Comparison of the Effect of Lidocaine versus a Lidocaine-Bupivacaine Combination in a Periprostatic Nerve Block Undergoing Transrectal Ultrasound-Guided Prostate Biopsy: A Double-Blind Randomized Controlled Trial.

INTRODUCTION: To determine whether a combination of the long acting local anesthetic, bupivacaine, and lidocaine is better than lidocaine alone in the long-term pain control, which is a short-acting anesthetic. MATERIALS AND METHODS: In group 1, periprostatic nerve block was applied to both neurovascular areas with 2% lidocaine (5 ml) in an isotonic solution (5 ml). In group 2, the combination of 2% lidocaine (5 ml) and 5mg/ml bupivacaine (5 ml) was used for the PPNB. RESULTS: In the first 30 minutes the mean VAS scores of groups 1 and 2 were 2.1 ± 0.2 and 1.2 ± 0.1, respectively (p = 0.002). VAS scores of group II determined at 1, 2, 4, 6, and 8 hours after the biopsy were significantly lower since it was (p < 0.05). CONCLUSION: While periprostatic nerve block for late phase pain control, applying a combination of a long-acting local anesthetic, such as bupivacaine, is effective in terms of pain control and patient comfort.

Posterior Urethral Polyp: First Holmium-YAG Laser Ablation on a 3-Month-Old Infant.

BACKGROUND: Urethral polyps are rare benign pathologies seen in the male posterior urethra, more frequently originating from verumontanum. In this article, we aimed to discuss diagnosis and treatment of a urethral polyp causing hematuria and urinary infection in a 3-month-old male infant. This is the first case in the literature in which a urethral polyp is treated with Holmium yttrium-aluminum-garnet (YAG) laser. CASE PRESENTATION: The patient was a 3-month-old male infant, and complains were hematuria and crying during micturition. Ultrasonography and voiding cystourethrogram were used for diagnosis. Urethral polyp was observed on urethrocystoscopy. Ablation was performed with a newborn cystoscope. CONCLUSION: Urethral polyp can cause hematuria and urinary obstruction and should be considered in the differential diagnosis of pathologies such as posterior urethral valve and cecoureterocele that could cause infravesical obstruction. Holmium-YAG laser is a good choice of treatment with easy application possibilities using a newborn cystoscope, especially for newborns and infants who have thin urethra.

The Relationship Between Endothelial Nitric Oxide Synthase Gene (NOS3) Polymorphisms, NOS3 Expression, and Varicocele.

BACKGROUND: Varicocele is an abnormal enlargement of the pampiniform venous plexus in the scrotum. Varicocele is the most common cause of secondary male infertility. Nitric oxide (NO), which has a role on varicocele pathophysiology, is synthesized by endothelial nitric oxide synthase gene (NOS3). OBJECTIVE: In our study, we aimed to explain the relationship between varicocele, three common NOS3 polymorphisms (T-786C, G894T, 4b/a), and NOS3 mRNA expression levels. METHODS: We investigated NOS3 T-786C, G894T, and 4b/a polymorphisms in 102 patients with varicocele and 100 healthy controls. Twenty-four patients and 17 controls were chosen for expression studies based on polymorphism subgroupings. Subgroup 1 includes patients who have no minor allele polymorphisms, and subgroups 2, 3, and 4 have T-786C, G894T, and 4b/a polymorphisms, respectively. RESULTS: The 4b/a polymorphism demonstrated significantly elevated levels in both allele and genotype analysis in the control group compared to the patient group. The G894T polymorphism was statistically elevated for genotypic frequencies in the patient group compared to the control group, but this finding did not extend to allelic frequencies. There were no statistically significant differences in either the allelic or genotypic frequencies between patients and control groups for the T-786C polymorphism. When patient and control expression levels were compared without considering the subgroups, the NOS3 expression level was found to be statistically higher in the patient group. There were no statistically significant differences in the patient and control group expression levels when stratified by subgroup, nor was there any effect of the polymorphisms under study on expression levels. CONCLUSIONS: The 4b/a polymorphism may have a protective effect for varicocelem and G894T polymorphism may contribute to varicocele occurrence by lowering the level of NO. The higher NOS3 expression levels in the patient group may be a kind of dilator compensatory mechanism to protect vascular anatomy in varicocele.

Rigid Ureteroscope Aided Insertion of Ureteral Access Sheath in Retrograde Intrarenal Surgery.

