Shear Wave Elastographic Alterations in the Kidney After Extracorporeal Shock Wave Lithotripsy.

OBJECTIVES: Extracorporeal shock wave lithotripsy (ESWL) is a method used frequently for the treatment of renal stone disease. Although its safety is proven, there are still concerns about its unwanted effects on kidneys. In this prospective study, we aimed to evaluate renal tissue alterations with shear wave elastography (SWE) after ESWL. We also studied the correlation between SWE and resistive index (RI) changes. METHODS: The study included 59 patients who underwent ESWL treatment for renal stone disease. We performed SWE and color Doppler ultrasonography to calculate SWE and RI values before, 1 hour after, and 1 week after lithotripsy treatment. A binary comparison was performed by the Bonferroni test. The correlation between SWE and RI values was evaluated by a Pearson correlation analysis. RESULTS: The patients included 26 women (44.1%) and 33 men (55.9%). Their ages ranged from 20 to 65 years (mean ± SD, 45.0 ± 1.1 years). Stone diameters ranged from 7 to 19 mm (mean, 13.0 ± 0.5 mm). There was a significant difference in SWE values before and 1 hour after lithotripsy treatment (P = .001; P < .01). In the follow-up measurement 1 week after treatment, this difference disappeared (P > .99; P > .05). Resistive index values increased significantly 1 hour after lithotripsy treatment and returned to prelithotripsy values 1 week after treatment. In the correlation analysis, SWE and RI values were not correlated. CONCLUSIONS: Measurements of alterations in SWE values after ESWL can provide useful information about renal tissue injury.

Comparison of robotic and laparoscopic partial nephrectomy for small renal tumours.

OBJECTIVE: To evaluate a single surgeon oncological and functional outcomes of laparoscopic partial nephrectomy (LPN) compared to robotic partial nephrectomy (RPN) for pT1a renal tumours. MATERIALS AND METHODS: Between 2006 and 2016, a retrospective review of 42 patients who underwent LPN (n = 20) or RPN (n = 22) by same surgeon was performed. Patients were matched for gender, age, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, tumour side, RENAL and PADUA scores, peri-operative and post-operative outcomes. RESULTS: There was no significant differences between the two groups with respect to patient gender, age, BMI, ASA score, tumours side, RENAL and PADUA scores. Mean operative time for RPN was 176 vs. 227 minutes for LPN (p = 0.001). Warm ischemia time was similar in both groups (p = 0.58). Estimated blood loss (EBL) was higher in the LPN. There was no significant difference with preoperative and postoperative creatinine and percent change in eGFR levels. Only one case in LPN had positive surgical margin. CONCLUSIONS: RPN is a developing procedure, and technically feasible and safe for small-size renal tumours. Moreover RPN is a comparable and alternative operation to LPN, providing equivalent oncological and functional outcomes, as well as saving more healthy marginal tissue and easier and faster suturing.

Single plus one port robotic radical prostatectomy (SPORP); Initial experience.

OBJECTIVE: This article reports on patients with early stage prostate cancer treated with single plus one port robotic radical prostatectomy (SPORP). MATERIALS AND METHODS: Since January 2014, we performed SPORP in 8 patients with localized prostate cancer. Age of patients, clinical stage, operation time, intraoperative and postoperative complications, blood loss, histopathological evaluation, postoperative continence, serum level of PSA were evaluated. RESULTS: Mean age of the 8 patients was 59.85 years. All operations were completed without conversion to standard robotic procedure or open surgery. No intra operative complications occurred. Mean operating time was 143 minutes; prostate excision 123 minutes and urethrovesical anastomosis 20 minutes. Mean blood loss was 45 ml. Preoperative Gleason scores were (3 + 4) in one patient and (3 + 3) in 7 patients. Postoperative Gleason scores were (3 + 4) in 2 patients, and (3 + 3) in 6 patients. All these 8 cases were in T1c clinical stage. Early postoperative complications were drain leakage (n = 1), atelectasis (n = 1), wound infection (n = 1) and fever (n = 1). There was no positive surgical margin. The serum level of PSA was less than 0.2 ng/ml and no other complications happened during the 4 to 12 months follow-up period. Postoperative continence and cosmetic results were excellent. CONCLUSIONS: It is relatively easy for urologists who are skilled in traditional laparoscopic and robotic surgeries to master SPORP. However long-term outcomes of this surgery need further investigations.

