Consensus statement addressing controversies and guidelines on pediatric urolithiasis.

PURPOSE: We aimed to investigate controversial pediatric urolithiasis issues systematically, integrating expert consensus and comprehensive guidelines reviews. METHODS: Two semi-structured online focus group meetings were conducted to discuss the study's need and content, review current literature, and prepare the initial survey. Data were collected through surveys and focus group discussions. Existing guidelines were reviewed, and a second survey was conducted using the Delphi method to validate findings and facilitate consensus. The primary outcome measures investigated controversial issues, integrating expert consensus and guideline reviews. RESULTS: Experts from 15 countries participated, including 20 with 16+ years of experience, 2 with 11-15 years, and 4 with 6-10 years. The initial survey identified nine main themes, emphasizing the need for standardized diagnostic and treatment protocols and tailored treatments. Inter-rater reliability was high, with controversies in treatment approaches (score 4.6, 92% agreement), follow-up protocols (score 4.8, 100% agreement), and diagnostic criteria (score 4.6, 92% agreement). The second survey underscored the critical need for consensus on identification, diagnostic criteria (score 4.6, 92% agreement), and standardized follow-up protocols (score 4.8, 100% agreement). CONCLUSION: The importance of personalized treatment in pediatric urolithiasis is clear. Prioritizing low-radiation diagnostic tools, effectively managing residual stone fragments, and standardized follow-up protocols are crucial for improving patient outcomes. Integrating new technologies while ensuring safety and reliability is also essential. Harmonizing guidelines across regions can provide consistent and effective management. Future efforts should focus on collaborative research, specialized training, and the integration of new technologies in treatment protocols.

Is stone free status really necessary for metabolic evaluation following stone removal procedures?

OBJECTIVE: To evaluate the impact of stone free status on the outcomes of metabolic evaluation in recurrent stone formers after ureteroscopic stone removal. PATIENTS AND METHODS: A total of 78 patients undergoing retrograde intrarenal surgery (RIRS) for renal stones were included and cases were divided into two groups after 4 weeks based on the NCCT findings. While cases in the Group 1 (n = 54) was completely stone free, cases in Group 2 (n = 24) had residual fragments in the kidney. A full 24-h urine analysis for relevant stone forming risk factors has been performed after 4 weeks following the fURS procedures in all patients of both groups. Outcomes of metabolic evaluation (24-h urine and serum) have been comparatively evaluated in both groups. RESULTS: Evaluation of the preoperative serum and urine stone forming risk factors revelaed no statistical difference in both groups. Comparative evaluation of the 24-h urinary stone forming risk factors also revealed no statistically significant difference between preoperative and postoperative findings in cases of Group 2 with residual stones. Last but not least, no significant difference was observed between the mean preoperative and postoperative serum variables between two groups. CONCLUSIONS: Our results show that in the light of the similar metabolic evaluation outcomes obtained in cases with and without residual fragments, 'stone free status' may not be an essential factor to perform a detailed metabolic evaluation (24-h urine analysis and serum parameters) after endourological stone removal procedures.

How does puncture modality affect the risk of intraoperative bleeding during percutaneous nephrolithotomy? A prospective randomized trial.

INTRODUCTION AND OBJECTIVES: To evaluate the possible effects of two different renal puncture techniques (ultrasound-assisted [US-assisted], fluoroscopic-guided [FG]) on the intraoperative hemorrhage risk during percutaneous nephrolithotomy (PCNL). MATERIAL AND METHODS: A total of 130 patients with Guy stone scores of 1-2 were prospectively allocated to US-assisted and FG puncture groups by simple randomization. Patients with intraoperative pelvicalyceal rupture and the ones requiring multiple accesses were excluded from the study. Apart from the puncture steps, all other steps of the PCNL procedure were performed with similar techniques by a single surgeon. Patient characteristics, operative data, and postoperative outcomes were compared. RESULTS: A total of 10 patients were excluded from the study due to intraoperative complications after puncture. Patient demographics and stone characteristics were similar between the two groups (p > 0.05). Mean hemoglobin drop was meaningfully greater in the FG group (1.7 g/dL) when compared with US-assisted group (1.3 g/dL) (p < 0.01). The mean duration of radiation exposure was significantly higher for the FG (p < 0.001). Total operative time, number of attempts for a successful puncture, length of hospital stay, and stone free rates were similar between the groups (p > 0.05). In addition, the remaining complications classified according to the modified Clavien-Dindo grading system were similar between groups (p > 0.05). CONCLUSION: US-assisted puncture provides significantly decreased level of hemoglobin drop and radiation exposure time when compared with FG.

