Radiation exposure of patient and surgeon in minimally invasive kidney stone surgery.

OBJECTIVE: Percutaneous nephrolithotomy (PNL) and retrograde intrarenal surgery (RIRS) are the standard treatments used in the endoscopic treatment of kidney stones depending on the location and the size of the stone. The purpose of the study was to show the radiation exposure difference between the minimally invasive techniques by synchronously measuring the amount of radiation the patients and the surgeon received in each session, which makes our study unique. MATERIALS AND METHODS: This is a prospective study which included 20 patients who underwent PNL, and 45 patients who underwent RIRS in our clinic between June 2014 and October 2014. The surgeries were assessed by dividing them into three steps: step 1: the access sheath or ureter catheter placement, step 2: lithotripsy and collection of fragments, and step 3: DJ catheter or re-entry tube insertion. RESULTS: For the PNL and RIRS groups, mean stone sizes were 30mm (range 16-60), and 12mm (range 7-35); mean fluoroscopy times were 337s (range 200-679), and 37s (range 7-351); and total radiation exposures were 142mBq (44.7 to 221), and 4.4mBq (0.2 to 30) respectively. Fluoroscopy times and radiation exposures at each step were found to be higher in the PNL group compared to the RIRS group. When assessed in itself, the fluoroscopy time and radiation exposure were stable in RIRS, and the radiation exposure was the highest in step 1 and the lowest in step 3 in PNL. When assessed for the 19 PNL patients and the 12 RIRS patients who had stone sizes≥2cm, the fluoroscopy time in step 1, and the radiation exposure in steps 1 and 2 were found to be higher in the PNL group than the RIRS group (P<0.001). CONCLUSION: Although there is need for more prospective randomized studies, RIRS appears to be a viable alternate for PNL because it has short fluoroscopy time and the radiation exposure is low in every step. LEVEL OF EVIDENCE: 4.

Treatment effect of sibutramine compared to fluoxetine on leptin levels in polycystic ovary disease.

Weight reduction on its own is observed to cause improvement in some of the abnormalities seen in patients with polycystic ovary syndrome (PCOS). With respect to this observation, we studied the possible effects of different serotonin reuptake inhibitors (fluoxetine and sibutramine) on serum leptin levels that might play a role in the obesity component seen in patients with PCOS. In a random design, sixteen patients were assigned to fluoxetine and sibutramine for a period of 10 days. In both treatment groups, no significant differences were observed between pre-treatment and post-treatment values in insulin levels (p > 0.05). There was no significant difference between pretreatment and post-treatment serum leptin levels in the fluoxetine treatment group (p > 0.05). However, a significant reduction was observed in the serum leptin levels at the end of treatment in the sibutramine group (p < 0.05). The observed difference in the serum leptin response to the treatment effect of sibutramine compared to fluoxetine seems to be due to a mechanism independent of serotonin reuptake inhibition, possibly to the thermogenic effect of the sibutramine itself. Further studies with larger groups are warranted, to examine the mechanism of the weight-reducing effect of sibutramine. Detailed analyses of basal metabolic activity and change in serum leptin levels should be carried out.

Risk factors for penile prosthetic infection.

OBJECTIVES: To determine the risk factors for penile prosthesis infection. METHODS: The records of 135 penile prosthesis implantation in 127 patients were reviewed. Of the 135 prothesis, 115 were malleable, 12 were self-contained and 8 were inflatable. Of these procedures, 111 were primary, 9 were primary with reconstructions and 15 were secondary. Mean follow-up was 47 months (minimum 6 months). All of the reconstructions were penile plications or plaque excisions for Peyronie's disease. RESULTS: The ratio of penile prosthesis infection was 8.89%. Secondary implantation, paraplegia, non-controlled diabetes mellitus (p < 0.001) and surgeon's inexperience (p < 0.05) were detected as the risk factors for penile prosthesis infection. But age, smoking, alcohol consumption, obesity, atherosclerosis, presence of diabetes mellitus (DM), history of penile surgery, simple penile reconstruction, type of the erectile dysfunction (ED), type of the penile prostheses and incision and were not found as the risk factors (p > 0.05). CONCLUSIONS: Paraplegie, non-controlled diabetes mellitus, secondary implantation and surgeon's inexperience appear to be the risk factors for penile prosthesis infection. In secondary implantation, longer operation time is detected as a factor increasing the risk of penile prosthesis infection. For these patients, careful preoperative preparation, more attention to perioperative antisepsis and postoperative follow-up are required. Since it has been determined that surgical experiences decrease the complication rate, these patients should be operated by experienced surgeons.

