Changes in percutaneous approach to kidney stones in children: A single institute experience over 500 cases.

PURPOSE: The aim of this study is to identify the changes in patient age and stone sizes with technological advancement over time. METHODS: This study was conducted retrospectively with 404 patients (504 renal units) who underwent percutaneous nephrolithotomy (PCNL) between January 1997 and June 2020. Patient characteristics and trends on instrument preferences were investigated. RESULTS: Median age was 7 (1-18) years. Male to female ratio was 1.48:1 (301/203). Median stone burden was 2 cm2 (0.20-25) and median operative time was 90 minutes (20-240). The stone-free rate was 74.6%. Patients were divided into four groups according to the size of the instrument. It was found that the size of sheath used increased significantly with increasing age and stone burden. The micro-PCNL group had the shortest hospitalisation and lowest blood transfusion rate. Chronologically categorised four equal groups were compared to analyse changing patient profiles and trends. Median patient age, stone burden, operation time, sheath size, blood transfusion and complication rates decreased significantly with time. However, the use of tracts smaller than 20F and the number of patients with previous intervention increased significantly. CONCLUSION: Our study demonstrated that the patient's age and stone size at the time of initial diagnosis decrease over time while miniaturisation techniques increase in paediatric urology.

Clinical practice in vesicoureteral reflux with respect to EAU guidelines: A multicenter study.

PURPOSE: We designed a multicenter, retrospective study to investigate the current trends in initial management of reflux with respect to European Association of Urology (EAU) Guidelines in Urology clinics of our country. MATERIALS AND METHODS: The study group consisted of 1988 renal units (RU) of 1345 patients treated surgically due to vesicoureteral reflux (VUR) (between years 2003 and 2017) in nine different institutions. Patients were divided into two groups according to time of initial treatment and also grouped according to risk factors by "EAU guidelines on VUR." RESULTS: In this series, 1426 RUs were treated initially conservatively and 562 RUs were initially treated with surgery. In initially surgically treated group, success rates of surgery decreased significantly in low and moderate risk groups after 2013 (P = .046, P = .0001, respectively), while success rates were not significantly different in high risk group (P = .46). While 26.6% of patients in low risk group were initially surgically treated before 2013, this rate has increased to 34.6% after 2013, but the difference was not statistically significant (P = .096). However, performing surgery as the initial treatment approach increased significantly in both moderate and high risk groups (P = .000 and P = .0001, respectively) after 2013. Overall success rates of endoscopic treatments and ureteroneocystostomy (UNC) operations were 65% and 92.9% before 2013 and 60% and 78.5% after 2013, respectively. Thus, the overall success rate for surgery was 72.6%. There was significant difference between success rates of UNC operations before and after 2013 (P = .000), while the difference was not significant in the injection group (P = .076). CONCLUSION: Current trends in management of reflux in our country do not yet follow the EAU guidelines on VUR in low and moderate risk groups despite these reliable and accepted guidelines were expected to influence our daily approach.

The SPARE score reliably predicts the conversion from open partial to radical nephrectomy.

AIM: To assess the power of nephrometry scores to predict the intraoperative conversion from partial nephrectomy (PN) to radical nephrectomy (RN). METHODS: We identified all the patients at our institution who were scheduled for PN between April 2012 and December 2017. Patients who underwent robotic or laparoscopic surgery were excluded. A total of 149 patients (94 men) who underwent open surgery and had complete data were included. The power of the R.E.N.A.L., PADUA, SPARE, and DAP scores to predict the conversion to RN, and the threshold values were assessed. In the multivariate analysis, the predictive power of the nephrometry scores was tested by separately including them in different models. RESULTS: The median age was 57 (48-67) years, while the median follow-up was 15 (7-29.5) months. The overall conversion rate was 10.7%. The optimal cut-off values for the R.E.N.A.L., PADUA, SPARE, and DAP scores were 7.5, 9.5, 5.5 and 7.5, respectively. The SPARE score had the highest area under the curve (AUC=0.807, P<0.001). In the multivariate analysis, the SPARE score had the highest odds ratio (OR 12.561; confidence interval 3.456-45.534, P<0.001]. CONCLUSION: A high SPARE score was significantly associated with the conversion to RN in patients who underwent open PN.

Assessing the Association of Surface-Intermediate-Base Margin Score with Perioperative Outcomes and Parenchymal Volume Preserved during Partial Nephrectomy.

