Optimal patient position for percutaneous nephrolithotomy in horseshoe kidneys: Traditional prone or supine?

OBJECTIVE: Although it was stated that supine percutaneous nephrolithotomy (PCNL) was associated with relatively shorter surgical times and comparable success and complication rates, there is no consensus in the current literature concerning the safety and efficacy of supine PCNL in patients with horseshoe kidneys. We aimed to compare supine and prone PCNL regarding safety and efficacy in patients with horseshoe kidneys. METHODS: Data of the patients with horseshoe kidneys who underwent PCNL for renal stones larger than 2 cm between January 2010 and May 2021 were retrospectively reviewed. The study patients were categorized as Group 1 (i.e., supine PCNL-SPCNL) and Group 2 (i.e., prone PCNL-PPCNL). Both groups were compared regarding demographic, clinical, and surgical data. RESULTS: Sixty-five patients were included. Among these patients, 31 (47.7%) were in Group 1, while 34 (52.3%) were in Group 2. Both groups were statistically similar in terms of demographic data, stone characteristics, perioperative parameters, and complication rates (p > 0.05). There was no statistical difference in terms of additional treatment rates, stone-free rates in the postoperative second-day and third-month evaluations (p > 0.05). Mean surgical time was significantly longer in Group 2 (113 ±â€¯17.1 min) than in Group 1 (90.6 ±â€¯11.3 min) (p = 0.000). CONCLUSION: Although it is traditionally performed in the prone position, the supine approach is as safe and effective as the prone approach. In addition, the supine approach is associated with significantly shorter surgical times.

Comparison of computed tomography and magnetic resonance imaging in the assessment of complex renal cysts by using the Bosniak classification. / Comparación entre tomografía computarizada y resonancia magnética en la evaluación de quistes renales complejos empleando la clasificación de Bosniak.

INTRODUCTION AND OBJECTIVES: The Bosniak classification of cystic renal lesions was first published in 1986 based on computed tomography (CT). In the present study, we aimed to investigate the effect of magnetic resonance imaging (MRI) on Bosniak category compared with CT, and to determine how this effect changed the treatment modality in the evaluation of complex renal cysts. MATERIAL AND METHODS: Data of 144 patients were collected retrospectively. After exclusion criteria, 102 cystic renal lesions with a Bosniak category of at least IIF on CT or MRI between 2013 and 2016 were evaluated by 2abdominal radiologists. The demographic data, Bosniak category, interobserver agreement, and pathologic data of patients who underwent surgery were recorded. RESULTS: The coherence between MRI and CT was 75.5%. The Bosniak classification of 17 patients was upgraded with MRI, and the treatment modality changed in 10 patients, and they underwent surgery. The Bosniak category was downgraded from III to IIF in 6 patients out of 8 whose Bosniak category was downgraded with MRI and the treatment modality changed. Surgery was performed in one patient out of these 6 patients, and the pathology was reported as benign. Progression was detected in the follow-up at month 18 of 1 patient out of 5, and surgery was performed. The pathology was reported as renal cell carcinoma. The pathology result was reported as RCC in 35 (68.6%) patients out of 51 who underwent surgery. Progression was detected in 7 patients out of 51 who were followed up (13.7%), and the pathology results were reported as RCC. The majority of the malignant tumors were low stage and grade. CONCLUSIONS: MRI may be successfully used in the evaluation of renal cystic lesions. In particular, the challenging Bosniak IIF and all Bosniak III lesions must be evaluated using MRI before making the decision for surgery. The upgrading of Bosniak category with MRI is more possible compared with CT due to its high-contrast resolution, therefore further studies are required to identify whether it was the cause of overtreatment of Bosniak III lesions.

Management of post-circumcision necrosis of the penis: the medicolegal aspect.

PURPOSE: To perform a medical evaluation of penile necrosis causes and treatment approaches by examining patients who had penile necrosis after circumcision surgery. METHODS: A total of 24 patients with penile necrosis after circumcision surgery, who presented at various hospitals in Turkey between September 2003 and April 2013 and whose cases were being reviewed at the Institution of Forensic Medicine with regard to malpractice, were evaluated retrospectively. RESULTS: The mean age of the patients was 5 ± 3.7 years, and the mean time of the necrosis diagnosis after circumcision was 5.2 ± 6.3 days. In etiologic terms, the predictive factors were monopolar cautery use in ten (41.6%) patients, post-circumcision infection in eight (33.3%), compartment syndrome due to post-circumcision dressing in three (12.5%), local anesthetic agent used for dorsal nerve blockage in two (8.3%), and methemoglobinemia in one (4.1%) patient. The first approaches to necrosis treatment were surgical intervention in 15 (62.5%) patients, hyperbaric oxygen treatment (HBOT) in 6 (25%), the conservative approach in 2 (8.3%), and HBOT plus surgical intervention in 1 (4.1%) patient. CONCLUSION: Penile necrosis is a preventable complication that requires early intervention. The current study will be helpful in preventing penile necrosis and in guiding surgeons in approaches following its occurrence.

