A preoperative prognostic model predicting recurrence-free survival for patients with kidney cancer.

OBJECTIVE: To develop a preoperative prognostic model in order to predict recurrence-free survival in patients with nonmetastatic kidney cancer. METHODS: A multi-institutional data base of 1889 patients who underwent surgical resection between 1987 and 2007 for kidney cancer was retrospectively analyzed. Preoperative variables were defined as age, gender, presentation, size, presence of radiological lymph nodes and clinical stage. Univariate and multivariate analyses of the variables were performed using the Cox proportional hazards regression model. A model was developed with preoperative variables as predictors of recurrence after nephrectomy. Internal validation was performed by Harrell's concordance index. RESULTS: The median follow-up was 23.6 months (1-222 months). During the follow-up, 258 patients (13.7%) developed cancer recurrence. The median follow-up for patients who did not develop recurrence was 25 months. The median time from surgery to recurrence was 13 months. The 5-year freedom from recurrence probability was 78.6%. All variables except age were associated with freedom from recurrence in multivariate analyses (P < 0.05). Age was marginally significant in the univariate analysis. All variables were included in the predictive model. The calculated c-index was 0.747. CONCLUSIONS: This preoperative model utilizes easy to obtain clinical variables and predicts the likelihood of development of recurrent disease in patients with kidney tumors.

The effects of fetal allogeneic umbilical cord tissue transplant following experimental spinal cord injury on urinary bladder morphology.

BACKGROUND AND PURPOSE: In continuation of our previous experimental study on spinal cord injury (SCI) using fetal stem cells, we investigated here the effects of fetal allogeneic umbilical cord tissue transplant on the urinary bladder morphology in a rat SCI model. MATERIAL AND METHODS: Five pregnant albino Wistar rats at 12 days of gestation were used to obtain the umbilical cord cell graft. In Group 1 (n = 5), Th8-Th9 laminectomy was performed. Group 2 (n = 5) received spinal cord injury. In Group 3 (n = 5), the cultured fetal umbilical cord cells coated with alginate gel were placed into the lesion cavity. In Group 4 (n = 5), only alginate sponges without umbilical cord cells were placed into the injury cavity. The bladders of animals were analyzed pathologically at 21 days after surgery. RESULTS: The thickness of the epithelium and the lamina propria did not differ among studied groups (p > 0.05). The lamina muscularis thickness was significantly higher in Group 2 and Group 4 than the others (p < 0.05). The bladder weight was similar among Groups 1, 2, and 3 (p > 0.05). Fibrosis was significantly increased in Group 2 (p < 0.05); it was greater in Group 2 than in Group 3 (p < 0.05) but did not differ between Groups 1 and 3 (p > 0.05). CONCLUSIONS: This study suggests that allogeneic umbilical cord tissue transplantation after SCI may prevent bladder wall hypertrophy and fibrosis in the rat SCI model.

The effects of two systemic alpha1-adrenergic blockers on pupil diameter: a prospective randomized single-blind study.

Our aim was to investigate the effects of two alpha(1)-adrenergic blockers-tamsulosin and alfuzosin-on pupil diameter (PD). In this prospective randomized single-blind clinical trial, 64 patients with benign prostatic hyperplasia received treatment with either tamsulosin or alfuzosin. The same ophthalmologist, masked to the given medication, evaluated patients prior to, 4 weeks after and 6 months after the start of the medication (day 0, day 28 and month 6). Best corrected visual acuity and PD under mesopic, scotopic, and dilated conditions were measured. t-test, ANOVA, and Dunnett's multiple comparison post-test were used for statistical analysis. With tamsulosin treatment, both mesopic and scotopic PD decreased, respectively, from 3.9 +/- 0.7 and 5.7 +/- 0.6 mm at day 0 to 3.6 +/- 0.9 and 5.5 +/- 0.8 mm at day 28, and 3.6 +/- 0.7 and 5.4 +/- 0.7 mm at month 6 (ANOVA; P = 0.021 and = 0.040, respectively). However, the difference in dilated PD was not significant (day 0 7.8 +/- 0.6 mm, day 28 7.7 +/- 0.7 mm, and month 6 7.6 +/- 0.6 mm, P = 0.379). In the alfuzosin group, PD did not differ significantly from the baseline except for the scotopic measurements, which decreased from 5.6 +/- 0.6 mm at day 0 to 5.5 +/- 0.6 mm at day 28 and 5.2 +/- 0.8 mm at month 6 (P = 0.004). Compared to baseline values, small but statistically significant decreases were detected in mesopic and scotopic illumination in patients treated with tamsulosin and in scotopic PD in patients treated with alfuzosin. The clinical significance of these differences needs further evaluation.

