Minimally Invasive Approach to Ureteral Stricture in Transplant Kidney by Periodic Retrograde Ureteral Stent Placement and Exchange.

PURPOSE: The aim of the study was to evaluate the effectiveness of minimally invasive treatment of ureteral strictures and describe the technique that we used for retrograde placement of ureteral stent in transplant kidneys. MATERIAL AND METHODS: We reviewed the medical cards of all transplant kidney patients with persistent ureteral strictures who were managed with periodical ureteral stent placement and balloon dilatation between 2008 and 2016. Different maneuvers that were used to overcome the difficulties for retrograde ureteral stent placement and exchange were discussed. Clinical characteristics and treatment outcomes of the study cohort were analyzed. RESULTS: Between 2008 and 2016, a total of 1026 transplantations were performed in our clinic, and ureteral stricture was found in 13 patients (1.26%). Of the 13 patients, 8 were treated with periodic ureteral stent insertion and balloon dilatation. Ureteral stent insertion or stent exchange was performed in 52 transplant renal units. The overall success rate of retrograde ureteral stent insertion at the first attempt was 75% and stent exchange success rate was 100%. Renal function remained stable in all patients during a median follow-up of 41 months (range, 13-60 months). No other local or systemic complication was encountered and no stent encrustation was noted. CONCLUSIONS: Endoscopic management of ureteral stricture by periodical retrograde ureteral stent replacement and balloon dilatation is safe, effective, and highly successful in transplant patients who are not eligible for open reconstructive surgery.

Primary squamous cell carcinoma of the ampulla of Vater: a case report.

BACKGROUND: Primary squamous cell carcinoma of the ampulla of Vater is a very rare type of tumor, and the prognosis is not well known mainly due to a limited number of cases reported. Here, we aimed to report a case with primary squamous cell carcinoma of the ampulla of Vater. CASE PRESENTATION: A 54-year-old woman presented with weight loss, jaundice, and pain in the epigastric and right upper quadrant of the abdomen. With extensive radiological imaging, the patient was diagnosed with periampullary tumor and Whipple's procedure was performed. The immunohistochemical analyses supported the diagnosis of primary squamous cell carcinoma. The postoperative course was uneventful. The patient was discharged, and adjuvant chemotherapy was recommended. CONCLUSION: Primary squamous cell carcinoma of the ampulla of Vater is a very rare histological type with an unclear pathogenesis. A better understanding of pathogenesis might be helpful in optimizing the treatment for this specific rare type of tumor.

Flexible Ureterorenoscopy and Laser Lithotripsy for the Treatment of Allograft Kidney Lithiasis.

OBJECTIVE: To evaluate the safety and effectiveness of flexible ureterorenoscopy (F-URS) and laser lithotripsy for the treatment of allograft kidney lithiasis. PATIENTS AND METHODS: In a retrospective analysis of 897 consecutive renal transplantations that were performed at our center between February 2008 and December 2014, 6 patients were found to have allograft lithiasis. F-URS and laser lithotripsy were performed 6 times on 5 patients (twice for 1 patient who had stone recurrence after 6 months). Percutaneous nephrolithotomy was used for the remaining patient. Patient demographics and stone characteristics (age, sex, stone size, stone analysis, location, history of shockwave lithotripsy) and perioperative measures (duration of operation, fluoroscopic imaging, success and complication rates) were reviewed. In addition, the technical difficulties of standard F-URS procedures in transplanted kidneys were reviewed and some facilitative techniques were defined to increase the success rate. RESULTS: A total of 5 patients underwent 6 F-URS procedures and laser lithotripsy operations for renal graft lithiasis. The mean stone size was 9.2 mm (7.5-11 mm). The mean operation and fluoroscopy times were calculated as 55 minutes (40-70 minutes) and 57.5 seconds (40-80 seconds), respectively. Treatment was successful in all patients and no severe complications or mortality occurred. One patient experienced transient hematuria and recovered within 36 hours. CONCLUSION: F-URS is a safe, effective, and minimally invasive treatment modality for small- and medium-sized stones in allograft kidney lithiasis.

The protective effect of losartan on diabetic neuropathy in a diabetic rat model.

