Laparoscopic heminephrectomy for benign and malignant diseases of the horseshoe kidney.

OBJECTIVES: In the current study, we present our pure laparoscopic heminephrectomy experience in 13 patients with horseshoe kidney (HK). MATERIAL AND METHODS: A total of 13 patients with HK underwent pure laparoscopic heminephrectomy (Transperitoneal= 7, Retroperitoneal = 6) due to benign and malign renal conditions (non-functional hydronephrotic and/or infected kidney = 12, kidney mass = 1). RESULTS: The mean age of the patients was 45.8 years. The mean operating time was 140 minutes, and estimated blood loss was 131 ml. The mean hospital stay was 2.3 days. Division of istmus was performed with stapler in 5 patients, ultrasonic scalpel in 3, 15 mm Hem-o-lok clip in 3, 10 mm LigaSure vessel seal system in one and endoscopic suture by 0 polyglactin in one patient without bleeding. Twelve patients underwent pure laparoscopic heminephrectomy due to nonfunctional hydronephrotic and or infected kidney. One patient underwent transperitoneal laparoscopic right heminephrectomy due to kidney mass. According to modifies Clavien classification, Grade I complication (wound infection) occurred in one patient (7.7%) who underwent heminephrectomy due to non-functional kidney. CONCLUSIONS: Laparoscopic heminephrectomy seems to be technically feasible and safe for benign and malignant diseases in patients with HK.

Simulation of RIRS in soft cadavers: a novel training model by the Cadaveric Research On Endourology Training (CRET) Study Group.

PURPOSE: The aim of the current study was to evaluate the use of fresh-frozen concurrently with embalmed cadavers as initial training models for flexible ureteroscopy (fURS) in a group of urologists who were inexperienced in retrograde intrarenal surgery (RIRS). METHODS: Twelve urologists involved in a cadaveric fURS training course were enrolled into this prospective study. All the participants were inexperienced in fURS. Theoretical lectures and step-by-step tips and tricks video presentations on fURS were used to incorporate the technical background of the procedure to the hands-on-training course and to standardize the operating steps of the procedure. An 8-item survey was administered to the participants upon initiation and at the end of the course. RESULTS: Pre- and post-training scores were similar for each question. All the participants successfully completed the hands-on-training tasks. Mean pre-training duration [3.56 ± 2.0 min (range 1.21-7.46)] was significantly higher than mean post-training duration [1.76 ± 1.54 min (range 1.00-6.34)] (p = 0.008). At the end of the day, the trainers checked the integrity of the collecting system both by endoscopy and by fluoroscopy and could not detect any injury of the upper ureteral wall or pelvicalyceal structures. The functionality of the scopes was also checked, and no scope injury (including a reduction in the deflection capacity) was noted. CONCLUSIONS: The fURS simulation training model using soft human cadavers has the unique advantage of perfectly mimicking the living human tissues. This similarity makes this model one of the best if not the perfect simulator for an effective endourologic training.

Azoospermia Type Does Not Affect Intracytoplasmic Sperm Injection Results When Microdissection Testicular Sperm Extraction Is Performed.

Objective: To investigate the effect of azoospermia type on fertilization and clinical pregnancy rates when microdissection testicular sperm extraction (TESE) is performed for sperm retrieval in nonobstructive azoospermia (NOA). Study Design: STUDY DESIGN: Patients who underwent microdissection TESE for NOA and conventional TESE for obstructive azoospermia (OA) were included in the study. Intracytoplasmic sperm injection (ICSI) results were compared between groups. Results: The mean ages in the 2 groups were similar. FSH and LH levels in the NOA group were significantly higher than those of the OA group. Between groups there was no statistically significant difference in testosterone levels. The sperm retrieval rate was 58.56% in NOA. Fertilization and clinical pregnancy rates were similar for patients with NOA and OA. Conclusion: In patients with NOA, microdissection TESE accurately determines active spermatogenesis areas via the high identification power of the operative microscope. From these areas surgeons can collect healthier spermatozoa, which can result in better ICSI outcomes, the results of which are similar to those with OA.

Electrophysiological Identification of Central Sensitization in Patients with Chronic Prostatitis.