Long Term Outcomes of Laparoscopic and Open Modified Lich-Gregoir Reimplantation in Adults: A multicentric comparative study.

BACKGROUND & OBJECTIVE: Obstructive ureteral pathologies in adult patients are most commonly due to ureteral strictures and secondary to surgical interventions. In this study, we aimed to compare open and laparoscopic modified Lich-Gregoir ureteral reimplantation with regards to outcomes in benign ureteral pathologies in adult patients. METHODS: Between December 2008 and December 2014, 32 open cases and 29 laparoscopic cases were performed as per the data retrieved from surgical databases. All laparoscopic procedures were performed in Bakirkoy Dr. Sadi Konuk Training and Research Hospital(BEAH) and all open ureteral reimplantation procedures in Kartal Dr Lutfi Kirdar Training and Research Hospital(KEAH) and Okmeydani Training and Research Hospital(OEAH). RESULTS: The mean operation time was significantly lower in the group of patients operated with open group (142.5 minutes versus 188.9 minutes; P< 0.0001). The mean duration of follow-up was longer in the laparoscopy group (31 versus 28 months; p< 0.0001). The mean amount of operation associated blood loss was significantly lower in patients operated laparoscopically (93.7 mL versus 214 mL; P< 0.0001). The mean VAS score obtained six hours after surgery was 6.6 ± 0.8 in open group, and 5.8 ± 0.7 in laparoscopic group (p=0.0004). The mean VAS scores measured at post-operative day 1 was 4.5 ± 0.7 in open group and 3.7 ± 0.9 in laparoscopy group. Time required to achieve the pre-operative capability of daily activities was significantly longer in open group (15 ± 1.4 days vs 11 ± 1.4 days; p< 0.0001). CONCLUSION: Despite open techniques provide shorter operation time and laparoscopic techniques require long learning curve, we think that laparoscopic techniques are superior to open ones since that they provide a better post-operative comfort and are better tolerated in terms of complications.

Flexible Ureteroscopy versus Retroperitoneal Laparoscopic Ureterolithotomy for the Treatment of Proximal Ureteral Stones >15 mm: A Single Surgeon Experience.

OBJECTIVE: To compare safety and effectiveness of flexible ureteroscopy (F-URS) and laparoscopic retroperitoneal ureterolithotomy (L-RU) in treatment of proximal ureteral stones larger than 15 mm. MATERIALS AND METHODS: This study included 103 patients treated with L-RU (Group I), and 80 patients treated with F-URS (Group II) due to proximal ureteral stones larger than 1.5 cm, in a single center. Patients' characteristics and procedure-related parameters including success rate, operation time, hospital stay, postoperative visual analogue scale (VAS) scores, auxiliary procedures, and complications were compared between Groups I and II. RESULTS: It was seen that both methods were effective in the treatment of large ureteral stones; however, R-LU provided a higher stone-free rate (100 vs. 87.5%), a lower complication rate (10.6 vs. 23.7%), and a shorter operation time (65.4 vs. 75.1 min). On the other hand, patients treated with F-URS had less postoperative pain, a shorter hospital stay, a faster return to daily activities. CONCLUSIONS: For treatment of large proximal ureteral stones, L-RU provides significantly higher success and lower retreatment rate compared with F-URS. Our results also indicate that R-LU, which has been regarded as an invasive procedure is not as invasive as it is thought to be, and it must be kept in mind that F-URS may cause complications despite its noninvasive nature.

Serum paraoxonase-1 gene polymorphism and enzyme activity in patients with urolithiasis.