INTRODUCTION: The present study aimed to compare the assessment of volume preservation and perioperative outcomes during partial nephrectomy (PN), according to the surface-intermediate-base (SIB) score. METHODS: This prospective study included 80 patients diagnosed with renal cell carcinoma who underwent PN for a renal mass from 2014 to 2017. SIB score was macroscopically evaluated immediately after the surgery. Preoperative assessment of volume preservation (PAVP), surgeon assessment of volume preservation (SAVP), duration of ischemia, perioperative complications, pathological data, and the values of preoperative and postoperative estimated glomerular filtration rate (eGFR) were recorded. RESULTS: A strong correlation was determined between PAVP and SAVP (R = 0.82, R2 = 0.68, p < 0.0001) and between vGFR-PAVP and vGFR-SAVP calculated using the adapted eGFR (preop eGFR × [PAVP or SAVP]) (R = 0.97, R2 = 0.95, p < 0.001). In multivariate analysis, preoperative tumor size, SIB score (1-2 vs. 3-5), and vGFR (PAVP and SAVP model) were significant predictors of postoperative eGFR. A low base score was associated with surgical margin positivity, and a high SIB score (≥3) was associated with perioperative complications (p = 0.017; p = 0.028). CONCLUSION: The SIB score can be considered a reliable surrogate for volume preservation after PN because it is strongly associated with both PAVP and SAVP. SIB score is useful in predicting functional outcomes, complications, and surgical margin positivity.

Is Low-risk Prostate Cancer Really Low-risk? Consider Factors Affecting Biochemical Recurrence and Tumour Upgrade.

OBJECTIVE: To evaluate the demographics, preoperative or pathological factors, and findings of magnetic resonance imaging (MRI) to predict the factors affecting biochemical recurrence and tumour upgrade in low-risk prostate cancer. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Department of Urology, Bolu Abant Izzet Baysal University, Bolu, Turkey, from January 2017 to December 2021. METHODOLOGY: The data of 135 patients, who underwent radical prostatectomy for low-risk prostate cancer according to prostate-specific antigen (PSA) level, biopsy result and clinical stage, were analysed. Preoperative clinicopathological factors, MRI findings, and the final pathological results were analysed. Prognostic factors affecting the biochemical recurrence in the follow-up and tumour upgrade in the final pathology according to the International Society of Urological Pathology (ISUP) were evaluated. RESULTS: Mean age and preoperative PSA level were 61.37 ± 5.53 (46-74) years and 6.74 ± 1.97 (range 1.88-9.9) ng/dL, respectively. Multivariate analysis showed that the prostate volume and diameter of lesions were statistically significant in the patients with ISUP upgrade (p=0.006, p=0.025, respectively), and surgical margin positivity in the final pathology specimen was statistically significant for biochemical recurrence (p=0.016). Logistic regression analysis revealed that prostate volume and diameter of the lesion in MRI were independent predictors of ISUP score upgrade. Receiver operating characteristic (ROC) curve analysis showed that tumour size on the MRI had 49.4% sensitivity and 77.8% specificity at 10 mm (AUC:0.634, p=0.009 for predicting). CONCLUSION: Lower prostate volume, higher diameter of lesions in multiparametric MRI and surgical margin positivity were associated factors affecting the ISUP score upgrade and biochemical recurrence. Therefore, patients should be evaluated preoperatively and patient-based factors should be considered in the choice of a treatment plan. KEY WORDS: Prostate cancer, Cancer upgrade, Tumour size.

Efficacy of intravesical cocktail therapy with or without dimethyl sulphoxide in interstitial cystitis.