The effects of systemic alpha-1 adrenergic antagonists on pupil diameter in rats.

PURPOSE: To investigate the effects of alpha-1 adrenergic blockers on pupil diameter (PD) in rats. METHODS: Four groups, with 10 rats each, were designed to receive terazosin, tamsulosin, doxazosin, and no medication. Dilated pupil diameter (PD) measurements were performed 24 hr before, 24 hr after, and 30 days after the initiation of medication, and after 30 days of washout. The intergroup and intragroup differences in PD were evaluated using one-way ANOVA and Wilcoxon signed rank test, respectively. RESULTS: In day 1, PD decreased in both eyes significantly only in tamsulosin and doxazosin groups, but these effects became insignificant at 30 days of treatment (p > 0.05). The control group showed no significant difference in PD (p > 0.05). PD values returned to baseline after the washout period in all groups. CONCLUSIONS: A significant reduction in PD occurred in two of the three groups with alpha-1 adrenergic blockers (tamsulosin and doxazosin), but this effect was not sustained at 30 days. Further functional and structural studies of the iris are needed to determine the clinical significance of these findings.

Ureteroappendiceal fistula due to gossypiboma.

A case of gossypiboma (retained surgical sponge) is described which caused ureteroappendiceal fistula 4 years after an open right ureterolithotomy operation. The patient was treated by removal of the retained sponges, appendectomy and ureteral stent insertion.

Prostate biopsy in the elderly: histologic findings and treatment necessity.

The aim of this study is to determine results of high prostate specific antigen (PSA) or abnormal digital rectal examination driven prostate biopsies performed in our Department in men aged 75 or more and to show the characteristics of pathology results. The hospital records of the patients who had high PSA or abnormal digital rectal examination driven prostate biopsy in two common university based research hospitals have been reviewed retrospectively. Patients aged 75 years or older at the date of biopsy whose records provided pathology results and full medical history were evaluated for the study. A total of 103 patients were evaluated with a mean age of 79.4±3.4 years. More than half of the patients (55.1%) were in their seventh decade and the rest were in the eighth decade. Median PSA value was 15.0 (range 2.1-4500) ng/ml. In most of the biopsies (67%), PSA levels were lower than 20 ng/ml. In almost half of the patients (48%), digital rectal examination was abnormal. In 68.9% of the patients, there were at least one or more associated co-morbid diseases. Gleason scores were 7 or higher in 73%, and 8 or higher in 37% of the patients with prostate cancer. Four of the 70 (6%) patients had bone metastases. Castrations were applied to most of the patients with prostate adenocarcinoma (%79). High percentage of high grade (Gleason 7 or more) prostate adenocarcinoma in the elderly refutes the perception of prostate cancer in this age group as clinically insignificant. Therefore, it is to be kept in mind that prostate cancer in the elderly an be clinically significant and prostate biopsies are to be performed when necessary.

Do patients on alpha-blockers for the treatment of benign prostatic hyperplasia have better results after shockwave lithotripsy of urinary stones?

