The histomorphological findings of kidneys after application of high dose and high-energy shock wave lithotripsy.

INTRODUCTION: In this animal study, we reviewed the histomorphological findings in rabbit kidneys after a high number of high-energy shock wave applications and observed if there were any cumulative effects after repeated sessions. MATERIAL AND METHODS: We formed 2 groups, each consisting of 8 rabbits. Group 1 received 1 session and group 2 received 3 sessions of ESWL with a 7 day interval between sessions, consisting of 3500 beats to the left kidney and 5500 beats to the right kidney per session. The specimens of kidneys were examined histomorphologically after bilateral nephrectomy was performed. For statistical analysis, 4 groups of specimens were formed. The first and second groups received 1 session, 3500 and 5500 beats, respectively. The third and fourth groups received 3 sessions, at 3500 and 5500 beats per each session, respectively. The sections were evaluated under a light microscope to determine subcapsular thickening; subcapsular, intratubular and parenchymal hemorrhage; subcapsular, intersitital, perivascular and proximal ureteral fibrosis; paranchymal necrosis; tubular epithelial vacuolization; tubular atrophy; glomerular destruction and calcification. RESULTS: In histopathological examinations capsular thickening, subcapsular hematoma, tubuloepithelial vacuolisation, glomerular destruction, parenchymal hemorrhage, interstitial fibrosis, and perivascular fibrosis were observed in all groups. In statistical analysis, on the basis of perivascular fibrosis and tubular atrophy, there was a beats per session dependent increase of both. CONCLUSIONS: The detrimental effects from ESWL are dose dependent but not cumulative for up to 3 sessions. Histopathological experimental animal studies will aid in understanding local and maybe, by means of these local effects, systemic effects.

Safety and efficacy of retropubic or transobturator midurethral slings in a randomized cohort of Turkish women.

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of retropubic (RP) or transobturator (TO) midurethral slings (MUS) in a prospective randomized cohort of Turkish women. PATIENTS AND METHODS: A total of 54 women with urodynamic stress urinary incontinence (SUI) were randomized to undergo either RP or TO MUS between August 2006 and February 2013 in a tertiary referral center by a single surgeon. All patients had history, physical examination, urodynamic evaluation and quality of life assessments. The validated Turkish versions of the SEAPI, ICIQ-SF and OAB-V8 questionnaires were used. The Advantage® RP and the Obtryx® TO MUS Systems were used for all RP and TO procedures. RESULTS: Twenty-seven patients were randomized to each group. The median follow-up was 48.5 ± 21.8 months. The median hospital stay was 24.0 ± 4.8 h and median operative time was 35.0 ± 19.9 min. The overall objective and subjective cure rates were 92.6 and 79.6%, respectively. The quality of life of all patients significantly increased after the operation compared to their preoperative status. Patients with a poorer subjective cure rate were those with mixed urinary incontinence, whose preoperative SEAPI and OAB-V8 scores were significantly higher. CONCLUSION: MUS surgery is highly effective and could safely be performed in a cohort of Turkish women with SUI in subspecialty centers by experienced surgeons. There is no significant difference between RP or TO applications in terms of safety and efficacy. Further studies with long-term follow-up data are required.

An alternative for short renal vein during kidney transplantation: long-term experience with polyethylene terephthalate (Dacron) vascular graft.

OBJECTIVE: To describe the first long-term experience with the polyethylene perephthalate vascular graft to lengthen a short renal vein during kidney transplantation. MATERIALS AND METHODS: The polyethylene terephthalate vascular graft was interposed between the short renal vein of the donor kidney and the recipient's external iliac vein using 6-0 Prolene suture on a 13-mm needle. The postoperative follow-up protocol of the patients included regular serum creatinine levels and Doppler ultrasound scans. RESULTS: The median follow-up period was 74.5 months (range 51-128). Postoperative Doppler ultrasonography showed no complications in any of the patients. None of our patients experienced any kind of rejection. The median creatinine level at the last follow-up visit was 0.99 mg/dL (range 0.73-1.56). CONCLUSION: In our experience, the use of polyethylene terephthalate vascular grafts as a venous graft for the short renal vein in kidney transplantation provides an alternative option with long-term success.

Transarterial glue embolization in iatrogenic renovascular injuries.

