The relationship between the force applied and perceived by the surgeon during ureteral access sheath placement: ex-vivo experimental model.

PURPOSE: To define a peak force of insertion (PFOI) threshold for ureteral damage during ureteral access sheath (UAS) placement on an experimental ureteral orifice model. METHODS: A specially designed water tank using 2 laparoscopic 5 mm ports and 2 different size (10 Fr and 8 Fr) sealing cap adaptors (SCA) as ureteral orifices was used to perform the test. A 10-12 Fr UAS was fixed to a load cell and the force of insertion (FOI) was continuously recorded with a digital force gauge.13 experts in the field of endourology who participated performed 3 UAS insertions. The FOI was recorded initially with 10 Fr followed by 8 Fr SCA. On the final insertion, the orifice was obstructed, leaving a 5 cm length to insert the UAS. The experts were asked to "Stop at the point they anticipate ureteral damage, and they would not proceed in real life". RESULTS: Using 10 Fr SCA the PFOI was 2.12 ± 0.58 Newton (N) (range:1.48-3.48) while 8 Fr SCA showed a PFOI 5.76 ± 0.96 N (range:4.05-7.35). Six of the experts, said they would stop proceeding when they reached above 5.1 N. Three experts had PFOI < 5.1 N and the other 4 stated they would go with PFOIs of 5.88, 6.16, 6.69 and 7.35 N when using SCA of 8 Fr.The highest load they would stop proceeding had a PFOI of 6.09 ± 1.87 N (range: 2.53-10.74). CONCLUSION: The PFOI threshold for ureteral damage inserting UAS of the experts is variable. Although FOI is a subjective perception, experience suggests that ureteral injury may occur at an average of 6.05 N perceived by surgeons' tactile feedback. In-vivo measurement of UAS PFOI may confirm a threshold.

Robotic Flexible Ureteroscopy: A Step-by-Step Video by Using Roboflex Avicenna Platform.

BACKGROUND: The management of kidney stones, particularly those in the renal pelvis, is a critical aspect of urology. The European Association of Urology guidelines recommend Extracorporeal Shock Wave Lithotripsy or Endourology methods, encompassing Percutaneous Nephrolithotomy and Ureterorenoscopy (URS), for stones ranging from 10-20 mm. Robotic-assisted urological procedures have gained prominence in recent years, promising enhanced precision and safety. OBJECTIVE: To provide a detailed account of the technical aspects and outcomes of a robotic URS (robo-URS) procedure in a 63-year-old male patient with a 15-mm renal pelvis stone, serving as a reference for urologists considering this approach. MATERIALS: The patient presented with right flank pain, and an unenhanced computed tomography scan confirmed the presence of a 15 × 12 × 13 mm stone in the right renal pelvis. After assessment and preparation, robo-URS was performed using the Roboflex Avicenna robotic platform (ELMED, Ankara, Turkey) in conjunction with conventional urological instruments and laser technology. RESULTS: The procedure was completed successfully in 50 minutes without any detectable blood loss or intraoperative complications. CONCLUSION: Robo-URS is a promising approach for managing renal pelvis stones. The procedure, demonstrated in this video article, underscores its technical feasibility, safety, and efficacy, making it a valuable resource for urologists seeking to expand their knowledge in stone management techniques.

An updated analysis of the surgical and urological complications of 789 living-related donor kidney transplantations: Experience of a single center.

BACKGROUND: This study aims to review retrospectively the surgical and urological complications encountered in 789 cases of living-related donor kidney transplantations (LRDKTs). METHODS: In this study, the clinical records of 789 LRDKTs, which were performed between 1983 and 2017, were reviewed retrospectively concerning surgical and urological complications. RESULTS: Overall, urological and surgical complications were encountered in 87 (11.02%) of the cases. Of the 789 patients, urological complications were detected in 44 of them (5.6%), including 8 urinary fistula (with 1 distal ureteral necrosis), 10 ureteric stenosis, 1 renal calculus, 9 symptomatic vesicoureteral reflux and 16 lymphoceles requiring intervention. As surgical complications (n=43), vascular complications were encountered in 8 cases; there were 5 cases with renal artery stenosis and 3 with renal vein thrombus. Wound infection was detected in 14 patients. Eighteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. CONCLUSION: In our series, urological and surgical complications were detected in 11.02% of the recipients. Although complications still encountered, early identification of these complications with proper management strategies significantly decreases the risk of graft loss.

