Factors affecting complication rates of percutaneous nephrolithotomy in children: results of a multi-institutional retrospective analysis by the Turkish pediatric urology society.

PURPOSE: We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS: We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS: Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Hyperoxaluria-induced tubular ischemia: the effects of verapamil and vitamin E on apoptotic changes with an emphasis on renal papilla in rat model.

An experimental study in rats was performed to evaluate the presence and the degree of both tubular apoptotic changes and crystallization at cortical, medullar and papillary regions of the kidney during hyperoxaluric phase and assess the possible protective effects of vitamin E and verapamil on these pathologic changes (particularly in papillary part of the affected kidneys). A total of 32 rats have been included into the study program. Hyperoxaluria was induced by continuous administration of ethylene glycol (0.75%). In addition to hyperoxaluria induction, animals in Groups 2 and 3 did receive a calcium channel-blocking agent (verapamil) and vitamin E, respectively. Histologic alterations of the kidneys including crystal formation together with apoptotic changes were evaluated on days 1, 14 and 28, respectively. Both apoptotic changes and the presence and degree of crystallization were assessed separately in renal cortical region, medulla and particularly papillary parts of the removed kidneys. Although verapamil did well limit the degree of crystal formation and apoptosis and brought it to the same levels observed in control group animals in all parts of the kidneys during intermediate phase, addition of vitamin E was failed to show the same protective effect during both intermediate and late phase evaluations. As demonstrated in our study, the limitation of both crystal deposition and apoptotic changes might be instituted by calcium channel-blocking agents. Clinical application of such agents in the prophylaxis of stone disease might limit the formation of urinary calculi, especially in recurrent stone formers.

Factors affecting complication rates of ureteroscopic lithotripsy in children: results of multi-institutional retrospective analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society.

PURPOSE: We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS: We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS: A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate. CONCLUSIONS: Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Comparison of ureteroscopic procedures with rigid and semirigid ureteroscopes in pediatric population: does the caliber of instrument matter?

OBJECTIVES: To compare the results of two different ureteroscopes in pediatric ureteroscopy (URS) procedures. PATIENTS AND METHODS: Sixty-five consecutive URS procedures in pediatric population (39 males, 26 females) were retrospectively evaluated. The subjects were divided in two groups according to the type of ureteroscope used: Group 1 (n = 32, Wolf 8F) and group 2 (n = 33, ACMI 6.9F). All the procedures performed in both groups were statistically compared regarding patient age, gender, lateralization, complication rates, whether the procedure was diagnostic or therapeutic, and whether a guide-wire was used. Additionally, in cases with ureteral stones, stone clearance rate and the necessity of a stone extractor were also compared between the groups. All data were statistically analyzed using chi-square and t tests, where appropriate. A p value less than 0.05 was considered as significant. RESULTS: Mean age of the groups were comparable (9.44 +/- 4.3 and 8.67 +/- 3.9, p = 0.456). There was no statistically meaningful difference between the groups regarding patients' gender, lateralization rates, whether the procedure was diagnostic or therapeutic, the need for a guide-wire use, and complication rates (p > 0.05). In cases with ureteral stones, both groups exhibited statistically comparable results in stone clearance rates and the use of a stone extractor (p > 0.05). CONCLUSIONS: Data on this comparison demonstrated that both ureteroscopy devices in pediatric population can be used safely in URS procedures. Neither the diameter nor the rigidity is significantly affecting the outcomes and success rates

Sixteen-slice multidetector computed tomographic virtual cystoscopy in the evaluation of a patient with suspected bladder tumor and history of bladder carcinoma operation.