AIM: Involvement of the peripheral and autonomic nervous systems is possibly the most frequent complication of diabetes. Important risk factors included hyperglycemia, dyslipidemia, hypertension, and smoking. Angiotensin-converting-enzyme inhibitor (ACE) inhibitors should be beneficial in all vascular beds, including neuropathy and retinopathy. In this study we aimed to evaluate the effect of the angiotensin receptor blocker losartan on diabetic neuropathy in a diabetic rat model. MATERIAL AND METHODS: 24 male, Sprague Dawley albino mature rats were divided into 3 groups; (1) control group: No drug was administered to the remainder of rats which blood glucose levels were under 120 mg/dl, (2) diabetic control: rats were given no medication, but 4 ml per day of tap water was given by oral gavage, (3) losartan groups: rats were given 10 mg/kg/day oral of losartan for 4 weeks. Electromyography (EMG) was applied to anesthetized rats at the end of 4(th) weekend. Then, the animals were euthanized and sciatic nerve was performed for histopathological examination. RESULTS: Compound Muscle Action Potential (CMAP) amplitude of diabetic rats receiving the Saline in the EMG was significantly reduced when compared to the control group. Distal latency value and CMAP duration of diabetic rats receiving the saline were meaningfully increased when compared to the control group. CMAP amplitude and CMAP duration of diabetic rats receiving the Losartan treatment in the EMG were meaningfully reduced when compared to diabetic rats receiving the Saline.Perineural thickness in the rats receiving the Losartan treatment was found to be significantly reduced when compared to the group receiving the Saline. CONCLUSIONS: As a result, it has been shown in this study that perineural thickness of the Losartan treatment was significantly reduced when compared to saline receiving group, significantly increased the immunoexpression of NGF, and also provided a significantly recovery in EMG when compared to Saline receiving group.

Comparison of nephron-protective effects of enalapril and GLP analogues (exenatide) in diabetic nephropathy.

BACKGROUND: One of the major concerns is a nephropathy in diabetes, which applies many different kinds of medicines. However, required level of the treatment of renal disease has not been achieved. AIM: To investigate and compare the effect of the enalapril and the exenatide on diabetic nephropathy in rats developed diabetes by streptozosin. MATERIAL AND METHODS: 32 male Sprague Dawley rats were divided into 4 groups: (1) Control, (2) Diabetic (DM), (3) DM+ Enalapril, and (4) DM+ exenatide groups. Then, the animals were euthanized and their blood samples were collected by cardiac puncture for blood glucose; blood urea nitrogen (BUN), creatinin, and nephrectomy were performed for histopathologic examination, and urine samples were taken on stick for proteinuria. RESULTS: Administration of the enalapril or the exenatide in diabetic rats resulted in a significant reduction both fibronectin, induced nitric oxide synthase (i-NOS) expression in glomerular area and urine protein levels. It was shown that both of enalapril and exenatide protected the renal glomerulus more than diabetic group in the nephropathy histopathologically. CONCLUSION: The beneficial effects of enalapril and exenatide which reduces fibronectin, i-NOS expression and urine protein levels or increases recovery of glomerules, might be used for preventing the harmful effects of diabetic nephropathy.

Assessment of fibrin-fibrinogen degradation products (Accu-Dx) test in bladder cancer patients.

OBJECTIVES: Measurement of urine fibrin-fibrinogen degradation products has been reported to be a useful marker for bladder malignancies. This is a simple, noninvasive and rapid method in the diagnosis and follow-up of bladder cancer. We performed a prospective study to evaluate the reliability of the Accu-Dx test which detects urinary fibrin and fibrinogen products associated with bladder cancer. MATERIAL AND METHODS: 97 patients were included in this study. 55 patients with bladder cancer were under surveillance, and 35 were evaluated as primary cases. The Accu-Dx test was performed in 7 additional patients presenting with hematuria due to benign disorders. Urine cytology specimens were collected in all, whereas bladder pathology specimens were obtained in 93. The Accu-Dx test was evaluated with regard to the results of urine cytology and pathological assessment, which constituted the gold standard. RESULTS: According to pathology, 69 patients had carcinoma of the bladder. In 48 (69.6%), the Accu-Dx test was positive whereas urine cytology was positive in only 31 (44.9%; p<0.001). Specificity rates were 67.9 and 96.4%, respectively. With higher stages and higher tumor grades, the Accu-Dx test yielded higher positive rates (50% in Ta versus 100% in T2 or higher and 42.9% in G1 versus 94.1% in G3). On the other hand, the test was positive in 6 patients with cystitis of various etiologies. The overall accuracy rate for Accu-Dx was 69%. CONCLUSIONS: The Accu-Dx test is a simple, rapid, reproducible and more importantly a noninvasive method in the detection of bladder malignancies. But it seems inadequate to replace conventional cystoscopy plus pathologic assessment due to its relatively low accuracy and specificity rates. It may be helpful in selecting patients who should be evaluated with rigid endoscopes together with bladder biopsies.

