The role of retrograde intrarenal surgery in kidney stones of upper urinary system anomalies.

INTRODUCTION: Fusion, pelvic, and duplicated urinary tract anomalies of the kidney are rarely seen. There might be some difficulties in the stone treatment, in the administration of extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrolithotomy (PCNL), and laparoscopic pyelolithotomy procedures in these patients due to the anatomical variations in kidneys with anomalies. AIM: To evaluate RIRS results on patients with upper urinary tract anomalies. MATERIALS AND METHODS: Data of 35 patients with horseshoe kidney, pelvic ectopic kidney, and double urinary system in two referral centers were reviewed retrospectively. Demographic data, stone characteristics, and postoperative characteristics of the patients were evaluated. RESULTS: The mean age of patients (n=35, 6 women and 29 men) was 50 years. Thirty-nine stones were detected. The total mean stone surface area in all anomaly groups was found to be 140 mm2, and the mean operative time was 54.7±24.7 minutes. The rate of using ureteral access sheath (UAS) was very low (5/35). Eight patients needed auxiliary treatment after the operation. The residual rate, which was 33.3% in the first 15 days, decreased to 22.6% in the third month follow-ups. Four patients had minor complications. In patients with horseshoe kidney and duplicated ureteral systems, it was observed that the risk factor increasing the presence of residual stones was the total stone volume. CONCLUSIONS: RIRS for kidneys with low and medium stone volume anomalies is an effective treatment method with high stone-free and low complication rates.

Comparison of ring instruments and classic circumcision methods: a systematic review and meta-analysis.

Aim: To determine the advantages and disadvantages of both methods by comparing classic circumcision methods with circumcision methods assisted by ring instruments. Material-Methods: Only studies that compared open procedures and ring devices for male circumcision were included. A total of 6226 patients were examined in 14 studies. The methodological quality of RCT was evaluated using Cochrane collaboration's tools. The Review Manager software statistical package was used to analyze the ORs for dichotomous variables and the mean differences for continuous variables. The proportion of heterogeneity across the studies was tested using the I 2 index. Potential publication bias was assessed by identifying the presence of visual asymmetry/symmetry with funnel plot studies. Results: There were 1812 patients in the open circumcision group and 4414 patients in the ring groups. In total, there was no difference identified between the groups. The open procedure had an advantage compared to the Plastibell subgroup for hemorrhage, while in the other two subgroups, the ring instrument groups had the advantage. Statistically significant in favor of ring devices was found in operating time.There was no difference between the groups for early (postoperative) pain scores. For late-period pain scores, differences with statistical significance were identified in favor of ring devices both in subgroups and in total. For satisfaction, apart from one study in the PrePex group, statistical significance was obtained in favor of ring devices for the other subgroups and in total. Conclusion: The main factors in favor of the use of ring instruments for circumcision are the short total surgical duration, not requiring advanced surgical experience, ease of learning and application, and patient relative satisfaction rates. However, it is a condition to know open circumcision methods and to have experience of this surgery for use in situations with hemorrhage complications, mainly, and without ring instruments of appropriate size.

Factors affecting success in the treatment of proximal ureteral stones larger than 1 cm with extracorporeal shockwave lithotripsy in adult patients.

The aim of the study was to analyze the factors predicting success for the treatment of proximal ureteral stones larger than 1 cm with extracorporeal shockwave lithotripsy (SWL) in adult patients. Between January 2014 and December 2018, 480 adult patients in total underwent SWL and data were retrospectively evaluated. Patients with multiple ureteral stones, solitary kidney, congenital abnormality, skeletal system abnormality, history of previous urinary system surgery and SWL, renal insufficiency, patients who could not tolerate SWL and pediatric patients were excluded from the study. The remaining 415 patients were divided into two groups as success (Group 1, n = 307) and failure (Group 2, n = 108). The overall success rate was 73.9%. The values of stone size, Hounsfield Unit (HU), skin to stone distance (SSD), ureteral wall thickness (UWT), proximal ureter diameter, renal pelvis diameter, hydronephrosis grade, and duration of renal colic were significantly higher in Group 2 compared to Group 1. In binary logistic regression analyses, HU, UWT, and proximal ureter diameter were found to be independent predictors. HU, UWT, and proximal ureter diameter had sensitivity and specificity of 92-92%, 88-23%, and 87-46%, with cutoff values of 740 HU, 2.5 mm and 8.5 mm, respectively. The area under the curve values were 0.96, 0.97, and 0.96 for HU, UWT, and proximal ureter diameter, respectively. The CT-based parameters, including HU, UWT, and proximal ureter diameter are independent predictive factors with excellent accuracy for the treatment of proximal ureteral stones larger than 1 cm with SWL in adult patients. Based on these factors, SWL can be considered for proximal ureteral stones larger than 1 cm.