PURPOSE: To investigate whether patients who are on alpha 1-adrenergic receptor (alpha 1-AR) antagonists for the treatment of benign prostatic hyperplasia (BPH) had better results after extracorporeal shockwave lithotripsy (SWL). PATIENTS AND METHOD: We retrospectively reviewed the records of male patients older than 50 years who underwent SWL. Clinical characteristics, including the use of alpha 1-AR antagonists for BPH were analyzed. Mann-Whitney U test was used for data not normally distributed and student's t test for data normally distributed. The categorical variables were analyzed by the Chi-square test. A multiple logistic regression analysis was used to analyze the associations of variables on successful treatment. RESULTS: A total of 264 renal units were treated. Complete stone clearance was achieved in 167 RUs (63.3%) and 28 RUs (10.6%) had clinically insignificant residual fragments. In 69 RUs (26.1%), SWL failed. More patients were on alpha 1-AR antagonists for BPH in the successfully treated group (p=0.028). The multivariate analysis revealed that the use of alpha 1-AR antagonists had significant effects on the success of SWL (p=0.047). SWL was performed to 34 RUs of 33 patients who were on alpha 1-AR antagonists and it was successful in 30 RUs (88.2%). In the remaining 230 RUs, stone-free state was achieved in 165 RUs (71.7%) (p=0.028). Stone-free rates were similar for patients on alfuzosine, tamsulosine, and doxazosine (p=0.310). CONCLUSION: Patients who are being treated with alpha 1-AR antagonist agents for BPH have better results after SWL treatment, compared to patients not receiving alpha 1-AR antagonist. The improved results are independent of the type of alpha 1-AR antagonist.

Public awareness of testicular cancer and self-examination in Turkey: a multicenter study of Turkish Urooncology Society.

BACKGROUND: Testicular self-examination is the easiest and cheapest way to scan testicular cancer. However, the public awareness about testicular self-examination is very low. We aimed to investigate the public awareness of Turkish people about testicular cancer and testicular self-examination. METHODS: We performed a survey consisting of 10 questions concerning testicular cancer and testicular self-examination in 799 students in the first year of 12 different medical schools. Aiming for a common method of data collection, the questionnaires were administered to the students during a class just before the lesson started. The whole data from all of the centers were pooled in a common data-base file. RESULTS: Eighty-nine (11.1%) of the participants reported that they had knowledge about testicular cancer, but only 11 (1.4%) of them answered all the questions about testicular cancer correctly. Eight (1%) of the participants reported that they had been performing testicular self-examination routinely once a month. Four (0.5%) of them were both well informed about testicular cancer and had been performing testicular self-examination once a month as suggested. CONCLUSION: The present study showed that awareness on testicular cancer and testicular self-examination is very low and suggests a need for efforts in Turkey to increase public awareness and education.

Percutaneous nephrolithotomy for staghorn kidney stones in elderly patients.

PURPOSE: We retrospectively analyzed the results of percutaneous nephrolithotomy operations for treatment of staghorn kidney stone disease in elderly patients and compared surgical parameters and outcomes with a control group of young adult patients. PATIENTS AND METHOD: Between 2002 and 2010, 300 consecutive patients underwent percutaneous nephrolithotomy operation for treatment of staghorn kidney stone disease. Forty-five of the patients were older than 65 years and considered to be in elderly group. Thirty-seven of the patients were between the ages 18 and 36 years and considered to be the control group. Surgical parameters and outcomes were compared between groups. RESULTS: There were no significant differences between groups for stone area, operation time, difference in hemoglobin levels before and after surgery, blood transfusion rate, and length of hospital (P = 0.230, P = 0.106, P = 0.395, P = 0.691, and P = 0.690, respectively). Success rates after the operations were 53% in elderly group and 38% in young adult group. The difference for the outcomes of the operations was statistically insignificant (P = 0.365). Thirty-three (73%) of the patients had associated comorbid diseases in elderly group, while no patients had any comorbid disease in control group. Statistical analyses revealed no significant relation between the presence of comorbid diseases or ipsilateral renal surgery with success rate of the operation in the elderly group (P = 0.26 and P = 0.222, respectively). CONCLUSIONS: The management of kidney stone disease by percutaneous nephrolithotomy in elderly patients is an adequate treatment modality even in the presence of complete staghorn calculi, comorbid diseases or previous ipsilateral renal surgery.

