Reasons for early readmission after percutaneous nephrolithotomy and retrograde intrarenal surgery.

INTRODUCTION: Hospital readmissions are frequent and costly. In many countries health governors focus on unplanned postsurgical hospital readmissions as an objective metric for quality of care. AIM: To investigate the rate of readmissions after retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) operations, classify these factors, define the higher risk patients for readmission and develop prevention strategies. MATERIAL AND METHODS: A historical cohort study was conducted for a period of 36 months, between 2013 and 2016. A total of 471 consecutive patients, of whom 177 had PCNL (37.6%) and the remaining 294 had RIRS (62.4%), were included. The two groups were compared in terms of stone burden, previous stone treatments, initial symptoms, ASA class, intra-operative complications, post-operative stenting, and drugs prescribed at discharge, so as to find the factors influencing the readmission rate for both groups. RESULTS: The PCNL operation was found to have a significantly higher risk for readmission when compared to RIRS (27.1% vs. 20.4%, respectively, p = 0.0041). Perioperative complications (p = 0.002 for PCNL and p = 0.001 for RIRS), residual stone(s) or fragments after the operation (p = 0.002 for PCNL and p = 0.001 for RIRS) significantly increased the readmission rate in both groups. The readmission rates were individually affected by postoperative JJ stent placement in the PCNL group (p = 0.001) and previous stone treatments for the RIRS group (p = 0.001). CONCLUSIONS: Readmission rates were higher in the PCNL group, but the influencing factors were similar for both groups. The presence of multiple stones preoperatively and residual stones or fragments postoperatively are the most important risk factors for early re-admission after PCNL and RIRS.

Investigation of Copy Number Variation by arrayCGH in Turkish Children and Adolescents Diagnosed with Autism Spectrum Disorders.

AIM: The development of whole-genome screening methodologies for the detection of copy number variations (CNVs), such as array-based comparative genomic hybridization (aCHG), provides a much higher resolution than karyotyping leading to the identification of novel microdeletion and microduplication syndromes often associated with an autism spectrum disease (ASD) phenotype. The aim of the study was to determine CNVs of patients with ASD by using array-based comparative genomic hybridization. METHODS: Fifty-three patients diagnosed with ASD between 20.01.2014 and 14.01.2015 were included in the study. Chromosome analysis of the patients was performed from peripheral blood cultures and analysed as normal. All patients were evaluated with P064C1 and P096A2 MLPA probes in terms of 16 mental retardation related syndromes. For aCGH method, SurePrint G3 Human microarrays 8x60K were used with genomic DNA isolated from peripheral blood. RESULTS: According to results of 53 patients who were included in and performed with arrayCGH, 8 (15%) patients had CNVs classified as pathogenic or variant of unknown significance (VOUS) in the study. We detected a pathogenic NRXN1 gene partial CNV deletion (2p16.3) in two patients. Also we identified a 900 kb duplication of 4p15.31 including SLIT2 gene, and a 245 kb duplication of 15q11.2 including PWRN1 gene in one patient. Our other findings are considered to be a variant of unknown significance (VOUS). CONCLUSION: The results of the study support the literature knowledge, where the copy number variations that cannot be detected with conventional cytogenetics methods in terms of size may happen in patients with ASD.

A giant case of pyonephrosis resulting from nephrolithiasis.

Pyonephrosis is an uncommon disease that is associated with suppurative destruction of the renal parenchyma in adults. Upper urinary tract infection and obstruction play a role in its etiology. Immunosuppression from medications (steroids), diseases (diabetes mellitus, AIDS), and anatomic variations (pelvic kidney, horseshoe kidney) may also be risk factors for pyonephrosis. Fever, shivering, and flank pain are frequent clinical symptoms. On physical examination, a palpable abdominal mass may be associated with the hydronephrotic kidney. Septic shock and death can occur if the disorder is not treated with urgent surgery. After the acute phase, most patients are treated with nephrectomy. In this paper, we share the etiology, clinical features, diagnosis and treatment of pyonephrosis using the background of a case with giant pyonephrosis developing due to a kidney stone, the most common cause of upper urinary tract obstruction.

Single vs. double dartos interposition flaps in preventing urethrocutaneous fistula after tubularized incised plate urethroplasty in primary distal hypospadias: a prospective randomized study.

INTRODUCTION: This prospective study was designed to compare symmetrical overlapping double flaps with a single dartos flap in regard to fistula formation as an adjunct to tubularized incised plate urethroplasty (TIPU). PATIENTS AND METHODS: 77 consecutive children with primary coronal or subcoronal hypospadias were randomized into 2 groups. A single layer dartos flap was used to cover the anastomotic site in the first group (37 patients). A wider dorsal dartos flap bisectioned in the midline was utilized in the second group of 40 patients. The complication rates were compared. RESULTS: There was no difference between the 2 groups in terms of age, and meatal location. Postoperative median follow-up was 34 months. Urethrocutaneous fistula occurred in 3 patients (8.1%) of the monolayer group. No fistula developed in the second group with double flaps. CONCLUSIONS: The current study proposes that the use of double dorsal flaps, although statistically not significant, better prevents fistula formation compared to monolayer dartos flaps following TIPU operation.