Endoscopic identification of urinary stone composition: A study of South Eastern Group for Urolithiasis Research (SEGUR 2). / Identificación endoscópica de la composición de los cálculos urinarios: un estudio del Southeastern Group for Lithiasis Research (SEGUR 2).

INTRODUCTION AND OBJECTIVES: To assess the surgeon's ability to evaluate the composition of the stone by observation of endoscopic images. MATERIALS AND METHODS: A series of 20 video clips of endoscopic treatments of urinary stones of which was also available the result of infrared spectroscopy was uploaded to a YouTube site accessible only to members of the South Eastern Group for Urolithiasis Research (SEGUR) who were asked to identify the composition of the stones. RESULTS: A total of 32 clinicians from 9 different countries participated in the study. The average number of correct detections of participants was 7.81 ± 2.68 (range 1-12). Overall accuracy was 39% (250 out of 640 predictions). Calcium oxalate dihydrate stones have been correctly detected in 69.8%, calcium oxalate monohydrate in 41.8%, uric acid in 33.3%, calcium oxalate/uric acid in 34.3% and cystine in 78.1%. Precision rates for struvite (15.6%), calcium phosphate (0%) and mixed calcium oxalate/calcium phosphate (9.3%) were quite low. CONCLUSIONS: Observation of the stone during the endoscopic procedure was not reliable to identify the composition of most stones although it gave some information allowing to identify with a good sensitivity calcium oxalate dihydrate and cystine stones. Nevertheless, photo or video reporting of the intact stone and its internal structure could should be encouraged to implement results of still mandatory post-operative stone analysis. Endourologists should improve their ability of visual identification of the different types of stones.

Role of Complementary Medicine (Music, Acupuncture, Acupressure, TENS and Audio-Visual Distraction) in Shockwave Lithotripsy (SWL): A Systematic Review From EAU Sections of Urolithiasis (EULIS) and Uro-Technology (ESUT).

We performed a systematic review to look at the role of alternative or complementary medicine such as music, acupressure, acupuncture, transcutaneous electrical nerve stimulation (TENS) and audiovisual distractions to decrease analgesia requirement and alleviate anxiety during SWL. Twenty-three papers(2439 participants) were included: Music (n = 1056.6%), Acupuncture (n = 517.7%), Acupressure (n = 13.8%), TENS (n = 617.2%), and audiovisual distraction (n = 14.6%). Most of the studies showed that complementary therapy, lowered pain, and anxiety with higher patient satisfaction and willingness to undergo the procedure. With its feasibility and convenience, urological guidelines need to endorse it, and more should be done to promote its use in outpatient urological procedures.

Could ureteral wall thickness have an impact on the operative and post-operative parameters in ureteroscopic management of proximal ureteral stones? / ¿Podría el espesor de la pared ureteral afectar a los parámetros intra y postoperatorios de la ureteroscopia para el tratamiento de piedras ureterales proximales?

AIM: To evaluate the possible impact of stone impaction in terms of ureteral wall thickness (UWT) on the success and procedure related parameters of ureteroscopic management in proximal ureteral calculi. PATIENTS AND METHODS: 82 patients with proximal ureteric stones were included and were divided into 2subgroups where UWT was> 5mm in 38 cases; and <5mm in 44 cases. Stone size, degree of hydronehrosis, diameter of proximal ureteral luz, UWT and patient's demographics were evaluated. Semi-rigid ureteroscopy with Ho-YAG laser was performed and the possible impact of UWT as an objective parameter for stone impaction on the success rates and procedure related parameters was evaluated. RESULTS: Mean patient age and stone size values were 47.55±1.78 years and 8.17±0.29mm respectively. Regarding the impact of UWT value at the stone site for the parameters mentioned above stone free rates particularly at 1-week after the procedure was higher in group 2 and the rate of residual fragments as well as the need for double J stent placement was higher in group 1. Additionally, mean duration of the procedures was significantly longer in Group 1 during which pathologic alterations were significantly higher in ureteral wall at stone site were observed in these cases (P=.0243). CONCLUSIONS: UWT may be used to predict the success of ureteroscopic management and other procedure related parameters for proximal ureteral stones in an effective manner. With this approach a more rational operative plan with higher success rates, limited complications and auxiliary procedures could be made.