Introduction: Interstitial cystitis (IC) is a chronic bladder inflammation with unknown etiologies that impairs the quality of life of patients. We aimed to investigate the efficacy of dimethyl sulphoxide (DMSO) use in the cocktail therapy in IC patients. Material and methods: Patients treated with intravesical cocktail therapy which contained a mixture of 10 mL of bupivacaine, 1 mL of heparin, and 9 mL of sodium bicarbonate, was introduced to Group 1, and, 25 mL of DMSO was added to this cocktail and introduced to Group 2. Statistical analyses between groups were assessed by Turkish validated O'Leary Sant score composed of IC Symptom Index (ICSI) and IC Problem Index (ICPI), visual analog scale (VAS) score, and short form-36 (SF-36) questionnaire in the baseline versus post-instillation week 6, month 6, and month 12, comparatively. Results: A total of 62 patients (58 women and 4 men) with a median age of 52 (28-76) years were included. Baseline versus post-instillation 6th week of ICSI and ICPI scores were 15 ±3.4 vs 7.4 ±2.9 and 12.6 ±2.8 vs 6.1 ±2.7, respectively (p <0.001 and <0.001, respectively). VAS scores of Group 2 were statistically significantly lower than that of Group 1 in the post-instillation month 6 (p = 0.03) whereas, the baseline of VAS scores were similar. Conclusions: Intravesical cocktail therapy is an effective and reliable treatment method and can be safely applied with or without DMSO. Adding DMSO to cocktail therapy provides a further decrease in VAS score in the post-instillation month 6.

Predictors of ISUP score upgrade in patients with low-risk prostate cancer.

INTRODUCTION: The literature contains few studies that focus on the relationship between International Society of Urological Pathology (ISUP) score upgrade and complete blood count (CBC) parameters for patients with low-risk prostate cancer and studies achieved inconclusive results. METHODS: We retrospectively analyzed our institutional database for patients with prostate cancer who underwent radical prostatectomy (RP) between 1994 and 2017. In total, we included 633 patients with low-risk prostate cancer in the study. We investigated the effects of clinicopathologic factors on ISUP score upgrade. Moreover, we compared RP pathologic outcomes between the patients with and without ISUP score upgrade. RESULTS: The mean age and follow-up periods were 61.09±6.61 years and 41.9±1.8 months, respectively. ISUP score upgrade was observed in 207 patients (32.7%). In multivariate analysis, high prostate-specific antigen (PSA) density and percentage of positive cores were found to be significantly associated with ISUP score upgrade (p = 0.003 and p = 0.003, respectively). The neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, and eosinophil-lymphocyte ratio were found to have no effect on ISUP score upgrade (p = 0.856, p = 0.353, p = 0.128, and p = 0.074, respectively). The percentage of tumors, surgical margin positivity, seminal vesicle invasion rate, and extraprostatic extension rate in RP pathology were higher in patients with ISUP score upgrade (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: Approximately one-third of the patients in our series had ISUP score upgrade in RP pathology. PSA density and the percentage of positive cores were found to be the factors significantly associated with ISUP score upgrade. CBC-related factors had no effect on ISUP score upgrade.

An Important Risk Factor Affecting Hypercalciuria in Children: Vesicoureteral Reflux.

INTRODUCTION: A large number of genes and environmental factors, like dietary habits, play a role in the development of hypercalciuria in children. In this study, we aimed to determine the effects of the presence and grade of vesicoureteral reflux (VUR) on hypercalciuria status in children. MATERIALS AND METHODS: Data for 165 patients who admitted to the Pediatric Urology Department were retrospectively analyzed. The patients were composed of following four different groups: (1) urinary stone patients, (2) VUR patients under follow-up, (3) corrected VUR patients, and (4) control. The demographic features, clinical data, and laboratory tests for the groups were compared. RESULTS: The mean age of the patients was 100.6 ± 54.69 months and the female/male ratio was 79:86. The mean urinary calcium/creatinine (UCa/Cr) excretion and the frequency of high UCa/Cr ratios in the corrected VUR group were similar to those in the control group (p = 0.375 and 0.965, respectively). In contrast, the mean UCa/Cr excretion and frequency of high UCa/Cr ratios in the urinary stone and follow-up VUR groups were significantly higher than those in the corrected VUR group (p < 0.001, < 0.001, 0.003, and 0.029, respectively). The mean UCa/Cr excretion and frequency of high UCa/Cr ratios in the follow-up VUR group were similar to those in the urinary stone group (p = 0.323 and 0.425, respectively). In the follow-up VUR group, although reflux laterality had no effect on the UCa/Cr ratios (p = 0.180 and 0.108, respectively), the mean and frequency of high UCa/Cr ratios were higher in high-grade reflux cases (p < 0.001 and p = 0.042, respectively). CONCLUSION: Both the mean UCa/Cr ratio and the rate of hypercalciuria in the corrected reflux group were significantly lower than the corresponding values in the follow-up VUR and urinary stone groups. Further, the follow-up VUR patients had similar urinary calcium excretion levels as the stone patients. VUR treatment is associated with a decrease in urinary calcium excretion to the normal population level. A positive correlation between reflux degree and calcium excretion was observed.