Prospective evaluation of the efficacy of antibiotic prophylaxis before cystoscopy.

BACKGROUND: The aim of this study was to prospectively compare single-dose intravenous antibiotic prophylaxis vs. no prophylaxis before minor cystoscopic procedures, including punch biopsy and transurethral resection (TUR) of small bladder tumors. MATERIALS AND METHODS: A total of 200 patients with a mean age of 47.3 years old (range: 19-84 years old) with initial negative urine cultures were recruited. All patients underwent a diagnostic cystoscopy. Patients were then randomized into 2 groups: One group that did not receive antibiotics (100 patients) and the other group that received antibiotic treatment (100 patients with a single intravenous dose of cefoperazone). All patients had urine analysis and urine cultures on the second day after the operation. Additionally, clinical parameters including fever and dysuria were recorded. In 15% of the patients, incidental additional interventions such as punch biopsy or TUR of a small bladder tumor that were similarly distributed in both groups were performed. RESULTS: In 1 patient from the antibiotic group and 2 patients from the no prophylaxis group, the urine cultures after cystoscopy were positive. No statistically significant difference was observed between these groups based on the microbiological and clinical parameters. CONCLUSION: The current study provides evidence that no antibiotic prophylaxis is required before diagnostic cystoscopy in patients without bacteriuria. But, the absolute risk of infection was small, suggesting that a much larger study is required.

High power diode laser vaporization of the prostate: preliminary results for benign prostatic hyperplasia.

PURPOSE: Vaporization techniques using lasers have gained wide acceptance for benign prostatic hyperplasia as an alternative to transurethral prostate resection. The high power, 980 nm wavelength diode laser is a new promising alternative with a more rapid ablation rate and excellent hemostatic properties, as shown in ex vivo and in vivo animal models. We prospectively evaluated vaporization efficiency of the high power, 980 nm diode laser for bladder outlet obstruction due to benign prostatic hyperplasia. MATERIALS AND METHODS: A total of 47 consecutive patients were included in the study. Inclusion criteria were maximal flow rate 12 ml per second or less with voided volume 150 ml or greater, International Prostate Symptom Score 12 or greater and quality of life score 3 or greater. Patients with a history of neurogenic voiding dysfunction, chronic prostatitis, or prostate or bladder cancer were excluded from analysis. Preoperative maximal flow rate, post-void residual urine, International Prostate Symptom Score, quality of life, International Index of Erectile Function-5, prostate specific antigen and prostate volume were compared with values at 3 and 6 months. Complications were assessed. RESULTS: Month 3 assessment revealed that the mean +/- SD International Prostate Symptom Score decreased significantly from 21.93 +/- 4.88 to 10.31 +/- 3.79 (p = 0.0001). The mean maximal flow rate increased significantly from 8.87 +/- 2.18 to 17.51 +/- 4.09 ml per second (p = 0.0001). Quality of life score changed considerably compared to baseline. All of these values showed slight improvement at month 6. There was no deterioration in erectile function according to the International Index of Erectile Function-5 short form. Post-void residual urine decreased significantly. Prostate volume and prostate specific antigen reductions were also significant. The most common postoperative complications were retrograde ejaculation (13 of 41 patients or 31.7%) and irritative symptoms (11 of 47 or 23.4%), which subsided in the maximal flow rate at 2 weeks. Recatheterization was necessary in 2 patients due to urinary retention after catheter removal. Two patients had temporary combined urge and stress incontinence for 2 weeks. Late bleeding in 1 patient 4 weeks postoperatively necessitated catheterization and irrigation. CONCLUSIONS: The high power diode laser provided significant improvements in International Prostate Symptom Score and the maximal flow rate with low morbidity. Thus, these results of prostate vaporization with the high power diode laser, representing what is to our knowledge the first clinical study in the literature, are encouraging.

Prospective assessment of the efficacy of single dose versus traditional 3-day antimicrobial prophylaxis in 12-core transrectal prostate biopsy.

OBJECTIVES: To prospectively evaluate the efficacy of single dose antibiotic prophylaxis in 12-core transrectal ultrasonography (TRUS) guided prostate biopsy. METHODS: A total of 400 patients who underwent prostate biopsy with TRUS guidance were included. The patients were prospectively randomized in three groups regarding antibiotic prophylaxis. The first group (139 patients) received a single gram of intramuscular ceftriaxone, while the second group (131 patients) had a 3-day course of oral ciprofloxacin. The third group (130 patients) had single oral 500 mg of ciprofloxacin. All patients had urine cultures prior to biopsy and on the second day after biopsy. RESULTS: The study groups were compared in terms of the results of urine cultures and clinical parameters. Overall, only seven patients (1.8% of the cases) had positive urine cultures with no difference between these three groups. Additionally, no significant difference was observed regarding morbidity rates in all groups. Only eight patients (2%) developed major complications requiring hospitalization. There was no increase in the rate of infectious complications when the biopsy core numbers were increased up to 12. CONCLUSIONS: The current study suggests that a single oral dose of antimicrobial prophylaxis is reasonable in TRUS prostate biopsy even in the case of 12-core sampling.

