Predictive factors affecting morcellation efficiency in holmium laser enucleation of the prostate.

PURPOSE: To determine the factors affecting morcellation efficiency in holmium laser enucleation of the prostate (HoLEP) surgery. MATERIALS AND METHODS: Patients who underwent HoLEP surgery by a single surgeon between 2018 and 2022 were included in the study. Our primary outcome of interest in this study was morcellation efficiency. The effect of preoperative and perioperative variables on morcellation efficiency was evaluated with linear regression analysis. RESULTS: A total of 410 patients were included in the study. The mean morcellation efficiency was 6.95±1.70 g/min. Univariable and multivariable linear regression analysis was performed to identify factors affecting morcellation efficiency. Presence of the "beach ball" effect (small, round prostatic tissue fragments that are fibrotic and difficult to morcellate), the learning curve, resectoscope sheath type, prostate-specific antigen (PSA) density, morcellated tissue weight, and the presence of prostate calcification were found to be independent predictive factors (ß=-1.107, 95% CI: -1.59 to -0.55, p<0.001; ß=-0.514, 95% CI: -0.85 to -0.17, p=0.003; ß=-0.394, 95% CI: -0.65 to -0.13, p=0.003; ß=-0.302, 95% CI: -0.59 to -0.09, p=0.043; ß=0.062, 95% CI: 0.05 to 0.06, p<0.001; ß=-0.329, 95% CI: -0.55 to -0.10, p=0.004; respectively). CONCLUSIONS: This study reports that presence of the beach ball effect, the learning curve, small resectoscope sheath, PSA density, and presence of prostate calcification negatively affect morcellation efficiency. On the contrary, morcellated tissue weight has a linear relationship with morcellation efficiency.

Comparison of Posterior and Antero-Lateral Renal Tumors in Retroperitoneal Laparoscopic Partial Nephrectomy: A Propensity Score Matching Analysis.

This study aimed to compare the antero-lateral and posterior localized renal masses in laparoscopic partial nephrectomy with the retroperitoneal approach in terms of operative, functional, and oncological outcomes. Patients who underwent retroperitoneal laparoscopic partial nephrectomy by a single surgeon between January 2013 and January 2021 were included in the study. A one-to-one propensity score matching (PSM) analysis was conducted to obtain two balanced groups. The patients were divided into two groups as posterior and antero-lateral according to the localization of the mass. A total of 239 patients were included in the PSM analysis, with 65 patients allocated to each group. The mean operative time was 79.2 ± 11.2 min in the posterior group, while it was 90.0 ± 11.6 min in the antero-lateral group (P < 0.001). Warm ischemia time was 15.9 ± 2.4 min in the posterior group and 18.6 ± 2.7 min in the antero-lateral group (P < 0.001). The median decrease in eGFR at 1 year was 4.8 (IQR, 2.9-6.9) mL/min in the posterior group and 5.0 (IQR, 2.8-11) mL/min in the antero-lateral group (P = 0.219). The warm ischemia time and clamping technique were found to be significant factors for predicting eGFR change after surgery (ß:0.693, 95% CI: 0.39-0.99, P < 0.001; ß:6.43, 95% CI: 1.1-11.7, P = 0.017, respectively). We report that retroperitoneal laparoscopic partial nephrectomy provided longer warm -ischemia and operative time for antero-lateral renal masses than posterior masses. However, long-term oncological and functional results were similar for both localizations.

Bladder calculi concomitant with benign prostatic enlargement: is prostate surgery mandatory in patients who have never received medical therapy?

The historical dogma that bladder calculi comprise the main indication for prostatic surgery has recently been questioned. In this study, we aimed to predict which patients should undergo simultaneous prostate and bladder calculi surgery or only bladder calculi removal by evaluating preoperative risk factors. One hundred and seventeen men with bladder stones and concomitant benign prostate enlargement (BPE) who had not received medical treatment before were included in the study. In the first step, only the bladder calculi of patients were removed and medical treatment was given for BPE. The patients who benefited from medical treatment during the follow-up were defined as Group 1 and the patients who required prostate surgery for any indication comprised Group 2. Risk factors for prostate surgery requirements were determined by comparing preoperative characteristics between the two groups with a cox regression model. In the follow-up of 117 patients with bladder stones removed and medical treatment initiated, 49 (41.9%) patients had prostate surgery indications. The indication for 33 (67.3%) of 49 patients was medical treatment failure. The presence of intravesical prostatic protrusion (IPP; hazard ratio: 2.071, 95% confidence interval [CI]: 1.05-4.05, P = 0.034), and high postvoiding residual urine volume (hazard ratio: 1.013, 95% CI: 1.007-1.019, P < 0.001) were found to be preoperative risk factors for needing future prostate surgery. In patients who have not received medical treatment for BPE before, bladder calculi developing secondary to BPE do not always constitute an indication for prostate surgery.

