagnoses include urinary tract infection, perineal irritation, trauma, meatal stenosis with ulceration, coagulation abnormalities, and urinary tract stones.
o    Less than half (44%) of children with gross hematuria had a cause that was either not obvious or that required additional or more sophisticated examinations. Among the diagnoses in this group are recurrent gross hematuria, acute nephritis, ureteropelvic junction obstruction, cystitis cystica, epididymitis, tumor, hyperuricosuria, and hypercalciuria.
o    These children require referral to a pediatric nephrologist for detailed investigation and management.

·         Microscopic hematuria with clinical symptoms
o    A child who presents with either symptoms of an illness or a physical abnormality and is discovered to have concurrent microscopic hematuria should be placed in this category.
o    Some of the clinical conditions with associated renal involvement that may be recognized by the primary physician are acute glomerulonephritis, acute interstitial nephritis, urinary tract infections, familial hematuria (both benign recurrent and progressive hereditary nephritis), Henoch-Schönlein purpura, systemic lupus erythematosus, hypertension, hypercalciuria, and urolithiasis.
o    Unless the patient falls into a clear category of illness that is easily identified, an early consultation with the pediatric nephrologist should be obtained, because most other illnesses require additional expertise in either delineation or management.
o    The child with microscopic hematuria associated with clinical symptoms may have a vast number of diseases or conditions, which makes this a difficult category for which to suggest specific evaluation.
o    The first step in this category is to direct the evaluation based on the symptoms or physical examination findings. The extent and thoroughness of the evaluation depends on the knowledge and experience of the physician.
o    The child with a complicated diagnosis or unexplained cause for the hematuria should be referred to a pediatric nephrologist or, in some cases, to an appropriate subspecialist. If a diagnosis is straightforward, the appropriate therapy or follow-up is administered.
o    If the child has recurrence of the symptoms and associated hematuria or if the hematuria is persistent, referral to a pediatric nephrologist is recommended.

·         Asymptomatic microscopic hematuria with proteinuria
o    In the asymptomatic child, simultaneous microscopic hematuria and proteinuria (>50 mg/dL) in 3 consecutive urine samples is unusual and occurred in the Galveston study, with a prevalence of 64 per 100,000 school children (approximately 0.06%).[4] All of the children in this survey who were thought to have significant renal disease were included in this group. Despite the obvious concern attendant to this combined finding, almost 50% of the children who were discovered to have both hematuria and proteinuria had spontaneous resolution of both findings during the course of the 5-year follow-up.[5]
o    The significance of the renal involvement, in most cases, correlates directly with the quantity of protein being excreted. Thus, the combination of asymptomatic microscopic hematuria and proteinuria seems to suggest that such patients are more likely to have significant renal disease.
o    The first step in this category is to quantitate the urine protein at the initial or follow-up visit. Asymptomatic patients who are found to have both hematuria and proteinuria in several samples collected over a few weeks should be referred to a pediatric nephrologist for further evaluation and recommendations.

·         Asymptomatic microscopic (isolated) hematuria
o    Asymptomatic microscopic hematuria is common in unselected populations of children. The discovery of hematuria alone in an asymptomatic child is merely an indication for repeat testing on one or more occasions.
o    The Galveston County epidemiology study found that, of children who had 3 consecutive urine samples that demonstrated hematuria, only 37% had hematuria 1 year later.[4] Thus, the cause for the asymptomatic hematuria had apparently resolved in 63% of the children over the course of a single year. Significant renal disease was almost nonexistent in patients in whom hematuria was the only abnormality found.
o    In cases involving the development of proteinuria or pyuria, the condition of isolated asymptomatic hematuria is no longer observed, and other studies should be performed. If the microscopic hematuria persists unchanged for more than 1-2 years, a few additional studies may be indicated.
o    One possible entity responsible for such an asymptomatic persistence of hematuria is idiopathic hypercalciuria or hyperuricosuria.
o    Familial or hereditary hematuria, whether benign, nonprogressive (ie, "thin basement membrane disease"), or progressive (ie, Alport syndrome or one of its variants), is another condition in which, early in the course, hematuria may be found in the absence of proteinuria.
o    IgA nephropathy may also present with microhematuria.


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