A single center's experience in pediatric cystine stone disease management: what changed over time?

The authors aimed to evaluate the factors affecting clinical outcomes of cystine stone disease in children and to understand the change in disease management over time. Between January 1991 and September 2017, the demographic and clinical data of pediatric patients with documented cystine stone disease were retrospectively analyzed. Patients with at least 12-month follow-up were included. Disease management and clinical outcomes were compared between the first and second 35 patients managed during the study's time frame. A total of 70 patients were included. The female to male ratio was 30/40. The mean age and follow-up period was 29.8 ± 40.1 months and 106.5 ± 56 months, respectively. The mean initial procedure number to treat the first stone episode was 2.4 ± 1.6. Single stone and single affected site were significant predictors for stone clearance. Overall, patients underwent a mean of 5.5 procedure during their follow-up. Recurrence was detected in 71.4% (50/70) of patients. Residual fragments and non-compliance to medical treatment after the initial intervention were significant predictors for recurrence within shorter interval period. 31.4% (22/70) of patients had renal atrophy during follow-up. They were older at the initial diagnosis and had average urine pH lower than 7.5. The first 35 patients had more open procedures. Still, they had more recurrence rate and tend to have more renal atrophy. As a conclusion, cystine stone disease has a recurrent course in children. Stone and fragments entirely removed (SaFER) concept with all minimally invasive methods available and strict follow-up should be the basis for any management plan.

Outcomes of Percutaneous Nephrolithotomy in Preschool Age Group: A Single-Center Study.

Objective: To determine the factors affecting the outcomes of percutaneous nephrolithotomy (PCNL) in patients in infantile/toddler and preschool age group. Materials and Methods: The data of 186 renal units from 152 patients who underwent PCNL were retrospectively analyzed. Patients under ≤72 months of age were included in the study. The patients were divided into two groups according to their age: infantile/toddler and preschool group. Demographics and stone features were compared between infantile/toddler and preschool age groups. Effects of different factors on complications and stone-free rates were investigated. Comparisons in the study were done using SPSS 24.0 software for Windows. Results: The mean age of the patients was 40.5 ± 16.5 months, and the female/male ratio was 87/99. The median stone burden was 1.92 cm2 (0.12-20). Stone-free rates were 75.3% and 84.4% when cases with Clinically Insignificant Residual Fragments were also included. The numbers of patients with Clavien grade 1, grade 2, and grade 3b complications were 7 (3.8%), 39 (21%), and 9 (4.8%), respectively. There was no difference between infantile/toddler and preschool children in terms of stone-free and complication rates (p = 0.082, p = 0.088, respectively). Mini PCNL and tubeless-totally tubeless- urinary diversion techniques were more frequently performed in the infantile/toddler group compared to the preschool group (p = 0.001, p = 0.028, respectively). Presence of staghorn stone was the only significant factor for complications, while the number of stones was significant for stone-free rates for patients ≤72 months (p = 0.012, p = 0.001, respectively). Stone burden was the only predictive factor for complications in patients aged ≤36 months, while number of stones was predictive for success in patients aged between 37 and 72 months (p = 0.034, p = 0.006, respectively). Conclusion: PCNL is a feasible and effective method in preschool age group with acceptable complications and high success rates. Presence of staghorn stone is predictive for complications, while number of stones is predictive for success in the preschool age group.

Semi-Rigid Ureteroscopy Should Not Be the First Option for Proximal Ureteral Stones in Children.