Hepatocyte apoptotic index and p53 expression in obstructive jaundice rats.

OBJECTIVE: Obstructive jaundice is a serious disease. It can deteriorate critical functions in the liver. MATERIAL AND METHOD: A total of 20 male Wistar-Albino rats were randomly allocated into two groups consisting of ten in each as follows: Group I (Control) was subjected to a sham operation isolating the bile duct. Group II(Study) was subjected to acute cholestasis induced by bile duct ligation with 4/0 silk suture from two different places and full fold cut between ligatures. On the 7th day, group II rats were re-operated for liver sampling and sacrification-aimed histological analysis through the old incision with anaesthesia. Hepatic tissues were histologically and immunohistochemically processed. The number of apoptotic and p53(+) cells were measured. RESULTS: On the 7th day, the averages of direct and indirect bilirubin values in Group II rats were found to be 6.99 and 11.70 mg/dl, respectively. They were observed to be statistically significant. In the immunohistochemical evaluation p53 expression in hepatocytes was assessed, p53-positive hepatocytes were determined to exist quite widely in the tissue samples taken from the livers of rats in the study group. Nevertheless, no cells exhibiting p53 expression were found in the tissue samples of the control group. CONCLUSION: Apoptosis is a closed box and it might make it possible to stop the many disease processes or accelerate the healing. If the principal effective mechanism in the liver under a certain stress factor is apoptosis, it is definite that it will make a difference in the treatment approach. Consequently, we can say that both apoptotic index and p53 expression increase in the rats' liver with biliary obstruction (Fig. 4, Ref. 51).

C.428_451 dup(24bp) mutation of the ARX gene detected in a Turkish family.

ARX mutations give rise to both syndromic and nonsyndromic forms of mental retardation (MR). We investigated the most common ARX mutations, c.428_451 dup(24bp) and c.333ins (GCG)7 in a series of 370 mentally retarded FMR1 (CGG)n expansion mutation negative Turkish patients using PCR amplification and high resolution MetaPhor agarose gel electrophoresis. Sequence analysis was also performed for confirmation and discrimination of the mutations. One patient representing non-syndromic X-linked MR showed an abnormal band pattern on agarose gel and sequence analysis of exon 2 of the ARX gene revealed that the patient had the c.428_451 dup(24bp) mutation. When we screened the family members, we found that his sister and mother were also carrier for the same mutation. The proband showed mild MR and subtle clinical findings like dysarthria and lack of fine motor functions. In conclusion, the patients with weak fine motor skills and positive family history for X-linked MR should be screened for the most common ARX gene mutations.

The effect of NG-nitro L-arginine methyl ester on colonic anastomosis after increased intra-abdominal pressure.

BACKGROUND: Intestinal ischemia-reperfusion (I/R) is associated with augmented nitric oxide (NO) production. Increased intra-abdominal pressure (IAP) during surgical pneumoperitoneum (P) facilitates I/R injury. We previously demonstrated decreased strength and healing of colocolic anastomoses after high IAPs. The effect of an NO synthase inhibitor, N (G)-nitro-arginine methyl ester (L: -NAME), on anastomoses realized in colonic tissue exposed to high IAPs was investigated in this study, a randomized, controlled, and experimental study with blind outcome assessment. METHOD: Fifty Wistar-albino rats were randomized to five groups; all underwent colocolic anastomosis. P was maintained for 60 min at IAPs of 14, 20, 25, and 30 mmHg in study groups 1, 2, 3, and 4, respectively; P was preceded by intraperitoneal L: -NAME (2.5 mg/kg) and followed by anastomosis. The control group was not subjected to IAP or L: -NAME. RESULTS: Anastomosis bursting pressure (ABP) values and histopathological findings were determined on the 7th-14th postoperative days. The ABPs of groups 3-4 were significantly lower than the others. Groups 1-2 had results similar to controls. Histopathological findings of the groups were consistent with their ABPs. CONCLUSION: Administration of a 2.5-mg/kg intraperitoneal L: -NAME dose was found to provide a beneficial role, implying a role in impaired anastomotic healing after IAPs of 14 and 20 mmHg.

A comparison of the oxidative stress response and antioxidant capacity of open and laparoscopic hernia repairs.