OBJECTIVE: To compare the outcomes of the ureteral access sheath (UAS) placement techniques in patients undergoing retrograde intrarenal surgery. MATERIALS AND METHODS: The patients were divided into two groups with respect to placement method of UAS. UAS was placed with the classical method, through the guidewire, in the first group of the patients (group I). The outer sheath of UAS was worn on the semirigid endoscope and placed into the ureter under direct vision in the second group (group II). The number of patients was the same in two groups (n = 42). RESULTS: Overall, 70 of 84 (83.3%) patients were stone free after the initial treatment. The success rates were comparable between the two groups (80.9% vs 85.7%, P = .859) 1 month after surgery. Fluoroscopy screening time (11.7 ± 5.7 seconds vs 0 second), UAS placement time (245 ± 138.4 seconds vs 40 ± 17.9 seconds; P < .001), and operation time (58.7 ± 17.1 minutes vs 51.2 ± 16.7 minutes; P = .046) were significantly longer in group I when compared to group II. The complication rate was higher in group I when compared to group II (23.8% vs 9.5%), but the difference was not statistically significant (P = .079). CONCLUSION: Introducing UAS into ureter under direct vision while it was precisely worn on ureteroscope makes this step safer, and protects the surgeon and patient from radiation exposure by shortening fluoroscopy and operation times.

Micropercutaneous Nephrolithotomy in the Management of Bilateral Renal Stones in a 7-Month-Old Infant: The Youngest Case in the Literature.

During infancy, the renal parenchyma and pelvicalyceal system are relatively fragile. Therefore, percutaneous nephrolithotomy for the management of renal stones in this age group is a challenging procedure for urologists. Herein, we present the uneventful management of bilateral renal stones using micropercutaneous nephrolithotomy (microperc) administered to a 7-month-old infant with recurrent urinary tract infections. In this paper, the advantages and disadvantages of the microperc procedure are discussed. As far as we know, our patient is the youngest case in whom the microperc procedure has been performed.

The Effects of RAAS Inhibition in Rate Limiting Step by Aliskiren on Testicular Torsion Injury in Rats.

PURPOSE: Testicular torsion is a urological emergency. Failure of timely intervention for this issue leads the testicles to go into necrosis. If left untreated, it can lead to loss of the reproductive organs. The aim of this study was to examine the role of aliskiren in testicular torsion and detorsion injuries. MATERIALS AND METHODS: Rats were divided into 8 groups of 12 each, including no torsion-detorsion, no torsion-detorsion plus 200 mg/kg aliskiren orally, torsion, torsion-detorsion, torsion plus 100 mg/kg aliskiren orally, torsion plus 200 mg/kg aliskiren orally, torsion-detorsion plus 100 mg/kg aliskiren orally and torsion-detorsion plus 200 mg/kg aliskiren orally. Aliskiren was administered 30 minutes before ischemia and reperfusion, and also 24 hours before the experimental protocol in all treatment groups. Ischemia and reperfusion were each applied for 2 hours. RESULTS: Testicular damage decreased superoxide dismutase and glutathione, and increased malondialdehyde in the testis tissues of rats. Aliskiren administration increased superoxide dismutase and glutathione, and decreased malondialdehyde in the testis tissues. Values were measured by a biochemical autoanalyzer. In addition, this torsion-detorsion damage caused a significant increase in levels of the inflammatory cytokine and agents interleukin-1ß and inducible nitric oxide synthase, as examined by real-time polymerase chain reaction. Aliskiren administration decreased these parameters. On pathological evaluation administration of a 200 mg/kg dose of aliskiren was found to protect the testis. Renin-angiotensin-aldosterone system inhibition by aliskiren caused an increase in serum renin levels and a decrease in serum angiotensin II levels. CONCLUSIONS: It appears that aliskiren protects the testis from ischemia-reperfusion damage by regulating inflammation and the oxidant-antioxidant balance via renin-angiotensin-aldosterone system inhibition.

Renoprotective effect of aliskiren on renal ischemia/reperfusion injury in rats: electron microscopy and molecular study.

