Intrarenal Surgery vs Percutaneous Nephrolithotomy in the Management of Lower Pole Stones Greater than 2 cm.

PURPOSE: To compare the efficacy of RIRS and PNL in lower pole stones ≥ 2 cm. Materials and and Methods: A total of 109 patients who underwent PNL or RIRS for solitary lower pole stone between April 2009 and December 2012, were retrospectively analyzed. Lower pole stone was diagnosed with CT scan. Stone size was assessed as the longest axis of the stone. All patients were informed about the advantages, disadvantages and probable complications of both PNL and RIRS before the selection of the procedure. Patients decided the surgery type by themselves without being under any influences and written informed consent was obtained from all patients prior to the surgery. Patients were divided into two groups according to the patients' preference of surgery type. Group 1 consisted of 77 patients who underwent PNL and Group 2 consisted of 32 patients treated with RIRS. Stone free statuses, postoperative complications, operative time and hospitalization time were compared in both groups. RESULTS: There was no statistical significance between the two groups in mean age, stone size, stone laterality, mean follow-up periods and mean operative times. In PNL group, stone-free rate was 96.1% at first session and 100% after the additional procedure. In Group 2, stone-free rate was 90.6% at the first procedure and 100% after the additional procedure. The final stone-free rates and operative times were similar in both groups. CONCLUSIONS: RIRS should be an effective treatment alternative to PNL in lower pole stones larger than 2 cm, especially in selected patients.

Intrarenal Surgery vs Percutaneous Nephrolithotomy in the Management of Lower Pole Stones Greater than 2 cm

Purpose To compare the efficacy of RIRS and PNL in lower pole stones ≥2 cm. Materials and and Methods: A total of 109 patients who underwent PNL or RIRS for solitary lower pole stone between April 2009 and December 2012, were retrospectively analyzed. Lower pole stone was diagnosed with CT scan. Stone size was assessed as the longest axis of the stone. All patients were informed about the advantages, disadvantages and probable complications of both PNL and RIRS before the selection of the procedure. Patients decided the surgery type by themselves without being under any influences and written informed consent was obtained from all patients prior to the surgery. Patients were divided into two groups according to the patients’ preference of surgery type. Group 1 consisted of 77 patients who underwent PNL and Group 2 consisted of 32 patients treated with RIRS. Stone free statuses, postoperative complications, operative time and hospitalization time were compared in both groups. Results There was no statistical significance between the two groups in mean age, stone size, stone laterality, mean follow-up periods and mean operative times. In PNL group, stone-free rate was 96.1% at first session and 100% after the additional procedure. In Group 2, stone-free rate was 90.6% at the first procedure and 100% after the additional procedure. The final stone-free rates and operative times were similar in both groups. Conclusions RIRS should be an effective treatment alternative to PNL in lower pole stones larger than 2 cm, especially in selected patients. .

The incidence of postoperative ileus in patients who underwent robotic assisted radical prostatectomy.

INTRODUCTION: Our aim was to examine the incidence and risk factors of postoperative ileus among patients who underwent robot-assisted radical prostatectomy (RARP). MATERIAL AND METHODS: We retrospectively reviewed 239 patients who underwent RARP transperitoneally between February 2009 and December 2011. Patients switched to open surgery were excluded. We defined postoperative ileus as intolerance of a solid diet continued until the third postoperative day and beyond. By Clavien classification, we evaluated the perioperative complications that cause or contribute to postoperative ileus. Similarly, we analyzed the impact of anesthesia risk score on the incidence of postoperative ileus. RESULTS: The study included 228 patients. The mean period to tolerate solid food was 1.24 days. Only 6 patients experienced postoperative ileus, all of whom were treated with a conservative approach. The two groups differed significantly in the duration of abdominal drainage, hospital stay, modified Clavien classification, and the presence of comorbidity diabetes mellitus (P <0.5 for all factors). Multiple logistic regression analysis revealed that diabetes mellitus was an independent risk factor for postoperative ileus. CONCLUSIONS: We suggest that diabetes mellitus is an independent risk factor for postoperative ileus in patients undergoing robot-assisted radical prostatectomy.

Is there a correlation between intravaginal ejaculatory latency time and enuresis? An exploratory study.

INTRODUCTION: Premature ejaculation (PE) is the most common male sexual dysfunction. Monosymptomatic enuresis (ME) is nocturnal bed wetting, without any daytime symptoms. Recent clinical studies report an association between lifelong PE and ME. The purpose of this study was to compare the intravaginal ejaculatory time (IELT) between lifelong PE in men with and without ME. The goal was to determine if there is an association between the severity of ME and of IELT. MATERIAL AND METHODS: A total of 137 men with lifelong PE were included in this study. Subjects were asked if they had childhood ME. The characteristics and mean IELTs of patients with and without ME were compared using the student's t-test, and the correlation between severity of ME and IELT was assessed with trend test. RESULTS: Of the 137 lifelong PE patients, 57 reported ME. There was a strong negative correlation in patients with ME between the severity of enuresis and IELT, with IELT being shorter in patients with severe ME. CONCLUSIONS: A strong correlation between IELT and the severity of ME suggests a common underlying mechanism. Further studies are required to confirm these findings and elucidate the exact pathophysiology.