OBJECTIVES: Paraoxonase-1 (PON1) is a high-density lipoprotein-associated enzyme implicated in the pathogenesis of atherosclerosis by protecting lipoproteins against peroxidation. PON1 has two genetic polymorphisms both due to amino acid substitution, one involving glutamine and arginine at position 192 and the other leucine and methionine at position 55. Recent reports suggest that nephrolithiasis and atherosclerosis share a number of risk factors. Our study aimed to compare the effects of PON1 192, PON1 55 polymorphisms, and PON1 activity in patients with urolithiasis and controls. MATERIALS AND METHODS: PON1's arylesterase/paraoxonase activities and phenotype were determined in 158 stone forming cases (Group 1) and 138 non-stone forming controls (Group 2). The PON1 192 and PON1 55 polymorphisms were studied by polymerase chain reaction/restriction fragment length polymorphism. RESULTS: Paraoxonase activity was significantly lower in Group 1 than Group 2 (112 ± 31.8 vs. 208 ± 53.1 IU/L) (p < 0.001). The PON1 L55M polymorphism was significantly higher in Group 1. The "M" allele coding for PON1 was higher in Group 1 (p < 0.001). PON1 192 RR homozygotes had significantly higher PON1 activity than QR and QQ genotypes among all the patients (p < 0.001). CONCLUSION: The results of our study demonstrate that the PON1 55 gene "M" allele is associated with renal stone disease. Individuals possessing the "M" allele have a higher incidence of urolithiasis. The results of this study provide genetic evidence that the PON1 gene may play a role in stone formation. PON1 genotype determination may provide a tool to identify individuals who are at risk of urolithiasis.

Flexible ureteroscopy versus laparoscopy for the treatment of patients who initially presented with obstructive pyelonephritis.

OBJECTIVE: To compare the safety and effectiveness of flexible ureteroscopy (F-URS) with transperitoneal laparoscopic ureterolithotomy (TPLU) in cases of obstructive pyelonephritis secondary to large proximal ureteral stones. METHODS: A series of 42 patients presenting with obstructive pyelonephritis due to proximal ureteral stones larger than 1.5 cm were included from April 2006 to February 2015 in this comparative study. After drainage of pyonephrosis and resolution of sepsis, 22 patients treated with TPLU (Group I), and 20 patients were treated with F-URS (Group II). Preoperative patient and stone characteristics, procedure-related parameters and clinical outcomes were assessed for each group. RESULTS: It was seen that both methods were effective in the treatment of large proximal ureteral stones. However TPLU provided a higher stone- free rate (100% vs 80%. p=0.043) and lower retreatment rate. There was no difference between the groups for the operative time and complication rate. On the other hand, patients treated with F-URS had less postoperative pain (p=0.008), a shorter hospital stay (p<0.001) and a faster return to daily activities (p<0.001). CONCLUSIONS: The results of our study show that both F-URS and TPLU are safe and effective surgical procedures for treatment of large proximal ureteral stones after controlling obstructive pyelonephritis. However, TPLU has a higher stone-free rate with comparable operating time and complication rate as compared to F-URS. On the other hand F-URS has the advantages of less postoperative pain, shorter hospital stay and faster return to daily activities.

Role of interleukin-6 and pentraxin 3 as an early marker in Peyronie's disease.

Inflammation is mechanistically involved in the development of Peyronie's disease (PD). The aim of this study is to assess the relevance of serum pentraxin 3 (PTX3) and interleukin-6 (IL-6) concentrations in PD. The study enrolled 40 patients with PD in the acute phase and 40 healthy controls. Plasma PTX3 and IL-6 concentrations were evaluated in 40 patients in the acute phase of PD and 40 healthy controls by enzyme-linked immunosorbent assay. Serum concentrations of both PTX3 and IL-6 were significantly higher in the PD patients than in the control group (p=0.001 and p=0.001, respectively). There was a significant correlation between concentration of PTX3 and painful erections. IL-6 concentrations were significantly higher in patients with erectile dysfunction. IL-6 and PTX3 levels showed no correlation with age, serum C-reactive protein, degree of curvature, and disease duration. IL-6 trans-signaling and PTX3 amplification at the site of inflammation could have a role in pathophysiological mechanisms of PD. Biological drugs may be used for treatment during the acute phase of the disease based on this mechanism.

Urinary IP-10, MCP-1, NGAL, Cystatin-C, and KIM-1 Levels in Prenatally Diagnosed Unilateral Hydronephrosis: The Search for an Ideal Biomarker.