PURPOSE: To determine the protective effect of aliskiren on ischemia-reperfusion (I/R) injury in a rat renal (I/R) model. METHODS: Rats were randomly divided into five groups: sham control group; sham control with aliskiren pretreatment; I/R group and I/R with two doses of aliskiren pretreatment. Rats were unilaterally nephrectomized and subjected to 45 min of renal pedicle occlusion followed by 24 h reperfusion. Aliskiren (50 and 100 mg/kg) was administered orally by gavage 24 and 1 h prior to ischemia. After 24 h reperfusion, kidney samples were taken for the determination of malondialdehyde (MDA) level, superoxide dismutase (SOD), glutathione (GSH) activity and histological evaluation. The level of serum creatinine (SCR) and blood urea nitrogen (BUN), renin and angiotensin II (AT-2) was measured in serum samples. RESULTS: Kidneys from I/R groups showed significant increase in MDA level and significant decrease in GSH, and SOD activity. IL-1ß, iNOS and NFkB gene expression significantly increased in the I/R groups in the rat kidney tissue. Aliskiren treatment showed a significant down-regulatory effect on IL-1ß, iNOS and NFkB mRNA expression. Compared with the sham group, SCR and BUN, renin and AT-2 were significantly increased in the I/R rats, accompanied by histopathological damage to the kidney. CONCLUSION: Pretreatment with aliskiren ameliorated I/R-induced renal injury through decreasing nitric oxide and AT-2 levels and by the reduction of injury induced by I/R injury and ameliorated renal histopathological molecular and biochemical changes.

Holmium laser lithotripsy with semi-rigid ureteroscopy: a first-choice treatment for impacted ureteral stones in children?

BACKGROUND: We aimed to assess the effectiveness of semi-rigid ureteroscopy and holmium laser lithotripsy in the treatment of impacted ureteral stones in children. MATERIAL/METHODS: We evaluated a total of 32 children under the age of 18 years treated with ureteroscopic holmium laser lithotripsy for impacted ureteral stones between January 2005 and July 2013. Their stone-free state was defined as the absence of any residual stone on radiologic evaluation performed 4 weeks postoperatively. Complications were evaluated according to the modified Clavien classification. RESULTS: The mean patient age was 9.5±5.1 years (range 1-18 years). Seven (21.8%) of the stones were located in the proximal ureter, 9 (28.2%) were in the mid-ureter, and 16 (50%) were in the distal ureter. The mean stone size was calculated as being 10.46±3.8 mm2 (range 5-20). The stone-free rate was 93.75% (30/32 patients) following primary URS. Additional treatment was required for only 2 (6.25%) of the patients. After the procedure, a D-J stent was placed in all the patients. The total complication rate was 15.6% (5 patients). The 10 total complications in these 5 patients were 5 (15.6%) Grade I, 1 (3.1%) Grade II, 2 (6.25%) Grade IIIa, and 2 (6.25%) Grade IIIb. The mean follow-up period was 16.5 months (range 3-55). CONCLUSIONS: For the treatment of impacted ureteral stones in children, holmium laser lithotripsy with semi-rigid ureteroscopy, with its low retreatment requirement and acceptable complication rates, is an effective and reliable method in experienced and skilled hands as a first-choice treatment approach.

Flexible ureterorenoscopy for the treatment of kidney stone within pelvic ectopic kidney.

OBJECTIVE: To present the outcomes of flexible ureterorenoscopy (F-URS) and laser lithotripsy for the treatment of calculi within pelvic ectopic kidney (PEK). PATIENTS AND METHODS: We retrospectively reviewed the medical records of 26 patients with calculi in PEK treated with F-URS in 5 referral hospitals between 2010 and 2013. Patient demographics and stone characteristics (age, sex, body mass index, stone size, location, history of shock wave lithotripsy or kidney surgery), and perioperative measures (duration of operation, fluoroscopic imaging, and hospitalization and success and complication rates) were reviewed. RESULTS: A total of 26 patients with mean age of 41.1 ± 15.8 years (7-72 years) were included in the study. The mean stone size was 17.0 ± 5.1 mm (10-28 mm). The mean procedure and fluoroscopy times were calculated as 52.1 ± 27.7 minutes (30-120 minutes) and 54.8 ± 48.9 seconds (10-180 seconds), respectively. The mean length of hospital stay was 2.7 ± 1.8 days (1-9 days). Treatment was deemed successful in 22 patients (84.6%). Ureteroscopy failed in 4 patients (15.4%) due to impaired passage of fragments (n = 3) or inability to reach the stone secondary to the location in an isolated lower calyx (n = 1). Minor postoperative complications were observed in 5 patients (19.2%; persistent hematuria [n = 1], fever [n = 1], renal colic [n = 2], and urinary tract infection [n = 1]). No severe complications or mortality occurred. CONCLUSION: Our results suggest that F-URS is a safe and effective minimally invasive treatment modality for small- and medium-sized stones in PEK.