PURPOSE: To investigate the factors that predict the success and complication rates of semi-rigid ureteroscopy (URS) in pediatric population. MATERIALS AND METHODS: This is a retrospective analysis of the database including 182 patients who underwent URS between 2001 and 2016. The possible factors that might affect the outcome were age, gender, stone laterality, largest stone size, number of stones, stone location, orifice dilatation status, and caliber of ureteroscope. RESULTS: The mean age was 68.1 (7-204) months, and male-to-female ratio was 94:88. Operative side was left for 97, right for 82, and bilateral for 3 patients. One hundred and forty-four patients had a single stone, and 38 patients had multiple stones. The median largest stone size was 7 (2-20) mm. Postoperative ureteral stenting was performed in 150 (86.2%) patients. The overall success rate was 84.6%, while 81.6% and 85.4% in 8F URS and 4.5F URS groups, respectively (p = 0.560). Stone-free rate was higher among patients who were older than 36 months, distal ureteral stones and single stones (p = 0.012, 0.002, and 0.009, respectively). Complication rate was higher for proximally located stones (p = 0.029). The mean follow-up was 23.9 ± 32.5 months. CONCLUSION: URS is a safe procedure with acceptable success rates in the pediatric population. Younger age, multiple stones, and proximal location are the predisposing factors for failure, whereas proximal location was the only factor for complication occurrence. Therefore, semi-rigid ureteroscopy should not be the first choice in the treatment of proximal ureteral stones, and alternative methods should be preferred, if available.

Positioning the Instillation of Contrast Cystography: Does It Provide Any Clinical Benefit?

OBJECTIVE: To outline positioning the instillation of contrast cystography (PICC)'s benefits in clinical practice. MATERIALS AND METHODS: A total of 198 patients underwent PICC with the following indications: patients with positive preoperative conventional voiding cystourethrography (VCUG) for a single ureteric side, patients with urinary tract infection (UTI), and negative VCUG for both ureteric sides. Patients with positive VCUG served as the control group. Preoperative, intraoperative, and postoperative features of all patients were compared. RESULTS: The reflux rate for the contralateral vesicoureteric reflux (VUR) investigation group was 39.1%. Only the cystoscopic view of the anatomically deficient ureteric orifice was found to be a significant predictor of contralateral reflux (P = .002). For patients who presented with UTI, the reflux rate was 58.3%. Resolution of infection was assessed for patients who presented with UTI, and 54.1% of these patients had a complete response in the follow-up period. When the patients were classified as PICC positive and negative, infection-free rates were 58.3% and 48%, respectively (P = .296). CONCLUSION: PICC is an effective diagnostic method for revealing occult reflux. However, the clinical significance of this finding is vague. In patients with UTI, PICC was useful for diagnosing occult VUR and clearing the symptoms in more than half of the patients. Further, the symptom-free state in the follow up period was slightly higher but not more significant than it was in those with no VUR diagnosed.

Percutaneous Nephrolithotomy in Solitary Kidneys: 17 Years of Experience.

OBJECTIVE: To compare the demographics and the results of patients who underwent percutaneous nephrolithotomy (PCNL) with solitary and bilateral kidneys. MATERIALS AND METHODS: Between January 1998 and August 2014, 2268 patients underwent PCNL at Hacettepe University Hospital. We retrospectively analyzed the data of 91 patients with a solitary kidney and 2177 patients with bilateral kidneys treated by PCNL. We compared the success and complication rates between patients with solitary and bilateral kidneys. Additionally, we determined the factors affecting success and serious complications for patients with a solitary kidney. All statistical analyses were performed using SPSS 17.0 for Windows. The threshold for statistical significance was set at P <.05. RESULTS: The median age was 48 years and 61 patients (67%) were male. The median stone burden was 400 mm2. The stones were located in the renal pelvis in 27 patients (30%), in calices in 50 patients (55%), and in the staghorn in 14 patients (15%). A total of 57 patients (62%) underwent a left-side surgery. The comparison between solitary and nonsolitary patients showed that stone free, transfusion, and postoperative urinary tissue infection rates were similar. Complication rates, postoperative JJ stent requirements, and length of hospital stay were statistically higher in patients with a solitary kidney. The presence of a staghorn stone, the stone number (single-multiple), and male gender were found to have a negative impact on success. The existence of upper-pole stones was found to be the only factor that led to serious complications (Clavien 3-4). CONCLUSION: PCNL is an effective but more complicated option in patients with a solitary kidney, with stone-free rates similar to patients with bilateral kidneys.

Is There Any Difference Between Questionnaires on Pediatric Lower Urinary Tract Dysfunction?