OBJECTIVE: To investigate the urinary interferon gamma-induced protein 10 (IP-10), monocyte chemotactic protein 1 (MCP-1), neutrophil gelatinase-associated lipocalin (NGAL), cystatin-C, and kidney injury molecule-1 (KIM-1) levels in the management of children with prenatally diagnosed unilateral hydronephrosis. MATERIALS AND METHODS: Twenty-seven children with antenatally diagnosed hydronephrosis were enrolled into the study. The controls consisted of 9 healthy children (6 boys, 3 girls; mean age: 41.77 ± 5.30 months). Thirteen children (9 boys, 4 girls; mean age: 48.46 ± 21.11 months) underwent pyeloplasty on follow-up; the remaining 14 (13 boys, 1 girl; mean age: 36.57 ± 14.02 months) were followed up after being diagnosed as having nonobstructive dilatation (NOD). The urinary marker levels were measured in the pyeloplasty, the NOD, and the control groups. RESULTS: The preoperative concentrations of IP-10, MCP-1, NGAL, and KIM-1 were significantly higher in the pyeloplasty group than in the control group (P = .024, P = .002, P = .032, P = .001, respectively). The urinary IP-10 and MCP-1 levels were also significantly higher in the pyeloplasty group than in the NOD group (P = .038, P = .037, respectively). There was no significant difference between the pyeloplasty group and the NOD group regarding urinary NGAL and KIM-1. In the pyeloplasty group, urinary marker levels except cystatin-C were significantly decreased in the postoperative period. CONCLUSION: A decrease in levels of IP-10, MCP-1, NGAL, and KIM-1 after pyeloplasty may be used as a predictor of surgical outcome. Additionally, IP-10 and MCP-1 were superior to NGAL and KIM-1 in predicting who required surgery.

Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery.

BACKGROUND AND OBJECTIVES: Our objective is to clarify the effect of previous transurethral resection of the prostate (TURP) or open prostatectomy (OP) on surgical, oncological, and functional outcomes after robot-assisted radical prostatectomy (RARP). METHODS: Between August 1, 2009, and March 31, 2013, 380 patients underwent RARP. Of these, 25 patients had undergone surgery for primary bladder outlet obstruction (TURP, 20 patients; OP, 5 patents) (group 1). A match-paired analysis was performed to identify 36 patients without a history of prostate surgery with equivalent clinicopathologic characteristics to serve as a control group (group 2). Patients followed up for 12 months were assessed. RESULTS: Both groups were similar with respect to preoperative characteristics, as mean age, body mass index, median prostate-specific antigen, prostate volume, clinical stage, the biopsy Gleason score, D'Amico risk, the American Society of Anesthesiologists (ASA) classification score, the International Prostate Symptom Score, continence, and potency status. RARP resulted in longer console and anastomotic time, as well as higher blood loss compared with surgery-naive patients. We noted a greater rate of urinary leakage (pelvic drainage, >4 d) in group 1 (12% vs 2,8%). The anastomotic stricture rate was significantly higher in group 1 (16% vs 2.8%). No difference was found in the pathologic stage, positive surgical margin, and nerve-sparing procedure between the groups. Biochemical recurrence was observed in 12% (group 1) and 11.1% (group 2) of patients, respectively. No significant difference was found in the continence and potency rates. CONCLUSIONS: RARP after TURP or OP is a challenging but oncologically promising procedure with a longer console and anastomosis time, as well as higher blood loss and higher anastomotic stricture rate.

Upper Tract Urological Laparoendoscopic Single-Site Surgery (LESS).

BACKGROUND AND OBJECTIVES: Our objective is to report intermediate-term outcomes for patients who have undergone upper tract urologic laparoendoscopic single-site surgery (LESS) at a single institution. METHODS: From January 1, 2008, through November 30, 2012, 107 cases treated with LESS were identified, including pyeloplasty (n = 30), ureterolithotomy (n = 32), nephrectomy (n = 35; simple = 31, partial = 4), and cyst decortication (n = 10). Perioperative data were reviewed, and conversion and complication rates were noted. RESULTS: The median follow-up was 21.5 months for pyeloplasty, 20.5 for ureterolithotomy, 28.0 for simple nephrectomy, 14.0 for partial nephrectomy, and 19.0 for cyst decortication. Major complications were encountered in 8 patients, including 3 intraoperative complications (2 bowel injury with serosal tearing and 1 intraoperative bleeding), which were recognized and repaired with LESS or conversion to conventional laparoscopy (CL). During the intermediate postoperative period (30-90 days) major complications occurred in 5 patients: 4 ureteral strictures (Clavien-Dindo grade [CG] IIIb) and 1 urinoma formation (CG IIIa). During the early postoperative period (<30 days), the most common minor complications were flank pain (CG I) in 16 patients and urinary tract infection (CG II) in 11, followed by urinary leakage (CG I) in 8. CONCLUSIONS: Intermediate-term functional outcomes of this single-center study confirm that upper tract LESS is a challenging procedure that can be safe and effective when performed by an experienced team. Prospective studies with longer follow-up periods are needed to investigate the safety of LESS in the treatment of various upper urinary tract conditions.