Effect of testicular morphology on embryo development to the blastocyst stage after round spermatid injection.

If spermatozoa cannot be found after testiculer sperm extraction (TESE) in patients followed up due to nonobstructive azospermia (NOA) and the patients do not want donor spermatozoa, performance of round spermatid injection (ROSI) with the current technology seems to be the last resort. This retrospective study was conducted to evaluate the effect of testicular morphology on the development of embryos to the blastocyst stage obtained from ROSI. Between September 2019 and March 2020, after TESE and biopsy 29 patients who had only spermatid were taken to study. Tubular appearance, basal membrane appearance, Johnson score, peritubular fibrosis, interstitial fibrosis, and Leydig cell proliferation were pathologically examined. Following egg collection, ROSI was applied to the oocytes using the piezoelectric method. The embryos were monitored until the blastocyst stage. The mean age of the 29 patients was 36.3±5.01 years. Also, 7 patients had not previously undergone TESE, 20 had previously undergone once, and 2 had previously undergone twice. It was observed that having a history of TESE and a high Johnson score increased the likelihood of the embryo remaining in the blastocyst stage (P=0.021 and 0.014, respectively). However, other parameters do not affect the likelihood of blastocyst formation (P>0.05). Low TESE history and high Johnson score were associated with embryo development to the blastocyst stage. If spermatozoa are not found in patients with nonobstructive azoospermia, ROSI performed during initial TESE increases the likelihood of blastocyst formation.

Keloid Formation after Circumcision: A Case Report and Current Literature Review.

Although penile keloid formation can be seen after major penile surgeries, it is rarely reported after circumcision and there is no standard method for the treatment of this complication. We present a patient who was admitted with a penile keloid mass that occurred after circumcision surgery and discuss the treatment we administered in light of the current literature review. A 7-year-old white boy was admitted to our clinic with a swollen stiff mass on the foreskin six months after circumcision. The parents indicated that no complication occurred in the early postoperative period. Physical examination revealed a white-colored stiff mass measuring approximately 2×1.5 cm in size along the penile ventral surface. Intralesional injection of 0.5 ml triamcinolone acetonide was administered for 12 weeks. At 9 months after circumcision, the keloid tissue was resected. Beginning from the first postoperative week, a silicone gel sheet and topical steroid application were administered for 8 weeks. At a 1-year follow-up, the penis had a satisfactory appearance.

Comparison of Retrograde Intrarenal Surgery and Laparoscopic Surgery in the Treatment of Proximal Ureteral and Renal Pelvic Stones Greater than 15 mm.

INTRODUCTION: There is insufficient data on which modality should be the first choice in the treatment of proximal ureteral and renal pelvic stones greater than 15 mm.Aim: To compare retrograde intrarenal surgery (RIRS) and laparoscopic stone surgery for big upper ureteral and renal pelvic stones. MATERIALS AND METHODS: We reviewed medical records of 163 adult patients who underwent RIRS or laparoscopic surgery for upper ureteral or renal pelvic stones ≥15 mm between January 2013 and February 2018. A total of 121 patients were included in the study. The patients were divided into two groups as RIRS (n=58) and laparoscopic surgery (n=63) and the groups were compared with regard to their demographic, stone, and operative characteristics and postoperative outcomes and complications. RESULTS: Both operation time and hospitalization time were significantly shorter in the RIRS group compared to the laparoscopic surgery group (p<0.001). Complete stone clearance was achieved in 44 (76%) patients in the RIRS group and in 57 (90%) patients in the laparoscopic surgery group (p=0.031). Both the VAS scores and postoperative analgesic requirement were lower in the RIRS group. Based on the modified Clavien-Dindo classification, the two groups were similar with regard to peri- and post-operative complication rates. However, the incidence of Grade 3b complications (e.g. ureteral rupture, conversion to open surgery) was significantly higher in the laparoscopic surgery group and the incidence of Grade 4b complication (urosepsis) was significantly higher in the RIRS group. CONCLUSIONS: Laparoscopic surgery can provide higher stone clearance and lower auxiliary treatment rates compared to RIRSalthough it can be more disadvantageous in terms of operative time, hospitalization time, postoperative VAS scores, and analgesic usage (narcotic and non-narcotic).

Modified Lich-Gregoir Ureteral Reimplantation for the Treatment of Unilateral Primary Vesicoureteral Reflux in Pediatric Patients: A Comparative Analysis with Medium-Term outcomes.