PURPOSE: Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) is a chronic pain condition and a com­mon problem in urology clinics. Although many different etiologies and mechanisms exist, the exact cause of the disease has been unknown. Central sensitization (CS) is defined as an augmentation of responsiveness of central cortical neurons to input from peripheral nociceptive structures. Somato-sensory evoked potentials (SEPs) is an electroneurophysiological method to assess cortical activity in somatosensory area of brain related to sensorial stimuli. We aimed to determine the presence of CS using the SEPs of dorsal penile nerve stimulation in patients with CP/CPPS. MATERIALS AND METHODS: Seventeen male patients diagnosed CP/CPPS and 17 male healthy controls were pro­spectively included in the study. For SEP study, electrical stimulus was applied with penile ring electrodes. Re­cording electrodes were placed as active to Cz' and reference electrode on Fz' according to the 10-20 Interna­tional System. Latency of N50 was defined as the second negative (up-ward) deflection of the W-shaped averaged cortical waveform. RESULTS: N50 latencies were significantly shortened in the patient group compared to the healthy controls (P < .001). CONCLUSION: These results support the presence of central sensitization because of exaggerated trans-mission of pain sensation to the somatosensory cortex. Therefore, normalization of transmission might be an important step in treatment of pain in patients with CP/CPPS. This study can be counted as an important guiding on pathogenesis and treatment of disease.

Flexible Ureterorenoscopy versus Extracorporeal Shock Wave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10-20 mm: a retrospective analysis of 174 patients.

To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm. A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications. 87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1) was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05). F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10-20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10-20 mm and reserved for cases with failure in ESWL.

Assessment of the effects of access count in percutaneous nephrolithotomy on renal functions by technetium-99m-dimercaptosuccinic Acid scintigraphy.

Objective. To determine the effects of percutaneous nephrolithotomy on renal functions by using DMSA scintigraphy while considering access counts. Material and Methods. A total of 37 patients who had undergone percutaneous nephrolithotomy were included. Preoperative DMSA scans were performed a day before the surgery, whereas postoperative scans were randomized by evaluating them before (n = 25) and after (n = 12) the 6th postoperative month. Twenty-six of 37 cases underwent percutaneous nephrolithotomy with a single access site and 11 with multiple access sites. Results. There were no significant changes of total renal functions in the whole study group (P = 0.054). In the single access group, total functions were significantly elevated (P = 0.03) In the multiple access group, while treated site functions were significantly decreased (P = 0.01), total functions did not change significantly (P = 0.42). There was an insignificant decrease in those evaluated before the 6th postoperative month (P = 0.27) and an insignificant increase in the others (P = 0.11). Conclusion. We could not find a superiority of single access over multiple accesses. There is a temporary functional loss in the treated site.

Intravenous dexmedetomidine for treatment of intraoperative penile erection.

BACKGROUND: Intraoperative penile erections following the initiation of either regional or general anaesthesia is rare; however, when it occurs in patients undergoing urologic procedures it may delay, or even cancel the planned surgery. The aetiology is unclear. Various treatments proposed for producing detumescence are not always effective. Use of intracavernous alpha-adrenergic agonists is an efficient and rapid but short-lasting treatment. Furthermore, repeated intracavernous injections of vasoactive drugs may be harmful. Dexmedetomidine is a potent, selective α(2)-adrenoreceptor agonist. In our study, we evaluated the effect of dexmedetomidine on intraoperative penile erection. METHODS: Penile erection developed during an endoscopic procedure in 12 more than 7,800 patients. Anaesthesia used was general in 3 patients, epidural in 1 patient and spinal in 8 patients. The erection rigidity was evaluated by the operating urologist. Dexmedetomidine was diluted in normal saline to a concentration of 4 µg/ml. In all of the cases, 0.5 µg/kg dexmedetomidine was injected intravenously. RESULTS: The incidence of intraoperative penile erection was 0.34% for general anaesthesia, 0.11% spinal anaesthesia and 1.72% epidural anaesthesia at our institution. Detumescence was achieved in 9 patients during the first 5 min and in one patient at the 9th minute after a single intravenous dexmedetomidine (83%). There was no detumescence in two patients after 15 min (17%). CONCLUSION: This study demonstrated that 0.5 µg/kg intravenous injection of dexmedetomidine is a simple, effective and safe method for immediate relief of intraoperative penile erection with high success rate.

Comparison of infection and urosepsis rates of ciprofloxacin and ceftriaxone prophylaxis before percutaneous nephrolithotomy: a prospective and randomised study.