The roles of serum and urinary carbohydrate antigen 19-9 in the management of patients with antenatal hydronephrosis.

INTRODUCTION: Serum carbohydrate antigen (CA) 19-9 has been clinically applied as a valuable tumor marker for pancreatic and gastrointestinal carcinoma. CA 19-9 is expressed in normal excretory epithelium tissues. Increased CA 19-9 has also been observed in uroepithelial tumors as well as in nonmalignant conditions including hydronephrosis secondary to ureteral stones. OBJECTIVE: The purpose of this article is to evaluate the role of urinary CA 19-9 as a non-invasive biomarker in the postnatal differentiation of obstructive and non-obstructive hydronephrosis in patients with unilateral antenatal hydronephrosis. STUDY DESIGN: Infants with isolated renal pelvic dilatation, defined as the presence of anteroposterior pelvic diameter (APPD) equal to or greater than 7 mm based on antenatal ultrasound after 28 weeks' gestation, underwent systematic investigation for uropathies and were prospectively followed up. The pyeloplasty group consisted of 17 patients with ureteropelvic junction (UPJ) obstruction who had undergone pyeloplasty. The non-obstructive dilatation (NOD) group consisted of 17 patients with non-obstructive hydronephrosis, and the control group consisted of 21 healthy children. Commercial enzyme-linked immunosorbent assay (ELISA) kits were used to measure the urinary and serum CA 19-9 levels. In both hydronephrosis groups (pyeloplasty and non-obstructive dilatation), the correlations between urinary and serum CA 19-9 levels with the anteroposterior pelvic diameter measured at the third trimester and the postnatal initial evaluation and differential renal function were investigated. RESULTS: The initial median urinary CA 19-9 levels were significantly greater in children who underwent pyeloplasty than in both the non-obstructive hydronephrosis (143 ± 38 vs. 68 ± 23, respectively; p = 0.007) and the healthy control groups (143 ± 38 vs. 13 ± 3, respectively; p = 0.001) (Figure). Three months after surgery, the urinary CA 19-9 levels had decreased significantly according to the preoperative levels in the pyeloplasty group (143 ± 38 vs. 55 ± 16, p = 0.039). In both the pyeloplasty and NOD groups, there was a correlation of urinary CA 19-9 levels with differential renal function and a correlation of serum CA 19-9 levels with the initial anteroposterior pelvic diameter. Receiver operator characteristic (ROC) analysis revealed a better diagnostic profile for the urinary CA 19-9 level than for the serum CA 19-9 level in terms of identifying obstruction in the hydronephrosis groups (areas under the curve = 0.8 and 0.7, respectively). The best cut-off value of for urinary CA 19-9 was 85.5 U/mL with 76% sensitivity, 85% specificity. The negative predictive value was 80%. DISCUSSION: The results suggest that voided urine CA 19-9 levels seems to be a more useful marker than serum CA 19-9 in obstructive dilatation. An appropriate decrease in urinary CA 19-9 levels after pyeloplasty may be used as a predictor of surgical outcome. In addition, the results have a number of important diagnostic implications that should be further validated in a larger study population. CONCLUSIONS: Based on these results, we suggest that a high urinary CA 19-9 level is a non-invasive clinically applicable marker for differentiating between obstruction and non-obstructive dilatation.

Residual valve and stricture after posterior urethral valve ablation: how to evaluate?