OBJECTIVE: To investigate the diagnostic properties of 3 different scoring systems (Dysfunctional Voiding Symptom Score [DVSS], Dysfunctional Voiding and Incontinence Symptoms Score [DVISS], Incontinence Symptom Index-Pediatric [ISI-P, for children older than 11 years]) that are used to evaluate lower urinary tract symptoms in pediatric population. MATERIALS AND METHODS: Eighty-four participants were evaluated by detailed history, physical examination, 3 different scoring systems (DVSS, DVISS, ISI-P), ultrasonography, and uroflowmetry. Depending on the tests, cases were stratified as healthy or lower urinary tract symptoms (LUTS) by 2 urologists who were blinded to the questionnaires. Patients were reevaluated by the same tests and questionnaires 3 months after treatment. Diagnostic properties of questionnaires were calculated. Additionally, parents were asked to scale the improvement of symptoms subjectively from 0% to 100% to correlate to each of the three scoring systems. RESULTS: The mean ages of the normal and the LUTS groups were 9.1 ± 2.6 years and 10.1 ± 2.8 years, respectively (P = .301). Gender (male:female) distribution was 21:21 in the LUTS group and 25:17 in the control group (P = .381). In terms of diagnosis, DVISS has the highest accuracy (sensitivity: 81%, specificity: 97.6%, accuracy: 89%) followed by ISI-P (sensitivity: 55.6%, specificity: 100%, accuracy: 82%) and DVSS (sensitivity: 54.8%, specificity: 97.6%, accuracy: 76%). The similar order was valid for the 23 patients older than 11 years (accuracy for DVISS: 87%, for ISI-P: 82%, and for DVSS: 78%). In terms of response to treatment, all 3 tests showed good correlation with parents' ratings (DVSS: P < .001, DVISS: P = .005, ISI-P: P = .042). CONCLUSION: Although DVISS had the highest accuracy in distinguishing the patients from healthy controls, all 3 questionnaires seem to be equivalent for the evaluation of response to treatment.

Predicting the stone composition of children preoperatively by Hounsfield unit detection on non-contrast computed tomography.

INTRODUCTION: Many studies have been performed on adult patients to reveal the relationship between Hounsfield unit (HU) value and composition of stone, but none have focused on childhood. OBJECTIVE: We aimed to predict stone composition by HU properties in pre-intervention non-contrast computed tomography (NCCT) in children. This could help to orient patients towards more successful interventions. MATERIALS AND METHODS: Data of 94 children, whose pre-intervention NCCT and post-interventional stone analysis were available were included. Stones were grouped into three groups: calcium oxalate (CaOx), cystine, and struvite. Besides spot urine PH value, core HU, periphery HU, and Hounsfield density (HUD) values were measured and groups were compared statistically. RESULTS: The mean age of patients was 7 ± 4 (2-17) years and the female/male ratio was 51/43. The mean stone size was 11.7 ± 5 (4-24) mm. There were 50, 38, and 6 patients in the CaOx, cystine, and struvite groups, respectively. The median values for core HU, periphery HU, and mean HU in the CaOx group were significantly higher than the corresponding median values in the cystine and struvite groups. Significant median HUD difference was seen only between the CaOx and cystine groups. No difference was seen between the cystine and struvite groups in terms of HU parameters. To distinguish these groups, mean spot urine PH values were compared and were found to be higher in the struvite group than the cystine group (Table). DISCUSSION: The retrospective nature and small number of patients in some groups are limitations of this study, which also does not include all stone compositions. Our cystine stone rate was higher than childhood stone composition distribution in the literature. This is because our center is a reference center in a region with high recurrence rates of cystine stones. In fact, high numbers of cystine stones helped us to compare them with calcium stones more accurately and became an advantage for this study. CONCLUSIONS: NCCT at diagnosis can provide some information for determination of stone composition. While CaOx stones can be discriminated from cystine and struvite stones using HU parameters, a simple spot urine pH assessment must be added to distinguish cystine stones from struvite stones.

Invasive Squamous Carcinoma and Adenocarcinoma of an Unreconstructed Exstrophic Bladder with HPV Infection.

Bladder exstrophy is a complex abnormality and is traditionally treated within the early years of life. It is associated with an increased risk of bladder cancer, with 95% of the arising tumors being adenocarcinomas and 3 to 5% being squamous cell carcinomas. HPV infections are also associated with an increased risk of bladder cancer. This case represents a patient with bladder exstrophy that gave rise to coinciding squamous cell carcinoma and adenocarcinoma. Final pathology results showed an infection with HPV. We presented the management of the case and discussed the diagnosis and treatment methods for this patient.