The Results of Peritoneal Re-Approximation Methods on Symptomatic Lymphocele Formation in Robot-Assisted Laparoscopic Radical Prostatectomy and Extended Pelvic Lymphadenectomy.

INTRODUCTION: To evlauate role of peritoneal re-approximation methods in the prevention of symphtomatic lymphocele formation in patients underwent transperitoneal robot-assisted laparoscopic prostatectomy (tRALP) and extendeded pelvic lympadenoctomy (ePLND). MATERIALS AND METHODS: Between January 2016 and April 2020, 120 consecutive patients who were administered anterior t-RALP and ePLND were analyzed retrospectively. In group 1 (n = 40), peritoneal approximation was not performed after t-RALP and ePLND application, peritoneal half re-approximation was performed in group 2 (n=40), and peritoneal full re-approximation was performed in group 3 (n=40). Operative parameters and symptomatic lymphocele rates were compared between the groups. RESULTS: There was no statistically significant difference between the groups in terms of mean age, body mass index and prostatespecific antigen levels, Gleason score on biopsy, D'amico risk groups, the mean number of lymph nodes removed, Clavien-Dindo complication grade and mean duration of the surgery. Patients with symptomatic lymphocele in Group 1, Group 2, and Group 3 were found to be 2 (5%), 3 (7.5%) and 5 (12.5%), respectively. There was no statistically significant difference between the groups in terms of symptomatic lymphocele formation. CONCLUSION: Half or full closure of the peritoneum does not affect the symptomatic lymphocele formation in patients who underwent tRALP and ePLND.

Comparison of Percutaneous Nephrostomy and Ureteral DJ Stent in Patients with Obstructive Pyelonephritis: A Retrospective Cohort Study.

PURPOSE: Comparing the two different drainage methods of percutaneous nephrostomy (PCN) versus retrograde ureteral double - J (DJ) stent insertion in patients with obstructive pyelonephritis cases. MATERIAL AND METHODS: In this retrospective study, patients with obstructive pyelonephritis secondary to urolithiasis who underwent PCN or DJ insertion were included in the study. Patients were divided into two groups according to drainage method. After exclusion criteria, the study included 105 patients. The groups were compared for intraoperative outcomes, duration of fluoroscopy usage, the time needed for normalization of infection parameters (white blood cells (WBC), C - reactive protein (CRP), procalcitonin), and complications were observed. RESULTS: From 105 patients, 56 patients were in DJ stent group and 49 patients were in PCN group. According to intraoperative data, operative time and fluoroscopy duration were significantly shorter in the DJ ureteral stent group (P < .001). WBC returned to normal range in mean 3.5 ± 1.3 days in the DJ stent group and 3.2 ± 1.1 days in the PCN group (95% CI: -0.76-0.21, P = .268). There were no statistically significant differences identified for the duration for CRP, PCT and fever to return to normal range between the drainage methods. The complication rates was 51.8% for DJ stent group and, 30.6% in PCN group (P = .028). CONCLUSION: Both methods are effective and safe in obstructive pyelonephritis. Despite the higher complication rate in DJ stent group, these complications were minor.

Comparison of three different modalities for the treatment of bladder calculi by size.