PURPOSE: To present the medium-term results for the modified Lich-Gregoir (LG) reimplantation technique in the treatment of unilateral primary vesicoureteral reflux (VUR) by comparing patients under and over 12 months of age. MATERIALS AND METHODS: Data for patients who underwent modified LG surgery between January 2006 and December 2018 were retrospectively reviewed from the hospital data-recording system and patients under the age of 18 years were included in the study. After exclusion criteria, 55 patients in total were included in advanced analysis. The patients were grouped as ≤12 months and >12 months. Demographic characteristics, operative, and postoperative follow-up data were comparatively analyzed. RESULTS: The mean±SD (range) of age was 10.4 ± 2.8 (6-12) and 41.4 ± 18.5 (13-96) months in the ≤12 months and >12 months groups, respectively. Mean operation time and hospitalization time were not significant between the groups. Mean follow-up times were 39.5 ± 14.1 and 38.4 ± 13.2 months, in the ≤12 months and >12 months groups, respectively. There was no difference in terms of complications between the groups and all of the complications in both groups were in grade 1 category according to the Modified Clavien complication classification. One (6.6%) patient in the ≤12 months group and 3 (7.5%) patients in the >12 months group had late (>30 days) febrile UTI, but none of them had a recurrence of VUR. Febrile infection did not recur during the follow-up period in these patients. While recurrent VUR was not seen in any patient in the ≤12 months group (success: 100%), it was observed in 2 (5%) patients in the >12 months group (success rate: 95%) (p = 0.38). CONCLUSION: The open LG ureteral reimplantation technique is an effective procedure for the treatment of unilateral primary VUR in children both under 12 months and over 12 months of age with minor morbidity.

The protective effect of L-arginine, tadalafil, and their combination in rat testes after ischemia and reperfusion injury.

INTRODUCTION: Nitric oxide (NO) plays an important role in the ischemia and reperfusion process. In this study, we aimed to examine the effect of L-arginine, tadalafil, and their combination for prevention of the ischemia reperfusion injury after testis torsion in rats. METHODS: A total of 40 adult, male Sprague-Dawley rats were allocated into five groups. Three hours of left testicular torsion was performed in each group, excluding the control group. While the ischemia reperfusion (I/R) group had no treatment, I/R + Arg group received L-arginine, I/R + Td group received tadalafil and I/R + Arg + Td group received tadalafil and L-arginine 30 minutes before the detorsion. Then the left testis was untwisted for four hours of reperfusion. After bilateral orchiectomy, lipid peroxidation (LPx) and glutathione (GSH) activities were examined in testicular tissue. Spermatogenesis was evaluated with Johnsen's score. RESULTS: LPx levels of the I/R group were found to be significantly higher than for groups that received drugs for both testes (p<0.001). GSH levels of the combination group were higher than I/R group in ipsilateral testis (p<0.01) and it was significantly higher than other groups for contralateral testis (p<0.001 for I/R group, p<0.01 for I/R + Arg, p<0.05 for I/R + Td). Mean Johnsen's score of the I/R group was found to be significantly lower than treatment groups in ipsilateral testis (p<0.001 for I/R + Arg + Td group, p<0.01 for other treatment goups) and contralateral testis (p<0.001). The mean Johnsen score of the combination group was significantly higher than that of other treatment groups in ipsilateral testis (p<0.05) and it was significantly higher than in the I/R + Td group in the contralateral testis (p<0.05). CONCLUSIONS: L-arginine, tadalafil, and combination of these two molecules showed protective effect against ischemia/reperfusion injury for both testes after unilateral testis torsion.

Comparison of ureteroscopic laser lithotripsy with laparoscopic ureterolithotomy for large proximal and mid-ureter stones.

OBJECTIVES: To compare the effectiveness and complications of ureteroscopic laser lithotripsy with laparoscopic ureter laparoscopic ureterolithotomy in mid- or proximal portion of large ureteral stones. MATERIAL AND METHODS: We reviewed patients with large (>15 mm) ureteral stone and those who underwent ureteroscopic laser lithotripsy (URS group) or laparoscopic ureterolithotomy (LU group). The first attempt was considered successful in patients who had residual fragments smaller than 2 mm and no conversion of the primary procedure to another. RESULTS: Sixty patients (URS group 29, LU group 31) met inclusion criteria. FURS was used as an adjunctive procedure in one patient for URS group and in two patients for LU group in the same season. LU had a higher success rate and the first-day stone-free rate when compared with URS. Number of procedures was also significantly higher in URS group. There was no difference in stone-free rates at the first and third months, and length of hospitalization and operation were higher in the LU group. Only two patients in the LU group and one patient in the URS group had major complications. CONCLUSIONS: Laparoscopy is an effective option of large proximal and mid-ureter stone treatment; however, URS provides similar stone-free rates at three months as a minimal invasive procedure.