The nomogram conundrum: a demonstration of why a prostate cancer risk model in Turkish men underestimates prostate cancer risk in the USA.

PURPOSE: The utility of a nomogram is based on the patient population it is designed for-and their inherent properties and biases. Our aim was to demonstrate the variability in predictive model accuracy and utility between different populations. METHODS: Our model is based on 761 men who underwent initial TRUS biopsy at a single institution in Turkey. Patients were included if they had at least 10 cores on biopsy and PSA level <20 ng/ml. Multivariable logistic regression models were used to develop a new nomogram. External validity was tested with two different cohorts one from another institution in Turkey (N = 136) and cohort from USA (N = 2242). RESULTS: Prostate cancer (PCa) and high-grade PCa was diagnosed in 249/761 (32.7 %) and 101/761 (13.3 %) patients from Ankara, Turkey, respectively. Predictors of PCa were age (p < 0.0001, OR 2.11), PSA (p = 0.044, OR 1.44), PV (p < 0.0001, OR 0.38), %fPSA (p = 0.016, OR 0.72), and abnormal DRE (p < 0.0001, OR 2.05). The predictive accuracy (c-index) of our nomogram was 73 %. C-indices of 71 and 70 % were recorded in external validation cohorts from Turkey and the USA, respectively. Virtually ideal calibration was recorded for the internal validated predictive model, and good calibration was recorded when applied to the Istanbul cohort. However, the model/nomogram underestimates PCa risk in the US cohort. CONCLUSION: This is the first nomogram predicting the risk of PCa at initial biopsy in a Turkish population and provides a good risk estimation tool with good predictive accuracy and calibration in the Turkish populations. However, our study demonstrates the poor transferability of predictive tools to widely different populations.

Factors affecting the success of endoscopic treatment of vesicoureteral reflux and comparison of two dextranomer based bulking agents: does bulking substance matter?

INTRODUCTION: Among the interventional treatment modalities for vesicoureteral reflux (VUR), endoscopic subureteric injection seems to be the least invasive method with acceptable outcomes when applied in appropriate patients. OBJECTIVE: The aim of the presented study is to investigate the parameters which may affect the outcomes of endoscopic injection and to compare the efficacy of two different bulking agents both composed of dextranomer-hyaluronic acid copolymer. STUDY DESIGN: The data of patients who underwent endoscopic VUR treatment between 2003 and 2012 were retrospectively reviewed. Patients with history of previous open antireflux surgery, more than one failed endoscopic treatment for reflux, VUR caused by posterior urethral valve, duplex system and overt spinal dysraphism were excluded. Surgical technique was the classical STING method. One of the two dextranomer-hyaluronic acid copolymer agents was used (Deflux in 109 and Dexell in 131 patients). Both agents were composed of similar amounts of hyaluronic acid gel (15 mg in Deflux versus 17 mg in Dexell) but different sized dextranomer microspheres (80-250 µm in Deflux and 80-120 µm in Dexell). During the follow-up, ultrasonography was performed with 3-month interval, antibiotic prophylaxis was continued until the control voiding cystourethrography (VCUG) was taken. Patient based success was defined as the disappearance of reflux on control VCUG performed 3-6 months after the operation. RESULTS: Data were available for 240 patients. Mean age and mean postoperative follow-up were 78 ± 41 months and 19 ± 18 months. The overall success rate was 73.2%. Gender, laterality, grade of VUR, presence of voiding dysfunction, renal scar and preoperative breakthrough infection (BTI) were not found to affect the outcome, whereas age younger than 54 months and previous history of failed endoscopic injection were found to negatively affect the outcome both in univariate and multivariate analysis. The postoperative UTI (5 febrile and 43 nonfebrile) rate was 20%. Both univariate and multivariate analysis showed that postoperative UTI was more common in patients with persisting reflux, with preoperative breakthrough infections and in girls. Patient characteristics, treatment outcome and postoperative UTI rate were similar regarding the used bulking agent. No ureteral obstruction was experienced within the follow-up period. DISCUSSION: Our success rate for second injection is about 60%, which is significantly lower than for the patients who underwent first injection. We could not find any affecting factor for this difference. Contrary to the literature, our success rates were similar in different reflux grades. We can explain this finding that we value the intraoperative orifice configuration more than the grade which can be accepted as a patient selection bias. The lower success rate in children younger than 54 months can be explained by unstabilized bladder dynamics and higher voiding pressures in this age group, who are still in the toilet-training phase. Despite successful endoscopic treatment, UTI might occur. Postoperative UTI was more common in patients with persisting reflux, preoperative BTI and girls. The similar success rates of both bulking agents proved that dextranomer size does not affect the clinical outcome. Limitations of our study can be counted as follows: 1. the data do not include the number of patients in whom conversion to open surgery was decided intraoperatively because of the unfavorable orifice configuration, 2. our data do not include the injected volume records. CONCLUSION: Endoscopic treatment of VUR has satisfying outcomes in properly selected cases. Younger age (<54 months) and previous history of failed injection history were found to be related to unfavorable results. Postoperative UTI occurs more frequently in patients with persisting reflux, preoperative breakthrough infection history and girls. The choice of one of the dextranomer-based substances does not affect the surgical outcome and postoperative UTI development.

