Comparison of intraoperative and postoperative complications based on ASA risks in patients who underwent percutaneous nephrolithotomy.

OBJECTIVE: In this study we aimed to evaluate intraoperative and postoperative complications which developed according to pre-operative American Society of Anesthesiologists (ASA) risk criteria in patients who had undergone percutaneous nephrolithotomy (PNL). MATERIAL AND METHODS: Five hundred and sixty patients who had undergone PNL between 2002 and 2014 were included in the study. Patients operated on the ipsilateral kidney, those with solitary kidney or the cases who had previously undergone more than one access were excluded from this study. Preoperative anesthesia risks were determined according to preoperative classification developed by ASA. Postoperative complications were evaluated using Clavien Complication Grading Scale. RESULTS: The mean age of the cases was 47±14 years. The 57% (n=319) of the cases were male, 241 (43%) of them were female. The average indwell time of nephrostomy catheter was 2.88±1.00 (1-8), and length of hospital stay was 4.91±1.54 (2-17) days. When the cases were assessed according to ASA risk groups, intraoperative complications were observed in 9 (5.5%) ASA I, 27 (8.6%) ASA II, and 18 (22%) ASA III patients and and distribution of the patients was statistically significant (p<0.001). When intraoperative complications were evaluated one by one, intraoperative hypotension developed in ASA I (n=3; 1.8%), ASA II (n=20; 6.4%) and ASA III (n=11; 13.4%) risk groups and this distribution (p=0.002) of patients was statistically significant. When assessed according to Clavien Postoperative Scale, postoperative complications developed (p=0.053) in ASAI (n=24; 14.7%), ASA II (n=27, 8.6%) and ASA III (n=13; 15.9%) risk groups, and this distribution of the patients was not statistically significant. In postoperative complications, Grade 3a complications developed in ASA I (n=12; 7.4%), ASA II (n=19; 6%) and ASA III (n=8; 9.8%) risk groups and this distribution was not seen to be statistically significant (p=0.485). CONCLUSION: A statistically significant difference observed regarding intraoperative complications in the groups formed according to ASA risk criteria, on Clavien Grading scale no statistically significant difference was observed as for postoperative complications. In this context, we considered that ASA risks are major risk factors for PNL operations in terms of intraoperative complications.

Publication rates of full-text journal articles converted from abstracts presented during the 22(nd) Turkish National Urology Congress.

OBJECTIVE: To analyze the publication rates of full-text journal articles converted from the abstracts presented in the 22(nd) Turkish National Urology Congress in 2012. MATERIAL AND METHODS: A total of 576 abstracts accepted for presentation at the 22(nd) Turkish National Urology Association Meeting were identified from the published abstract book. The abstracts were categorized into subsections such as endourology and pediatric urology. The subsequent publication rate for the studies was evaluated by scanning PubMed Medline. Abstracts published before the proceedings were excluded from the study. RESULTS: The abstracts were categorized as being presented orally (n=155), by poster (n=421), or by video (n=78). Of the 28 (18.3%) of 155 oral and 34 (8.15%) of 421 poster presentations, were subsequently published in several journals until March 2015. The publication rates of the abstracts based on urology subsections were as follows: neurology (25%), andrology (18.6%), endourology (17.2%), urolithiasis (15.3%), general urology (12.5%), infectious diseases (7.14%), pediatric urology (6.25%), uro-gynecology (6.06%), reconstructive urology (5.8%), and urooncology (3.8%). The average time to publication was 11.77 (0-33) months. CONCLUSION: This is the first study assessing the publication rates of abstracts presented at a Turkish National Urology Congress. It reveals that more qualified randomized studies need to be done to improve the rate of publication.

Factors affecting hospital readmission and rehospitalization following percutaneous nephrolithotomy.