Intraoperative floppy iris syndrome: facts for the urologist.

Intraoperative floppy iris syndrome (IFIS) consists of a triad of flaccid and billowing iris, iris prolapse through the surgical incisions, and progressive pupil constriction. IFIS increases the risk for complications during cataract surgery. It was first described in patients on tamsulosin treatment but can also be seen in patients on other non-subtype specific alpha(1)-adrenergic receptor (alpha(1)AR) antagonists. Urologists who are initiating treatment with alpha(1)AR antagonists should inform their patients that these drugs may increase the difficulty of cataract surgery, but once the ophthalmologists are forewarned, necessary safety measures can be taken to achieve good surgical results.

Long-term renal function and stone recurrence after percutaneous nephrolithotomy in patients with renal insufficiency.

PURPOSE: We analyzed long-term results after percutaneous nephrolithotomy (PCNL) in patients with impaired renal function. PATIENTS AND METHODS: Nineteen (6.3%) of 300 patients who underwent PCNL had serum creatinine values above 1.4 mg/dL before surgery and were considered to have impaired renal function. Success rate of operation, recurrence rate, and renal functional status were evaluated. RESULTS: Mean follow-up time was 51.1 +/- 10.1 months. Sixteen patients completed the study, but three patients were lost to follow-up. The results of the operation were as follows: stone free in 50%, clinically insignificant residual fragments in 25%, and clinically significant residual fragments in 25% of the patients. Mean serum creatinine value was 2.30 +/- 0.56 mg/dL before surgery and 2.67 +/- 1.41 mg/dL at the end of follow-up (p = 0.386). Creatinine values decreased to normal range in six patients (37.5%). Six patients (37.5%) had stable renal function (creatinine: 1.4-4 mg/dL). Creatinine values increased (>4 mg/dL) in four patients (25%) who required renal replacement therapy. Three new patients progressed to end-stage renal failure. These three had insulin-dependent type II diabetes mellitus and one also had solitary kidney and atherosclerosis. Two patients (12.5%) had recurrences, one of these had hypercalciuria, and the other had infection stone. CONCLUSION: Our results indicated that most patients presenting with kidney-stone disease and renal insufficiency experience improvement or stabilization of renal function after PCNL. The patients with solitary kidney and those with conditions such as diabetes and atherosclerosis might be at greater risk for deterioration of renal function. Patients with metabolic abnormalities and infection stones might be at higher risk for recurrence.

Single-knot running suture anastomosis (one-knot pyeloplasty) for laparoscopic dismembered pyeloplasty: training model on a porcine bladder and clinical results.

OBJECTIVES: The one-knot running ureteropelvic anastomosis is a modification of the single-knot running suture that was previously described for urethrovesical anastomosis. In this study, we present a novel porcine model for laparoscopic pyeloplasty training and report the results obtained in patients who underwent one-knot pyeloplasty. MATERIALS AND METHODS: A porcine bladder was used for the ureteropelvic junction simulation in this training model. The laparoscopic one-knot pyeloplasty technique was attempted by five laparoscopic surgeons using this model, and the technique was then incorporated into clinical practice. The data of all patients who underwent this procedure between January 2006 and February 2008 were evaluated. RESULTS: The one-knot pyeloplasty technique was easily applied in a short time by laparoscopic surgeons in a novel porcine pyeloplasty model. The participants successfully performed a watertight anastomosis in the porcine bladder model, completing the task in <30 min by the fifth attempt. The time required to succeed before and after training decreased by 20.8% (P = 0.01). In the clinical portion, 40 laparoscopic pyeloplasty procedures were performed with this technique, and the mean time to complete the anastomosis was 27.1 min (range: 12-41). This time was concordant with the final anastomosis time performed in the pelvitrainer. CONCLUSIONS: The one-knot pyeloplasty is feasible and reproducible, and it overcomes the obstacles caused by multiple intracorporeal knots when performing laparoscopic pyeloplasty. Furthermore, the porcine bladder model that we introduce herein is a readily available and simple model to refine suturing techniques for pyeloplasty.