A new nomogram for prediction of outcome of pediatric shock-wave lithotripsy.

INTRODUCTION: Despite the fact that shock-wave lithotripsy (SWL) remains a very good treatment option for smaller stones, it is being challenged by endourologic treatment modalities, which offer similar or even higher success rates in a shorter time, with minimal morbidity and invasiveness. The present study aimed to bring a new and practical insight in order to predict the outcomes of pediatric SWL and to provide objective information about pediatric SWL outcomes. OBJECTIVE: To design a nomogram for predicting the outcomes of pediatric shock-wave lithotripsy. STUDY DESIGN: The study was conducted with a retrospective design and included 402 renal units who underwent SWL between January 2009 and August 2013. Patients with known cystine stone disease and cystinuria, with internal or external urinary diversion, were excluded. Analysis was performed on 383 renal units. Postoperative imaging was performed by plain abdominal graphy and ultrasonography with 3-month intervals. Patients who were completely free of stones were considered to be a success and statistical analysis was done regardingly Multivariate analysis was conducted by logistic regression analysis and a nomogram was developed. RESULTS: The male/female distribution was 216/167, with a mean age of 48 ± 40 months and a mean stone size of 9 ± 3.5 mm. The overall stone-free rate was 70% (270/383) and efficacy quotient was 0.57. Mean follow-up was 11 ± 11 months (3-54 months). The number of shock waves and amplitude of energy were higher in failed cases. Multivariate analysis showed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. A nomogram was developed using these parameters. In this nomogram, the points achieved from each parameter are summed and total points correspond to the risk of failure in percent. DISCUSSION: A previous nomogram study by Onal et al. showed that younger age (<5 years), smaller stone burden (<1 cm), absence of previous stone treatment history, single stone, pelvis or upper ureter location (in girls) were favorable prognostic factors for successful outcome. As being the first pediatric study, it had some shortcomings. The study included 381 patients within a time period of 16 years. The present study included a similar number of cases within a 4-year period, which may reflect more homogeneity of data collection. Another issue is concern about the practical use of that nomogram. It constitutes two pages, which is a limiting factor for daily use. From a statistical point of view, they performed 200 bootstrapings with the aim of internal validation, which is less than the ideal number of 1000 bootstrapings, which was performed in the present nomogram. The presented nomogram is more practical, in that the pre-operative factors can be placed on the nomogram, the points can be added up and the parents can be given the approximate percentage of predicted stone-free rate after a single session. The expected treatment modality shown to the parents and patients ought to be the least minimally invasive, have the highest success rate, the least complication rate, and show the efficacy in one procedure at a time within the shortest period. However, SWL does not completely meet these criteria. The results gained from the present critical analysis of SWL in children, which was based on a strict definition of success, showed that outcome after a single session is not that good. Therefore, defining the patients who will benefit the most became one of the main issues. A more objective and skeptical look at SWL data enabled a nomogram to be developed that brings a new and practical insight in order to predict the outcomes of pediatric SWL. CONCLUSION: In most of the pediatric stone cases, SWL is the first-line treatment option. However, it is wise to define the patients who will benefit the most. Therefore, nomograms can be useful for this purpose. The nomogram in the present study revealed that gender, stone size, number of stones, age, location of the stone, and history of previous intervention were found to be the independent prognostic factors for assessing the stone clearance rates. This nomogram can practically be used to inform the parents, and for proper patient selection for SWL.