Effect of JJ stent on outcomes of extracorporeal shock wave lithotripsy treatment of moderate sized renal pelvic stones: A randomized prospective study. / Resultados de LEOCH con o sin catéter para el tratamiento de cálculos en la pelvis renal: un estudio aleatorizado.

PURPOSE: To evaluate the effect of JJ stents on SWL treatment of moderate (15-25mm) renal pelvic stones. MATERIALS AND METHODS: Between January 2016 and December 2017, a total of 152 adult patients who were planned to undergo SWL for a single radiopaque renal pelvic stone were included in the study. Patients with solitary kidney, congenital abnormality, skeletal tract abnormalities, previous urinary system surgery, hydronephrosis (grade 2 or more), untreated urinary tract infection, bleeding disorder, and suspected pregnancy were excluded. The remaining 114 patients were randomly divided into two groups; non-stented and stented. Twenty-two patients whose stone could not be fragmented despite 3 consecutive sessions were also excluded from the study. A total of 92 patients (54 non-stented and 38 stented) were included in the final analysis. RESULTS: There was no significant difference in terms of age, sex, body mass index, renal parancyhimal thickness, hydronephrosis, skin-to-stone distance, Hounsfield units, and stone size between the groups. Success was significantly higher in the stented group than in the non-stented group (71% vs. 39%, P=.002). In stone-free patients, the number of emergency department visits and analgesic tablet consumption was significantly lower in the stented group than in the non-stented group (P<.001 and P<.001, respectively). In non- stone-free patients, analgesic tablet consumption was significantly lower in the stented group than in the non-stented group (P=.004). CONCLUSIONS: Pre-stenting before SWL treatment of moderate sized renal pelvic stones has some advantages in terms of success, emergency service visits, and analgesic tablet consumption.

Super-mini percutaneous nephrolithotomy for renal stone less than 25mm in pediatric patients: Could it be an alternative to shockwave lithotripsy? / Supermini nefrolitotomía percutánea para cálculos renales menores de 25mm en pacientes pediátricos: ¿podría ser una alternativa a la litotricia por ondas de choque?

AIM: To evaluate the efficacy of 2 different techniques: shock wave lithotripsy (SWL) vs. super-mini percutaneous nephrolithotomy (SMP), in terms of success as well as complication rates in pediatric renal stones sizing<25mm. PATIENTS AND METHODS: A total of 219 children (aging between 1-17 years) undergoing 2 different treatment modalities (SWL vs. SMP) for kidney stones<25mm were included. Depending on the type of the procedure applied, children were divided into 2 different groups: group 1 (n=108), children treated with SWL, and group 2 (n=111), children treated with SMP. All treatment related parameters (stone free rates, number of sessions, treatment duration, hospitalization, presence of the residual fragments, complications as well as the need for additional interventions) were noted and evaluated between 2 groups in a comparative manner. RESULTS: Evaluation of our data have clearly demonstrated that the percentage of residual fragments after SWL was significantly higher when compared with SMP. Although SWL required several sessions under general anesthesia in a certain per cent of the cases (54.6%), SMP was successful in one session in all of the cases. Last but not least, in addition to the similar minor complication rates observed in both group of cases, no major complication observed in any case and no case in both groups again required blood transfusion after these 2 procedures with no significant drop rates in hemoglobin levels. CONCLUSIONS: Although SWL is still the preferred treatment modality for the majority of kidney stones in children due to its safe and non-invasive nature, SMP modality may be applied as a valuable alternative in this specific patient population for its excellent stone free rates obtained in a single session and acceptable complication rates in the minimal invasive management of stones<25mm.

Retrograde intrarenal surgery in the management of pediatric cystine stones.