This study aimed at determining the choice and administration duration of ideal antibiotic prophylaxis before percutaneous nephrolithotomy (PNL) operation, a treatment modality for nephrolithiasis. The study included 90 patients who had no internal problem, yet had a negative urine culture and underwent a PNL operation. We compared infection rates between ciprofloxacin and ceftriaxone groups and their subgroups. The results showed no statistical difference between ciprofloxacin and ceftriaxone groups in terms of systemic inflammatory response syndrome (SIRS) (CIP(P) = 0.306, CTX P = 0.334. As a result of this study no statistical difference was observed between ciprofloxacin and ceftriaxone in terms of SIRS. It seems, however, reasonable to choose ceftriaxone, considering antibiotic sensitivity of microorganisms and detection of three cases accepted as urosepsis in the ciprofloxacin group. As there is no difference between short, and long-term prophylactic use of these antibiotics, preference of short-term prophylaxis for patients with no risk of infection will be important to avoid inappropriate antibiotic usage.

Is ureteral stenting really necessary after ureteroscopic lithotripsy with balloon dilatation of ureteral orifice? A multi-institutional randomized controlled study.

PURPOSE: Our aim was to evaluate the role of balloon dilatation of the ureteral orifice on the decision to stent after ureteroscopy. MATERIALS AND METHODS: We prospectively enrolled 505 patients from two clinics, undergoing ureteroscopy (URS) for urolithiasis. Patients having balloon dilatation of the ureteral orifice and uncomplicated ureteroscopy were randomized to be either stented (n = 144) or nonstented (n = 142). Ureteroscopy was done with a 9.8 rigid ureteroscope. For dilatation of ureteral orifice, 18Fr-4 cm balloons were used (Uromax™, Boston Scientific, USA). Holmium laser or pneumatic devices were used for lithotripsy. In the second postoperative week, patients were asked to assess: pain, dysuria, and urgency using a 10-cm visual analog score (VAS) and unplanned visits. In each visit, urinalysis, urine culture, plain X-ray, and ultrasound examinations were performed. Six months after URS, follow-up IVU was performed to evaluate ureteral narrowing. Results for the separate clinics were not revealed until the end of study. RESULTS: There were no significant differences between the two groups regarding gender, age, preoperative serum creatinine levels, stone size, stone side and location, lithotripsy type, pain, infectious complications, unplanned visits, and ureteral narrowing. However, irritative symptoms were more common in the stented group. Success rates of 97.8 and 97.2% were similar in the unstented and stented groups. CONCLUSION: In uncomplicated URS, balloon dilatation of the ureteral orifice should not significantly affect the decision for or against stent placement. Avoiding stents lowers costs and gives fewer irritative symptoms.

Effect of simple malrotation on percutaneous nephrolithotomy: a matched pair multicenter analysis.

PURPOSE: In this multicenter study we compared the outcome of percutaneous nephrolithotomy in patients with and without malrotated kidneys. MATERIALS AND METHODS: A total of 44 patients (group 1) at 6 institutions who underwent percutaneous nephrolithotomy for kidneys with simple malrotation were enrolled in our study. Attending physicians in our group also provided the same number of cases of percutaneous nephrolithotomy done for nonmalrotated (normal) kidneys (group 2). Group 2 patients were selected by match pairing. Operative and postoperative data on the 2 groups were compared using the chi-square, Student t and Fisher exact tests. RESULTS: As a result of match pairing, the 2 groups were similar in age, gender, body mass index, and stone size and site. Mean ± SD stone size was 5.9 ± 3.5 cm(2) in group 1. Multiple access attempts were required in 9 (20.5%) and 7 cases (15.9%) in groups 1 and 2, respectively (p >0.05). Mean fluoroscopy time was 7.0 ± 3.9 minutes in the malrotated kidney group and 7.3 ± 4.5 minutes in the nonmalrotated kidney group (p >0.05). The mean hemoglobin decrease after percutaneous nephrolithotomy was significantly higher in group 1 (-1.9 vs -1.3 gm/dl, p = 0.008) but the blood transfusion rate was similar in the 2 groups. The procedure success rate in groups 1 and 2 was 77.3% and 79.5%, respectively (p >0.05). CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective even in patients with larger kidney stones and malrotated kidneys.

Assessment of in vivo calculation with ultrasonography compared to physical sections in vitro: a stereological study of prostate volumes.