Diabetes mellitus is the only independent predictor of both postoperative and long term renal functions in elective laparoscopic partial nephrectomy with limited or overextended warm ischemia.

OBJECTIVE: To investigate the predictive factors of renal functional change at postoperative period and at last follow-up in patients undergoing elective and clamped laparoscopic partial nephrectomy (LPN) with limited (≤20 minutes) and overextended (≥40 minutes) warm ischemia time (WIT). MATERIAL AND METHODS: From our prospectively collected LPN database, elective and warm ischemia-applied LPNs were retrospectively analyzed in two groups: limited (n=55, Group 1, WIT≤20 minutes) and overextended (n=28, Group 2, WIT≥40 minutes) WITs. Preoperatively, estimated glomerular filtration rate (eGFR) was ≥60 mL/min/1.73 m2 in all patients. Demographic, clinical, perioperative and renal functional parameters were compared between two groups. Age, diabetes mellitus (DM), pathological tumor size, preoperative eGFR and WIT were used in multivariable analyses to investigate the independent predictors of de novo Stage 3 or greater chronic kidney disease (CKD) (eGFR<60 mL/min/1.73m2) at postoperative period and at the last follow-up. RESULTS: Preoperative (p=0.009) and pathological (p=0.011) tumor size, PADUA (p=0.001) and R.E.N.A.L. Nephrometry (p=0.006) scores and operative time (p<0.001) were significantly higher in Group 2. Preoperative eGFR (86 vs. 88 mL/min/1.73 m2, p=0.328) was similar between two groups. In postoperative period, compared to Group 1, decreased eGFR (86 vs. 62.5 mL/min/1.73 m2, p<0.001) and percent preserved eGFR (97.2 vs. 77.2%, p<0.001) were found in Group 2. After median follow-up of 33 and 30 months (p=0.732) for Groups 1 and 2, respectively, eGFR at the last follow-up (84 vs. 80.0 mL/min/1.73 m2, p=0.347) and percentage preserved eGFR at last follow-up (97.7 vs. 92.5%, p=0.806) were similar between two groups. Overextended WIT (≥40 minutes), preoperative decreased eGFR (<77.5 mL/min/1.73m2) and DM were the independent predictors of de novo Stage 3 or greater CKD at postoperative period, while DM and age were the predictors of de novo Stage 3 or greater CKD at the last follow-up. CONCLUSION: Overextended WIT (≥40 minutes) caused significant postoperative renal functional loss in elective LPN but this functional loss recovers at long term follow-up. However, diabetes mellitus is the only predictor of renal functional loss both in the postoperative period and at the last follow-up.

Effects of Different Volatile Anesthetics on Cytokine and Chemokine Production After Ischemia-Reperfusion Injury in Patients Undergoing Living-Donor Kidney Transplant.

OBJECTIVES: Renal transplant is the treatment of choice for patients with end-stage renal disease. Ischemiareperfusion damage is a major cause of early renal dysfunction during the perioperative period. Ischemic hypoxic damage increases local inflammation, leading to secretion of cytokines and chemokines. Anesthetic conditioning is a widely described strategy to attenuate ischemia-reperfusion injury. Here, we compared the effects of desflurane and sevoflurane on serum proinflammatory cytokines and urine chemokines in living-donor kidney transplant recipients. MATERIALS AND METHODS: Eighty donor-recipient couples were included in this randomized study. Anesthesia maintenance was provided by desflurane or sevoflurane. Patient demographic characteristics, immunologic data, clinical data, and hemodynamic parameters were recorded. Tumor necrosis factor α, interleukins 2 and 8, chemokines 9 and 10, and serum creatinine levels were studied from pretransplant, posttransplant days 1 and 7, and posttransplant months 1 and 3 sample results. Estimated glomerular filtration rates were calculated. Acute rejection episodes and graft loss within 6 months posttransplant were recorded. RESULTS: Seventy donor-recipient couples completed the study. There were no significant differences in demographic, immunologic, and clinical data between desflurane and sevoflurane groups (P > .05). Tumor necrosis factor α, interleukin 2, chemokine 9, and chemokine 10 levels were similar preoperatively and on postoperative days 1 and 7 and months 1 and 3 (P > .05). Serum interleukin 8 levels were significantly higher in patients who received sevoflurane on postoperative days 1 (P = .045) and 7 (P = .037). No significant differences were detected in serum creatinine and estimated glomerular filtration rate between groups (P > .05). No graft loss occurred within 6 months posttransplant. CONCLUSIONS: Although sevoflurane seemed to produce higher interleukin 8 levels posttransplant, both desflurane and sevoflurane had similar effects on posttransplant kidney function. We suggest that both agents have protective effects on ischemic-reperfusion damage in living-donor kidney transplant recipients.

