A new simple scoring system for prediction of success and complication rates in pediatric percutaneous nephrolithotomy: stone-kidney size score.

INTRODUCTION: Nomograms and scoring systems designed for predicting the success of percutaneous nephrolithotomy (PCNL) in adults are currently available. However, no scoring system currently exists primarily for predicting PCNL success in children. OBJECTIVES: The objective of this study was to develop a scoring system to predict the stone-free and complication rates by using pre-operative parameters. STUDY DESIGN: A retrospective analysis was conducted on data from 434 renal units belonging to patients with kidney stones who underwent PCNL between 1997 and 2017. Renal stone index was calculated by dividing the length of the stone along its longest axis by the length of the kidney along its longest axis. Guy's Stone scores, S.T.O.N.E scores, and CROES scores for adults were calculated by filling in the variables for each patient. Factors that predicted success and complications were examined by univariate and multivariate analyses. RESULTS: Mean age was 8.3 (1-16) years, and male to female ratio was 236:165. When stone-free patients were compared with other patients, there was a statistically significant difference in the average stone/kidney index (SKI) value (stone size/kidney size on longitudinal axis) (0.266 vs 0.339, P < 0.001). In multivariate analysis, factors that predicted success were the SKI and number of stones. A newly developed scoring scale, the stone-kidney score (SKS), combined scores for both the SKI and the number of stones into one value. A minimum total SKS score was 2, and a maximum total SKS score was 4. Success rates for SKS scores of 2, 3, and 4 were 86.4%, 73%, and 62.9% (P < 0.001), respectively. Complication rates for SKS scores of 2, 3, and 4 were 13%, 22.1%, and 23.8%, respectively. DISCUSSION: The new scoring system has only two variables (number of stones and SKI) and three risk groups. An SKS score is easier to use and calculate. An SKI value can be simply calculated on any imaging modality by dividing the length of the stone along its longest axis by the length of the kidney along its longest axis. As in the new scoring system, the SKI value combined with the number of stones is useful in predicting stone-free rates after PCNL. CONCLUSION: When evaluated together, the SKI and presence of multiple stones may predict stone-free rates pre-operatively. The SKS is an individual-specific method that can be easily used in pediatric clinical practice. Further studies are required to develop and standardize this method.

Memantine induces apoptosis and inhibits cell cycle progression in LNCaP prostate cancer cells.

Deregulated cancer cell metabolism plays an important role in cancer progression. Cancer cell metabolism has been in the centre of attention in therapeutical cancer cell targeting. Repurposed chemical agents, such as metformin and aspirin, have been studied extensively as preventive and therapeutic agents. Metformin is Food and Drug administration (FDA)-approved antidiabetic drug cheaper than other chemotherapeutic agents that were shown to have anticancer effects. Memantine is an FDA-approved Alzheimer's drug. Drug repositioning studies offer wide range of benefits, such as reduced time, cost and risk over de novo drug discovery. Therefore, we aimed to target glucose and glutamine metabolism in androgen-dependent LNCaP cells by using metformin and memantine and investigate these agents' effects on prostate cancer cell proliferation in vitro. We evaluated the effects of metformin and memantine on the protein expression levels of genes that play significant roles in apoptosis and cell cycle progression (Casp3, Casp9, Bcl-2, Survivin, Bax, c-Myc, HIF1A, CCND1, CDK4 and GAPDH) by Western blotting. Alzheimer's drug memantine exerted cytotoxic effects at 0.25 mM and metformin at 2.5 mM. We identified for the first time that memantine exerts antineoplastic activity (0.25 mM) by triggering Bax-dependent pathway of apoptosis. In addition to that both molecules have shown similar patterns on pro- and anti-apoptotic protein expression levels, such as Bcl-2, Casp3, Survivin and Bax. Our preclinic results indicate that memantine might be used as a new repositioned drug in cancer treatment. Beyond targeting glucose metabolism, glutamine metabolism also holds great promise for a potential treatment option.