We compared three methods for the determination of prostate volume: prostate volume measured via transrectal ultrasonography (TRUS); the Cavalieri method for measuring physical sections; and volume by displacement. TRUS volumes were calculated by the prolate ellipsoid volume formula. Five patients underwent TRUS examination of the prostate prior to radical prostatectomy; specimens were measured when freshly excised. Mean prostate volume by fluid displacement, before formalin fixation was 52.8 ± 21.5 cm(3), and after formalin fixation 50.4 ± 20.9 cm(3). Volumes determined by the Cavalieri principle (point-counting and planimetry) were 47.8 ± 19.3 and 49.1 ± 20.5 cm(3); volume measured by TRUS was 42.9 ± 21.9 cm(3). Thus TRUS underestimated prostate volume by 21.4%, but excellent agreement was found between actual volume and point counting techniques. We believe that the classic ellipsoid formula is inadequate for determining prostate volume.

Is type 2 diabetes mellitus a predictive factor for incontinence after laparoscopic radical prostatectomy? A matched pair and multivariate analysis.

PURPOSE: We evaluated the effect of diabetes mellitus on incontinence after laparoscopic radical prostatectomy. MATERIALS AND METHODS: From a series of 2,071 patients 135 with type 2 diabetes mellitus undergoing laparoscopic radical prostatectomy without radiotherapy and with a minimum followup of 24 months were identified. These patients were randomly matched with 135 nondiabetic controls for age, body mass index, preoperative prostate specific antigen, clinical stage, neoadjuvant hormonal therapy, prostate volume, previous surgery, surgeon skills, surgical approach, presence of bladder neck sparing, lymphadenectomy, technique of urethrovesical anastomosis and attempted nerve sparing surgery. RESULTS: Using multivariate analysis age, diabetes mellitus and duration of diabetes mellitus were independent factors for post-prostatectomy incontinence in the whole group. Early continence (0 to 3 months) was observed in 43.7% of patients with diabetes and in 57.8% of nondiabetic controls which was statistically significant (p = 0.02). The rates of continence in patients with diabetes mellitus for 5 or more years at 3, 12 and 24-month evaluations were less than those in patients with diabetes mellitus for less than 5 years, and the difference was statistically significant (36% vs 50%, p = 0.001; 63.9% vs 82.4%, p = 0.02; 91.8% vs 98.6%, p = 0.03, respectively). CONCLUSIONS: Patients with type 2 diabetes mellitus need longer to recover continence than nondiabetics after laparoscopic radical prostatectomy. However, type II diabetes mellitus did not affect overall return to continence. Patients with diabetes mellitus for 5 or more years have an almost 5 times increased risk of post-prostatectomy incontinence compared to those with diabetes mellitus for less than 5 years. Diabetic patients should be counseled for the potential negative impact of diabetes mellitus on the recovery of continence after laparoscopic radical prostatectomy.

What is the role of percutaneous needle core biopsy in diagnosis of renal masses?

OBJECTIVE: To define the accuracy and acceptability of ultrasonography-guided percutaneous needle core biopsy in diagnosis of renal masses. METHODS: The data of 42 consecutive patients on whom needle biopsies were performed and were surgically treated for suspicious renal masses in our clinic between January 2001 and April 2008 were evaluated. In all patients, needle biopsies were done percutaneously with an 18-gauge needle under local anesthesia in prone position with ultrasonography guidance. Two cores were taken from each tumor. The pathology results of biopsy and surgical specimens were compared. RESULTS: The mean age was 56.1 years (range, 21-77 years). The mean follow-up period was calculated as 44.8 months (range, 10-85 months). The abdominal computed tomography imaging showed that the mean mass size was 63.9 mm (range, 25-140 mm). Of 42 patients, 39 were diagnosed (92.8%) after the first biopsy. The accuracy of percutaneous needle biopsy in differentiating between malignant and benign masses was calculated as 90% (36/40).The accuracy of histopathological diagnostic typing as against the postsurgical pathologic examination results was 77.5% (31/40) and the accuracy in the Fuhrman grade was 51.5% (17/33). The sensitivity was calculated as 91.4% and specificity as 60%. Its negative predictive value was 50% and positive predictive value was 94.1%. CONCLUSIONS: In conclusion, percutaneous renal needle core biopsy has an acceptable sensitivity and specificity in the diagnosis of renal masses. The major limitation of percutaneous core biopsy is the technical failure that leads to insufficient material for accurate diagnosis.

Rigorous bicycling does not increase serum levels of total and free prostate-specific antigen (PSA), the free/total PSA ratio, gonadotropin levels, or uroflowmetric parameters.