PURPOSE: The purpose of this study was to evaluate the use of virtual cystoscopy performed with multidetector computed tomography (CT) in patients with suspected bladder tumors and histories of bladder carcinoma operation. MATERIAL AND METHODS: Thirty-six patients (29 men and 7 women) with a mean age of 66 years (range, 24-88 years) with suspected bladder tumors and histories of bladder carcinoma operation were included in this prospective study. Virtual cystoscopy was performed by 16-slice multidetector CT scanner. The bladder was filled with diluted contrast material solution through a Foley catheter. Then, all patients underwent conventional cystoscopy examination. RESULTS: Two reviewers found 18 lesions detected by virtual cystoscopy by consensus, whereas 19 lesions were depicted by conventional cystoscopy. At virtual and conventional cystoscopies, the conditions of 3 patients, 2 with chronic inflammations and 1 with foreign body reaction, were wrongly diagnosed as tumors. At conventional cystoscopy, one patient's result was wrongly interpreted as normal. In pathologic evaluation, all tumors were diagnosed as transitional cell carcinoma. CONCLUSIONS: Bladder tumor can be noninvasively diagnosed using virtual cystoscopy. Use of virtual cystoscopy should be considered inpatients who present with hematuria or have histories of bladder carcinoma operation and are for follow-up because of its lesser complication risk and its being a less invasive, easily applied procedure without need of anesthesia. In the future, owing to the development of the CT technology and image processing technique, virtual cystoscopy may have a part in the detection of bladder cancer.

Low free and bioavailable testosterone levels may predict pathologically-proven high-risk prostate cancer: a prospective, clinical trial.

OBJECTIVE: To determine the predictive value of free and bioavailable testosterone levels on the detection of high-grade prostate cancer proven by histopathological examination of transrectal prostate biopsy specimens. MATERIAL AND METHODS: A total of 405 patients who underwent transrectal prostate biopsy due to high prostatic specific antigen (PSA) (>2.5 ng/mL) and/or abnormal findings at digital rectal examination were included in this study. Blood free and bioavailable testosterone levels were calculated by the formula recommended by International Society for the Study of the Aging Male (ISSAM). The patients were stratified according to the D'Amico classification based on PSA levels and histological outcomes of prostate biopsies as benign, low, intermediate and high-risk prostate cancer. Patients were also divided into five groups according to the percentage of cancerous cores. RESULTS: Prostate cancer was detected in 160 of 405 (39.5%) patients. Total, free and bioavailable testosterone levels did not differ significantly between the patients with benign or malign histology. However, mean free (6.2 vs. 5.2 ng/dL, p=0.02) and bioavailable (151 vs. 125 ng/dL, p=0.001) testosterone levels were found to be significantly different in men with low-intermediate and high-risk prostate cancer. Moreover, a significant correlation was found between free, and bioavailable testosterone levels and percentage of cores with cancer (p=0.002 for free and p=0.016 for bioavailable testosterone, respectively). CONCLUSION: This prospective clinical study demonstrates that reduced levels of calculated blood free and bioavailable testosterone levels are associated with an increased risk of high-grade prostate cancer. Based on these findings blood free and bioavailable testosterone levels may be be thought to be an adjunctive factor in the prediction of high-risk prostate cancer.

The importance of active surveillance, and immediate re-biopsy in low-risk prostate cancer: The largest series from Turkey.