Association between methylenetetrahydrofolate reductase (MTHFR) gene promoter hypermethylation and the risk of idiopathic male infertility.

Epigenetics has become a major field of reproductive medicine after the epigenetic regulation of gene expression was discovered. The aim of this study was to find out whether or not methylenetetrahydrofolate reductase (MTHFR) gene promoter hypermethylation in the spermatozoa of men who were offered assisted reproduction is associated with idiopathic male infertility. Sperm DNAs from 40 idiopathic infertile men with normozoospermia and 40 controls consisting of healthy fertile men were isolated. Following the modification of DNAs by sodium bisulphite, the methylation status of the MTHFR gene promoter was quantified by pyrosequencing. No significant differences were observed between the clinical characteristics of patients and controls. The percentage of MTHFR promoter methylation in infertile men with normozoospermia (11%) was significantly higher than that in the healthy control (4.3%) group (p = .01). A 9.5% of methylation level was determined via receiver operator characteristic (ROC) analysis as the cut-off value. There were 21 (53%) hypermethylated men among the infertile men and 2 (5%) in the control group (p = .0001). The intragroup analysis of the infertile group did not reveal any statistically significant differences in terms of overall clinical characteristics between hyper- and normo-methylated infertile men. Our results suggest that epigenetic silencing (hypermethylation) of MTHFR could result in an elevated risk of male infertility.

Percutaneous Nephrolithotomy in Children: 17 Years of Experience.

PURPOSE: We analyzed factors that might affect outcome in terms of success and incidence of complications in children up to 17 years after undergoing percutaneous nephrolithotomy. MATERIALS AND METHODS: The data of 346 renal units (294 patients) were analyzed in terms of postoperative outcome. Factors investigated that might affect outcome were patient gender, age, stone laterality, largest stone size, stone burden, number of stones, location of a single stone, previous intervention and instrument size. RESULTS: Mean ± SD patient age was 8.51 ± 4.91 years, and male-to-female ratio was 209:137. Mean ± SD stone burden was 3.49 ± 3.3 cm(2). Stone-free rates after a single procedure were 84.4% and 73.1% in patients with and without clinically insignificant residual stones, respectively. On univariate and multivariate analyses stone burden and number of stones affected the stone-free rate. Complications consisted of bleeding in 41 patients (11.8%), postoperative urinary tract infection in 21 (6%), urosepsis in 4 (0.1%) and hydrothorax in 4 (0.1%). One patient died of multiple organ failure. Through the years blood transfusion and complication rates decreased, and the use of smaller instruments increased significantly. Although bleeding occurred less often in cases where a 14Fr sheath was used rather than a larger sheath (5% vs 12%, p = 0.142), the difference was not significant. No significant factor affecting complication rates was detected. CONCLUSIONS: As in adults, percutaneous nephrolithotomy can be used in children with acceptable complication rates and good success rates for surgical treatment of complex renal stones. Number of stones and stone burden are predictive of postoperative stone-free rate.

Is localized prostate cancer an obstacle for an immediate consideration for renal transplantation? A case report.

Currently, renal failure patients with a history of prostate cancer are recommended to have a 2 to 5-year disease-free interval prior to being allowed to receive a kidney transplant. This disease is now amenable to curative therapy if diagnosed at an early stage when the tumor is organ-confined. We report a patient undergoing immediate renal transplantation following a laparoscopic radical prostatectomy for the treatment of prostate cancer. Candidates for renal transplantation who are diagnosed with early stage, organ-confined prostate cancer may be immediately considered for transplantation following radical prostatectomy in view of the high likelihood of cure of their prostate cancer.

Laser-assisted fluoroscopic puncture: a new technique for accessing the kidney.