Impact of ureteral access sheath force of insertion on ureteral trauma: In vivo preliminary study with 7 patients.

BACKGROUND: Ureteral access sheaths (UASs) are commonly used in retrograde intra-renal surgery (RIRS). Despite their advantages, there is a risk of ureteral trauma during their placement and subsequent stricture following surgery. The aim of this study was to evaluate the UAS force of insertion (FOI) during placement and its impact on ureteral trauma. METHODS: Seven female patients who underwent RIRS for kidney stones were included in the study. A digital force gauge (Chatillon DFX II; Ametek Test and Calibration Instruments, Largo, Florida, USA) was connected to the distal end of the UAS and the UAS FOI was continuously measured during insertion. UASs of different sizes were used and ureteral injury was evaluated under direct vision with the Post-Ureteroscopic Lesion Scale (PULS) score. RESULTS: Five pre-stented patients and 2 non-stented patients were included in the study. The size of the UASs used in non-stented patients was 9.5/11.5-F and 10/12-F, whereas one 11/13-F and four 12/14-F sheaths were used in the pre-stented patients. The highest maximal UAS FOI observed was 5.9 Newton (N) in a pre-stented patient with a 12/14-F UAS, where a second attempt was performed after initial failure. The lowest maximal UAS FOI was 0.91 N in a non-stented patient using a 9.5/11.5-F UAS. A semirigid ureteroscopy with a 7.8-F sheath was performed in this patient prior UAS placement. The PULS score was 1 in the 2 non-stented patients and 0 in all of the pre-stented patients. CONCLUSION: In this small cohort, a preoperative JJ stent seemed to protect the ureter, even with larger diameter UASs of 12/14- F. Non-stented RIRS with a UAS is possible, but may cause low-grade ureteral trauma.

Serum and Urinary Levels of Tumor Necrosis Factor-Alpha in Renal Transplant Patients.

OBJECTIVES: Allograft rejection is an important cause of early and long-term graft loss in kidney transplant recipients. Tumor necrosis factor-alpha promotes T-cell activation, the key reaction leading to allograft rejection. Here, we investigated whether serum and urinary tumor necrosis factor-alpha levels can predict allograft rejection. MATERIALS AND METHODS: This study included 65 living related-donor renal transplant recipients with mean follow-up of 26 ± 9 months. Serum and urinary tumor necrosis factor-alpha levels were measured at pretransplant and at posttransplant time points (days 1 and 7 and months 3 and 6); serum creatinine levels were also monitored during posttransplant follow-up. Standard enzyme-linked immunoabsorbent assay was used to detect tumor necrosis factor-alpha levels. Clinical variables were monitored. RESULTS: Nine of 65 patients (13.8%) had biopsy-proven rejection during follow-up. Preoperative serum and urinary tumor necrosis factor-alpha levels were not significantly different when we compared patients with and without rejection. Serum tumor necrosis factor-alpha levels (in pg/mL) were significantly higher in the allograft rejection versus nonrejection group at day 7 (11.5 ± 4.7 vs 15.4 ± 5.8; P = .029) and month 1 (11.1 ± 4.8 vs 17.8 ± 10.9; P =.003). Urinary tumor necrosis factor-alpha levels (in pg/mL) were also elevated in the allograft rejection versus the nonrejection group at days 1 (10.2 ± 2.5 vs 14.1 ± 6.8; P = .002) and 7 (9.8 ± 2.2 vs 14.5 ± 2.7; P < .001) and at months 1 (8.0 ± 1.7 vs 11.8 ± 2.4; P < .001), 3 (7.7 ± 1.6 vs 9.6 ± 1.7; P = .002), and 6 (7.4 ± 1.6 vs 8.9 ± 0.9; P = .005). CONCLUSIONS: Our preliminary findings suggest that tumor necrosis factor-alpha has a role in diagnosing renal transplant rejection. Serum and urinary tumor necrosis factor-alpha levels may be a possible predictor for allograft rejection.