OBJECTIVE: To evaluate long-term outcomes of active surveillance (AS) applied in low-risk prostate cancer patients, and the impact of re-biopsy results on the prediction of progression. MATERIAL AND METHODS: In our clinic, patients who had undergone AS for low-risk localized prostate cancer between the years 2005-2013 were included in the study. Our AS criteria are Gleason score ≤6, prostate-specific antigen (PSA) level <10 ng/mL, number of positive cores <3, maximum cancer involvement ratio <50% each core. Immediate re-biopsy (within 3 months) was performed to 65 patients who accepted AS. Finally, 43 patients who met re-biopsy criteria were included in the study. Prostate biopsy specimens were harvested from 12 cores under the guidance of transrectal ultrasound (TRUS). Re-biopsy was performed within 3 months (1-12 weeks). In re-biopsy, a total of 20 core biopsies were performed including the far lateral (6 cores) and transition zone (2 cores) in addition to standard 12 core biopsy. Our follow-up protocol is PSA measurement and digital rectal examination (DRE) every 3 months within the first 2 years, than every 6 months. Control biopsies was performed one year later and once upon every 3 years to patients whose PSA levels and DREs were normal at follow-up visits. More than 2 tumor invaded cores or 50% tumor in one core, and Gleason score exceeding 6 points were accepted as indications for definitive treatment. Patients were divided into two groups by re-biopsy results and compared according to the time to progression. We have done multivariate regression analysis to predict prognosis by using data on age, PSA level, and detection of tumor in re-biopsy specimens. RESULTS: Patients' median age was 61 years and PSA level was 5 (2.7-9) ng/mL. Tumor was detected in 22 (34%) patients at re-biopsy and they underwent definitive treatment. Additionally tumor was detected in 9 patients, but active surveillance was maintained because their pathologic results met active surveillance criteria. Median follow time was 42 (24-117) months. Definitive treatment was performed in 9 (21%) patients. PSA recurrence was not detected in none of 9 patients during 38 months of follow up. Only the presence of tumor in re-biopsy specimens was found predictor of disease progression in multivariate analysis. CONCLUSION: We think that AS is safe method for low-risk localized prostate cancer patients, if it is performed in compliance with certain criteria and regular follow up, and early re-biopsy can be useful either during early period or long term follow-up.

Which treatment method should be used in pregnant patients with ureteral calculi? Two center comparative study.

OBJECTIVES: We aimed to compare ureterolithotripsy and inserting only ureteral-j stent in terms of efficiency, safety and patient comfort in treatment of ureteral calculi in pregnant patients. METHODS: Seventy patients who developed hydronephrosis due to ureteral calculi during pregnancy, and on whom endoscopic intervention was performed were included in the study. In a center, the stones were broken up by ureteroscopy, and then ureteral stents (JJ) were placed if needed. In the other center, nothing was performed on the stones, and only ureteral stents (JJ) was placed. For the statistical analysis, Pearson's chi squared test and the Mann-Whitney U tests were used and the significance level was determined as p < 0.05. RESULTS: The average age of the patients was 26.2 years (18-39) and the average gestational week was 23.4 weeks (8-36). While no significant difference was found between the two groups in terms of the frequency of complications (p=0.381) and post-operative pyelonephritis (p=0.2), the need for additional intervention in the group on whom ureteroscopy was performed was found to be less (9.7% vs. 31%; p=0.032). Moderate or severe LUTS or flank pain during the period between the procedure and the birth was found to be significantly less in the group in which ureterolithotripsy was performed (14% vs. 55%; p=0.036). CONCLUSIONS: Ureterolithotripsy is a safe and more comfortable procedure than only ureteral double-j insertion on pregnant patients with ureterolithiasis.

The effect of stone localization on the success and complication rates of percutaneous nephrolithotomy.

PURPOSE: To evaluate the effect of stone localization on the success and complication rates of the percutaneous nephrolithotomy (PNL) procedure. MATERIALS AND METHODS: Five hundred seventy-eight PNL procedures that were performed in our clinic were retrospectively evaluated. The patients were divided into seven groups according to the localization of the renal stones as: group 1, patients having stones only in the upper calyx; group 2, patients having stones only in the pelvis; group 3, patients having stones only in the lower calyx; group 4, patients having partial staghorn stones; group 5, patients having multiple calyx stones; group 6, patients having stones in both the pelvis and lower calyx and group 7, patients having complete staghorn stones. The first three groups were defined as simple stones, and the other four groups were defined as complex stones. RESULTS: The mean stone clearance rate was 77% in simple stones and 53% in complex stones (P = .005). The complication rate was significantly higher only in the group with complex staghorn stones at a rate of 19.5% (P = .006). The difference between preoperative and postoperative hematocrit concentrations was the least in the group that had stones in the pelvis and this value was statistically significantly lower than the patients with complex staghorn stones (P = .027). The mean duration of the operation and the number of ports was higher in patients with complex stones. CONCLUSION: The localization of stone affects the success and complication rates of the operation. 

Comparison of laparoscopic and open ureterolithotomy in impacted and very large ureteral stones.