PURPOSE: Treatment recommendations for kidney or ureteral stones are based on stone size; however, this is uncertain for bladder stones. This study aims to determine the best approach to bladder stones based on their size. MATERIALS AND METHODS: We retrospectively analyzed 401 patients with bladder stones. Patients were divided into three different groups according to stone size (11-20 mm, 21-30 mm, 31-40 mm as groups 1, 2, and 3 respectively). Patients had transurethral cystolithotripsy (TUCL), percutaneous cystolithotripsy (PCCL), and open cystolithotomy (OCL) performed. RESULTS: Stone fragments were removed completely in all patients. When catheter time, postoperative stay, and hematocrit decrease values were compared, the results were significantly higher for OCL in all three groups (p: 0.001). When the relationship between stone sizes and operation time is evaluated, TUCL had shorter operation times (34.1 ± 10.6 min) in group 1. However, TUCL had longer operation times in group 2 and group 3 compared to OCL and PCCL. CONCLUSION: TUCL may be preferable due to better postoperative outcomes and shorter operative time for ⩽2 cm stones. As the stone size increases, PCCL is more favorable in terms of operation time.

Does transition from standard to Retzius-sparing technique in robot-assisted radical prostatectomy affect the functional and oncological outcomes?

OBJECTIVE: To appraise the outcomes on the Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) learning curve of a surgeon with previous experience of anterior (standard) RARP. MATERIALS AND METHODS: The first 50 cases during the Rs-RARP learning curve (group 1) and 50 cases after the second 100 cases with the standard approach (group 2) were comprised in the study. Patients who used zero or one safety pads were considered continent. Erectile function recuperation was characterized as the competence to achieve penetrative intercourse without receiving any medication. All patients were reevaluated at two weeks, first, third, sixth, and 12th months after surgery using IIEF-5, PSA level, and continence status. RESULTS: Immediate continence rates following catheter removal were 32/50 (64%) in Rs-RARP group and 26/50 (52%) in S-RARP group (p = 0.224). The continence recovery rate was 48/50 (96%) in Rs-RARP group and 46/50 (92%) in the S-RARP group at 12 months follow-up (p = 0.400). Total nerve-sparing surgery was enforced in 36/50 (72%) patients for group 1 and 35/50 (70%) patients for group 2. Potency recovery was 27/43 (62.8%) in Rs-RARP and 30/44 (68.2%) for S-RARP at 12 months follow up (p = 0.597). Surgical margin positivity was detected in 6/50 (12%) cases in the Rs-RARP group and in 4/50 (8%) cases in the S-RARP (p = 0.444). CONCLUSIONS: Functional and oncological results are not negatively affected in the first 50 cases for a surgeon who is experienced in S-RARP before transition to the Rs-RARP method.

Predicting Strict Trifecta Outcomes after Robot-Assisted Partial Nephrectomy: Comparison of RENAL, PADUA, and C-Index Scores.

Nephrometry scores are designed to characterize tumors and stratify the surgical complexity. It remains unclear as to which nephrometry score can accurately predict the surgical outcomes. We aimed to assess the utility of radius, exophytic/endophytic, nearness, anterior/posterior, location (RENAL), preoperative aspects and dimensions used for anatomic classifications (PADUA), and centrality index (C-index) nephrometry scores for predicting the strict Trifecta achievement from a single institution series robotic-assisted partial nephrectomy (RAPN). We retrospectively identified the prospectively maintained robotic surgery database records of 91 patients who underwent RAPN between June 2015 and September 2020 in Antalya Training and Research Hospital. The main outcome of the study was the achievement of strict Trifecta (negative surgical margin, no major urologic complications, warm ischemia time ≤25 min, and ≥85% preservation of estimated glomerular filtration rate). A multivariable analysis was performed to identify the factors of strict Trifecta success. The mean patient age was 55.82 ± 13.37 years with a median clinical tumor size of 3.5 cm (IQR 2.5-4.9). The median RENAL, PADUA, and C-index score were 7(IQR 6-8), 8(IQR 7-10), and 2.01(IQR 1.64-2.72), respectively. A strict Trifecta could be achieved in 54 patients (59.3%). Clinical tumor size (P = 0.011), RENAL risk groups (low:reference; intermediate; P = 0.040; high; P = 0.009), PADUA risk groups (low:reference; intermediate; P = 0.044; high; P = 0.001) and C-index risk groups (low:reference; high; P = 0.015) were the independent predictors of strict Trifecta attainment in the multivariate analysis. None of the nephrometry scores were a superior predictor compared to other nephrometry scores in comparative analysis. RENAL, PADUA, and C-index scores were all independent predictors of a strict Trifecta achievement. Our comprehensive comparison of the three scores identified that none of the nephrometry scores proved to be inferior to others nephrometry scores.

