The effect of smoking on spontaneous passage of distal ureteral stones.

BACKGROUND: Animal studies have shown that nicotine affects the peristalsis of the ureter. The aim of the study is to analyze the effect of smoking on spontaneous passage of distal ureteral stones. METHODS: 88 patients in whom distal ureteral stone below 10 mm diameter diagnosed with helical computerized tomography enhanced images were reviewed. Patients were grouped as either smokers (n:33) or non smokers (n:50). Follow-up for spontaneous passage of stones was limited with 4 weeks. Patients did not receive any additional medical treatment other than non-steroid anti inflammatory drugs only during painful renal colic episodes.Two groups were compared with the chi-square test in terms of passing the stone or not. Stone passage was confirmed with either the patient collecting the stone during urination or by helical CT. RESULTS: Smoking habits was present in 30(34%) patients and the frequency in both groups were similar (smokers: 23(76%) vs non-smokers: 46(79%)). Spontaneous passage of the stone was observed in 69(78%) patients. The two groups were comparable in terms of patient age, male to female ratio and stone size. Stone passage decreased as stone diameter increased. Total stone passage rates were similar in both groups (smokers: 76% vs. non-smokers: 79%) (p > 0.05). Passage of stones > 4 mm was observed in 46% and 67% of smokers and non-smokers respectively. However passage of stones with a diameter ≤ 4 mm were similar in both groups (smokers: 100% vs non-smokers: 92%) (p > 0.05). CONCLUSION: Smoking has neither a favorable nor un-favorable effect on spontaneous passage of distal ureteral stones. However, spontaneous passage rates in patients with a stone diameter > 4 mm was lower in smokers. These results should be further confirmed with studies including larger numbers of patients.

Re: totally tubeless percutaneous nephrolithotomy: a prospective randomized controlled study.

The study is unique in terms of defining the safety of totally tubeless percutaneous nephrolithotomy (PNL). Furthermore, the authors state that the tubeless group has an advantage of less pain. However, we interpreted the results of pain-related comparisons different than that the authors had. In our opinion, the results gained show that there is no difference in terms of pain in both groups. The authors state that they have inserted a double J catheter to patients that were included in the tubeless group in addition to the nephrostomy as a conventional procedure. However, routine Double-J placement in addition to nephrostomy is not a common procedure. Additionally, the large-bore nephrostomy tube preferred is certain to cause pain, as stated in the previous studies. It has been shown that small-bore tubes cause less pain. It may have been more appropriate to compare the groups in such a manner. Even though we have stated our comments with respect to pain issues, it is evident that the study is unique in terms of defining the safety of a totally tubeless procedure.

Semirigid ureteroscopy: the effect of previous ipsilateral intraureteral manipulations on stone clearance.

We investigated whether previous intraureteral manipulations had an effect on the stone-free rates (SFR) after semi-rigid ureteroscopy (URS) with pneumatic lithotripsy. A retrospective review of all patients who were treated for ureteral stones at two different institutions from June 2003 through January 2010 was performed. Data of 161 URS procedures were analyzed. Stone size, location (distal, mid and proximal) and number (single and multiple), patient demographics and previous intraureteral manipulations were recorded. Patients were grouped as having undergone a previous ipsilateral intraureteral manipulation (Group 1) or not (Group 2). Stone location and number, stone clearance and ancillary procedures were compared. There were no significant differences between Group 1 versus Group 2 for age (p > 0.05), gender (p > 0.05), stone site (p > 0.05) and stone size (p > 0.05). Stones with multiple locations were more frequent in Group 1 (18.5%); however, the difference did not reach statistical significance between the two groups. Similarly, the frequency of multiple stones was also higher in Group 1 (29.6%). Stone site, diameter and gender were comparable in both groups. Stone-free rate of all patients was 84.6% after the first intervention. This rate increased to 98.1% after secondary procedures. Univariate analysis revealed that SFR after URS were low in patients who underwent previous intraureteral manipulations (Group 1:55.6% vs. Group 2:89.1%). SFR after the first intervention were related with stone size, location and number. Additionally, multiple logistic regression analysis indicated a relationship between previous intraureteral manipulations and initial stone clearance rates. Spontaneous passage of stone fragments after URS was associated with stone burden, location, number and previous intraureteral manipulations. Further multiple logistic regression analysis showed that only previous intraureteral manipulations were associated with the expulsion of the stones left for passage.

Analysis of factors related with bleeding in percutaneous nephrolithotomy using balloon dilatation.