PURPOSE: To compare the efficacy of laparoscopic and open ureterolithotomy in patients with ureteral stones. MATERIALS AND METHODS: Patients who had undergone open or laparoscopic ureterolithotomy between 2001 and 2013 in our clinic were enrolled in the study.Ureterolithotomy was performed due to the following reasons: failure to position the patient for ureteroscopy, unreachable stone with ureteroscopy also use of balloon dilatation, high stone volume, and the need for removal of kidney stones at the same session.. The patients' demographic data, the volume of the stones, the duration of the operation and the hospital stay, the amount of analgesics administered after the operation, and the need for another procedure were compared. RESULTS: Of study subjects 32 patients had undergone open and 20 patients had undergone laparoscopic ureterolithotomy. When the two groups were compared, there was no statistically significant difference with regard to the mean age (44.5-44 years), the body mass index (26-24.7 kg/m²), the stone volume (420-580 mm³), the duration of operation (122-123 min), the need for another procedure and complications. The mean amount of analgesics administered after the operation (3.6 and 1.81 doses, P = .02) and the mean hospital stay (6.1 and 2.9 days, P = .01) were significantly lower in the laparoscopic ureterolithotomy group. CONCLUSION: Laparoscopic ureterolithotomy is a good alternative with less need for analgesia and a shorter hospital stay when compared with open ureterolithotomy.

Utility of diffusion-weighted MRI in the diagnosis of bladder carcinoma.

BACKGROUND: The purposes of our study were to investigate the feasibility of diffusion-weighted imaging in the detection of malignant bladder tumors, with comparison to the high-resolution thin-section fast spin-echo (FSE) T2-weighted MRI, and also to compare the apparent diffusion coefficient (ADC) values of the bladder tumors with the surrounding structures. MATERIAL AND METHODS: Fifty-three consecutive patients consisting of 44 males and 9 females who presented with a bladder mass were prospectively enrolled in this study. Mean age was 62.53 ± 12.03 (age range, 33-86 years). These patients were evaluated by high-resolution thin-section FSE T2-weighted and diffusion-weighted MRI for the detection of bladder masses. Following MRI, within 2 weeks, all patients were subjected to either surgery or cystoscopic biopsy, and the obtained histopathological proofs were used as the reference standard. Furthermore, ADC values of the bladder tumors, urine, the normal bladder wall, the central and peripheral zones of the prostate, the seminal vesicule, and the uterus outer myometrium were also calculated. ADC values of the bladder carcinomas and the related surrounding structures were compared as to whether a statistically significant difference was present or not. RESULTS: In a total of 47 patients, consisting of 39 males and 8 females, bladder carcinomas were clearly shown as having conspicuous high and intermediate signal intensity masses, relative to the surrounding structures on diffusion-weighted and T2-weighted images, respectively. An 89% sensitivity and a 100% positive predictive value were obtained for both FSE T2-weighted and diffusion-weighted MRI in the diagnosis of bladder carcinoma. Mean ADC values and standard deviations of the bladder tumors and the surrounding structures were as follows: bladder carcinomas (n=47): 1.28 ± 0.31, normal bladder wall (n=47): 1.98 ± 0.41, urine (n=47): 3.12 ± 0.24, seminal vesicle (n=39): 1.82 ± 0.33, peripheral zone of prostate (n=39): 1.80 ± 0.29, central zone of prostate (n=39): 1.55 ± 0.33, and uterus outer myometrium (n=8): 1.53 ± 0.19. It can be clearly seen that the mean ADC values of the bladder carcinomas were significantly lower than the surrounding structures (P<.05). CONCLUSION: High-resolution thin-section FSE T2 and diffusion-weighted MRI show high diagnostic performance and are comparable in the detection of bladder tumors. Diffusion-weighted MRI provides high quality images of the malignant bladder tumors against a suppressed background signal. Diffusion-weighted MRI using ADC measurements may be useful in the evaluation of tumor invasion to the adjacent organs.

Preoperative evaluation of pediatric kidney stone prior to percutaneous nephrolithotomy: is computed tomography really necessary?