OBJECTIVE: To investigate the efficacy and safety of retrograde intrarenal surgery (RIRS) in the treatment of pediatric cystine stones. STUDY DESIGN: Data of the pediatric patients who underwent RIRS for kidney stones were retrospectively evaluated. A total of 14 children with cystine stones managed with RIRS were identified. In addition to the patient demographics and stone characteristics, all retrospectively obtained operative data were evaluated and discussed in detail, with an emphasis on the success and complication rates. RESULTS: Mean age of the 14 cases was 10.9 ± 2.2 years (range: 7-15). Mean stone size was 13.6 ± 2.4 mm (range: 10-18) (Summary table). Of these stones, four were located in the renal pelvis, three were in the lower, three were in the middle and the remaining four were located in upper calyx. Ureteral access sheath was used in 12 (85.7%) patients. The double-J ureteral stent was placed pre-operatively in one case and was inserted postoperatively in 12 cases. Mean operation time was 38.2 ± 7.2 min (range: 30-50). Complications were observed in two cases: mild ureteral laceration in the first and fever on the second postoperative day in the second patient. All of the patients were stone free on sonographic evaluation at the 4-week follow-up evaluation. Although potassium citrate treatment was initiated in 11 patients, tiopronin treatment was initiated in four patients for recurrence prophylaxis during long-term follow-up. During a mean follow-up period of 25.7 ± 5.2 months, stone recurrence was noted in one patient. DISCUSSION: Treatment of patients with cystine stones is challenging, due to high risk of rapid recurrence in the presence of residual fragments. Besides allowing complete stone clearance in all cases in the current series, RIRS is a highly reproducible method that can be safely performed, even in recurrences. The major limitations of the current study were low number of patients and short follow-up period. CONCLUSION: The results clearly indicated that RIRS is a safe treatment modality in the management of pediatric cystine stones.

Impact of gender on success and complication rates after ureteroscopy.

PURPOSE: To investigate the impact of gender differences on treatment success, intraoperative and postoperative complications in patients undergoing ureteroscopy (URS). MATERIALS AND METHODS: A prospectively maintained database of 927 consecutively performed ureteroscopies on solitary ureteral stones in four different centers was retrospectively analyzed. Stones were detected with preoperative computed tomography scans or intravenous urography imaging. Patients received intravenous antibiotics as perioperative prophylaxis. Patients with symptomatic urinary tract infections (UTI) prior to surgery were excluded. Follow-up was up to 2 weeks after URS or stent removal. RESULTS: Two hundred and eighty-six women and 641 men were included in this study. Mean stone size was 9 mm (range 2-35 mm). A double-J stent was placed in 240 (83 %) women and 527 (82 %) men at the end of surgery (p = 0.075). There was no significant gender difference in terms of stent dislocation (p = 0.239). Two hundred and fifty-one women (87 %) and 564 men (87 %) were stone-free after the first procedure (p = 0.917). Intraoperative complications were observed in 14 (4.8 %) women and 37 (5.9 %) men (p = 0.313). Severe UTI presenting with fever (>38 °C) and requiring prolonged hospitalization with parenteral antibiotics were observed in 11 (3 %) women and 8 (1 %) men postoperatively. This difference was statistically significant (p = 0.025). CONCLUSION: No significant differences between female and male patients harboring ureteral stones with respect to intraoperative complications were detected. Although stone characteristics were comparable between groups, a small number of women had significantly more severe UTI's postoperatively. Our current therapy regimen for URS seems to be efficient and safe both for females and males.

Escitalopram treatment for premature ejaculation has a negative effect on semen parameters.

The aim of this study was to determine the impact of long-term escitalopram treatment on semen parameters of patients with lifelong premature ejaculation (PE). Between November 2008 and January 2010, patients admitted to urology outpatient clinic with a self-reported complaint of PE were evaluated. Medical and sexual history of patients were recorded and patients with lifelong PE (a total of 25 patients) who met the International Society of Sexual Medicine definition were asked to record their intravaginal ejaculatory latency time (IELT) for 1 month, complete Premature Ejaculation Diagnostic Tool (PEDT) questionnaire and give semen samples. Afterwards, patients received 10 mg escitalopram daily for 12 weeks and were invited for control visits at first and third month of treatment. During control visits, PEDT was administered again whereas IELTs were recorded and semen samples were re-examined. PEDT scores, arithmetic means of IELTs and results of semen analyses, which were recorded at baseline, first and third month were compared. At the third month of treatment, a significant increase in mean IELTs and a significant decrease in PEDT scores were detected. However there was a significant decrease in sperm concentration, motility and morphology when compared with the baseline semen measures. Daily escitalopram treatment effects the semen parameters of patients with lifelong PE. Further investigations with larger series are needed to see whether other serotonin reuptake inhibitors have similar side effects and to expose the exact mechanism underlying it. Different treatment modalities should be suggested to patients who desire fertility.

Treatment of ureteral calculi with semirigid ureteroscopy: where should we stop?