Assessment of changes in penile sensation by electrophysiological study after radical prostatectomy: A pilot study.

BACKGROUND: To evaluate the changes in penile sensation by electrophysiological tests in patients who underwent radical prostatectomy (RP) and to demonstrate the role of dorsal penile nerve injury in postoperative erectile dysfunction. MATERIALS AND METHODS: Twenty-six volunteer patients who were eligible for RP were included in the study. Preoperative penile sensory electromyography and the International Index of Erectile Function-5 (IIEF-5) questionnaire were done for each patient. Erectile function assessment and electrophysiological evaluation of penile sensation were repeated at postoperative 3rd and 6th months. RESULTS: Postoperative IIEF-5 scores and electromyography values were significantly lower than preoperative findings (p < 0.05). The IIEF-5 scores in the nerve sparing-RP (NS-RP) group were significantly higher than the non-nerve sparing-RP (NNS-RP) group in the postoperative period. Nerve conduction velocity values in the NS-RP group were also higher than the NNS-RP group at the postoperative 3rd and 6th months. However, these changes were not statistically significant (p > 0.05). CONCLUSIONS: Patients who underwent RP have decreased penile sensation due to cavernous nerve damage and a possible dorsal penile nerve injury. The decrease of penile sensation may be associated with postoperative erectile dysfunction.

The associations of RENAL, PADUA and C-index nephrometry scores with perioperative outcomes and postoperative renal function in minimally invasive partial nephrectomy.

OBJECTIVE: This study aimed to assess the utility of the radius, exophytic/endophytic, nearness, anterior/posterior, location (RENAL); preoperative aspects and dimensions used for an anatomic evaluation (PADUA), and centrality index (C-index) scores for the outcomes of partial nephrectomy (PN). MATERIAL AND METHODS: The patients who underwent PN with contrast-enhanced preoperative imaging from January 2015 to June 2018 were identified. The RENAL, PADUA, and C-index scores were assigned. The correlation between these scoring systems and perioperative and long-term renal functional outcomes were evaluated. RESULTS: A total of 78 patients were included in the study (58 men and 20 women; age, 58±11.4 years). Median warm ischemia time (WIT), estimated blood loss (EBL), and operation time (OT) were 26 min, 115 mL, and 140 min, respectively. The RENAL score was related to WIT, EBL, and OT (p<0.001, p=0.003, and p=0.023, respectively). The PADUA score was associated with WIT, EBL, and OT (p<0.001, p=0.013, and p=0.005, respectively). The C-index score was correlated with WIT, EBL, and OT (p<0.001, p=0.010, and p=0.001, respectively). The C-index score also correlated with the percentage change in the estimated glomerular filtration rate (p=0.037). However, on univariable and multivariable regression analyses, only WIT significantly affected the postoperative estimated glomerular filtration rate reduction. CONCLUSION: The RENAL, PADUA, and C-index scores were significantly associated with perioperative outcomes of PN. In addition, the C-index score was correlated with long-term renal functional outcomes.

Long-term outcomes of minimally invasive surgeries in partial nephrectomy. Robot or laparoscopy?

BACKGROUND: To compare long-term oncological and renal functional outcomes of laparoscopic and robotic partial nephrectomy for small renal masses. METHODS: A total of 103 patients who underwent laparoscopic (n = 31) and robotic (n = 72) partial nephrectomy between April 2015 and November 2018 were included in the study. Perioperative parameters, long-term oncological and functional outcomes were compared between the laparoscopic and robotic groups. RESULTS: No significant differences were found in terms of age, tumour size, RENAL and PADUA scores, pre-operative estimated glomerular filtration rate (eGFR), and presence of chronic hypertension and diabetes (P = .479, P = .199, P = .120 and P = .073, P = .561, and P = .082 and P = .518, respectively). Only estimated blood loss was significantly higher in the laparoscopic group in operative parameters (158.23 ± 72.24 mL vs. 121.11 ± 72.17 mL; P = .019), but transfusion rates were similar between the groups (P = .33). In the laparoscopic group, two patients (6.5%) required conversion to open, while no conversion was needed in the robotic group (P = .89). There were no differences in terms of positive surgical margin and complication rates (P = .636 and P = .829, respectively). No significant differences were observed in eGFR changes and post-operative new-onset chronic kidney disease at 1 year after the surgery (P = .768, P = .614, respectively). The overall mean follow-up period was 36.07 ± 13.56 months (P = .007). During the follow-up period, no cancer-related death observed in both group and non-cancer-specific survival was 93.5% and 94.4% in laparoscopic and robotic groups, respectively (P = .859). CONCLUSIONS: In this study, perioperative and long-term oncological and functional outcomes seems to be comparable between laparoscopic and robotic partial nephrectomies.