An unanswered question in pediatric urology: the post pubertal persistence of prepubertal congenital penile curvature correction by tunical plication

ABSTRACT Objective: The aim of this study is to analyze post pubertal results of pre pubertal tunica albuginea plication with non-absorbable sutures in the correction of CPC. Materials and Methods: The files of patients who underwent tunica albuginea plication without incision (dorsal/lateral) were retrospectively reviewed. Patients younger than 13 years of age at the time of operation and older than 14 years of age in November 2015 were included. Patients with a penile curvature of less than 30 degrees & more than 45 degrees and penile/urethral anomalies were excluded. All of the patients underwent surgery followed by circumcision. Results: The mean age of patients at the time of the operation was 9.7 years (range, 6-13 years). The mean degree of ventral penile curvature measured during the operation was 39 degrees while it was 41 degrees in the lateral curvatures. All of the patients were curvature-free at the end of the operation. At the time of the follow-up examination, the mean age was 16.7 years (range, 14-25 years). Six patients had a straight (0-10 degrees) penis during erection and seven patients had recurrent penile curvatures ranging from 30 to 50 degrees. Conclusion: Pre pubertal tunica albuginea plication of congenital penile curvature (30-45 degrees) with non-absorbable sutures performed without incision is a minimal invasive method especially when performed during circumcision. However, recurrence might be observed in half of the patients after puberty.

An unanswered question in pediatric urology: the post pubertal persistence of prepubertal congenital penile curvature correction by tunical plication.

OBJECTIVE: The aim of this study is to analyze post pubertal results of pre pubertal tunica albuginea plication with non-absorbable sutures in the correction of CPC. MATERIALS AND METHODS: The files of patients who underwent tunica albuginea plication without incision (dorsal/lateral) were retrospectively reviewed. Patients younger than 13 years of age at the time of operation and older than 14 years of age in November 2015 were included. Patients with a penile curvature of less than 30 degrees & more than 45 degrees and penile/urethral anomalies were excluded. All of the patients underwent surgery followed by circumcision. RESULTS: The mean age of patients at the time of the operation was 9.7 years (range, 6-13 years). The mean degree of ventral penile curvature measured during the operation was 39 degrees while it was 41 degrees in the lateral curvatures. All of the patients were curvature-free at the end of the operation. At the time of the follow-up examination, the mean age was 16.7 years (range, 14-25 years). Six patients had a straight (0-10 degrees) penis during erection and seven patients had recurrent penile curvatures ranging from 30 to 50 degrees. CONCLUSION: Pre pubertal tunica albuginea plication of congenital penile curvature (30-45 degrees) with non-absorbable sutures performed without incision is a minimal invasive method especially when performed during circumcision. However, recurrence might be observed in half of the patients after puberty.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years.

AIM: To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications. MATERIALS AND METHODS: Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications. RESULTS: A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS. CONCLUSION: Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

The use of self-retaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy: outcomes of a matched-pair analysis.