The objective of the study was to investigate the precise role of computed tomography (CT) in preoperative radiologic evaluation and surgical planning of kidney stone in children prior to percutaneous nephrolithotomy (PNL). A total of 113 pediatric patients (aged ≤18 years) undergoing PNL for renal stone(s) in three referral hospitals between March 2010 and August 2012 were retrospectively evaluated. Depending on the preoperative radiologic evaluation, patients were divided into two groups. Those evaluated with CT were classified as group-1 (n = 50) and the remaining cases undergoing intravenous urography (IVU) examination were classified as group-2 (n = 63). Patient- and procedure-related variables and perioperative measures were compared between the groups. The mean age, stone size and localization were similar in both groups (p = 0.07, p = 0.57, p = 0.6, respectively). Although the postoperative hemoglobin drop was found to be significantly higher in group-2 (1.5 ± 1.3 vs. 0.9 ± 0.6 g/dL, p = 0.005), the mean operation time, fluoroscopic screening time, access number, overall success and complication rates were comparable (p = 0.06, p = 0.94, p = 0.75, p = 041, and p = 0.41, respectively). However, the mean hospitalization time was significantly prolonged in group-2 than in group-1 (p = 0.03). Our findings clearly demonstrate that, despite the key role of preoperative CT in particular patients with anatomically abnormal kidneys, IVU is a valuable alternative imaging modality with comparable radiation doses in children.

Revisiting the predictive factors for intra-operative complications of rigid ureteroscopy: a 15-year experience.

PURPOSE: To revise the predictive factors for intra-operative complications of rigid ureteroscopy in the treatment of ureteral calculi. MATERIALS AND METHODS: During a 15-year period (1993 to 2008), a total of 1496 consecutive patients who had undergone 1660 ureteroscopy procedures were retrospectively reviewed. After exclusion of the cases for diagnostic purposes, diseases other than ureteral calculi, and repeated ureteroscopy procedures, 1189 patients were left as the study population. Those patients were then divided into two groups based on the presence of the complications: complication-positive (group 1, n = 57) and complication-negative (group 2, n = 1132). Both groups were statistically compared regarding patients' age and gender, stone surface area, lateralization and localization of the stone, impaction of the stone, type of the ureteroscope, necessity of ureteral orifice dilation, and use of a catheter during and after the procedure. Furthermore, the effect of leaving the fragmented stones in situ small enough to pass spontaneously (break'n'leave) on occurring of the complications has been investigated. RESULTS: The complication rate was recorded as 4.7%. Success rate after a single intervention was 86.3%, whereas increased to 94.1% after ancillary procedures. Stone surface area, lateralization, and type of lithotripter used were comparable between the groups, but impacted stones and the stones located at the upper ureters were associated with significantly increased complication rates. Furthermore, significantly less complication has been observed in cases where we performed break'n'leave. Furthermore, multivariate analysis revealed that stone impaction and failure to adhere to the "break'n'leave" principle were the independent predictors of occurring of the complications. CONCLUSION: Ureteroscopy is safe and effective in the treatment of ureteral calculi. Careful attention for the patients having a potential for occurrence of the complications and selection of the techniques are of importance for reducing untoward events.

Emergent stenting after uncomplicated ureteroscopy: evaluation of 23 patients.

OBJECTIVES: To evaluate the causes of emergent stent placement during the postoperative early period after uncomplicated ureteroscopy in 23 patients. METHODS: Of 276 uncomplicated ureteroscopy procedures performed for the management of ureteral calculi, double-J stent placement was necessary on an emergent basis in 23 patients because of intolerable colic pain and extreme patient discomfort. All stents were inserted within 24 hours after the procedure. RESULTS: Of the 23 patients requiring emergent stent placement, 14 were men and 9 were women. The stones had been located in the lower ureter in 11, mid-ureter in 6, and upper ureter in 6 patients. All patients had undergone an uncomplicated procedure with no complication evident either during or immediately after ureteroscopic stone management. The intraoperative findings for the 23 patients revealed extensive edema formation, unrecognized small stones embedded in the edematous ureteral wall, unpassed small fragments gathered at the orifice, obstructing blood clots, and kinking of the ureter. A retrospective evaluation of the operative CD recordings and radiographic findings clearly showed that a longer operative time, repeated access, management of a large stone, impacted calculi with ureteral wall edema, a mildly narrowed ureteral segment, ignored caliceal small calculi, and a recent history of urinary tract infection contributed to the need for postoperative intervention. CONCLUSIONS: Ureteral catheterization, at least in the form of overnight stent placement, might prevent the formation of transient ureteral obstruction, with resultant postoperative patient discomfort and colic pain evident in selected cases.

Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage?

OBJECTIVE: To comparatively evaluate the efficacy of ureteroscopic stone treatment immediately after the first colic attack and in an electively planned manner. METHODS: A total of 145 patients underwent semirigid ureteroscopic removal of obstructive ureteral calculi using 2 different approaches (group 1, 69 patients, and group 2, 76 patients). The 69 patients in group 1 were treated with appropriate medical therapy for a period of ≥7 days for colic pain and subsequently underwent either semirigid ureteroscopy or pneumatic lithotripsy in a planned manner. The 76 patients in group 2 underwent semirigid ureteroscopy after the first colic attack. The stone-free status, auxiliary procedures, and complications were evaluated between the 2 groups using the Mann-Whitney U test; for qualitative data, Fisher's exact test was used. RESULTS: Of the 145 patients who underwent semirigid ureteroscopy, the mean stone size was 11.80±3.95 mm and 8.32±2.08 mm in the 2 groups. No patient experienced a major complication during or after the procedure. The stone-free rate was 87% and 90.7% in groups 1 and 2, respectively. The mean readmission rate to the emergency department for the management of a colic attack was 3.03±2.84 in group 1; no patient in group 2 required readmission. CONCLUSION: Ureteroscopic stone removal immediately after the first colic attack in the cases of obstructive ureteral stones proved to be safe and effective. It has the main advantage of offering both immediate stone fragmentation and the relief of acute onset colic pain causing extreme discomfort.

Twelve-year experience with Hinman-Allen syndrome at a single center.

OBJECTIVE: To report the long-term follow-up results of patients with Hinman-Allen syndrome (HAS) at our institution. METHODS: The data from 22 children with HAS were retrospectively analyzed. The patients were followed up every 3-6 months with serial physical examinations, voiding charts, urine culture, postvoid residual urine volume determination, serum creatinine measurement, and urinary imaging. The follow-up time was calculated from the day of the first visit to the day of the latest dimercaptosuccinic acid scan. Urotherapy, pharmacotherapy, clean intermittent catheterization, biofeedback therapy, and surgery were performed sequentially and/or combined, depending on the disease course. Renal deterioration was defined as any presence of a new scar or cortical thinning compared with the findings from the first dimercaptosuccinic acid scan. Upper urinary tract deterioration was defined as the persistence or progression of hydronephrosis on ultrasonography. RESULTS: The mean age at referral was 9.18 ± 3.36 years (range 2-14), and the mean follow-up period was 80.90 ± 19.57 months (range 54-144). Conservative therapy resulted in improvement of the bladder function in 14 patients; however, 8 patients required surgery owing to failure of this approach. Asymptomatic bacteriuria developed in one half of the children (n = 11, 50%), and in 6 (22.7%), ≥1 febrile urinary tract infection developed. None of the patients had upper urinary tract deterioration; however, renal deterioration developed in 3 patients (13.6%). The mean creatinine levels had remained stable at the end of the follow-up. CONCLUSION: Close follow-up at a single institution and proactive treatment resulted in successful stabilization of HAS in most of our children with HAS.

Photoselective potassium titanyl phosphate (KTP) laser vaporization versus transurethral resection of the prostate for prostates larger than 70 mL: a short-term prospective randomized trial.