Influence of exogenous estrogen administration on serum CA-125 originating from the endometrium.

OBJECTIVES: The purpose of the study is to assess the endometrial contribution of serum CA-125 using exogenous estrogen administration by ruling out ovarian activity. A randomized, controlled, prospective study was designed to assess the endometrial contribution of serum CA-125 and its influence from estrogen administration in menopausal women. METHODS: Twenty menopausal women with intact uterus and ovaries (study group) and 10 cases with previous total hysterectomy with intact ovaries (control group) were included in the study. The mean age of subjects in the study and control groups were similar at 53 +/- 1.9 (S.D.) and 51 +/- 2.7 years. The length of menopause in the study and control groups were also similar at 61.0 +/- 18 and 52.6 +/- 26.5 months, respectively. Group 1 consisted of 10 randomly selected cases and five controls who received 15 days of 50 microg/day transdermal 17beta-estradiol (TE). Group 2 consisted of the next randomly selected 10 cases and five controls who had 15 days of transdermal 100 microg/day 17beta-estradiol (Estraderm-Ciba) administration. Serum CA-125 and estradiol were measured at day 0, 15 by radioimmunoassay (RIA). RESULTS: Serum mean CA-125 levels increased significantly in endometrium intact menopausal women from day 0 to 15 of TE administration in group 2 and 1, 70% and 6%, respectively (P=0.03 and P=0.05, respectively). Interestingly, the increase in serum estradiol levels accompanied this change only in group 2. CONCLUSIONS: These results suggest that endometrial CA-125 secretion to serum is dependent on the dose of administered exogenous estrogen.

Contraceptive practices of women after abortion in Turkey.

OBJECTIVES: The aim ofthis study was to determine the postabortion contraception choices of women and the subsequent reduction in pregnancy rate. The changes in method of contraception during the 1-year follow-up period were also assessed. METHODS: Ninety women decided to practice family planning methods following an abortion procedure. The family planning choices of the postabortion family planning group were determined by active immediate family planning counselling. The control group, which consisted of 23 women who had had an abortion and wanted to become pregnant again, were followed-up for 1 year to determine their pregnancy rate. The pregnancy rates and methods used were determined during a 12-month follow-up period. RESULTS: Following counselling, 79.64% of the patients signed for immediate family planning practice. In the postabortion family planning group, one out of 90 patients (1.1%, Pearl index 1.29) practising contraception with a condom became pregnant. However, ten out of 23 (43.5%, Pearl index 54.2) patients in the control group became pregnant during the 1-year follow-up period (p < 0.05). In the postabortion family planning group, intrauterine devices (IUDs) (n = 43), injectable monthly contraceptives (n = 24) and tubal ligation (n = 9) were the most commonly preferred methods, with 47%, 27% and 10% of the women using these methods, respectively. At the end of the 12-month period, the drop-out rate among women using the injectable monthly contraceptives was significantly higher (13 patients, 54%) compared to other methods (p < 0.05). In one case out of 43 using an IUD (2.38%), the IUD was expelled during follow-up. CONCLUSION: The use of postabortion family planning significantly decreased the postabortion pregnancy rate. The use of an IUD was the preferred immediate method of choice. Use of injectable monthly contraceptives was the method with the highest drop-out rate. The expulsion rate of postabortion IUDs was acceptable in our practice. The pregnancy rate in the control group was lower than the physiological fecundity would predict. This may suggest that, although couples plan to get pregnant, they do not concentrate on the ideal conditions for conception or they do, in fact, practice some form of family planning.