Effects of Listening to Binaural Beats on Anxiety Levels and Pain Scores in Male Patients Undergoing Cystoscopy and Ureteral Stent Removal: A Randomized Placebo-Controlled Trial.

Purpose: To investigate the effects of pure binaural beats on anxiety and pain scores in male patients undergoing diagnostic cystoscopy (DC) and ureteral stent removal (USR) under local anesthesia. Materials and Methods: This was a prospective, randomized placebo-controlled study. Patients in the DC group (DCG) and USR group (USRG) were divided into three subgroups according to interventions applied; DCG-1 and USRG-1, patients listened to binaural beats; DCG-2 and USRG-2, patients listened to classical music; and DCG-3 and USRG-3, patients wore headphones, but were not exposed to audio (control group). The State-Trait Anxiety Inventory (STAI) and Visual Analog Scale (VAS) were used for measuring anxiety and pain scores, respectively. Demographic data, initial STAI, tolerance rate of interventions, terminal STAI (STAI-T), differences of STAI (delta STAI, STAI-D), and VAS scores were compared. Results: Between July 2019 and March 2020, a total of 252 and 159 eligible male patients for DCG and USRG were included, respectively. After exclusions, remaining patients were DCG-1, n = 61; DCG-2, n = 73; DCG-3, n = 75; USRG-1, n = 41; USRG-2, n = 50; and USRG-3, n = 52. The tolerance rate in binaural beat groups was significantly lower than in other groups (p < 0.05 for all). There were significant decreases in terms of STAI-T when DCG-1 and DCG-2 were compared with DCG-3 and USRG-1 and USRG-2 were compared with USRG-3 (p < 0.05 for all). There were significant decreases in STAI-D scores when DCG-1 and DCG-2 were compared with DCG-3 and when USRG-1 and USRG-2 were compared with USRG-3 (p < 0.001 for all). Binaural beat groups had significantly lower VAS scores than other groups and classical music groups had significantly lower VAS scores than control groups (p < 0.05 for all). Conclusions: Listening to pure binaural beats may be a simple and effective method to reduce anxiety levels and pain scores associated with the DC and USR procedures in males.

Preoperative Inflammation Markers and De Ritis Ratio in Predicting Clinical Presentation and Prognosis of Patients with Testicular Germ Cell Tumors.

OBJECTIVE: To evaluate the importance of neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-monocyte ratio (NMR) and De Ritis ratio (DRR) in predicting clinical presentation and prognosis of patients with testicular germ cell tumors (TGCTs). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Antalya Training and Research Hospital Antalya, Turkey, from January 2009 to March 2020. METHODOLOGY: The characteristics and the results of biochemical and pathological examinations of patients who underwent radical orchiectomy were recorded. NLR, LMR, PLR, NMR, and DRR were calculated. The relationship among inflammation markers and DRR and clinical presentation and prognosis of TGCT was evaluated. RESULTS: Data of 99 patients were eligible for the study. Median age was 32 (27-39)  years. Average size of the tumor was 5 (2.7 - 7) cm. Average duration of follow-up was 35.4 (8-62) months. Higher NLR and lower LMR were significantly correlated with higher rates of advanced-stage cancer, metastasis, and retroperitoneal lymph node invasion (RPLNI) (p<0.05). Based on the optimal cut-off values, there was a significantly higher rate of S stage, RPLNI, and metastatic disease in the high NLR group (p<0.05). Kaplan-Meier survival analysis found a statistically significantly lower mean survival rate in the high NLR group (p<0.05). There was no statistically significant difference between the DRR groups in the above-mentioned parameters (p>0.05). CONCLUSION: Preoperative NLR can be used as an inexpensive and easily accessible marker to predict clinical presentation at diagnosis and mortality rates during follow-up of patients with TGCT. Preoperative LMR can also be associated with the clinical picture at the time of diagnosis of TGCT. Key Words: De ritis ratio, Lymphocyte-to-monocyte ratio, Neutrophil-to-lymphocyte ratio, Neutrophil-to-monocyte ratio, Platelet-to-lymphocyte ratio, Testicular  germ cell tumor.