Role of RigiScan in the etiologic differential diagnosis of erectile dysfunction.

OBJECTIVE: The aim of this prospective study was to assess the reliability of nocturnal penile tumescence monitoring by an ambulatory RigiScan device in the etiological diagnosis of erectile dysfunction. PATIENTS AND METHODS: A total of 64 randomized patients with a complaint of impotence for at least 6 months initially underwent nocturnal penile tumescence rigidity (NPTR) monitoring on 2 consecutive nights in a private setting as session 1. All subjects then underwent a comprehensive multidisciplinary diagnostic approach including dynamic color Doppler sonography and pharmaco-cavernosometry as a second session in a blind fashion. The results of both sessions were compared with each other. RESULTS: Sensitivity, specificity, positive predictive value and accuracy rate of NPTR monitoring in discriminating organic from psychogenic impotence with respect to a multidisciplinary diagnostic approach using sophisticated techniques were as 80.9, 81.8, 89.4 and 81.2%, respectively. CONCLUSION: Although RigiScan differentiates organic from psychogenic impotence with a relatively high sensitivity, a multidisciplinary diagnostic approach is mandatory in establishing the ultimate diagnosis.

Penile fracture: differential diagnosis, management and outcome.

OBJECTIVE: To determine the value of a diagnostic and therapeutic approach for patients presenting with acute penis and the effects of this management on the outcome. PATIENTS AND METHODS: The study comprises 21 consecutive patients (mean age 33.3 years, range 19-53) who presented with acute penis (acute pain and swelling during and soon after intercourse). The mean interval between the accident and the treatment was 6 h (range 2-20). All patients initially underwent cavernosography, followed by surgical exploration. RESULTS: Cavernosography showed extravasation of the contrast medium, indicating a corporal tear, in 19 of 21 patients. Surgical exploration revealed rupture of the deep dorsal vein in two patients whose radiological examinations were normal. In the remaining 19 patients, corporeal tears were repaired. The mean follow-up was 26.7 months; all patients regained penile function (potency). Penile curvature was the only adverse effect in three of the 21 patients, all of whom presented for medical treatment relatively late after the initial accident. CONCLUSION: In the management of the acute penis, cavernosography should be performed first and the treatment policy should be determined from the radiological findings. Conservative therapy should be chosen only when the corporeal bodies are intact.

Prospective comparison of colour Doppler ultrasonography and testicular scintigraphy in acute scrotum.

The aim of this prospective study was to compare the effectiveness of colour Doppler ultrasound and testicular scintigraphy in the differential diagnosis of acute scrotum. Ten patients were investigated by clinical examination initially and by both techniques afterwards. Scintigraphy was performed in a blind fashion. According to the findings, 3 patients were categorized as acute ischaemia and 7 as inflammation. The 3 patients diagnosed as ischaemia underwent surgical exploration. Both imaging techniques predicted ischaemia (100%). In the inflammation group conservative therapy and follow-up were chosen. Ultrasonography alone established the correct diagnosis in 7/7, whereas scintigraphy in 5/7 of the patients.

Judgment of color Doppler ultrasound with respect to cavernous artery occlusion pressure in dynamic infusion cavernosometry when evaluating arteriogenic impotence.