Combined periprostatic and intraprostatic local anesthesia for prostate biopsy: a double-blind, placebo controlled, randomized trial.

PURPOSE: Transrectal ultrasonography guided prostate biopsy is the principle procedure in the histological diagnosis of prostate cancer. Recently a trend toward increasing the number of cores has been popularized. This practice further increases the need for a proper anesthetic application. However, there is no consensus on a standard local anesthetic strategy, while groups at most institutions currently prefer periprostatic anesthesia. We prospectively evaluated the contribution of intraprostatic anesthesia for transrectal prostate biopsies even when the sampling number was doubled to 12 cores. MATERIALS AND METHODS: A total of 200 patients who underwent prostate biopsy with transrectal ultrasound guidance were included. The 2 groups received the usual periprostatic anesthesia. Consequently patients were prospectively randomized into 2 groups. Group 1 received additional intraprostatic lidocaine injection, while group 2 received the same amount of injection of 0.9% NaCl. The efficiency of applied local anesthesia was assessed by a visual analog pain scale. RESULTS: The study groups were comparable regarding patient age, prostate size and cancer rate. Pain scores revealed that the combination of intraprostatic and periprostatic local anesthesia provided significantly better pain control than periprostatic infiltration alone. No difference was observed regarding the morbidity rate in the 2 groups. CONCLUSIONS: The current study suggested that adding intraprostatic local anesthesia provides a significantly efficient strategy during transrectal ultrasound prostate biopsy, even in cases of 12-core sampling. Subsequent trials are needed to establish a standard analgesia policy for prostate biopsy.

Isolated congenital urethrocutaneous fistula.

Congenital urethrocutaneous fistula of the male urethra is an extremely rare anomaly that is commonly seen in association with anorectal malformations or chordee. A case of congenital urethrocutaneous fistula not associated with other congenital anomalies is reported, discussing possible etiologies and surgical management.

Short-term subjective efficacy of doxazosin in predicting probability of prostatectomy in the management of benign prostatic hyperplasia in patients with severe symptoms.

BACKGROUND: The severity of symptoms still constitutes the major indication for transurethral prostatectomy, despite the extensive utilization of medical treatments. The aim of the study presented here was to investigate the impact of doxazosin on symptoms in relation to the probability of consequent surgery in severely symptomatic patients. METHODS: Patients with an International Prostate Symptom Score (IPSS) between 18 and 35 were included in the study. The patients received 4 mg/day doxazosin, and subjective efficacy was assessed by IPSS at the first and third months. In addition, the patients were classified at the third month according to a single question regarding satisfaction with medical treatment in terms of symptom relief as 'ineffective, no change, and effective'. RESULTS: A total of 178 patients constituted the study group. Mean total symptom scores were 24, 19 and 17 at baseline, first and third months, respectively (P < 0.05). According to results of the questionnaire, 23% of the patients claimed the treatment was ineffective, and subsequently, the majority of this group (93%) underwent prostatectomy in a year. In addition, 33% of the patients reported no change in their symptoms, while 44% reported that the medication was effective. However, after 1 year, 59% and 15% of these cases underwent surgical treatment, respectively. The probability of surgery in the 'ineffective' group was significantly higher compared to the remaining groups (P < 0.05). CONCLUSION: The majority of patients with severe symptoms who were not satisfied with the medication at the 3rd month underwent surgery. This observation may provide a predictor for subsequent probability of prostatectomy. Therefore, reassessment of patients would be a cost-effective approach for the treatment of BPH in severely symptomatic patients.

Is midazolam effective as an antioxidant in preventing reperfusion injury in rat kidney?

This experimental study was designed to investigate whether midazolam has antioxidant effects in reperfused rat kidneys following ischemia. Twenty Wistar Albino rats were included in the study. Rats were anesthetized with the mixture of ketamine 90 mg/kg and xylazine 10 mg/kg administered intraperitoneally. Following anesthesia, the rats were divided into two groups. The first group was considered as the control group, whereas the second group received additional midazolam 3.5 mg/kg intraperitoneally. The left kidney was approached via a transabdominal incision and the left renal artery was dissected. Left renal ischemia was created by clamping the left renal artery for 45 minutes. Following the ischemia period, the kidney was reperfused for one hour. Both kidneys were then removed. Half of the left kidneys were immediately immersed in liquid nitrogen for transportation and then frozen at -70 C until measurements of tissue malondialdehyde (MDA) and glutathione (GSH) levels. The remaining halves of the left kidneys and right kidneys were fixed in 10% formalin. The changes which developed during the ischemia-reperfusion period in the left kidney were investigated by histopathological examination and compared with those of the normal contralateral kidney. When compared with the control group, tissue MDA and GSH levels were similar in the midazolam group (p > 0.05). Tubular damage with tubulitis and focal interstitial inflammatory infiltration were observed in histopathological examinations of reperfused left kidneys of the control group. There was PMNL infiltration only in perirenal fat tissue of the midazolam group. Right kidneys were histopathologically normal in both groups. We concluded that within this dosage midazolam does not have any antioxidant effect in reperfused rat kidneys following ischemia.