PURPOSE: To identify patient- and procedure-related factors that increase the risk of hospital readmission and emergency room (ER) visits after percutaneous nephrolithotomy (PNL). MATERIALS AND METHODS: We retrospectively reviewed the records of patients with kidney stones treated via PNL in two tertiary referral hospitals between 2008 and 2014. Patient demographics including age, body mass indices, ASA score, stone size, presence of anatomic abnormality and comorbidity, operative and postoperative measures, and ER visit and rehospitalization rates were reviewed. Unplanned readmission to the hospital, including elective, and ER visits due to any reason related to the PNL procedure were primarily examined. The factors affecting ER visit and rehospitalization rate were analyzed using logistic regression analysis. RESULTS: A total of 1024 patients (mean age 46.57 years) were enrolled into the study. Mean stone size was 28.5 mm. Stone-free status was achieved in 81.7 % of the procedures. Complications occurred at a rate of 6.44 % in the postoperative period. ER visit and rehospitalization rates were 5.76 and 5.27 %, respectively. While stone complexity, anatomic abnormalities, and postoperative course were found to be factors affecting ER visit, postoperative course and hospitalization time were main predictors for rehospitalization rate. CONCLUSIONS: Our outcomes demonstrate that patients, who had an anatomic abnormality and complex kidney stone, were more likely to have an unplanned hospital readmission. Patients with a history of perioperative and/or postoperative complication seem to have a tendency to unplanned readmission and rehospitalization.

Comparison of microperc and mini-percutaneous nephrolithotomy for medium-sized lower calyx stones.

The objective of this study was to present the outcomes of comparative clinical study of microperc versus mini-percutaneous nephrolithotomy (mini-PNL) in the treatment of lower calyx stones of 10-20 mm. Patients with lower calyx stones treated with microperc (Group-1) or mini-PNL (Group-2) between 2011 and 2014 were retrospectively analyzed. Demographics of the patients were compared, including age, gender, BMI, stone size, laterality and procedural parameters (operation and fluoroscopy time), and outcomes (success and complication rates). A total of 98 patients were evaluated, assigned to Group-1 (n = 58) and to Group-2 (n = 40). Groups were statistically similar in terms of age, stone size, and BMI (p = 0.3, 0.07, 0.6, respectively). The mean procedure and fluoroscopy duration for Group-1 were 43.02 ± 27.98 min and 112.05 ± 72.5 s, and 52.25 ± 23.09 min and 138.53 ± 56.39 s in Group-2 (p = 0.006 and 0.006). The mean hematocrit drop was significantly higher in Group-2 compared to Group-1 (3.98 vs. 1.96%; p < 0.001); however, none of the cases required blood transfusion. Overall complication rates exhibited no statistically significant difference (p = 0.57). Stone-free status was similar (86.2 vs. 82.5%, p = 0.66). The tubeless procedure rate was significantly higher in Group-1 (p < 0.001). In Group-2, duration of hospitalization was significantly longer than in Group-1 (2.63 vs. 1.55 days; p < 0.01). Outcomes of the present retrospective study show that microperc is a treatment option for medium-sized lower calyx stone, being associated with lower blood loss, procedure, reduced fluoroscopy and hospitalization time, and a higher tubeless rate.

Are the urology operating room personnel aware about the ionizing radiation?

PURPOSE: We assessed and evaluated attitudes and knowledge regarding ionizing radiation of urology surgery room staff. MATERIALS AND METHODS: A questionnaire was sent by e-mail to urology surgery room personnel in Turkey, between June and August 2013. The questionnaire included demographic questions and questions regarding radiation exposure and protection. RESULTS: In total, 127 questionnaires were answered. Of them, 62 (48.8%) were nurses, 51 (40.2%) were other personnel, and 14 (11%) were radiological technicians. In total, 113 (89%) participants had some knowledge of radiation, but only 56 (44.1%) had received specific education or training regarding the harmful effects of radiation. In total, 92 (72.4%) participants indicated that they used a lead apron and a thyroid shield. In the subgroup that had received education about the harmful effects of radiation, the use ratio for all protective procedures was 21.4% (n=12); this ratio was only 2.8% (n=2) for those with no specific training; the difference was statistically significant (p=0.004). Regarding dosimeters, the use rates were 100% for radiology technicians, 46.8% for nurses, and 31.4% for other hospital personnel; these differences were statistically significant (p<0.001). No significant relationship between working period in the surgery room, number of daily fluoroscopy procedures, education, task, and use of radiation protection measures was found. CONCLUSIONS: It is clear that operating room-allied health personnel exposed to radiation do not have sufficient knowledge of ionizing radiation and they do not take sufficient protective measures.