OBJECTIVES: To evaluate the efficacy of semirigid ureteroscopy in the management of ureteral stones located in different parts of the ureter. METHODS: 1,503 patients were treated with semirigid ureteroscopy. All ureteral stones were either removed only by a basket catheter or disintegrated by pneumatic lithotripsy. Success rates, auxiliary procedures, complication rates and operation time were comparatively evaluated according to stone location. RESULTS: Overall, mean stone size and age were 12.1 +/- 3.7 mm and 43.2 +/- 9.72 years, respectively. While 1,416 patients (94.2%) were completely stone-free, the procedure was unsuccessful in 87 cases (5.8%). The success rate was relatively low in the proximal ureter (71.7%) when compared with the mid (94.8%) and distal ureter (98.9%) (p = 0.021). Mean operation time was 25.4 +/- 11.7 min. Longer duration of operation and higher complication rate were found in proximal ureteral calculi. Stone migration to the kidney and hematuria were the main reasons of failure in the proximal ureter and ureteral stenting was needed for 56.4% of patients with upper ureteral stone. CONCLUSIONS: Semirigid ureteroscopy can be the treatment of choice in lower and midureteral stones. However, it is an invasive and less successful treatment modality for proximal ureteral stones with relatively high complication rates.

Double-blind, placebo-controlled, randomized clinical trial of sublingual or intramuscular piroxicam in the treatment of renal colic. A comparative study.

AIMS: To investigate the therapeutic effect of the fast-dissolving dosage form (FDDF) of sublingual piroxicam on renal colic compared with the intramuscular (IM) injection form of the same agent in a randomized, double-blind, placebo-controlled clinical trial. METHODS: 80 patients were assigned to one of two treatment groups: Group 1 received 40 mg piroxicam FDDF sublingual tablets and IM injection of 2 ml distilled water. Group 2 received an IM injection of 40 mg piroxicam and two sublingual tablets of placebo. At baseline and 30 min after the medication, vital signs were recorded and the pain intensity was evaluated by the patient using a numeric rating scale. RESULTS: The overall efficacy of the treatment was 90%. There was no significant difference with respect to the required rescue treatment (p = 0.328), pain relapse within 24 h (p = 0.434) and the decrease in vital signs and numeric rating scale in both groups (p > 0.05). CONCLUSION: The piroxicam FDDF tablet was found to be as effective as the IM injection form of the same agent in the treatment of renal colic. The FDDF is a good alternative to the parenteral form because of its earlier onset of action and ease of self-administration which increases patient compliance.

Ureteroscopic management of ureteral calculi in children.

PURPOSE: To evaluate the efficacy and safety of rigid ureteroscopy for the treatment ureteral calculi in children. PATIENTS AND METHODS: Between January 2002 and January 2006, 16 boys and 25 girls with an average age of 9.5 years (range 3-15 years) were treated with a 95F rigid ureteroscope for stones 4 to 10 mm (mean 5.6 mm) in 46 renoureteral units (RUUs), and the results were evaluated. The stones were located in the upper ureter in 4 RUUs, the middle ureter in 15, and the lower ureter in 27. Dilatation of a tight ureteral orifice was necessary in 17 cases (36.9%). RESULTS: On examination during ureteroscopy, all calculi were well fragmented, and in 33 patients (94%), stone fragments were removed directly. Stones were fragmented with pneumatic lithotripsy in 23 RUUs and removed by forceps with or without fragmentation in the remaining 23. Whereas the treatment was successful in 36 children (87.8%), it was unsuccessful in 5 (12.2%) secondary to bleeding and mucosal injury in 3 children (7%; 1 middle- and 2 upper-ureteral stones) and severe ureteral stenosis with kinking in 2 (4.8%; 1 middle- and 1 upper-ureteral stone) children. In two other cases, although the fragments in the upper portion of the ureter could be reached with the ureteroscope, the stones migrated into the renal collecting system during pneumatic lithotripsy and were treated successfully with subsequent SWL (4.8%). At the end of the procedure, a 4.8F Double-J stent was left in place in 9 cases. There were no serious complications, and the children were not specifically evaluated for postoperative vesicoureteral reflux. Follow-up ranged from 1 to 36 months with an average duration of 22.4 months. CONCLUSION: With the aid of the experience gained in the adult population and careful instrumentation, we believe that, in skilled hands, rigid ureteroscopy can be applied in a safe and efficient manner for stones located in different portions of the pediatric ureter.