Simultaneous laceration of external iliac artery and vein complicating anterior vaginal wall sling operation for stress urinary incontinence.

CASE REPORT: We report a case of simultaneous injury of right external iliac artery and vein by a needle carrier that was inserted from the suprapubic area down to the vaginal lumen during anterior vaginal wall sling procedure. DISCUSSION: The risk factors and measures to be taken to avoid this life threatening complication are discussed.

Percutaneous nephrolithotomy in patients with normal versus impaired renal function.

This study aimed to compare the results of percutaneous nephrolithotomy (PCNL) in patients with impaired renal function (IRF) and normal renal function (NRF). Records of 300 consecutive patients who underwent PCNL from July 2002 to July 2005 were retrospectively reviewed. Nineteen patients (6.3%) had serum creatinine values higher than 1.5 mg/dl before surgery (IRF Group). Nineteen gender and age matched patients with normal renal function were chosen as controls (NRF Group). The surgical parameters, outcome, and complication rates were compared. The effect of PCNL on the renal function was assessed in patients with IRF. There were 13 male and 6 female patients in both groups. In the IRF group, seven patients had a solitary kidney and three had bilateral stones. Thus, PCNL was performed on 22 kidneys. No patients in the NRF Group had solitary kidney or bilateral stones and PCNL was performed on 19 kidneys. There were no statistically significant differences between the two groups for success and complication rates (P = 0.376 and P = 0.184, respectively). In a mean follow-up of 15.6 months, mean serum creatinine decreased from 2.8 to 2.6 mg/dl (P = 0.273) in patients of the IRF group. Similar stone clearance and complication rates were obtained with PCNL in patients with impaired and normal renal function. Surgery does not cause biochemical deterioration in patients with compromised renal function before treatment.

Isolated renal hydatid disease causing ureteropelvic junction obstruction and massive destruction of kidney parenchyma.

Isolated hydatid disease of the kidney is a rare condition that can be challenging to diagnose. We describe a case in which isolated renal hydatid disease obstructed the ureteropelvic junction, resulting in hydronephrosis and complete destruction of the renal parenchyma.

Management of complete ureteral obstructions with a transluminal puncture technique.

INTRODUCTION: The traditional delayed treatment of iatrogenic complete ureteral obstruction is open surgery. An easy endourological technique, transluminal re-canalization of the ureter by guide-wire puncture under fluoro-endoscopic control, which has been performed on 4 patients, is described. SURGICAL TECHNIQUE: With the guidance of C-arm fluoroscopy, by moving the C-arm to different planes, the tip of the ureteroscope is directed to the correct plane to meet the obliterated proximal end of the ureter and under direct vision, transluminal puncture is performed using the stiff end of a 0.035-inch guide wire. Once the stiff end of the guide-wire is in the lumen of the proximal ureter, an ureteral catheter is introduced over the guide wire, the guide wire is then removed and reinserted through the ureteral catheter with its soft end leading and a double J catheter is inserted. Ureteral stricture, if later encountered, is treated with balloon dilatation. RESULTS: Continuity of the ureter was restored in all 4 patients. The double J stents were removed 6 weeks later and a retrograde pyelography revealed resolution of the hydronephrosis without extravasation of urine. CONCLUSION: Although a very satisfactory result was achieved in our cases, more cases are needed to show if it can be an alternative to conventional surgical repair. However, we believe that this minimally invasive technique can be used for short obliterated ureteral segments and neither delays nor does it preclude further management using open surgery.