Low magnesium levels an important new prognostic parameter can be overlooked in patients with Fournier's gangrene: a multicentric study.

INTRODUCTION: We evaluated low magnesium levels and three different scoring systems including the Fournier's Gangrene Severity Index (FGSI), the Uludag Fournier's Gangrene Severity Index (UFGSI), and the Charlson Comorbidity Index (CCI) for predicting mortality in a multicentric, large patient population with FG. METHODS: The medical records of 99 FG patients who were treated and followed up in different clinics were reviewed. The biochemical, hematological, and bacteriological results from the admission evaluation were recorded. The CCI, FGSI, and UFGSI were evaluated and stratified by survival. RESULTS: The results were evaluated for the following patients: the survivors (n = 82) and the nonsurvivors (n = 17). The magnesium level for the survivors and nonsurvivors was 2.09 ± 0.28 and 1.68 ± 0.23, respectively (p 0.004). The admission FGSI, UFGSI, and CCI scores were significantly higher in nonsurvivors (p 0.001, p 0.001, p < 0.001, respectively). The receiver operating characteristics analysis revealed that the UFGSI was more powerful than the FGSI. The hypomagnesemia, low hemoglobin and hematocrit, low albumin and HCO3 levels; high alkaline phosphatase; and the high heart and respiratory rates, an FGSI >9, rectal involvement, and a high CCI were associated with a worse prognosis. CONCLUSION: Low magnesium levels might be an important parameter for a worse FG prognosis. Monitoring the serum magnesium levels might have prognostic and therapeutic implications in patients with FG. High CCI, FGSI, and UFGSI scores might be associated with a worse prognosis in patients with FG. The UFGSI might be more powerful scoring system than the FGSI.

Are the urology operating room personnel aware about the ionizing radiation?

ABSTRACT Purpose: We assessed and evaluated attitudes and knowledge regarding ionizing radiation of urology surgery room staff. Materials and Methods: A questionnaire was sent by e-mail to urology surgery room personnel in Turkey, between June and August 2013. The questionnaire included demographic questions and questions regarding radiation exposure and protection. Results: In total, 127 questionnaires were answered. Of them, 62 (48.8%) were nurses, 51 (40.2%) were other personnel, and 14 (11%) were radiological technicians. In total, 113 (89%) participants had some knowledge of radiation, but only 56 (44.1%) had received specific education or training regarding the harmful effects of radiation. In total, 92 (72.4%) participants indicated that they used a lead apron and a thyroid shield. In the subgroup that had received education about the harmful effects of radiation, the use ratio for all protective procedures was 21.4% (n=12); this ratio was only 2.8% (n=2) for those with no specific training; the difference was statistically significant (p=0.004). Regarding dosimeters, the use rates were 100% for radiology technicians, 46.8% for nurses, and 31.4% for other hospital personnel; these differences were statistically significant (p<0.001). No significant relationship between working period in the surgery room, number of daily fluoroscopy procedures, education, task, and use of radiation protection measures was found. Conclusions: It is clear that operating room-allied health personnel exposed to radiation do not have sufficient knowledge of ionizing radiation and they do not take sufficient protective measures.

The protective effects of tadalafil on renal damage following ischemia reperfusion injury in rats.

Ischemia-reperfusion injury can cause renal damage, and phosphodiesterase inhibitors are reported to regulate antioxidant activity. We investigated the prevention of renal damage using tadalafil after renal ischemia reperfusion (I/R) injury in rats. A total of 21 adult male Wistar albino rats were randomly divided into three groups of seven, including Group 1-control, Group 2-I/R, and Group 3-tadalafil + I/R group (I/R-T group) received tadalafil intraperitoneally at 30 minutes before ischemia. Inducible nitric oxide synthase, endothelial nitric oxide synthase, malondialdehyde, and total antioxidant capacity levels were evaluated, and histopathological changes and apoptosis in the groups were examined. Tadalafil decreased malondialdehyde levels in the I/R group and increased the total antioxidant capacity level. Histopathological and immunohistochemical findings revealed that tadalafil decreased renal injury scores and the ratios of injured cells, as measured through apoptotic protease activating factor 1, inducible nitric oxide synthase, and endothelial nitric oxide synthase levels. We suggest that tadalafil has protective effects against I/R-related renal tissue injury.