Pediatric urolithiasis: etiology, specific pathogenesis and medical treatment.

Pediatric urolithiasis is an endemic disease in certain parts of the world, namely Turkey and the Far East. As a recurrent pathology which may reveal functional as well and morphologic changes in the urinary tract, environmental factors together with urogenital abnormalities should be evaluated thoroughly in each patient. The aims of management should be complete clearance of stones, treatment of urinary tract infections, preservation of renal function and prevention of stone recurrence. In addition to certain minimally invasive stone removal procedures, treatment of pediatric urolithiasis requires a detailed metabolic evaluation in all patients on an individual basis. Obstructive pathologies have to be corrected immediately and children with a positive family history should be followed carefully with respect to a high likelihood of stone re-growth and recurrence. Although specific management of each metabolic abnormality seems to be the key factor in the medical management of stone disease, as general advice each child should be forced to adequate fluid intake which will reveal the urine volume increase in accordance with the body mass index. Moreover, medical therapeutic agents which increase urine citrate levels should be encouraged.

Renal tubular injury induced by hyperoxaluria: evaluation of apoptotic changes.

In order to evaluate the injurious effect of hyperoxaluria on renal tubular epithelium, as judged by apoptotic changes in the renal parenchyma, we performed an experimental study in 20 rabbits. In the experimental group animals (n = 10) severe hyperoxaluria was induced by continuous ethylene glycol (EG; 0.75%). Histologic alterations, including crystal formation, together with apoptotic changes were evaluated after 7 and 28 days. Control group animals (n = 10) received normal distilled drinking water. Following 7- and 28-day periods, tissue sections obtained from kidneys were examined histopathologically under light microscopy for the presence and the degree of crystal deposition in the tubular lumen. Apoptotic changes in renal tubular cells were examined using the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP in situ nick and labeling (TUNEL) method during the same follow-up period. Crystal deposition was evident in the tubular lumen of tissue sections obtained during the 7-day examination period. During the 28-day examination period, however, these findings were found to be either limited or to have disappeared. In relation to apoptotic changes, the percentage of positive nuclei stained using the TUNEL method was from 11 to 20% in the experimental group and 5.6% in the control group. Our findings indicate that both calcium oxalate (CaOx) crystals and hyperoxaluria itself may be injurious to renal tubular cells, as indicated by apoptotic changes. These changes may be responsible for the pathologic course of urolithiasis.

Unilateral testicular torsion: evaluation of bcl-2, p-53 and PCNA expression in contralateral testes.

OBJECTIVES AND METHODS: The present study aims to evaluate the histologic as well as apoptotic changes indicated by PCNA, p-53 and bcl-2 expression in the contralateral testes after a period of unilateral testicular torsion of 4 h. RESULTS: Regarding the histologic changes, while some significant alterations such as complete or incomplete spermatocytic arrest as well as sertoli cell only formation have to some extent been noted after the detorsion procedure, reasonably better preserved histology could be demonstrated following the orchiectomy procedure both in the early and late follow-up. Thus, the orchiectomy procedure was found to be limiting enough on the severity of the histologic changes in the contralateral testes after a certain period of time following the torsion procedure. On the other hand, however, in relation to the apoptotic events indicated by the three markers, while PCNA activity was found to be significantly different depending on the procedure performed (detorsion or orchiectomy), p-53 and bcl-2 positivity did not exhibit any difference in this aspect. Increased PCNA activity (especially after the detorsion procedure) together with marked positivity of p-53 both in the early and late follow-up indicated the increased cell turnover in the contralateral testes, which in turn may be accepted as a sign of increased apoptosis in these testes. In addition to these findings, bcl-2 expression has been found to be consistently negative in all specimens evaluated both in the early and late follow-up. CONCLUSION: Taking into account the strong inhibitory effect of bcl-2 during apoptotic events, these findings again support the likelihood of increased apoptosis in the contralateral testes.

Ureteral displacement due to a migrated intrauterine contraceptive device.

Perforation of the uterus is rare but potentially fatal. During puerperium when the uterus is small and its wall is thin, the risk of perforation increases. We report a rare complication from an intrauterine contraceptive device (IUD) which caused deviation of the right ureter in a 31-year-old woman who presented with complaints of insomnia and abdominal pain. Our case shows that perforation of the uterus by an IUD can cause a silent urological complication. The possibility of ureteral involvement and displacement should be kept in mind in a woman in whom a missing IUD is encountered.