OBJECTIVE: To investigate the clinical and radiological parameters of posterior urethral valve (PUV) patients with residual valve or strictures after primary valve ablation. PATIENTS AND METHODS: A total of 127 PUV patients were treated in our clinic between 1986 and 2009. We retrospectively reviewed the records of 101 patients, who had at least 1 year of follow-up data, regarding the presence of valve remnants or urethral strictures after PUV ablation. RESULTS: A total of 21 patients (20.8%) underwent repeat-urethroscopy and, of these, residual valve leaflets or stricture were detected in 10 patients (10/101, 9.9%). In 2 of these 10 (20%), the urethra had been found to be normal on the first voiding cystourethrogram following ablation. However, these two boys underwent re-urethroscopy due to persistent vesicoureteral reflux in one and persistent hydroureteronephrosis in the other, and valve remnants were detected. The remaining 8 cases had radiological signs consistent with persistent infravesical obstruction in the early period. Obstruction was due to urethral stricture and residual valve remnants in 2 and 6 cases, respectively. CONCLUSIONS: There was clinical suspicion of residual valve in about 20% of the cases and in half of these the urethra was found to be normal on urethroscopy. The possible presence of residual valve remnants after primary valve ablation should be confirmed by careful clinical, radiological and endoscopic evaluation.

Fetal urinoma and prenatal hydronephrosis: how is renal function affected?

OBJECTIVE: In our study, the functional prognosis of kidneys with prenatal urinomas were investigated. MATERIAL AND METHODS: Between 2006 and 2010, fetal urinomas were detected in 19 fetuses using prenatal ultrasonography (US), and the medical records were reviewed retrospectively. Of the 19 cases, the follow-up data were available for 10 fetuses. The gestational age at diagnosis, prognosis of urinomas, clinical course and renal functions were recorded. Postnatal renal functions were assessed with renal scintigraphy. RESULTS: Unilateral urinomas and increased parenchyma echogenicity in the ipsilateral kidney were detected in all of the fetuses. Of the 10 fetuses with follow-up data, the option of termination was offered in 6 cases of anhydramnios, including 3 cases with signs of infravesical obstruction (a possible posterior urethral valve (PUV) and poor prognostic factors and 3 cases with unilateral hydronephrosis and increased echogenicity in the contralateral kidney. Only one family agreed the termination. The other 5 fetuses died during the early postnatal period. The average postnatal follow-up period in the 4 surviving fetuses was 22.5 months (8-38 months). One patient with a PUV underwent ablation surgery during the early postnatal period. In the postnatal period, none of the 4 kidneys that were ipsilateral to the urinoma were functional on scintigraphic evaluation. The urinomas disappeared in 3 cases. Nephrectomy was performed in one case due to recurrent urinary tract infections. CONCLUSION: In our study, no function was detected in the ipsilateral kidney of surviving patients with urinomas. Upper urinary tract dilatation accompanied by a urinoma is a poor prognostic factor for renal function.

How does the presence of antenatally detected caliectasis predict the risk of postnatal surgical intervention?

OBJECTIVE: To determine the effect of antenatally detected caliectasis on the postnatal surgical intervention rate. METHODS: From 2006 to 2010, 56 patients with an anteroposterior diameter (APD) of 7-20 mm on the prenatal ultrasound scan performed in the third trimester of pregnancy were included in the present study. In these 56 patients, other anomalies (vesicoureteral reflux, posterior urethral valves, duplex system, megaureter) were excluded, and the postnatal clinical and radiologic follow-up data were available. The mean follow-up was 12.82 ± 10.72 months. These 56 patients were divided into 2 groups: those with (n = 32) and without (n = 24) caliectasis. In the caliectasis group, the mean follow-up was 13.6 ± 12.09 months and was 11.7 ± 8.70 months in the group without caliectasis. The statistical correlation between the postnatal operation rates and the presence of caliectasis (APD range 7-20 mm in third trimester) was investigated using the chi-square test. RESULTS: In the study group (n = 56) with an APD range of 7-20 mm in the third trimester, postnatal surgical treatment (pyeloplasty) was performed in 12 (37.5%) and 3 (12.5%) of the children with and without caliectasis, respectively (P = .037). The risk of postnatal surgical treatment increased threefold in patients with an APD of 7-20 mm and a diagnosis of caliectasis (relative risk 3.0, 95% confidence interval 1.07-8.40). CONCLUSION: In our study, the presence of concomitant caliectasis within the APD range of 7-20 mm on the third trimester ultrasound scan increased the risk of surgical treatment threefold. During prenatal counseling, the presence of caliectasis requires more rigorous follow-up.