INTRODUCTION: The aim of the present study is to determine the preoperative and operative factors associated with bleeding in percutaneous nephrolithotomy (PNL) operations where tract dilatation was formed by balloon dilators. MATERIAL AND METHODS: A total of 378 patients underwent PNL in our department between 2003 and 2008. After excluding missing data 310 patients were included in the study in whom nephrostomy tract dilatation was performed using balloon dilators. The amount of blood loss was estimated by calculating the change in hemoglobin (Hgb). Preoperative and operative factors were assessed for association with the change in Hgb levels. The preoperative factors were age, sex, hypertension, diabetes mellitus (DM), smoking, ipsilateral pyelonephritis, body mass index, serum creatinine level, stone localization and burden, previous ipsilateral renal stone surgery and extracorporeal shock wave lithotripsy and degree of hydronephrosis. Operative factors were operation time, calyx of puncture and tract number. The possible effect of surgical experience was also taken into consideration. Univariate and stepwise multiple linear regression analysis were performed. RESULTS: The average Hgb drop was 1.9 g/dL (range: 0.1 g/dL-8.8 g/dL). Ancillary procedures were performed due to the residual calculi in 23% of patients. The stone free rates increased from 77% to 94% after the secondary interventions. Prolonged operation time and presence of diabetes mellitus (DM) had a significant association with the decrease in Hgb levels (p < 0.05). However the remaining factors analyzed did not have any association with the change in Hgb values (p > 0.05). Previous ipsilateral open renal stone surgery was not associated with a change in Hgb levels (p > 0.05). Staghorn stones and operation expertise were the factors related with operation time (p < 0.05). CONCLUSIONS: In patients where tract dilatation is gained by balloon dilators prolonged operation time and DM are the major risk factors related with a higher incidence of blood loss. Surgical expertise is highly related with operation time. It would be wise to operate staghorn stones when a high surgical experience is gained.

Perivesical inflammation and necrosis due to mitomycin C instillation after transurethral resection of bladder tumor: we must be vigilant!

The instillation of chemotherapeutic agents after transurethral resection of bladder tumor as an adjuvant treatment in bladder tumors is accepted as being safe if there is no associated bladder perforation. Mitomycin C (MMC) is a widely used agent for the adjuvant treatment of bladder tumors. A patient who developed MMC-induced bladder perforation and perivesical necrosis after an uneventful endoscopic tumor is presented. We suggest that the possible reason for such a complication could be deep resection at the anterior bladder wall. The treatment of the situation continued for an extended period, causing serious discomfort for the patient. Withholding immediate intravesical MMC instillation after resection of tumors on the anterior bladder wall ought to be considered in the early postoperative hours.

Urinary undiversion transforming an ileal conduit into an orthotopic continent neobladder: First case in our country.

Radical cystectomy (RC) with urinary diversion (UD) is still the standard treatment method for muscle-invasive bladder cancer. Type of UD is determined according to some characteristics of the patient and the tumor. Even in the most experienced hands, alternative scenarios may require an alternative diversion, including emergency UD for complications requiring immediate take down of the initial UD, tumor recurrence impacting the urinary tract or the UD, progressive impairment of renal function (in patients with a continent UD), malfunction/complications of the initial UD, and patient dislike of a stoma. We report a case of undiversion with natural history and outcome in a patient who had previously undergone RC and ileal conduit performed.

The effect of varicocele repair on experimental varicocele-induced testicular germ cell apoptosis.

The purpose of this study was to evaluate the variance of apoptosis in rats in which experimental varicocele was induced and then treated by varicocelectomy. Forty adult male Wistar albino rats were used in this experimental study. Experimental varicocele was created in 30 rats. A total of 5 rats underwent a sham operation, and the remaining 5 rats were the control group. A total of 5 rats from the varicocele group were sacrificed on the 14th postoperative day, and 5 more were sacrificed on the 28th postoperative day to document the level of apoptosis due to varicocele. Varicocelectomy was performed on 20 rats with varicocele on the 14th postoperative day. These 20 rats were divided into 4 groups to evaluate the level of apoptosis in their testis after varicocelectomy. They were sacrificed on days 7, 14, 21, and 28 after varicocelectomy. The testes were fixated by perfusion with 10% formaldehyde and then placed in paraffin blocks. From each testis, 2 samples were stained with hematoxylin and eosin, and 2 samples were stained using the TUNEL method. In each specimen, apoptotic germ cells stained by TUNEL were counted in the cross section of 100 seminiferous tubules. The apoptotic index was defined by calculating the number of apoptotic cells per seminiferous tubule. Apoptotic index = total apoptotic germ cell count/100. In the adult rats on which experimental varicocele was performed, both in the second and fourth week, apoptosis in both left and right testes were significantly higher compared with the control group (with varicocele day 14: 0.25-0.26, with varicocele day 28: 0.28-0.32, control: 0.11-0.13). After varicocelectomy on the 7th and 14th days, the slight increase in the level of apoptosis continued (day 7 left testis: 0.30, day 7 right testis: 0.28; day 14 left testis: 0.25, day 14 right testis: 0.31). After varicocelectomy, apoptosis decreased significantly on day 21 (left testis: 0.16, right testis: 0,22), and on day 28 it was almost equal to the level of the control group (left testis: 0.14, right testis: 0.16). After the creation of unilateral varicocele, the level of apoptosis increased in both the left and right testes. Apoptosis in both testes decreased after surgical treatment.