PURPOSE: We developed a laser pointer device that is mounted on the image intensifier of a C-arm fluoroscope. The laser-assisted fluoroscopic puncture technique (LAFPT) is an alternative method of accessing the kidney. MATERIALS AND METHODS: The LAFPT was assessed both in an in vitro model and in a series of cases. The in vitro model was composed of Foley balloons filled with contrast medium of different volumes (2-6 mL) embedded in silicone pads. The total fluoroscopy times and attempts required for a successful puncture with LAFPT were compared with those of conventional fluoroscopic access. RESULTS: The number of attempts required to puncture the 2-mL balloons was significantly greater with the conventional fluoroscopic technique than with LAFPT. The fluoroscopy time in vitro was reduced 50% with LAFPT. However, there was no statistically significant difference in the time required for the two techniques in the clinical series. CONCLUSION: The laser-assisted fluoroscopic puncture technique allows accurate positioning of a needle with reduced radiation exposure.

Intratesticular varicocele treated with percutaneous embolization.

Intratesticular varicocele is an extremely rare and a relatively new clinical entity. A 22-year-old man was admitted to our hospital with left testicular pain. On physical examination, a grade III varicocele was noted on the left side, and the testis was soft as well. Gray-scale ultrasound and color Doppler ultrasound examinations revealed intratesticular and extratesticular varicocele. Testicular venography failed to demonstrate the testicular vein. Percutaneous embolization was performed through direct puncture to the dilated veins. Percutaneous embolization under local anesthesia is an alternative treatment to other techniques.

Is scrotal violation per se a risk factor for local relapse and metastases in stage I nonseminomatous testicular cancer?

OBJECTIVES: To determine the risk of local recurrence and relapse in patients with Stage I nonseminomatous testicular cancer with scrotal violation. METHODS: From 1983 to 1998, 75 patients with clinical Stage I nonseminomatous testicular cancer who were initially treated with orchiectomy and surveillance alone were retrospectively reviewed. RESULTS: Of 75 patients with Stage I nonseminomatous testicular cancer, 13 had scrotal violation. The surgical margins and the spermatic cords were free of tumor in all patients. Five patients (38%) in the scrotal violation group and 17 patients (27%) in the inguinal orchiectomy group experienced relapses. The difference was not significant (P = 0.41). Local recurrence was not observed in either group. All relapses, except one in the standard inguinal orchiectomy group, were treated successfully with chemotherapy and postchemotherapy surgery, if needed. The progression rate and survival were not significantly different between the two groups. CONCLUSIONS: Scrotal violation without positive surgical margins and tumor spillage does not adversely affect relapse rate and survival. Therefore, scrotal violation per se is not an exclusion criterion for the surveillance-only policy in patients with Stage I nonseminomatous testicular germ cell cancer.

Clinical experience with BCG alone versus BCG plus epirubicin.

BACKGROUND: Bacillus Calmette-Guérin (BCG) and epirubicin have both been shown to be effective in the treatment of superficial bladder cancer. We studied whether the alternating combination of these agents could improve the efficacy with tolerable side-effects in the treatment of high-risk superficial bladder tumors. METHODS: Forty-one patients with high-risk superficial bladder transitional carcinoma were included in this study. Twenty-one patients were randomized into the BCG group and 20 patients were treated with sequential BCG and epirubicin. The patients were followed for 9-24 months (mean 18 months). Recurrence rates, median time to the first recurrence, progression rate and complications were compared. RESULTS: Fifteen percent of the patients in the BCG and epirubicin group and 19% of the patients in the BCG alone group developed tumor recurrence. Tumor progression was observed in 4.7% and 10% in the BCG/epirubicin group and the BCG alone group, respectively. Median time to first recurrence was 11 months for the BCG/epirubicin group and 16 months for the BCG group (P > 0.05). Three patients in the BCG/epirubicin treatment group developed serious side-effects, which necessitated antituberculosis treatment. CONCLUSION: Because the efficacy of combination was no better than the standard treatment and the alternating combination seemed to be related to a higher incidence of side-effects, this study albeit small, does not recommend combination therapy of BCG and epirubicin in high risk patients with superficial bladder cancer.

Human papillomavirus associated with bladder carcinoma? Analysis by polymerase chain reaction.