Preoperative Inflammation Markers in Predicting Biochemical Recurrence after Robot-assisted Radical Prostatectomy.

OBJECTIVE: To evaluate the importance of preoperative neutrophil-to-lymphocyte ratio (NLR),  lymphocyte-to-monocyte ratio (LMR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-monocyte ratio (NMR) in prostate cancer patients, who underwent robot-assisted radical prostatectomy (RARP). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Urology Department, Antalya Training and Research Hospital, Turkey, between March 2015 and September 2019. METHODOLOGY: Four hundred and fifty-four patients underwent RARP were scanned. Clinical characteristics and pathological features of patients were recorded. Patients were excluded, if they had persistent PSA; a history of any autoimmune or inflammatory disease; anti-inflammatory agents use; blood transfusion within 3 months; or a follow-up time shorter than 3 months. Systemic inflammation markers were calculated and correlated with patients' data and biochemical recurrence (BCR). Biochemical recurrence was defined as two repetitive measurements of PSA levels ≥0.2 ng/mL at 3  months after the radical prostatectomy. Mann-Whitney U-test, Fisher's exact test, and Pearson Chi-square test, ROC curve, Kaplan-Meier survival analyses, and Cox proportional hazard regression model were used as statistical methods. RESULTS:   Four hundred and two patients were eligible. The median age at RP was 65.5 (61-69) years and median PSA of the patients was 8.3 (5.76-12.61)  ng/ml. Median NLR, LMR, PLR, and NMR were 2 (1.55-2.61), 3.86 (3.14-5), 105.69 (85-134.29), 7.82 (6.25-9.71); and  optimal cut-off values were 2.33, 3.75, 106.6, and 8.75, respectively. Low LMR was found as  an important predictor of biochemical recurrence (hazard ratio, HR=1.769, 95% confidence interval, CI=1.091 - 2.868, p=0.021). A significant association was found between lower LMR and decreased BCR -free survival (p <0.001). CONCLUSION: Pretreatment low LMR might be a simple and inexpensive index, which reflects the host systemic immunity and can predict independently BCR after RARP. Key Words: Biochemical recurrence, Lymphocyte-to-monocyte ratio, Neutrophil-to-lymphocyte ratio, Neutrophil-to-monocyte ratio, Platelet-to-lymphocyte ratio, Prostate cancer.

The effect of peritoneal re-approximation on lymphocele formation in transperitoneal robot-assisted radical prostatectomy and extended pelvic lymphadenectomy.

OBJECTIVE: The objective of the study was to evaluate the effect of peritoneal re-approximation at the end of the procedure in transperitoneal robot-assisted radical prostatectomy (tRARP) and extended pelvic lymphadenectomy (ePLND) on operative, oncologic, and symptomatic lymphocele rates. MATERIAL AND METHODS: A total of 79 patients were included in the study who underwent tRARP and bilateral ePLND performed by two different experienced surgeons. One of the surgeons performed the peritoneal re-approximation (Group 1, n=41) and the other did not re-approximate the peritoneum (Group 2, n=38) at the end of the procedure in tRARP and ePLND. Operative parameters and symptomatic lymphocele rates were compared between the groups. RESULTS: There were no significant differences between the preoperative parameters age, body mass index, and preoperative prostate-specific antigen values (p>0.05). The perioperative parameters were as follows: the operation time and estimated blood loss (EBL) was less, and the number of removed lymph nodes was higher in Group 2. However, only the difference in the EBL was statistically significant (p=0.03). Hospitalization time, symptomatic lymphocele, intervention requiring lymphocele, and complication rates were found to be less in Group 2, but only hospitalization time was statistically significant (p=0.04). Pathological parameters were similar for both groups. There was a significant correlation between lymph node positivity and the presence of symptomatic lymphocele in the correlation analysis (p=0.05). CONCLUSION: It has been shown in this study that the re-approximation of the peritoneum does not provide any additional benefit in terms of complications. Considering that this process also increases the operation time and lymphocele formation, we think there is no need for re-approximation after robot-assisted radical prostatectomy and pelvic lymphadenectomy.