BACKGROUND: Free radical-induced lipid peroxidation that is associated with a decrease in the antioxidant status of plasma occurs in many kinds of surgical procedures. In this study, we aimed to investigate markers of oxidative stress--malondialdehyde (as thiobarbituric acid reactive substances), protein carbonyls, and protein sulfhydryls--in patients undergoing Lichtenstein tension-free hernioplasty (LH) or laparoscopic preperitoneal hernia (LPPH) repair. METHODS: Seventeen patients with unilateral inguinal hernia and no complications or recurrence were included in this study. Ten were randomized to undergo LH and seven to LPPH repair. Heparinized blood samples were taken to measure the levels of oxidative stress markers in the patients undergoing hernia repair. Levels of malondialdehyde, protein carbonyls, and protein sulfhydryls were measured preoperatively and at 6 and 24 hours postoperatively in all patients. RESULTS: Both types of hernia repair caused a significant increase in the oxidative stress response and a decrease in antioxidant activity. Plasma levels of malondialdehyde and carbonyls (indicators of oxidant activity) were significantly higher in the LH than in the LPPH repair group (P<.05), and plasma sulfhydryl levels (indicators of antioxidant activity) were significantly lower in the LH than in the LPPH group (P<.05). In both groups, significant differences were also found between the preoperative levels and the postoperative levels 6 and 24 hours (P<.05). CONCLUSIONS: These data demonstrate that both LH and LPPH repair cause a significant increase in markers of oxidative stress; however, the oxidative stress response associated with LH is greater than that associated with LPPH repair.

The effects of increased intraabdominal pressure on colonic anastomoses.

BACKGROUND: This experimental, randomized, controlled study was designed to investigate the effects of increased intraabdominal pressure (IAP) on colocolic anastomoses. To our knowledge, this is the first study to address this important issue. METHODS: For this study, 50 Wistar albino rats were randomized into five groups. The animals in all the groups underwent laparotomy and colocolic anastomosis. The rats in the control group were not subjected to increased IAP. Accordingly, IAP's of 14, 20, 25, and 30 mmHg were established by carbon dioxide insufflation and maintained for 60 min in study groups 1, 2, 3 and 4, respectively. Colocolic anastomosis was realized after these periods of IAP in the study groups. Half of the surviving rats in all the groups were sacrificed on postoperative days 7 and 14 to allow comparison between the control and study groups with respect to their mean body weights, mean anastomosis bursting pressures, and histopathologic characteristics of their anastomosis sites. RESULTS: The mean body weights of all the groups were comparable at all times during the study. The anastomosis bursting pressures of the animals subjected to increased IAP were lower than that of the control group, with the differences reaching statistical relevance for the animals subjected to an IAP of 20 mmHg or higher on postoperative day 7 (p <0.0005 for study groups 2, 3, and 4 vs the control group) and becoming more pronounced by the day 14 (p <0.0005 for study groups 2, 3, and 4 vs the control group). The anastomosis bursting pressure showed an inverse correlation with IAP. The adequacy of mucosal layer formation at the anastomosis line was lower and the degree of inflammation was higher in the groups exposed to an IAP of 20 mmHg or higher in the control group (p <0.05 for both comparisons among study groups 2, 3 and 4 vs the control group). CONCLUSIONS: An IAP increased to 20 mmHg and higher was found to result in impaired strength and wound healing in colocolic anastomoses, as reflected by the decreased bursting pressure and mucosal layer formation, and by the increased inflammation at the anastomosis sites of animals subjected to high IAP values.

Human immunodeficiency virus infection in pregnancy.

The incidence and prevalence of human immunodeficiency virus (HIV) infection in women of child-bearing age continue to increase both internationally and in Canada. The care of HIV-infected pregnant women is complex, and multiple issues must be addressed, including the current and future health of the woman, minimization of the risk of maternal-infant HIV transmission, and maintenance of the well-being of the fetus and neonate. Vertical transmission of HIV can occur in utero, intrapartum and postpartum, but current evidence suggests that the majority of transmission occurs toward end of term, or during labour and delivery. Several maternal and obstetrical factors influence transmission rates, which can be reduced by optimal medical and obstetrical care. Zidovudine therapy has been demonstrated to reduce maternal-infant transmission significantly, but several issues, including the short and long term safety of antiretrovirals and the optimal use of combination antiretroviral therapy in pregnancy, remain to be defined. It is essential that health care workers providing care to these women fully understand the natural history of HIV disease in pregnancy, the factors that affect vertical transmission and the management issues during pregnancy. Close collaboration among a multidisciplinary team of knowledgeable health professionals and, most importantly, the woman herself can improve both maternal and infant outcomes.