الفهرس 
Materials and methodsOnly 14 pages are availabe for public view
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Abstract
Summary ct Conclusions 117
SUMMARY AND CONCLUSIONS
The endoscopic transurethral approach to many lower urinary tract disorders is sometimes associated with difficulty and limitations resulting in complications.
This work has been performed to assess whether percutaneous antegrade suprapubic endoscopic surgery can be helpful in situations where transurethral access is inadequate, difficult, or likely to be associated with urethral injury.
In this work, we have applied a novel technique for percutaneous access to the bladder by using the self-retaining laparoscopic trocar-sheath unit. This technique was successfully performed without complications.
The study was carried out on 70 male patients treated with percutaneous bladder procedures. Their ages ranged from 2-80 years old with a mean age 48.1 years. Through the wide bore of the self-retaining sheath, many procedures have been performed both in children and adults. According to the procedures done, 60 patients underwent percutaneous stone bladder clearance; 18 of them underwent a concomitant antegrade bladder neck incision. Four patients underwent placement of large-bore suprapubic catheters for long term bladder drainage. Four patients treated with
Summary & Conclusions 118
antegrade dilatation of impassable stricture posterior urethra, and 2 children underwent antegrade ablation of PUV.
Complete removal of bladder stones was achieved in 58 patients (97% successful rate). There were 2 failures due to non disintegration of the stones by ultrasound. The wide diameter of the laparoscopic sheath allows a wide range of urological endoscopes to • be passed as required without risk of urethral injury either from the passage of large instruments, or as a result of their repeated insertion and removal as may be necessary for lithotripsy. Percutaneous stone bladder clearance is a viable alternative to open surgery or transurethral cystolitholapaxy. It may now be the treatment of choice in children as well as adults with bladder
stones.
Antegrade bladder neck incision was successfully performed in 18 adult patients with bladder stones associated with bladder neck obstruction; secondary to bladder neck contracture or small fibrous prostate. The postoperative follow up demonstrated subjective and objective improvement in all patients. Antegrade bladder neck incision offers an added advantage to percutaneous bladder intervention in management of patients with stone bladder associated with bladder neck contracture or obstructing fibrous prostate. Both procedures; stone bladder clearance and bladder neck incision; can performed simultaneously through the same approach without compromising urethral integrity.
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Summary & Conclusions 119
Percutaneous placement of large-bore suprapubic catheter is a simple and safe procedure. It avoids the complications of small bore catheter that introduced via the Cystocath. Meanwhile, it avoids formal suprapubic cystostomy to place a large-bore catheter for long-term bladder drainage.
Antegrade dilatations of stricture posterior urethra was performed in 4 patients with impassable stricture posterior urethra. All patients cured symptomatically and objectively after the operation. The procedure has the advantages of early convalescence and short hospital stay. It resulted in stable urethra without jeopardizing continence or potency. More experience and longer follow-up are needed before one can advocate this treatment regimen as being comparable to the results achieved with surgical urethroplasty, which must still be regarded as the gold standard to which all forms of therapy are compared.
Two children with posterior urethral valves were treated with antegrade valves ablation via an established vesicostomy. Complete valve ablation was possible in one session. Postoperatively, both patients manifested resolution of their symptoms and normalization of the posterior urethra without residual valves. Percutaneous antegrade valve ablation is a viable alternative to transurethral approach, as it avoids urethral injury, perforation or hemorrhage.
Summary & Conclusions 120
In conclusion, percutaneous bladder procedure: as a minimally invasive treatment; has a particular advantage in management of children with lower urinary tract disorders, where the transurethral endoscopic approach may be associated with difficulties due to small urethral caliber. Meanwhile adult patients: especially when the transurethral route is not accessible; can benefit from percutaneous bladder access to perform maneuvers that were customarily performed through open surgery due to non availability of urethral access. Avoidance of risks which may be associated with open surgery or transurethral endoscopic surgery, early convalescence, and short hospital stay are the primary advantages of percutaneous bladder procedures.
Percutaneous access to the bladder by self-retaining laparoscopic sheath is simple and safe technique. It avoids drawbacks of the other techniques of creating and dilating a tract over a guidewire.
This novel technique has the following advantages :
•It provides a much rapid access to the urinary bladder.
•It avoids tract loss during manipulations, thanks to the self-retaining sheath.
•Awide range of instruments may be passed down the sheath as required to perform many procedures in the bladder and posterior urethra without compromising urethral integrity.
•Potential risks of radiation are avoided due to non usage of tluroscopy.
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