Colon perforation related to percutaneous nephrolithotomy: from diagnosis to treatment.

We present our experience with the largest series of colon perforation (CP) as complication of percutaneous nephrolithotomy (PNL). From January 1998 to August 2014, 22 cases that presented with PNL-related CP from seven referral centers were retrospectively reviewed. The patients with CP were evaluated in terms of probable risk factors. Peri-operative and postoperative findings, timing of diagnosis, and treatment modalities of the CP were reviewed. Of the 22 patients, previous ipsilateral renal surgery (n:2) and retrorenal colon (n:5) were the risk factors for CP. The CP was directly visualized via nephroscopy during the surgery in 3 (13.6%) and with nephrostography at the end of the procedure in 4 patients (18.2%). In two patients, perforation was realized via the passage of contrast into the colon with nephrostography on the postoperative second day. Postoperative passage of feces through the nephrostomy tube was seen in six patients. The clinical signs in 13 cases directed CP diagnosis. The confirmation of the CP was achieved with a CT scan in all the patients. The patients with extraperitoneal perforation were primarily managed conservatively. Open surgical treatment was performed in cases with intraperitoneal perforation (n:5) and those with extraperitoneal perforation resistant to conservative treatment (n:5). Meticulous evaluation of the risk factors preoperatively is the initial step in the prevention of CP. Timely diagnosis plays essential role in the management of this PNL complication. Although extraperitoneal CP may be managed conservatively, surgery is required for intraperitoneal CPs.

Dickkopf-1 levels in Turkish patients with bladder cancer and its association with clinicopathological features.

BACKGROUND: Evidence indicates that Dickkopf-1 (DKK-1) levels may be a biomarker for cancer risk. The aim of this study was to assess DKK-1 and its correlation with clinic-pathological features in patients with bladder cancer. MATERIALS AND METHODS: DKK-1 levels were determined in serum samples from 90 patients with bladder cancer before transurethral tumor resection. The concentrations of DKK-1 were determined by using enzyme linked immune-sorbent assay (ELISA). RESULTS: Elevated preoperative DKK-1 levels were associated with tumor stage (p<0.001), grade (p<0.001) and histological grade (p<0.001). CONCLUSIONS: The results of our study demonstrated that the level of serum DKK-1 is correlated with both disease progression and increase in the tumor grade. Preoperative serum DKK-1 elevation may thus represent a novel marker for the determination of bladder cancer and the detection of patients with a likely poor clinical outcome.

Biochemical and histologic study of lethal cisplatin nephrotoxicity prevention by mirtazapine.

BACKGROUND: Cisplatin is a platinum derivative frequently used in the chemotherapy of different solid tumors. This biochemical and histologic study investigated a possible protective effect of mirtazapine with regard to cisplatin-induced nephrotoxicity in the rat. METHODS: The animals were divided into 4 groups: 15 mg/kg mirtazapine + 10 mg/kg cisplatin, 30 mg/kg mirtazapine + 10 mg/kg cisplatin, only 10 mg/kg cisplatin and negative control (healthy) group. During 14 days, the treatment and treated control group took drugs, while the healthy animals were given distilled water on the same schedule. All animals were sacrificed by high-dose anesthesia at the end of the 14 days of treatment; their kidneys were removed and subjected to histologic and biochemical study. RESULTS: In both of the doses we used, mirtazapine decreased the levels of malondialdehyde, creatinine, blood urea nitrogen and myeloperoxidase activity when compared to cisplatin group. On the other hand, it increased total glutathione level in all doses. Slight histopathological findings were determined in mirtazapine groups when compared to cisplatin control group. CONCLUSION: In the light of our results and literature knowledge, we can conclude that the protective effect of mirtazapine in cisplatin toxicity originates from its own antioxidant activity.