PURPOSE: To investigate the efficacy of self-retaining barbed suture (SRBS) on reducing renorrhaphy time and warm ischemia time (WIT) during laparoscopic partial nephrectomy (LPN), in comparison with conventional polyglactin suture. PATIENTS AND METHODS: Between February 2008 and June 2012, 115 patients underwent LPN for renal tumors at our institution. Among them, the patients whose inner layer renorrhaphy was performed using SRBS (group 1, n=33) or polyglactin suture (group 2, n=33) were retrospectively identified from prospectively collected institutional laparoscopic database (unmatched comparison). Furthermore, 17 patients from each group were matched at a 1:1 ratio in terms of sex, age, body mass index, preoperative aspects and dimensions used for an anatomic (PADUA) classification scoring system, and operative approach (transperitoneoscopic/retroperitoneoscopic) to eliminate the effects of these variables on WIT (matched-pair comparison). Demographic, perioperative, and pathologic parameters were evaluated between groups in both unmatched and matched-pair comparison. RESULTS: The perioperative parameters including inner layer renorrhaphy time, WIT, estimated blood loss, operative time, length of hospital stay, and complication rate were not statistically different between the two groups in the unmatched comparison. Median PADUA score (9 vs 8, P=0.006), median preoperative (4 cm vs 3.6 cm, P=0.049), and pathologic (4.5 cm vs 3.5 cm, P=0.009) tumor size, however, were significantly higher in group 1. In the matched-pair analysis, inner layer renorrhaphy time (350 sec vs 505 sec, P=0.004) and WIT (19 min vs 28 min, P=0.037) were significantly reduced with the use of SRBS in group 1 without a difference of median PADUA score (8 vs 8, P=1), median preoperative (3.8 cm vs 4 cm, P=0.959), and pathologic (4.2 cm vs 4 cm, P=0.284) tumor size. CONCLUSIONS: The SRBS significantly reduced inner layer renorrhaphy time and WIT during LPN and may enable urologists to perform LPN in more challenging and larger tumors, in comparison with conventional polyglactin suture.

Residual valve and stricture after posterior urethral valve ablation: how to evaluate?

OBJECTIVE: To investigate the clinical and radiological parameters of posterior urethral valve (PUV) patients with residual valve or strictures after primary valve ablation. PATIENTS AND METHODS: A total of 127 PUV patients were treated in our clinic between 1986 and 2009. We retrospectively reviewed the records of 101 patients, who had at least 1 year of follow-up data, regarding the presence of valve remnants or urethral strictures after PUV ablation. RESULTS: A total of 21 patients (20.8%) underwent repeat-urethroscopy and, of these, residual valve leaflets or stricture were detected in 10 patients (10/101, 9.9%). In 2 of these 10 (20%), the urethra had been found to be normal on the first voiding cystourethrogram following ablation. However, these two boys underwent re-urethroscopy due to persistent vesicoureteral reflux in one and persistent hydroureteronephrosis in the other, and valve remnants were detected. The remaining 8 cases had radiological signs consistent with persistent infravesical obstruction in the early period. Obstruction was due to urethral stricture and residual valve remnants in 2 and 6 cases, respectively. CONCLUSIONS: There was clinical suspicion of residual valve in about 20% of the cases and in half of these the urethra was found to be normal on urethroscopy. The possible presence of residual valve remnants after primary valve ablation should be confirmed by careful clinical, radiological and endoscopic evaluation.

Nitric oxide synthase (eNOS4a/b) gene polymorphism is associated with tumor recurrence and progression in superficial bladder cancer cases.

PURPOSE: We investigated the relationship between the distribution of the eNOS4a/b polymorphism and the clinical features of superficial bladder cancer. MATERIALS AND METHODS: This study included 201 healthy controls with a mean ± SD age of 62.35 ± 7.96 years and 123 patients with a mean age of 64.03 ± 11.00 years diagnosed with histopathologically confirmed superficial bladder cancer. The eNOS4a/b polymorphism genotype (aa, bb or ab) was identified by polymerase chain reaction. Blood glutathione and plasma malondialdehyde levels were measured by spectrophotometry as an indicator of oxidative stress. We estimated total plasma levels of nitric oxide metabolites using a colorimetric assay kit. RESULTS: There were no significant differences in age or body mass index between patients and controls. Malondialdehyde and nitric oxide metabolite levels were statistically significantly increased (p = 0.000 and 0.024, respectively) and glutathione levels were decreased (p = 0.000) in patients with superficial bladder cancer. The bb genotype of the eNOS4a/b polymorphism is the most frequent one in the Turkish population and the aa genotype was significantly more common in patients with superficial bladder cancer (p = 0.000). Also, the aa plus ab genotype was significantly more common in patients with high grade tumors (p = 0.013) and in those with more progression to muscle invasive disease (p = 0.000). This genotype was also a significant independent risk factor for recurrence after adjusting for smoking status, stage, grade and the presence of carcinoma in situ on logistic regression analyses (OR 3.095, 95% CI 1.21-7.86, p = 0.018). CONCLUSIONS: The current study suggests that a genotype containing the a allele of the eNOS4a/b polymorphism may be a risk factor for bladder cancer. Additionally, patients harboring the aa plus ab genotype are more likely to experience tumor recurrence and progression.