Knowledge on lactational amenorrhoea and contraception in Kocaeli, Turkey.

OBJECTIVE: To determine the knowledge of women about lactational amenorrhoea and contraceptive properties of breastfeeding. DESIGN: A prospective, randomised descriptive study. SETTING: Kocaeli University School of Medicine, Department of Obstetrics and Gynecology. SUBJECTS OR PARTICIPANTS: Nine hundred and twenty-two women in their reproductive ages. INTERVENTION: A questionnaire was filled by doctors or nurses during face to face interview. MAIN OUTCOME MEASURES: There was significantly less knowledge for the importance of frequency and duration of suckling (p < 0.0001). The education increases the knowledge of lactational amenorrhoea as a interruptus contraceptive method. RESULTS: More than fifty-three per cent of women were using one of the modern contraceptive methods, 23.86% were using natural methods and 22.78% not using any family planning method. Intrauterine devices (30.15%), coitus interuptus (21.69%) and condom (16.48%) were the most common contraceptive methods. Nearly fifty-two per cent of women were not aware of the contraceptive property of breastfeeding, 25.68% of women knew lactation had a protective effect from pregnancy, 48.16%, did not know the importance of frequency and duration of suckling on fertility reducing effect of lactation. CONCLUSION: The level of knowledge on lactational amenorrhoea and frequency of suckling was significantly low in our study, especially in the illiterate group. Since efficacy of natural family planning depends on the compliance of women, education of women about lactation is very important. Family planning programmes should be focussed on breastfeeding and type of breastfeeding practices used, especially where there are no contraceptive alternatives.

PIP: This prospective, randomized, descriptive study examined the contraceptive choices and knowledge of women about lactational amenorrhea and contraceptive properties of breast-feeding in Kocaeli, India. A total of 922 women of reproductive age were surveyed, and a Chi-square test was used for data analysis. Results showed that 53.36% of the women used modern contraceptive methods, 23.86% preferred natural methods, and 22.78% were not using fertility control methods. The most commonly used contraceptive methods included IUDs (30.15%), coitus interruptus (21.69%), and condoms (16.48%). Almost 52% of the women were not aware of the contraceptive effect of breast-feeding; 25.68% knew that lactation had a contraceptive effect. Lactation was accepted as a contraceptive method by 48.16% of the women, while 51.8% of the women did not accept this type of method. Overall, the level of knowledge on lactational amenorrhea and suckling frequency was significantly low, particularly among illiterate women. Family planning programs should focus on breast-feeding as a fertility control method, especially when no contraceptive alternatives are available.

Does ovulation induction affect the pregnancy rate after laparoscopic treatment of endometriosis?

OBJECTIVE: To determine the effectiveness of ovulation induction after laparoscopic treatment of endometriosis in an infertile population. DESIGN: An observational prospective study in which infertility cases were treated with laparoscopic surgery was followed up (mean 11 months), either by treatment (ovulation induction) or no further treatment (expectant management) and the outcomes recorded. In both groups pregnancies were compared by Cox's regression survival model. SETTING: Gazi University Hospital, Department of Obstetric and Gynecology, Ankara, Turkey. PATIENTS: Infertile women with different stages of endometriosis who were treated by laparoscopic surgery, with a mean duration of infertility of 80.7 (+/-50 [SD]) months. INTERVENTIONS: Patients were treated by cauterization of the foci, adhesiolysis, endometrioma stripping, and distal tubal reconstruction according to their lesions. Postoperatively, patients had either ovulation induction (clomiphene, hMG) therapy or no further treatment. MAIN OUTCOME MEASURE: Cumulative pregnancy rate of infertile women after laparoscopic treatment of endometriosis with or without ovulation induction. RESULTS: A total of 36 out of 128 patients became pregnant after laparoscopy, with a 34% cumulative pregnancy rate. In the ovulation induction group, relative risk (chance) of pregnancy was 1.42 (1.02-2.05, 95 % CI) when the duration of infertility was less than 5 years. In this lower risk group, the overall cumulative pregnancy rate was 46%--56% and 27% for the ovulation induction and expectant management groups, respectively. In the expectant management group, per cycle fecundity was 0.021, whereas it was 0.066 and 0.174 (p = 0.001) in the clomiphene citrate- and hMG-treated patients, respectively. Expectant management significantly increased the likelihood of pregnancy compared to ovulation induction in previous pregnancy, stage 1 or 2 endometriosis, and no male infertility groups (p = 0.04-0.009). CONCLUSION: After laparoscopic treatment of endometriosis, ovulation induction has a positive effect only if done with hMG and the duration of infertility was less than 5 years (P<.05).