BACKGROUND: The aim of the present study was to assess the possible etiologic role of human papillomaviruses (HPV) in bladder tumors. METHODS: Forty-two fresh biopsy specimens from different grades and stages of bladder tumor cases and 10 normal bladder mucosa biopsies were studied. Specimens were analyzed by polymerase chain reaction (PCR) with HPV-specific general primer set for the detection of viral DNA. Polymerase chain reaction-positive samples were also tested with HPV 16- and 18-specific primers by the same method. RESULTS: We found two samples (4.8%) containing HPV DNA among the TaG1 bladder tumors. All other specimens, including the control group, were found to be negative by PCR. Neither of the two HPV-positive patients had immune deficiency and/or genital wars. Human papillomavirus 16 was detected by type-specific primers in one sample, but the other HPV-positive sample could not be typed. CONCLUSIONS: The low prevalence of HPV in this and many previous studies does not support an etiologic role of HPV in bladder carcinogenesis. We detected the virus in two early stage tumors, but none was detected in the high-grade samples. However, to clarify the positivity of HPV in these occasional cases, future studies must be designed by using in situ PCR techniques, including samples from tumors and normal bladder mucosa from the same patient.

The management of brain metastasis in nonseminomatous germ cell tumours.

OBJECTIVE: To review our experience of patients with brain metastases from nonseminomatous germ cell tumours (NSGCTs) and to indicate important clinical observations. PATIENTS AND METHODS: Between 1990 and 1996, 167 patients with metastatic NSGCT were treated in our department; 11 had brain metastases (eight with solitary metastases and three with multiple lesions, mean age 27 years, range 18-41). These patients were treated initially with either; cisplatin, bleomycin, etoposide and/or cisplatin, vincristin, methotrexate, bleomycin, actinomycin-D, cyclophosphamide, etoposide and intrathecal methotrexate chemotherapy protocols. Six patients received chemotherapy alone, one had chemotherapy plus radiotherapy and four had all three treatments. Patients with brain metastases were classified according to mode of presentation, and their treatments and outcomes analysed. RESULTS: Ten patients presented with symptoms related to intracranial lesions, e.g. intractable headache, seizures, severe vomiting, hallucinations and hemiparesis. All patients with brain metastasis had bulky thoracic disease. The incidence of clinical brain metastases in patients with advanced thoracic disease was 32% (11/34). Four patients with brain metastases at presentation were alive after 3, 12, 34 and 47 months. The only patient with isolated brain relapse died within 7 months, despite combined treatment. Two of the five patients who developed brain metastases during the course of the disease are alive with no evidence of disease at 3 and 6 months after salvage chemotherapy. CONCLUSION: Patients with single brain metastasis seem to have a better prognosis in the present than in other reported series. Chemotherapy was used initially, followed by surgery and radiotherapy in those who did not achieve complete remission with chemotherapy. Patients with progressive disease and multiple brain metastasis do not seem to benefit from initial surgical resection. Importantly, a significant proportion (32%) of patients with bulky lung metastases had or subsequently developed brain metastases. Thus it is suggested that routine cranial imaging should be performed in patients with bulky thoracic disease.

Multicentricity in renal cell carcinoma.

OBJECTIVE: To find the incidence of multicentric renal cell carcinoma and its possible relationship to the other clinical and pathologic findings. METHODS: A total of 40 patients with renal cell carcinoma underwent radical nephrectomy between March 1994 and January 1996 at Hacettepe University, School of Medicine, Department of Urology. All of the materials were examined grossly and histologically by the same pathologist. RESULTS: Among 40 kidneys 4 had satellite carcinoma (10%), 3 of them had been shown by preoperative imaging techniques, 1 was found histopathologically. CONCLUSION: If preoperative imaging techniques do not show additional lesion in the kidney besides the small early stage primary in incidentally discovered patients, the incidence of satellite renal cell carcinoma is low enough to justify nephron sparing surgery.

Nonoliguric renal failure after transurethral resection of prostate.