Despite the lack of association between different genotypes and the presence of prostate cancer, endothelial nitric oxide synthase a/b (eNOS4a/b) polymorphism may be associated with advanced clinical stage and bone metastasis.

OBJECTIVES: To investigate the relationship between the distribution of endothelial NO synthase (eNOS4a/b) gene polymorphism and clinical features of prostate cancer (PCa). METHODS AND MATERIALS: One hundred thirty-two patients with PCa (mean age 64.10 ± 7.23 years) and 158 healthy controls (mean age 62.50 ± 7.53 years) with normal serum total prostate specific antigen (PSA) levels (<4 ng/ml) and digital rectal examinations (DRE) were enrolled in this prospectively designed study. PCa patients were classified as clinical T1 and T2 stages (Group 1), clinical T3 and T4 stages without bone metastasis (Group 2), and patients with bone metastasis (Group 3). Genotypes (aa, bb, ab) for eNOS4a/b gene polymorphisms were identified by polymerase chain reaction analysis. Meanwhile, plasma nitrate and nitrite levels (NO(x)) were used to estimate the amounts of endogenous NO formation for both groups of patients. RESULTS: Despite lack of statistically significant differences between PCa patients and the control group in terms of distribution of genotypes and frequency of alleles, plasma NO(x) levels were found to be significantly increased in PCa patients compared with controls. Meanwhile, there was no significant difference between the group of PCa patients with high and low grade tumors (Gleason score ≥ 7 vs. < 7) in terms of genotype (aa + ab genotypes or a-allele vs. bb genotype) distribution. However, bb genotype was observed to be present at a higher frequency (85.1% vs. 60%) in Group 1; whereas a-allele was more frequent in Group 2 (13.3% vs. 5.7%) and Group 3 (26.7 vs. 9.2). In addition, patients with a-allele had a 3.79-fold risk of having advanced disease and bone metastasis in comparison with bb genotype. Moreover, multivariable logistic regression analysis revealed that eNOS4a/b polymorphism and plasma NOx levels were predictive factors for developing bone metastasis and high stage disease after adjustment for age and BMI. CONCLUSIONS: Our data did not reveal any relationship between any of these genotypes and the presence of PCa. However, the finding that PCa patients with bb genotype generally manifest localized disease and develop bone metastasis less frequently in comparison patients with a-allele may indicate an important role for this polymorphism in the molecular pathophysiology of PCa.

Laparoscopic nephrectomy in patients undergoing hemodialysis treatment.

BACKGROUND AND OBJECTIVES: To report our experience with laparoscopic nephrectomy (LN) in patients undergoing hemodialysis compared with normal counterparts. METHODS: Seventeen patients (20 renal units, Group 1) undergoing hemodialysis underwent LN, which was indicated due to nonfunctioning kidney in 17 and suspected malignancy in 3 renal units. Radical nephrectomy (RN), simple nephrectomy (SN), and simple nephroureterectomy (SNU) were performed in 3, 9, and 8 cases, respectively. For comparison, 101 patients (Group 2) without CRF (chronic renal failure) who had undergone LN were evaluated. In this group, RN, SN, SNU and radical nephroureterectomy (RNU) were performed in 48, 41, 8, and 4 patients, respectively. RESULTS: The mean age (36.9 ±13.1 vs. 48.7±19.4yr, P=0.002) and BMI (22.1±4.8 vs. 26.2±5.1kg/m(2), P=0.001) were lower in Group 1, whereas ASA (physical status score of American Society of Anesthesiologists) score (2.8±0.4 vs. 1.5±0.7, P<0.001) was lower in Group 2. The estimated blood loss (111±114 vs. 184±335mL, P=0.34) was higher in Group 2. Both groups were comparable in regard to mean operative time (133±79 vs. 119±45, P±0.70), hematocrit drop (4.69±3.9 vs. 3.86±3.0, P=0.29) and hospital stay (3.6±3.3 vs. 3.3±2.4 days, P=0.34). Meanwhile, when only patients undergoing SN and SNU in the study cohort (n=17 in Group 1 and n=49 in Group 2) are taken into consideration, no significant difference was observed between the 2 groups in terms of any kind of above-mentioned perioperative parameters. No case in Group 1 was converted to open surgery due to metabolic problems. CONCLUSIONS: LN in patients undergoing hemodialysis may be performed safely by an experienced laparoscopy team.