This prospective study was designed to compare the parameters obtained by color Doppler ultrasound to cavernous artery occlusion pressure measured by dynamic pharmacoinfusion cavernosometry in evaluating arterial components of erectile dysfunction. Four indexes were determined as parameters of sonography to indicate arterial competence. Indexes 1 and 2 reflected peak systolic velocities with respect to the cut-off values 25 and 30 cm/s after pharmacological stimulation with 60 mg papaverine hydrochloride respectively. Index 3 was the percentage of diameter changes in cavernosal arteries which was expected to be > 75%. The sum of the percents of increases in diameters of both cavernosal arteries which should be > 200, formed index 4. The sensitivity, specificity, positive predictive value and accuracy rates were 76, 100, 100 and 90% for index 2. These values were 50, 100, 100 and 71% for index 1. Very low statistical values were obtained for indexes 3 and 4. Although the gold standard in the diagnosis of arterial impotence is pharmacoangiography, color Doppler sonography using the parameter peak systolic flow rate > 30 cm/s may be a reliable, easily obtained, noninvasive technique for evaluating arterial components of erectile dysfunction.

Correlation of ultrastructural alterations in cavernous tissue with the clinical diagnosis vasculogenic impotence.

Cavernous tissues of 27 impotent and 4 potent men were evaluated in order to determine the ultrastructural changes in patients with vasculogenic impotence. Tissue samples were obtained during penile prosthesis insertions and surgical repairs of penile fractures in impotent and potent patients, respectively. For the clinical evaluation (pharmacologic color Doppler ultrasound, dynamic pharmacocavernosometry and nocturnal penile tumescence monitoring) patients were divided into three groups: slight/moderate arterial dysfunction (n = 5), severe arterial dysfunction (n = 9) and purely cavernous erectile dysfunction (n = 9). No significant ultrastructural alteration was noticed in the group with moderate arterial dysfunction; decrease and deterioration of smooth muscle cells was the prominent finding in the severe arterial and venogenic dysfunction groups. Preliminary examination of cavernous tissue may be a part of routine evaluations in the approach to the management of erectile dysfunction.

Renal hemodynamics in patients with obstructive uropathy evaluated by color Doppler sonography.

OBJECTIVES: Prior animal studies have shown through direct pressure measurements that there is a definite rise in the renal vascular resistance in obstruction. Therefore intrarenal hemodynamic changes can be determined by the vascular impedance expressed as pulsatility and resistive indexes (PI and RI) obtained from the Doppler waveforms of intrarenal arteries. We investigated whether various degrees of obstruction result in different hemodynamic responses according to color Doppler sonography. METHODS: 22 kidneys with varied degrees of hydronephrosis and 19 normal kidneys were examined. The pulsatility and resistive index of Doppler waveforms from interlobar arteries were obtained. The grade of hydronephrosis was based upon the width of parenchyma. RESULTS: The mean resistive index in the study and controls were 0.70 +/- 0.07 and 0.60 +/- 0.03, respectively. The difference was significant (p < 0.001). Pulsatility indexes in the study and controls were 1.07 +/- 0.34 and 0.98 +/- 0.23, respectively. The difference was not significant (p > 0.005). Significant difference was also noticed in the parenchymal widths between both groups (p < 0.001). CONCLUSION: It appeared that intrarenal color Doppler sonography can provide physiologic information reflecting renal vascular resistance status by means of an easily obtained parameter: resistive index.

Value of color Doppler sonography in the diagnosis of venous impotence.

The gold standard in the diagnosis of venous impotence is cavernosometry. But a less invasive and time-consuming screening test for patients with a high probability of venous impotence is required. Therefore we evaluated 82 men with erectile dysfunction by color Doppler sonography after intracavernosal injection of 60 mg papaverine. 28 of them who had a poor erectile response but sufficient arterial inflow were included in this study. 6 patients who were previously found to have psychogenic impotence formed the control group. After pharmacological stimulation by papaverine, all patients were examined for 20 min by color Doppler sonography in order to detect diastolic flow velocities in the cavernosal arteries and erectile responses. Both groups of patients underwent pharmaco-cavernosometry in a blind fashion afterwards. The diagnosis of venous impotence with color Doppler sonography was confirmed by dynamic pharmaco-cavernosometry in 25 of 28 (89%) and 6 of 6 (100%) subjects of the study and control groups, respectively. Statistically, in the diagnosis of venous dysfunction, color Doppler sonography had a sensitivity of 100%, specificity of 66.6%, accuracy rate of 91% and a positive predictive value of 0.892. The gold standard in the diagnosis of venous impotence is still cavernosometry, but it seems that color Doppler sonography may provide a sensitive assessment of penile venous competence.