Retroperitoneoscopic nephrectomy for non-functioning kidneys related to renal stone disease.

Laparoscopic nephrectomy has become the gold standard procedure for nonfunctioning or symptomatic benign kidneys due to renal calculi, obstructive, refluxive, and inflammatory nephropathies or renovascular hypertension. We aimed to investigate the effect of renal calculi as a reason of non-functioning on the progress and complication rates of the retroperitoneoscopic nephrectomy (RPN). During a 2-year period, 108 patients with benign renal conditions underwent RPN by single surgeon. Among these patients, total of 27 (Group 1) with a non-functioning kidney due to renal calculi were retrospectively compared with 27 patients (Group 2) with other benign renal conditions. The two groups were matched for age, body mass index, and previous renal surgery. We analyzed operative and post-operative findings and complications. The mean age and the BMI of the groups were similar. The operation time was significantly longer in Group 1 than Group 2 (p = 0.0001). There was no significant difference between the groups with respect to mean hemoglobin drop postoperatively (p = 0.9) and hospitalization time (p = 0.06). The perioperative and postoperative complication rates were higher in Group 1 but not statistically different from Group 2 (p = 0.19, p = 0.29, respectively). RPN for nonfunctioning calculous kidneys is more challenging procedure and is associated with prolonged operation time related to difficult dissection of dense adhesions. It can be safely performed by experienced hands with similar perioperative and postoperative complication rates as well as for other benign conditions of the kidney.

Effect of mirtazapine on oxidative stress created in rat kidneys by ischemia-reperfusion.

In this study, the effect of mirtazapine on rat kidneys versus ischemia-reperfusion (IR) damage was biochemically and histopathologically investigated. The results have shown that malondialdehyde (MDA) level of healthy rat group is 15.2 mol/g protein. The level of this substance was measured as 26.7 mol/g in only ischemia group. The MDA levels of IR and mirtazapine + renal ischemia-reperfusion (MRIR) groups were 39 ± 17.6 mol/g protein. While myeloperoxidase activity of healthy rat group was 20.2 u/g, the activities of only ischemia, IR, and MRIR groups were 28, 36.3, and 21 u/g, respectively. The glutathione levels were measured as 17.7, 12.8, 7.5, and 16.2 nmol/g in healthy, only ischemia, IR, and MRIR groups, respectively. Finally, glutathione S-transferase activities of healthy, only ischemia, IR, and MRIR groups were determined as 20, 13.8, 7.1, and 18.3 u/g, respectively. Histopathologically, while hemorrhage in interstitial area was observed in only ischemia group, significant tubular epithelial swelling, necrosis, and cast accumulation were seen in IR group. In MRIR group, only mild tubular epithelial swelling and mild hyaline cast accumulation were observed in kidney tissue. Consequently, it can be said that mirtazapine has a protective effect on IR-induced kidney damage.

The effects of percutaneous nephrolithotomy on renal function in geriatric patients in the early postoperative period.

Since percutaneous nephrolithotomy (PNL) is a surgical intervention, it may show deteriorative effects on renal function in the early postoperative period. In this study, the deteriorative effects of PNL on renal function were investigated in the geriatric population, and it was compared to the non-geriatric population.A total of 711 patients [64 in the geriatric group (female/male ratio: 33/31, mean age: 70.4 +/- 4.2 years), 647 in the non-geriatric group (female/male ratio: 267/380, mean age: 40.9 +/- 12.7 years)] were included in the study. Demographic data, biochemical parameters, stone diameters, duration of the operation and estimated glomerular filtration rates (eGFR) were recorded both preoperatively and postoperatively.The eGFR ratio (post-/preoperative) was 1.13 +/- 1.00 in the geriatric group, 0.98 +/- 0.20 in the non-geriatric group (P < 0.001). Although the mean stone diameter was larger in the geriatric group than the non-geriatric group (10.08 +/- 6.5 mm, 8.28 +/- 5.54 mm, P = 0.037), the mean duration of the operation was shorter in the geriatric group than in the non-geriatric group (55.7 +/- 13.6 min, 61.3 +/- 20.9 min, P = 0.036). Hematocrit, hemoglobin, urea levels, and grade of hydronephrosis were not different between the groups.Renal function impairment is expected to be common in the geriatric patient population since they already have lower basal renal function. In the present study, the ratio of postoperative to preoperative eGFR was higher in the geriatric group. Hematocrit, hemoglobin, and urea levels and degree of hydronephrosis of these two groups did not show a great difference. The relatively short duration of the operation in the geriatric group and the diversity of perioperative and postoperative care of these two groups may explain the difference.