Renal epithelioid angiomyolipoma mimicking urothelial carcinoma of the upper urinary tract.

Epithelioid angiomyolipoma is a rare mesenchymal tumor arising mainly in the kidney that can potentially behave aggressively. Epithelioid angiomyolipoma can often resemble sarcomatoid renal cell carcinoma, high grade renal carcinoma or sarcoma. Its similarity to renal cell carcinoma has been emphasized in most of the cases reported in literature. With the purpose of contributing to the awareness of this similarity, a 32-year-old female patient with renal epitelioid angiomyolipoma in the left kidney which radiologically mimicked urothelial cell carcinoma of the upper urinary tract is presented.

Extracorporeal shockwave lithotripsy under sedoanalgesia for treatment of kidney stones in infants: a single-center experience with 102 cases.

OBJECT: We present the efficacy of shockwave lithotripsy (SWL) therapy administered with sedoanalgesia in infants with kidney stones. MATERIALS AND METHODS: We enrolled 102 patients aged 5-24 months who had kidney stones and received SWL therapy under sedoanalgesia using a Siemens Lithostar Modularis device. Patient and stone characteristics, therapy parameters, pain score, complications, discharge time, and follow-ups were registered and evaluated. Pain score was assessed using a Neonatal Infant Pain Score (NIPS). Postanesthetic discharge scoring system (PADSS) was used for the assessments of postprocedural discharge procedure. RESULTS: Mean age of the patients was 17.2 ± 6.3 months (5-24 months). Mean stone size was 7.9 ± 3.3 mm (5-23 mm). The most common concomitant metabolic disorders were hypercalciuria and hypocitraturia. The stone-free rates of the infants were 70.6, 87.3, and 99.1 % after the first, second, and third sessions of SWL therapy, respectively. The mean NIPS scores procedure during, and at 1 h after SWL procedure were determined as 0.24 ± 0.45 and 0.34 ± 0.47, respectively. There was no statistically significant difference between two pain score values (P = 0.114). The mean discharge time of patients after the SWL procedure were 108.6 ± 27.9 min. Forty-two patients (41.1 %) were followed up. The follow-up period varied between 8 and 48 months (mean 19.5 months); none of those patients showed evidence of diabetes mellitus, hypertension, or renal function impairment. CONCLUSIONS: SWL therapy under sedoanalgesia is a safe and efficient treatment modality that can be administered with low complication rates and high stone-free rates in the treatment of renal stones in infants.

Primary vesical actinomycosis in a 23-year-old man.

Introduction. Actinomycosis can affect any organ of the body, although cutaneous fistulas are common in actinomycotic infections, and other organs such as the bladder are only rarely involved. Case Presentation. Herein we report and discuss a young male patient with primary vesical actinomycosis. A 23-year-old man was hospitalized complaining of intermittent gross hematuria over a 6-month duration. The patient underwent a cystoscopic examination under general anesthesia; an edematous, hyperemic, wide-based mass, which protruded from the dome of the bladder, was seen and incompletely resected. The histopathological examination of the material showed Actinomyces organisms surrounded by inflammation and a photomicrograph showed the microorganism. After confirmation of bladder actinomycosis, the patient received penicillin. A CT scan of the abdomen and pelvis showed no evidence of the mass at the postoperative 6th month. Cystoscopic examination showed complete healing of the transurethral resection area at the dome of the bladder. Conclusion. In conclusion, we believe that the gold standard treatment for vesical actinomycosis should include the combination of a transurethral resection of the mass and long-term penicillin treatment.

Endoscopic guided additional access for staghorn calculi.

BACKGROUND AND PURPOSE: Flexible nephroscopy is an important technique in the management of staghorn renal calculi to reach peripheral calices. In this study, we present our experience with flexible nephroscopy and fluoroscopy-guided additional access creation for staghorn renal calculi. PATIENTS AND METHODS: We conducted a retrospective analysis of patients with staghorn renal calculi who were treated with multiple percutaneous renal tracts created with the guidance of flexible nephroscopy and fluoroscopy. Additional tracts were performed with combined flexible nephroscopy and fluoroscopy guidance. Flexible nephroscopy was used to help target the calix and ensure the safety of access. RESULTS: Additional percutaneous renal access was achieved using combined flexible nephroscopy and fluoroscopy guidance in 26 patients with complete staghorn (n=21) and partial staghorn (n=5) kidney stones. The cumulative stone size was 59.3 mm. The mean procedure times, fluoroscopy times, and hospitalization times were 91.5 minutes, 3.4 minutes, and 2.7 days, respectively. The postoperative hematocrit drop was 4.96±3.8. Upper and lower calices were the most common primary access tracts in 11 and 15 patients, respectively. Stone-free status was achieved in 22 (84.6%) patients with a mean 2.1±0.3 tract number. Postoperative complications were observed in six (23.1%) patients. CONCLUSIONS: In the requirement of additional access for staghorn renal calculi, use of flexible nephroscopy with fluoroscopy increases the safety of the procedure by confirmation of precise renal access.