Diagnostic significance of biopsies in renal masses.

INTRODUCTION: We investigated the reliability and mapping of percutaneous needle core biopsies in the kidney in histopathological diagnosis of renal masses particularly for those with suspicious radiologic appearance in an attempt to prevent unnecessary nephrectomies. MATERIAL AND METHODS: Overall, 96 cases were included in our study that underwent radical nephrectomy or partial nephrectomy due to renal mass between November 2007 - March 2010. Ex-vivo biopsies 1 cm apart were obtained from the peripheral region of the mass. Additionally, half of these peripheral biopsies were obtained from the central region of the mass. Diagnostic yield of the biopsy cores were correlated. Sensitivity and specificity of peripheral and central biopsies in differentiating benign and malignant tissues were calculated. RESULTS: Sensitivity and specificity in differentiating malignant lesions were 93% and 87%, and 90% and 93% for peripheral and central biopsies, respectively. Positive and negative predictive values were 97% and 68%, and 98% and 64% for peripheral biopsies and central biopsies, respectively. Hazard ratio for cigarette smoking and presence of necrosis on CT scans were 4.76 (CI 1, 6-14.3; p = 0.04) and 3.32 (CI 1,2-9.2; p = 0.017) and 3.71 (CI 1.3-10.7; p = 0.013) and 3,51 (CI 1.3-9.6; p = 0.012) for peripheral and central biopsies, respectively. CONCLUSIONS: Kidney biopsies can be performed in suspicious renal masses of central and peripheral biopsies with similar efficacy.

What is the best radiological method to predict the actual weight of the prostate?

AIM: We compared the weight of the prostate specimen extracted after radical prostatectomy with preoperatively estimated weights of the prostate by different imaging techniques. MATERIALS AND METHODS: Prostate weights were estimated by transabdominal ultrasonography (TAUS), transrectal ultrasonography (TRUS), and computed tomography (CT) preoperatively before radical prostatectomy. Prostatectomy specimens were weighed postoperatively and the actual prostate weights were calculated. Statistical analyses were done using 95% confidence intervals with repeated measurement analysis of variance and intraclass correlation coefficients. RESULTS: Of the 163 patients enrolled in the study, the mean age was 64.2 +/- 6.4 (range: 45 to 76) years. The mean postoperative prostate weight was 54.7 +/- 27.9 g. Preoperative mean prostate volumes calculated by TAUS, TRUS, and CT were 50.2 +/- 24.1, 50.7 +/- 24.6, and 62.7 +/- 28.2 mL, respectively (P < 0.001). The actual prostate weight measured using an electronic scale was correlated with the estimated prostate weight in each of 3 methods, the best of which was that of TRUS. CONCLUSION: The actual prostate weight is best estimated by measurements done with TRUS. However, clinicians should consider that some errors and deviations may occur with these imaging techniques.

Robot-assisted laparoscopic nerve-sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal studer pouch construction: outcomes of first 12 cases.

PURPOSE: We report our initial experience with robot-assisted laparoscopic neurovascular bundle (NVB) sparing radical cystoprostatectomy (RALRC), bilateral extended lymph node dissection (BELND) with intracorporeal Studer pouch construction for invasive bladder cancer. PATIENTS AND METHODS: After initially performing >50 cases of robot-assisted laparoscopic radical prostatectomies (RALRP), between December 2009 and April 2010, we performed 12 RALRC procedures with BELND. Bilateral (n=10) and unilateral (n=1) intrafascial NVB preservation was performed in 11 patients; nonnerve-sparing RALRC was performed in 1 patient. RESULTS: Patient characteristics and surgical and postoperative parameters were mean patient age (y): 60 (43-80); American Society of Anesthesiologists score: 2 (1-3); body mass index (kg/m(2)): 24.5 (19.3-31.2); preoperative International Index of Erectile Function (IIEF) score: 25 (5-65); operative time (h): 10 (8.1-11.5); intraoperative blood loss (mL): 455 (100-700); lymph node (LN) yield: 21.3 (8-38); hospital stay (d): 10.7 (9-16); lodge drain removal (d): 10 (9-15). Five patients received neoadjuvant chemotherapy. Surgical margins were negative in all patients. Postoperative pathologic stages were: pT(0) (n=2), pT(1) (n=1), pT(2a) (n=2), pT(2b) (n=2), pT(3a) (n=4), and pT(4a) (n=1). Positive LNs and incidental prostate cancer were detected in five and three patients, respectively. Perioperative death rate was zero. Right external iliac vein injury occurred in one patient during the performance of BELND; surgery was converted to an open procedure and the injury was repaired. Colonic fistula developed in one patient at postoperative day 40; the patient died from cardiac disease at day 60. At a mean follow-up of 7.1 ± 2.3 months, three patients died from metastatic disease. Of the available seven patients, six were fully continent and one had mild daytime incontinence. CONCLUSIONS: Although RALRC with bilateral intrafascial NVB preservation, BELND, and intracorporeal Studer pouch formation is a complex procedure, it can be performed with excellent short-term surgical and pathological outcomes and satisfactory functional results after considerable experience gained with RALRP procedures.