OBJECTIVES: To compare the short term outcomes of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) for glands larger than 70 mL in a prospective randomized trial. METHODS: Seventy-six consecutive patients with enlarged prostatic adenomas of 70 to 100 mL were randomly assigned for surgical treatment with TURP (n = 37) or PVP (n = 39). International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) scores, maximum flow rates (Qmax), postvoid urine residues (PVR), and transrectal ultrasound (TRUS) volumes were recorded. Operative data, complications, catheter removal, and hospitalization periods were also recorded. Patients were reassessed at 3 and 6 months. RESULTS: Baseline characteristics of both groups were similar. Mean preoperative TRUS volume was 88 +/- 9.2 mL in the TURP group and 86.1 +/- 8.8 mL in the PVP group. The procedure was significantly shorter for the TURP group (51 +/- 17.2 minutes versus 87 +/- 18.3 minutes, P <0.05), catheter removal (3.9 +/- 1.2 days and 1.7 +/- 0.8 days, P <0.05), and hospital stay (4.8 +/- 1.2 days versus 2 +/- 0.7 days, P <0.05) were shorter in the PVP group. A significant difference in IPSS, Qmax and PVR values was observed within the follow-up period in favor of the TURP. The percentage volume reduction was significantly higher in TURP group. Reoperation was necessary in 7 patients in PVP but none in TURP group. CONCLUSIONS: Although PVP offers advantageous over TURP with regard to intraoperative and perioperative safety, early functional results of TURP are superior to PVP in patients with enlarged prostates larger than 70 mL.

The learning curve in the training of percutaneous nephrolithotomy.

OBJECTIVES: To investigate the learning curve in the training of percutaneous nephrolithotomy (PCNL). METHODS: A total of 104 PCNL cases were included in this evaluation to define the learning curve of a surgeon with no previous experience at performing solo PCNL. Two parameters of expertise were reviewed, namely the operation and fluoroscopic screening times. The operation time was calculated as the beginning of access with the needle until the nephrostomy tube was placed and secured. PCNL procedures were analyzed in seven sets of 15 cases regarding the operation and fluoroscopy times, stone size, stone clearance rate, blood transfusion rate, and estimated blood loss. RESULTS: The mean operation time was 2.4 h for the first 15 patients. It decreased to a mean of 1.5 h for cases 46 through 60. No further decrease in the operation time was observed after case 60. The fluoroscopic screening time was a peak of 17.5 min in the first 15 cases, whereas it dropped to a mean of 8.9 min for cases 46 through 60. The decline in the mean fluoroscopy screening time continued in cases 61 to 104, but the decline was not significant. There was no significant difference in stone size, stone clearance rate, blood transfusion rate, and estimated blood loss among each set of cases. CONCLUSIONS: This study suggests that the surgical competence in PCNL can be reached after 60 cases. PCNL and fluoroscopy times drop to a steady-state level after performing 60 procedures.

Operative failure during ureteroscopic pneumatic lithotripsy: factors affecting successful outcome.

AIM: We aimed to evaluate the predictive factors that would in turn indicate stone migration and the effects of these factors on the ultimate success of the intervention. METHOD: Patients were divided into two groups with respect to the migration of the stone treated. Group I: patients demonstrating stone migration during manipulation; group II: no migration of the stones noted. In the second phase of the study, the results of ureteroscopic management in 433 patients were evaluated with respect to the success rates obtained. Parameters such as stone size, stone burden, experience of the surgeon, length of the ureter proximal to the stone treated, and lastly transverse diameter of the ureter were noted in all patients as possible risk factors for stone migration. RESULTS: Statistical analysis of ureteroscopic success in all patients revealed that there was a meaningful correlation with respect to the length of the proximal ureteral portion (p < 0.0001) and surgeon's experience (p = 0.004). p value for the correlation between stone burden and operative success was 0.056. There was no significant correlation between stone size (p = 0.51), ureter diameter (p = 0.78), and operative success. CONCLUSION: Stones that are close to the renal pelvis and treated by inexperienced physicians are the ones most likely to migrate to the renal pelvis during manipulation with pneumatic lithotripsy.