When should the evaluation of erectile function be done before radical prostatectomy?

The aim of this study is to assess the erectile function of patients before and after transrectal ultrasound prostate biopsy comparatively in order to determine the appropriate time to evaluate erectile function before radical prostatectomy. A total of 44 patients underwent transrectal ultrasound biopsy. We used the International Index of Erectile Function-5 questionnaire to assess all the patients. In total, 44 volunteered patients were included in this study. All patients were evaluated with the International Index of Erectile Function-5 questionnaire before the biopsy and at 4 weeks after the transrectal ultrasound biopsy. A total of 50% of patients were potent before the biopsy was done. A month after the biopsies, erectile dysfunction was reported by 29 of 44 patients (66%) as mild in 10 (22.7%), as mild-moderate in 14 (31.8%), as moderate in 4 (9.1%), and severe in 1 (2.3%). The differences were statistically significant in the first month of the biopsy (p < 0.05). The effect of prostate biopsy upon the erectile function is non-negligible. However, this situation is temporary and transient. Therefore, it is recommended that the International Index of Erectile Function-5 questionnaire is to be administered prior to prostate biopsy rather than before surgical treatment.

Does Robot-Assisted Radical Prostatectomy Affect Renal Intravascular Parameters and Glomerular Filtration Rate?

BACKGROUND: We aimed to investigate the effects of intra-abdominal pressure and steep Trendelenburg position on the intrarenal vascular parameters and estimated glomerular filtration rate (eGFR) in the first 24 hours of robot-assisted radical prostatectomy (RARP) surgery. METHODS: We prospectively studied 31 men who underwent RARP for prostate cancer in our clinic between September and December 2017. Preoperative color Doppler ultrasonographic (CDUS) measurements of renal intravascular parameters were obtained 24 hours before the operation. Similarly, postoperative CDUS measurements were performed 24 hours after RARP. Preoperative serum creatinine (Cr) level and eGFR were noted. On the postoperative first day, serum Cr levels were checked and eGFR was calculated. RESULTS: The mean age of men was 61.9 years, and the mean operation time was 268.5 minutes. No significant differences between preoperative and postoperative intrarenal vascular parameters were observed (P > .05). Serum creatinine was significantly increased (P = .019), but eGFR did not change statistically significant after RARP (P = .144). While the change in the mean resistive index (ΔRI) was affected by intravenous (i.v.) infused fluid volume and renal width; the change in the mean pulsatility index (ΔPI) was only affected by renal width. Also, the change in the mean peak systolic velocity (ΔPSV) was related to age, i.v. infused fluid volume, and renal parenchymal thickness. Finally, the change in the mean end-diastolic velocity (ΔEDV) was related to age and renal width. CONCLUSION: Renal functions and intrarenal vascular parameters return to baseline levels 24 hours after RARP.

Outcomes of infants undergoing laparoscopic pyeloplasty: A single-center experience.

PURPOSE:: The aim of this study was to evaluate the outcomes of laparoscopic pyeloplasty in children less than 12 months of age. MATERIALS AND METHODS:: The records of 20 infants, who had pelviureteric junction obstruction and subsequently underwent LP from January 2013 to November 2016 with at least 1 year of follow-up, were retrospectively reviewed. Patients demographics, the results of preoperative and postoperative imaging studies, perioperative details, complications, and results were noted. RESULTS:: The mean age of 20 infants was 4.75 months. The gender of cases was 5 females (25%) and 15 males (75%). Of that, 13 (65%) laparoscopic pyeloplasties were in left side and 7 (35%) were in right side. No cases needed open conversation. Aberrant crossing vessel was observed in three patients (15%). The mean operation time was 79.35 min (45-128 min). The mean hospital stay was 2.9 ± 0.308 days (2-3 days). There were complications in three children (15%); two patients developed stent migration and one child had fever over 38°. Three children with complications did not require a second intervention. In one child, the kidney was non-functioning in follow-up and nephrectomy was performed. The anteroposterior diameter significantly reduced. Preoperative mean value was 24.305 ± 5.6157 and postoperative mean value was 15.40 ± 6.030 (p = 0.000, p < 0.05). There was a significant degree of improvement in renal split function for all patients. Preoperative mean values were 45.53 ± 11.512, while postoperative values were 47.850 ± 13.347 (p = 0.029, p < 0.05). CONCLUSION:: Although there are doubts about the reliability and efficacy of results for pyeloplasty in children less 12 months, many studies including this study show that laparoscopic pyeloplasty is an effective and reliable method for infants.