The incidence and management of pleural injuries occurring during open nephrectomy.

OBJECTIVE: To evaluate the incidence, management, and risk factors of pleural injuries occurring during open nephrectomy. METHODS: Between June 2004/and June 2008, 165 patients (167 renal units) underwent open simple (n = 37, 22.2%), partial (n = 39, 23.4%) or radical (n = 91, 54.5%) nephrectomy in our institution. RESULTS: Flank, Chevron, and abdominal midline incisions were used in 148(88.6%), 17(10.2%), and in 2(1.2%) surgical procedures, respectively. Ribs were excised in 109(65.3%) procedures (11th rib, 10th-11th ribs, and 11th-12th ribs). Intraoperative pleural injuries were detected in 20(12%) procedures, 16(80%) were treated successfully with simple evacuation technique, and 4 required chest tube insertion. Age, sex, surgery type, incision type, and surgery site were not associated with pleural injury occurrence (P > .05). Rib resection was the only parameter associated with pleural injury occurrence. CONCLUSION: Pleural injuries occur in 12% of open nephrectomy procedures, and 80% can be repaired successfully. Few of them (2.4%) need chest tube insertion. Performing rib resection is a significant risk factor for pleural injury occurrence during nephrectomies.

Testis sparing surgery for sequential bilateral testicular tumors.

OBJECTIVE: We present our experience in performing testis sparing surgery (TSS) to treat sequential bilateral testicular tumors. MATERIAL AND METHODS: We performed TSS on two patients with bilateral sequential testicular tumors. RESULTS: A 43-year-old patient (Case 1) and a 33-year-old patient (Case 2) had previous inguinal orchiectomy for seminoma. The patients were diagnosed with secondary testicular tumors in the contralateral testes on follow up. They were treated with TSS after frozen section analysis of the peritumoral testicular tissue. Pathologic evaluation of the removed tumors revealed immature teratoma and Leydig cell tumor. Both patients are disease free without local recurrence and do not have erectile dysfunction, and thus do not need androgen replacement therapy after a follow up of 6 months and 44 months, respectively. CONCLUSIONS: TSS after frozen section analysis appears to be a safe and feasible procedure that, in carefully selected cases, offers adequate cancer control, preserves sexual function, and provides psychological benefits.

Ileal ureteral replacement in a man with Studer pouch.

Use of a bowel segment for ureteral replacement is a reliable and a feasible procedure with satisfactory results. We present a patient with a complete left ureteral necrosis due to infection; with an abscess formation in the retroperitoneum after a radical cystoprostatectomy and Studer pouch operation.

Factors affecting urethral stricture development after radical retropubic prostatectomy.

OBJECTIVE: We determined the factors that can cause urethral stricture after radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 56 patients underwent radical retropubic prostatectomy for clinically localized prostate cancer between June 2004 and July 2006. The patients were invited for cystography and removal of the urethral catheter at the 7th postoperative day if no extravasation was seen. Otherwise, the same procedures were repeated at postoperative days 14 and 21 until complete healing at urethrovesical anastomosis was observed. The patients were followed up for the occurrence of urethral stricture with PSA blood levels, residual urine assessment and uroflowmetry at least for 1 year. The impact of age, preoperative PSA level, prostate weight, biopsy Gleason score, bladder neck reconstruction, neurovascular bundle preservation, presence of a water-tight anastomosis, amount of peroperative bleeding and catheter removal time on the development of urethral stricture was evaluated with logistic regression analysis. RESULTS: A statistically significant correlation was observed between catheter removal time, which reflects complete healing of the urethrovesical anastomosis, and development of urethral stricture (P = 0.004). Only 1 (4%) of 25 patients whose catheter was removed on postoperative day 7 developed urethral stricture, whereas 2 of 16 (12.5%) and 6 of 15 (40%) patients whose catheters were removed on postoperative days 14 and 21 developed urethral strictures. Additionally, patients with postoperative urethral strictures were found to be slightly older than those without (67.4 +/- 4.5 vs. 63.1 +/- 6.5, P = 0.048). CONCLUSION: Our study showed that early healing of vesico-urethral anastomosis may allow early catheter removal and results in decreased rates of urethral stricture formation.