Impact of percutaneous access point number and location on complication and success rates in percutaneous nephrolithotomy.

OBJECTIVES: Percutaneous nephrolithotomy (PNL) is sometimes associated with complications, especially in patients with complex stones. Herein, we review our experience with PNL to determine the impact of percutaneous access number and location on success and complication rates. PATIENTS AND METHODS: During a 2-year period, a total of 275 patients with a mean age of 42.3 +/- 14.8 (range: 13-75) years underwent PNL. Stones were classified as simple in 51.6%, and complex (staghorn calculi or renal pelvis stones coexisting with caliceal stones) in 48.4%. Percutaneous access was done under C-armed fluoroscopy and the tract was formed with a high-pressure balloon dilation system. One single percutaneous access was sufficient in 210 (76.4%), while 2 accesses were utilized in 44 (16%), and > or =3 accesses in 21 cases (7.6%). Supracostal access was performed in 23 (8.4%) patients. RESULTS: An overall success rate of 94.9% was achieved. Stone location, but not the access point location, was the major determinant for success, which was 99.3 and 90.2% in patients with simple and complex stones, respectively (p < 0.01). Significant complications included bleeding necessitating blood transfusion in 28 (10.2%), and hydropneumothorax in 2 (0.7%) patients. Bleeding was observed in 39.1 and 7.5% of patients managed with supracostal access, and subcostal access, respectively (p < 0.01). An increased number of access points significantly augmented the risk for bleeding. Bleeding was encountered in 7.6% of patients managed with 1 percutaneous access point, and in 18.5% of cases managed with > or =2 access points (p < 0.05). Hydropneumothorax occurred in patients with supracostal access. CONCLUSION: Supracostal access as well as multiple punctures may be needed especially in the management of complex stones, and the need for multiple access points and supracostal access significantly increases complication rates.

When is open ureterolithotomy indicated for the treatment of ureteral stones?

AIM: Improvements in extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy have almost eradicated the need for open surgery in ureteral stones. The aim of this study was to assess characteristics of patients who underwent open ureterolithotomy. METHODS: During a 5-year period, a total of 654 patients with ureteral stones were treated. Initial management consisted of ureteroscopy in 524 patients, ESWL in 62 patients and percutaneous nephrolithotomy (PCNL) in 12 patients. Open surgery was performed in 56 patients. Stone location, size and success rates were retrospectively analyzed. RESULTS: Ureteroscopy resulted in successful stone removal in 94%, 98% and 98.5% of proximal, mid and distal ureteral stones, respectively. A total of 14 patients with ureteroscopy failure were referred for open surgery. ESWL treatment resulted in success in 55 patients (88%), and those with ESWL failure were referred for either ureteroscopy (n = 3) or open surgery (n = 4). Open surgery was performed in a total of 56 patients, 38 of whom had been referred from other centers. Stone location was proximal ureter in 25 (44.6%) patients (stone size: 2-12 cm(2)), mid ureter in five (8.9%) patients (stone size: 2-6 cm(2)) and distal ureter in 26 (46.4%) patients (stone size: 4-9 cm(2)). A history of previous unsuccessful endourological procedure was observed in 33 (58%) of 56 patients. Children under age 16 (range 1-15 years) comprised 17.8% of patients undergoing open surgery. CONCLUSION: Open surgery, which is nowadays being replaced with laparoscopic techniques, is generally indicated for failed endourological procedures (58%), particularly in centers that do not have flexible ureteroscopy or laser lithotriptor, and in patients with larger stones (>3 cm). Children (17.8%) are also candidates for open surgery, if specifically designed endourological equipment is not available.