Percutaneous nephrolithotomy: primary patients versus patients with history of open renal surgery.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is the management choice for stones larger than 2 cm or for staghorn calculi. PCNL in secondary or tertiary patients poses some difficulties. In this study, we compared these patients with patients who were operated on for the first time. PATIENTS AND METHODS: A total of 328 PCNLs were performed between January 2003 and June 2007. One hundred and forty-two patients who had undergone open renal surgery in the past (126 secondary and 16 tertiary were compared with patients who had no previous history of open renal stone surgery. The tract was formed by balloon dilators, and in situations where it was necessary, fascial dilators were used. The operation was concluded by inserting a 14Ch Malecot nephrostomy tube in all cases. The number of tracts, operative time, transfusion rate, hospitalization time, and residual stones were recorded. RESULTS: Significant differences are not observed when the results are compared with the primary cases in terms of tract numbers (multiple tracts: 8.5% v 10.2%), operative time (2.3 v 2.2 hours) (P > 0.05), transfusion rate (540 v 495 mL) (P > 0.21), hospitalization time (4.4 v 4.2 days) (P = 0.94), complication rate (1.4% v 3%) (P > 0.05), and residual stones (5% v 3%) (P > 0.05). CONCLUSIONS: Although the anatomic positional differences of the kidney and fibrosis makes access and the procedure technically difficult in secondary or tertiary cases, PCNL can be performed with low complication and high success rates if safety rules are followed strictly. Difficult access can be overcome either by newly developed high-pressure balloons, assistance of fascial dilators, or by mechanical dilators.

A placebo-controlled comparison of the efficiency of triple- and monotherapy in category III B chronic pelvic pain syndrome (CPPS).

OBJECTIVES: To perform a prospective, placebo-controlled study to examine the efficacy of alpha-blocker compared with triple therapy (alpha-blocker, anti-inflammatory, and muscle relaxant) in the treatment of Category IIIB chronic pelvic pain syndrome (Category IIIB CPPS). MATERIALS AND METHODS: The study was conducted between September 2004 and December 2005, and included 90 treatment naïve patients, aged 22-42 yr (mean age: 29.1+/-5.2) with Category IIIB CPPS, who were randomized into three groups: group 1, alpha-blocker; group 2, combination of alpha-blocker, anti-inflammatory, and muscle relaxant; group 3, placebo once daily. The patients were treated for 6 mo and were followed up for a further 6 mo. Changes from baseline in the total and domain scores of the NIH Chronic Prostatitis Symptom Index (NIH-CPSI) were evaluated. The primary criterion for response was scoring 50% reduction in NIH-CPSI pain score. RESULTS: The NIH-CPSI initial and sixth-month total scores were 23.1 and 10.7, respectively, in group 1, and 21.9 and 9.2, respectively, in group 2. The initial and sixth-month scores remained stable in group 3 (22.9 and 21.9, respectively). There was no statistically significant difference between two treatment arms with respect to efficiency of treatment (p>0.05). The responses in groups 1 and 2 were found durable at the end of 12 mo. CONCLUSIONS: We found that alpha-blocker monotherapy was as effective and safe as triple therapy in the treatment of Category IIIB CPPS.

Ureteroscopy and pneumatic lithotripsy, followed by extracorporeal shock wave lithotripsy for the treatment of distal ureteral stones.

BACKGROUND: We retrospectively reviewed our experience with retrograde ureteroscopy (URS) and a pneumatic lithotriptor in 160 patients with distal ureteral stones to determine whether prior extracorporeal shock wave lithotripsy (ESWL) is a limiting factor in the ureteroscopic procedure. METHODS: From January 1999 to September 2000, we performed URS and pneumatic lithotripsy in 160 patients with distal ureteral stones. Seventy-four patients were treated with URS primarily (Group 1), while the remaining 86 patients received URS only after ESWL had failed (Group 2). For URS and lithotripsy, we used a 9.5 French rigid instrument and vibrolith (Elmed, Ankara, Turkey). RESULTS: In Group 1, 73 of 74 patients (98.6%) were treated successfully by URS alone, as were 81 of 86 patients (94.4%) in Group 2. Impacted stones were also observed in 17 patients from Group 2. In these patients, endoscopic observation revealed edematous inflammation above and below the calculus. Ureteral perforation occurred in one patient from Group 2, which required surgical repair. There was no significant difference in the stone-free rates of the two groups t = 1.4 < 1.96t( infinity,0.05). CONCLUSION: Our data demonstrate that when ESWL fails, URS and pneumatic lithotripsy is as safe and effective as primary URS. Pneumatic lithotripsy also seems to be an effective treatment modality for impacted stones.