PURPOSE: To define the relation of nonoliguric renal failure to transurethral resection of the prostate (TURP), its clinical importance, and predictive factors. PATIENTS AND METHODS: The files of 439 patients who had undergone TURP at Hacettepe University School of Medicine, Department of Urology, between January 1991 and 1994 were analyzed. The patients were divided into three groups according to postoperative serum creatinine concentration and the presence of clinical signs and symptoms of TUR syndrome (Group I: patients with preoperative and postoperative creatinine in the normal range; Group II: patients suffering nonoliguric renal failure; and Group III: patients with TUR syndrome). The data of the groups were compared in terms of factors influencing nonoliguric renal failure. RESULTS: The mean postoperative concentrations of sodium, blood urea nitrogen, creatinine, and albumin in Groups II and III were statistically different from those in Group I (P < 0.001). There was a moderate relation between hyponatremia and the occurrence of nonoliguric renal failure (r(s) = -0.56). Capsule perforation increased the risk of nonoliguric renal failure 10.6 fold. All of the patients were managed by a conservative approach, and none of the patients died or progressed to end-stage renal disease. They were all discharged with a mean hospitalization period of 7 days and normal renal function tests. CONCLUSION: Nonoliguric renal failure was thought to be an early step in the pathophysiology of TUR syndrome with acute renal failure. It is an asymptomatic clinical picture that is undiagnosed unless laboratory examinations are performed. A conservative therapeutic approach is enough.

Occupational risk of hepatitis B and C infections in urologists.

The purpose of this study is to evaluate the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and the related risk factors among urologic surgery patients and urologists. This cross-sectional, prospective study included 300 consecutive urologic surgery patients and 24 urologists working in our department. The patients and urologists with positive serology for any of the hepatitis viruses were questioned for risk factors including previous transfusions, surgery, endoscopy, intravenous drug abuse and homosexuality. Positive serology for HBV and/or HCV was found in 47.4% of the patients, and the rate of the patients with antigenemia, the major risk group for the urology team, was 9.9%. Of the 24 urologists working in our department, 3 were antibody to HCV (anti-HCV) positive and 2 were hepatitis B surface antigen (HBsAg) positive. The presence of a risk factor among patients with HBsAg was found in 78.9% and in 100% of those with anti-HCV. The prevalence of hepatitis in urologic surgery patients and urologists is poorly described. This study indicates a high prevalence of HBV and HCV seropositivity in urology patients. In urology wards, the risk of hepatitis transmission is estimated to be appreciably high because of the renal transplantation procedure and frequent use of blood and blood-contaminated solutions for transurethral resections or catheter irrigations. Vaccination with HBV vaccine and application of universal precautions during daily practice seem to be the only and most effective means of protection against blood-borne infections.

Ureteroscopic management of lower ureteral stones: two years' experience.

A total of 140 ureteroscopies in 119 patients done between January 1992 and December 1994 at the Department of Urology, Hacettepe University Hospital, were reviewed. Factors such as previous ESWL therapy, previous surgery and use of in situ lithotripsy were noted. Success was defined as complete removal or disintegration and partial removal of the lower ureteral stones. All successes were confirmed by plain abdominal X-rays postoperatively. Of 140 stone manipulations attempted in 119 patients 106 (75.7%) were successful (in 80 by retrieval and in 26 by disintegration using electrohydraulic or laser). Perforation occurred in 4 of 13 cases where electrohydraulic lithotripsy was used for disintegration of stones. Extraction by ureteroscopic manipulation following extracorporeal shock wave lithotripsy (ESWL) was successful in all of the 12 cases of lower ureteral calculi. The success rate was found to be low for lower ureteral stones in patients with previous open surgery (2/9). A total of 43.2% of the patients were medically indicated to be hospitalized following the procedure with a mean hospitalization time of 5 days (ranging in between 1 to 7 days). Ureteroscopy is an effective method for management of lower ureteral stones. Use of the electrohydraulic lithotriptor may be associated with a high percentage of complications. Previous ESWL may be associated with a high rate of success. Results in patients with previous open surgery are not encouraging. Although all patients can be subjected to the procedure on an outpatient basis, a significant percentage need a short hospitalization.