Inguinal orchiectomy for the extra testis with suspected tumor in a polyorchidic patient: a case report.

A 29-years-old male patient presented with complaint of the small size of his left testicle. The physical examination revealed a normal right testicle with 15 cc volume, a small left testicle (5 cc) and a 4 cc mass under the left testicle, which was thought to be a spermatocele. Ultrasonographic imaging was performed and the mass was defined as a third testicle with a heterogenic epididymis. Scrotal magnetic resonance imaging (MRI) confirmed the diagnosis. An inguinal exploration was performed, which resulted in a left orchiectomy and biopsy of the superior left testicle. The pathologic examination revealed hyperplasia with microcystic changes in the orchiectomy specimen and severe hypospermatogenesis in the biopsy sample. There were no significant changes in semen analysis after the operation.

Lower urinary tract reconstruction in ectopic ureteroceles.

OBJECTIVES: The management of ectopic ureteroceles is a challenging entity in pediatric urology. In our study, we aimed to determine the outcome after lower urinary tract reconstruction in ectopic ureteroceles. MATERIALS AND METHODS: A total of 18 (12 girls, 6 boys) children with ectopic ureteroceles, treated between 1993 and 2003 by complete reconstruction, were enrolled in the study and their records were retrospectively reviewed. RESULTS: Ureterocele was found to be unilateral in 16 and bilateral in 2 children. Four patients had been previously managed by endoscopic interventions and 1 patient underwent partial nephrectomy. Ureterocelectomy was performed on 20 renal units, and of these 20 renal units, 9 underwent heminephroureterectomy, 1 ureterectomy, and 3 (with single system ureteroceles) nephroureterectomy. Seven (35%) renal units with adequate function underwent ureteral reimplantations. After a mean follow-up of 5.4 years (range 4 months to 9.5 years), no patient required a second procedure. Contralateral reflux that developed in 2 children after surgical treatment resolved spontaneously after 1 year of follow-up. CONCLUSION: In the management of ectopic ureterocele, lower urinary tract reconstruction is an effective treatment alternative. According to the functional status of the renal parenchyma involved, the surgical procedure was limited to the lower urinary tract in 35% of the cases.

Failed orchiopexy.

INTRODUCTION: Failure after orchiopexy or cryptorchidism after inguinal surgery are not so rarely encountered conditions. Reoperative orchiopexies are technically demanding procedures. In our study, we aimed to examine the causes of failures and outcomes of reorchiopexies. PATIENTS AND METHODS: Between 1993 and 2003, a total of 28 children who underwent reoperative orchiopexy were included into the study. Undescended testes was detected as unilateral in 24 and bilateral in 4 cases. The mean age of patients at the time of second operation was 6.8 years. The mean period of time between the first and the second operations was 3.2 (1-13 years) years. RESULTS: The first operations were orchiopexies in all patients. After the first operations, 15 testes were found to be localized at the high scrotal position, 8 at the level of the external ring and 9 within the inguinal canal. Overall, reorchiopexies were performed on 32 testes in 28 patients. During the second operation, patent processus vaginalis was detected in 11 (34.4%), and unsuccessful hernia repair in 9 (28.1%) cases. After reorchiopexies, two testes with preoperative inguinal location could only be brought to high scrotal position and in another case orchiectomy was performed to an atrophic testis. Overall, after a mean follow-up period of 3.8 (1-7 years) years following the second operations, 29 (93.5%) testes were scrotal without evidence of atrophy. CONCLUSION: In our series, inadequate repair of inguinal hernia or patent processus vaginalis, as noted in 62.5% of the cases, was determined as an important factor leading to failure after surgical treatment of undescended testis. Adequate dissection and correction of inguinal hernia increase the success rate after orchiopexies.