The effects of human amniotic membrane and fibrin sealant in the prevention of postoperative adhesion formation in the rabbit ovary model.

The study group consisted of 29 female, white New Zealand rabbits. The rabbits were randomized into 3 groups and a midline laparotomy was performed in order to make a 4-5 mm long lesion using a scalpel in both ovaries. In Group 1, both of the ovaries were left uncovered. In Group 2, the right ovaries were covered by human amniotic membrane graft. In Group 3, 0.1-0.2 mL of Tisseel solution was applied to the lesion in the right ovaries. No medication was applied to the left ovaries in any of the groups and thus this ovary acted as an individual control. After 2 weeks the adhesion scores were graded by relaparotomy in a blind manner. Fibrin sealant showed a significant reduction in postoperative adhesion formation compared with the amniotic membrane graft and control groups (p<0.001). Therefore, it can be concluded that fibrin sealant can be used as an adjuvant during reproductive surgery.

Efficacy of transurethral electrovaporization of the prostate with respect to standard transurethral resection.

Transurethral electrovaporization of the prostate (TVP) has been introduced as an alternative to standard transurethral resection of the prostate (TURP) with lesser morbidity. However, the efficacy of this new technique has not been well known. To compare the results of standard TURP and TVP, 76 patients with symptomatic benign prostatic hyperplasia (BFH) were divided into two groups in a randomized clinical trial. Preoperative assessment included AUA Symptom score, maximum flow rates (Qmax), digital rectal examination, serum prostate specific antigen, and transrectal ultrasonography, with biopsy if the patient was randomized to vaporization. Transrectal temperature measurements and the hemoglobin concentration of the irrigation fluid were investigated in all the patients during the procedure. Although the transrectal temperature was higher in the TVP group (0.53-1.27 degrees C; mean 0.83 degrees C), no associated complication were determined. However, blood loss was significantly lesser than with TURP (340 mL v 60 mL). Two patients in the TURP group required blood transfusions, and one had sphincteric incontinence, whereas one postoperative retention, one reoperation with bladder perforation, and one sphincteric incontinence were seen in the TVP group. On the other hand, 12-month follow-up demonstrated that the uroflow rates improved in a similar manner. The Qmax increased in the TURP and TVP groups from 8.8 and 8.3 mL/sec to 19.6 and 17.2 mL/sec, respectively. The mean AUA Symptom Score decreased from 13.7 to 7.9 and 6.1 at 6 and 12 months, respectively. In the TVP group and from 14.6 to 7.3 and 7.0 at 6 and 12 months, respectively, in the TURP group. There were significant differences in the mean catheterization time (P < 0.0001) and hospital stay (P < 0.0001) in favor of TVP. Our results suggest that TVP is a safe and effective alternative treatment for symptomatic BPH.

Small diameter versus conventional laparoscopy: a prospective, self-controlled study.