Does extracorporeal shock wave lithotripsy-related pain get affected by menstrual cycle and menopause?

The objective of the study was to investigate the effect of the menstrual cycle and menopause on extracorporeal shock wave lithotripsy (ESWL)-related pain outcome. Since March 2017, we evaluated a total of 145 women who underwent the first session of ESWL for renal or ureteral stones. Patients were divided into two groups, as menstruating and menopaused women. For menstruating women, the number of days between the last day of mens and ESWL was noted and women were separated as in the follicular phase (1-14 days) or in the luteal phase (15-30 days) of menstruation. To control these two female groups, 149 men of similar age were included in the study. After the procedure, the experienced pain was recorded on a ten-point visual analog scale (VAS) by the patient and they also rated the severity of pain as no, mild, tolerable, and intolerable on the pain questionnaire. The mean age of the patients was 43 ± 15 years for the female group and 42 ± 13 years for the male group. While stone burden was not different between the female and male groups (p = 0.459), VAS score was not statistically different between genders (p = 0.293). However, men reported a higher rate of mild pain, while women reported a higher rate of tolerable pain (p = 0.008) in the pain questionnaire. Mean VAS score was significantly lower for the menopaused women group than menstruating women, young and old men (p = 0.001). In a subgroup analysis, menopaused women group reported lower VAS score and better pain questionnaire result than menstruating women (p < 0.001). There was no statistically significant difference between the follicular and luteal phase of the menstrual cycle in terms of mean VAS score and pain questionnaire results (p = 0.891 and 0.441, respectively). When compared with the young men group, the only significant difference was pain questionnaire results between women in the luteal phase (p = 0.014). Multiple regression analysis showed that only menstruation (ß = 0.639, p < 0.001) was an independent factor for VAS score. Menstrual cycle phase had no effect on pain perception during the ESWL session and menopaused women felt less pain than menstruating women during this procedure. The control male group showed that the reduction of ESWL-related pain in menopause was not related to aging.

The Learning Curve Does Not Affect Positive Surgical Margin Status in Robot-Assisted Laparoscopic Prostatectomy.

PURPOSE: To assess the oncologic results of our robot-assisted laparoscopic prostatectomy (RALP) cases and investigate whether the learning curve (LC) affects the oncological outcomes.  Materials and Methods: Between March 2015 and September 2017, 111 patients underwent RALP by a single surgeon in our clinic. The learning curve was analyzed using the moving average method. We compared the rate of positive surgical margins(PSM) and oncological outcomes, operation times, hematocrit changes and duration of hospitalization among the patients during and after the LC. Complications were also noted according to Clavien system. RESULTS: LC analysis using the moving average method showed that the LC stabilized between cases 51-60. So, patients were classified into two groups; 1-50 cases (Group 1) and 51-111 cases (Group 2). PSM rates were 36% for group 1 and 18% for group 2, and statistically different (p=0,032). Extracapsular invasion (ECI) was significantly higher in group 1 (56,5%) than in group 2 (29,5%) (p=0,005). Multiple logistic regression analysis revealed that presence of ECI was an independent factor for PSM associated with the groups (OR: 2.512; 95% CI: 1.055-5.979). Both operation time and duration of postoperative hospitalization were significantly reduced from group 1 to group 2. A total of 11 patients (10%) had complications and one of them (0,9%) required surgical intervention. CONCLUSION: We can conclude that at least 50 RALP cases are needed to gain proficiency even for an experienced surgeon in laparoscopic radical prostatectomy. Our study demonstrates that surgeons experience can affect the perioperative variables but the LC does not affect PSM status in RALP.