OBJECTIVES: To determine whether cycling has an effect on serum PSA, gonadotropins, and uroflowmetric parameters. METHODS: A total of 34 healthy male athletes from the National Cycling Team and 24 healthy male student volunteers from University and medical staff were prospectively enrolled in the study. Blood samples for serum total prostate-specific antigen (tPSA), free PSA (fPSA, fPSA/tPSA, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone determinations were obtained before and after cyclists completed 300 km bicycle ride and with each cyclist seated without changing posture and with minimal movement for 10 minutes before blood collection. The cyclists also performed uroflowmetric and postvoid residual urine volume analysis before, and 1 hour after cycling course. Blood samples from the control group were drawn for serum hormones. They also underwent uroflowmetric and postvoid residual analysis. RESULTS: The athletes and the control group were well matched by age. There was no significant difference between the 2 groups in terms of serum tPSA, fPSA, f/t PSA values, FSH, LH, and testosterone levels and uroflowmetric parameters (P >.05). The differences between pre- and postcycling values for tPSA, fPSA, f/t PSA, FSH, LH, and uroflowmetric parameters were not statistically significant. The postcycling serum testosterone level was significantly lower than precycling levels (mean, 603.6 ng/dL [range, 300-949] vs 424.8 ng/dL [range, 193-723], P = .001]. There was no correlation between body mass index values, postcycling serum FSH, LH levels, age, and testosterone levels. CONCLUSIONS: There is no effect of professional bicycle riding on serum total and fPSA levels and uroflowmetric parameters.

Which urine marker test provides more diagnostic value in conjunction with standard cytology- ImmunoCyt/uCyt+ or Cytokeratin 20 expression.

BACKGROUND: Because of the poor sensitivity of urinary cytological findings for the diagnosis of especially low grade urinary bladder carcinoma, new molecular diagnostic methods have been proposed. We decided to verify the ImmunoCyt/uCyt+ (UCyt+) test and cytology combination and cytokeratin 20 (CK20) and cytology combination in urine as possible diagnostic and monitoring tool for bladder cancer. METHODS: Evaluation of CK20 expression and UCyt+ was performed in urine of 90 patients of which 54 with bladder cancer with primary/recurrent diagnosis (low grade urothelial carcinoma (LGUC) = 23/8 patients, high grade urothelial carcinoma (HGUC) = 18/5 patients), and 36 patients as control; except of neoplastic bladder disease patients. For the evaluation of the three tests, CK20 and UCyt+ tests were combined with urine cytology and compared with each other. RESULTS: The overall sensitivity detected for each tumor marker was as follows: for urine cytology was 75.9% and UCyt+ was 83.3%, for CK20 70.4%, while the specificity was 66.7% for urine cytology and 86.1% for UCyt+ and 83.3% for CK20. The sensitivity of cytology and UCyt+ combination was higher (88.9%) than the sensitivity cytology and CK20 combination (77.8%). The simultaneous use of the three markers, sensitivity was reaching 92.5%. CONCLUSION: The UCyt+ test and CK20 expression are valid tools for the performance of adjunctive analyses with conventional cytologic examination.

Comparison of 3 doses of ropivacaine for epidural anesthesia in transurethral surgery.

OBJECTIVE: To investigate the use of 3 different doses of ropivacaine on the quality of anesthesia and hemodynamics in epidural anesthesia for transurethral surgery. METHODS: The current study was conducted in the Department of Anesthesiology, Medical Faculty of Erciyes University, Turkey, between May 2004 and June 2006. The study recruited 81 males of ASA I- II group, ages 60-80 years, undergoing transurethral resection of prostate or bladder tumors. Patients were randomly assigned to 3 groups receiving epidural ropivacaine in different doses and concentrations. Group I (n=27) received 15 ml (102.5mg) of 0.75% solution, group II (n=27) received 10 ml (75 mg) of 0.75% solution, and group III (n=27) received 10 ml (50mg) 0.5% ropivacaine. The quality of the blocks and the hemodynamic changes were compared. RESULTS: Motor block was significantly less in group III than in groups I and II. The sensory block level was T6 or more in 55% of patients in group I, 35% in group II, and 21% in group III. The duration of sensory block was less, and the time to achieve the T10 level was greater in group III. Hypotension and bradycardia were more frequent in group I. CONCLUSION: Effective anesthesia with few side effects was obtained with low dose ropivacaine.