The objective of this study was to determine visual quality, diagnostic accuracy, and surgical merits of small diameter laparoscopy (SDL). Thirty-seven patients were randomly selected. The indications for laparoscopy were infertility, desire for tubal sterilization or chronic pelvic pain. Patients underwent SDL, followed by conventional laparoscopy (CL) as a control under general anaesthesia. Findings at operation were compared. The mean time for diagnostic work-up was longer with SDL than CL, 11.7 +/- 5.6 versus 7.6 +/- 3.2 min respectively (P < 0.04). Visual quality was scored from 4 to 1 by the operator; mean visual quality, mean endometriosis score and mean adnexal adhesions score were slightly lower with SDL than CL. Sensitivity of SDL in diagnosing endometriosis, adhesions, ovarian, uterine and pouch of Douglas lesions were 71, 58, 81, 89 and 73% respectively; specificity was 100, 96, 100, 100, 100% in the same order. Suction irrigation, cyst aspiration, tissue biopsies, simple adhesiolysis, tubal ligation and cauterization were easily performed with SDL. We conclude that SDL seems a good alternative to CL in diagnosing macro-pelvic anatomy and coarse pelvic pathologies and may also be good in performing surgical procedures such as: tubal ligation, biopsies and differential diagnosis of pelvic fluids. But SDL must be used cautiously in micro-oriented, functional conditions such as infertility, pelvic pain, endometriosis and adhesion scoring or treatment. SDL may be regarded as a less invasive but less sensitive tool with limited surgical merits.

The incidence of congenital malformations in a Turkish population.

OBJECTIVE: To determine the incidence and types of congenital anomalies in a Turkish population. METHOD: The total number of neonates (9160) born in the Department of Obstetrics and Gynecology, Gazi University Faculty of Medicine during 1988-1995 were studied retrospectively. Newborns with congenital anomaly were identified from their birth registries. The total incidence, types and combined anomalies were determined. Also, the relationship between congenital anomalies and maternal age and/or gender were investigated. For statistical evaluation, Chi-square test, Yates correction and Fisher's exact tests were used where appropriate. RESULTS: The overall congenital anomaly incidence was 1.11% and the NTD incidence was 0.27% in our population. Anencephaly was the second most common NTDs with the ratio of 40%, following the spina bifida cases. There was a significant difference between female and male newborns with ancephalocele (P < 0.05). Urogenital system anomalies were found to be the second most common type of malformation with an incidence of 0.21%. Facial and musculoskeletal system abnormalities were the third and fourth most common malformations. Omphalocele incidence in our population was 5 in 9160 births and gastrochisis was 1 in 9160 births. CONCLUSION: The overall congenital anomaly incidence in newborns in our population is 1.11%. The most common malformations were CNS and urogenital abnormalities. NTDs incidence was 0.27% in a Turkish population.

The effects of 3-day clomiphene citrate treatment on endocrine and ovulatory responses.

A prospective cohort, paired clinical trial was carried out to test a shorter clomiphene citrate regimen of 3 days, measuring the endocrine outcomes and ovulatory responses. The trial took place at Gazi University Medical School Department of Obstetrics and Gynecology. The 28 infertile patients were newly accepted to the clinic with hypothalamopituitary disorder according to WHO classification Group II. They were treated with 50 mg/day clomiphene citrate (CC) for 3 days in 63 cycles. The control group of 28 paired patients were treated with 50 mg/day CC for 5 days in 40 cycles. The main outcome measures were: serum estradiol levels on day 11 (E-11), 14 (E-14) and postovulatory day 7 (E+ 7); serum progesterone levels on postovulatory day 7 (P+ 7); endometrial thickness on day 14 of the cycle; mean follicular phase length; and ovulation rates. The mean ages, gravidas, paritas, menstrual histories, E-11, P+ 7 levels, mean follicular phase length and luteal phase length were similar in both groups. E-14 (229.76 +/- 156.05 pg/ml vs. 338.25 +/- 350.60 pg/ml) and E+ 7 (217.30 +/- 114.95 pg/ml vs. 310.6 +/- 11.05 pg/ml) were significantly lower, whereas mean endometrial thickness on day 14 (10.30 +/- 1.39 mm vs. 9.52 +/- 1.96 mm) were significantly higher in the study group compared to controls (p < 0.05). Ovulation occurred in 82.53% of cycles in the study group and 95% in controls. In the study group, pregnancy was achieved in 17.3% of the ovulatory cycles; this rate was 10.5% in the control group. To decrease the peripheral antiestrogenic effects of CC, a regimen of 50 mg/day for 3 days may be used as a starting dose instead of the standard 5-day regimen.