Ureteroscopy and holmium laser lithotripsy: is this procedure safe in pregnant women with ureteral stones at different locations?

OBJECTIVES: The aim of this study was to assess the safety and effectiveness of ureteroscopy and Holmium: Yttrium-Aluminum-Garnet lithotripsy for the treatment of ureteral stones with different localizations in symptomatic pregnant women. METHODS: A retrospective analysis was performed on 19 pregnant patients referred to our center between January 2005 and December 2012 with symptomatic hydronephrosis requiring surgical intervention. 7.5 F and 9.5 F semirigid ureterorenoscopy with Holmium laser lithotripsy was used for treatment in all patients. Complications were stratified according to modified Clavien criteria. RESULTS: The mean age of patients was 25.4 (18-41) years, and the mean gestation duration was 24.8 (7-33) weeks. Six cases (31.5%) had a history of stone. Solitary kidney secondary to previous nephrectomy was observed in 2 patients and 1 patient had a hypoplastic kidney. Abdominal ultrasonography was used as the main diagnostic tool. Mean stone size was 9.2 mm (6-13). The location of the stones was the lower, middle, and upper ureter in 8 (42.1%), 5 (26.3%) and 6 (31.5%) cases, respectively. All stones were fragmented with Holmium laser lithotripsy. Of the 19 patients, 11 (57.8%) required double J stent insertion peroperatively. Intraoperative urological and obstetric complications were not observed. Postoperatively two complications were noted. According to Clavien criteria a complication was level 1, and the other was level 2. CONCLUSIONS: For treatment of pregnant women with symptomatic ureteral stones in every location, Holmium laser lithotripsy with a semirigid ureteroscopy can be used as judicious treatment. This approach is effective and safe with an acceptable complication rate.

Giant isolated renal cyst hydatid: From diagnosis to treatment.

Hydatid cyst disease is a parasitic infestation caused by Echinococcus granulosus. Renal involvement is rarely seen as 2-4% of all cases. Rarely renal involvement is isolated whereas commonly it accompanies involvement of other organs. We aimed to present a 30-year-old male patient with renal involvement reaching a giant size and undiagnosed in another center.

Minipercutaneous nephrolithotomy in infants: a single-center experience in an endemic region in Turkey.

The objective of the study is to evaluate the effectiveness and safety of miniaturized percutaneous nephrolithotomy (mini-PNL) method in infantile patients <3 years of age diagnosed with renal stones. We studied 48 renal units in 40 patients of infantile patients <3 years of age who underwent mini-PCNL at our institute. The mean age of the patients was 24.02 (5-36) months. The mean diameter of the stones was 22.3 mm (11-45 mm). Intrarenal access was achieved under fluoroscopic (n = 43) or ultrasonographic (n = 5) guidance under general anesthesia. A 20 Fr peel-away sheath, a 17 Fr rigid nephroscope and a pneumatic intracorporeal lithotripsy were used. Mean operative time for PNL was 85 (25-135) min. Mean fluoroscopy time was estimated as 3.7 min. The mean hospital stay was 4.3 days (2-10). Mean hemoglobin loss was 0.89 g/L (11.56-10.67) and three of the patients, including one case during the perioperative period, required blood transfusions. Colonic perforation developed in one case. In two patients, urinary drainage persisted for more than 24 h after withdrawal of the nephrostomy tube. Seven patients developed urinary tract infections (UTI). At the end of the postoperative first week, the stone-free rate was estimated to be 81.2 %. In conclusion, for percutaneous management of renal stones in the infantile age group, mini-PNL is an applicable treatment modality that can be applied through small incisions. It has higher stone-free rates, shorter hospital stays, and excellent esthetic outcomes. In this age group especially, surgical exposure to hypothermia and radiation should be avoided.