Endometrial assessment by vaginal ultrasonography might reduce endometrial sampling in patients with postmenopausal bleeding: a prospective study.

The purpose of this study is to compare transvaginal sonographic endometrial assessment with histology obtained by endometrial curettage in postmenopausal patients and to determine a cut-off point for endometrial thickness to reduce unnecessary diagnostic curettage for postmenopausal bleeding. A total number of 289 postmenopausal women were studied prospectively; 192 patients with postmenopausal bleeding and 97 postmenopausal women without bleeding comprised the study and control groups respectively. All patients were scanned by ultrasound transvaginally, then dilatation and curettage was performed for endometrial evaluation. In all women with and without postmenopausal bleeding, endometrial thickness of 4 mm or less as depicted by sonography correlated well with 'atrophic endometrium' (100%). Of 158 women with an endometrium > 4 mm in both groups, 40 women (25.1%) had a negative result (tissue insufficient for diagnosis or atrophic endometrium), while 118 patients (74.8%) had a positive result which included proliferative and secretory endometrium, endometrial hyperplasia, polyps and cancer. As the endometrial thickness increased, the probability of finding pathology with curettage was increased linearly in postmenopausal bleeding (PMB) positive and negative groups and there was a significant linear positive correlation between PMB (+) and (-) cases (Linear regression, R = 0.91, p < 0.03). A significant difference was found between endometrium carcinoma and all other endometrial pathologies concerning the mean endometrial thickness of 22.7 +/- 10.2 mm (chi-square, p < 0.0001). Also, the mean endometrial thickness of 4.7 +/- 3.3 mm for atrophic endometrium and 6.1 +/- 3.7 mm for 'tissue insufficient for histological diagnosis' were found significantly different than all other endometrial pathologies (chi-square, p < 0.0001). Endometrial thickness of < or = 4 mm may serve as cut-off point for predicting pathology negative cases with an accuracy of 100% in postmenopausal bleeding positive and negative cases. Then as the endometrial thickness increases, the probability of finding endometrial pathology in curettage increases linearly with a positive predictive value of 74.6%.

An extraperitoneal burch procedure: a case report.

A new laparoscopic Burch procedure with preperitoneal balloon dissection is introduced. A stress incontinence case without cystocele was operated by laparoscopic extraperitoneal colposuspension. The procedure was found to be effective a year after and no complications were seen. The extraperitoneal Burch procedure has the advantages of easy dissection, less bleeding, pain, and adhesion formation, a lower chance of injury to intraperitoneal organs, and short hospital stay and operation time; but the procedure has the disadvantages of a new anatomy orientation and the additional cost of a disposable balloon dissection set.

[25 patients undergoing laparoscopy for pelvic pain]. / A propos de 25 patientes ayant subi une coelioscopie pour douleurs pelviennes.

25 patients have involved in this research, who have chronic gynecologic pelvic pain and each of them had normal gynecologic examination. Chronic pelvic pain has been found mostly between 30-39 years age group married, multipar females, associated with 44% dysmenorrhea, 36 p. cent dyspareunaie. Cultures and clinical examinations were all negative as a sign of infection. Experienced intra-abdominal operation or infection were causes of pelvic pain (48%), especially appendectomy has a prominent place (75%). Laparoscopic investigation showed: 16 p. cent adhesions, 28 p. cent chronic annexitis, 16 p. cent experienced pelvic inflammatory disease, 8 p. cent uterine leiomyoma, 4 p. cent each endometriosis, experienced parametritis and haemorrhagic lutein cysts. Instead of making group of lesions, we prefer to describe it, in numbers as infection importance coefficient (IIC), which is developed for this research. IIC 0-2 points presents insufficient organic causes, it does not represent the cause of pain. Non organic and non gynecologic reasons must be the cause of pain. Non organic and non gynecologic reasons must be investigated. IIC 3-5 points presents minor experienced intraabdominal infection. Secondary cases like myoma, ovarian cysts, chronic cervicitis should be considered first as reason. IIC 6 points and more presents direct organic deficiency suitable surgery is the treatment of choice of this group.