Iatrogenic injuries of the intrarenal arterial system include pseudoaneurysms and fistulas. They can cause hematuria and life-threatening hemodynamic instability, and therefore should be treated promptly. Endovascular treatment is recommended for these cases due to its effectiveness. Among the different agents used for embolization, n-butyl-2-cyanoacrylate (glue) has rarely been used. We present 15 patients with pseudoaneurysms and/or arteriovenous or caliceal fistulas who were treated by glue embolization. In our patient group, five had a history of percutaneous nephrolithotomy, six had renal biopsies, three had nephron-sparing surgery, and one had percutaneous nephrostomy. Glue embolizations were performed with the microcatheter technique. All patients were successfully treated, and all but one had excellent follow-ups. One patient suffered from disseminated intravascular coagulation secondary to transfusion and died after the procedure. We think glue embolization is a safe and effective treatment for this group of patients and present our experience along with the technical approach.

Solitary fibrous tumor of the kidney. Case report.

Solitary fibrous tumors are rare spindle cell neoplasms usually arising in the pleura. They have, however, also been reported at extrapleural locations. Solitary fibrous tumor (SFT) of the kidney is rare. Despite its rarity, histological diagnosis of solitary fibrous tumor is crucial to avoid misdiagnosis with other more aggressive tumors arising in the kidney. We report a solitary fibrous tumor of the left kidney that presented as a malignant tumor in a 51-year-old woman, and include clinical and radiographic findings. The tumor was well circumscribed and composed of spindle cells in a collagenous stroma. Immunohistochemistry showed reactivity for vimentin, CD 34, BCL-2 protein and CD99. Immunohistochemical stains for cytokeratin, S-100, desmin, alpha-smooth muscle actin and HMB-45 were negative. A diagnosis of SFT was made based on light microscopy and immunohistochemistry.

Are myelodysplastic children receiving sufficient health care in Turkey? An analysis of the problems in primary management and their impact on neuro-urological outcome.

OBJECTIVE: To investigate the problems in the primary care of children with spina bifida and to analyze their impact on neuro-urological outcome in Turkey. Information from mothers about the disease, difficulties in getting medical services, availability and efficacy of prenatal ultrasound, and folic acid intake was also assessed. PATIENTS: A retrospective review of 476 children registered in the pediatric urology section of our institutional multidisciplinary spina bifida clinic between 1996 and 2005 was made. All children were assessed for the time of primary repair, time to first neuro-urological visit, and compliance to follow up. A phone interview was made with 166 mothers to obtain data regarding their educational status, supplementary folic acid intake before/during gestation, compliance to obstetric follow up, prenatal diagnosis and counseling, information about the importance of neuro-urological surveillance, and difficulties in neuro-urological follow up. RESULTS: Two-thirds of the mothers had an educational status of elementary school or lower. Phone interviews revealed inadequate obstetric follow up in 42% and a low prenatal diagnosis rate (49%) in those under regular follow up. Chart review revealed a significant delay in timing of primary surgical closure (mean 3 months and 2.9 years for open and closed lesions, respectively) and first neuro-urological follow-up visit (mean 1.8 years and 9.7 months after primary repair for open and occult lesions, respectively). Reasons for delayed closure were misguided advice of the nurse/midwife involved in delivery and inability to obtain tertiary health care. Socioeconomic inadequacy of the families and inefficacy of the health insurance system were the most important factors impairing follow up. CONCLUSIONS: Serious problems exist in the prevention, prenatal diagnosis and primary management of children with myelodysplasia in Turkey. As a consequence, neuro-urological follow up starts relatively late, which adversely affects the urological prognosis.

Does surgical release of secondary spinal cord tethering improve the prognosis of neurogenic bladder in children with myelomeningocele?

PURPOSE: The diagnostic criteria for secondary tethering of the spinal cord in children with prior closure of an open spinal defect are not well defined. Urological, neurological or orthopedic deterioration during followup remains the only strong indicator for the diagnosis of this condition. However, the outcome of untethering surgery cannot always be predicted. The aim of this study was to determine neurourological outcome after secondary untethering surgery in children with myelomeningocele. MATERIALS AND METHODS: Of 401 children with myelomeningocele followed at our multidisciplinary spina bifida clinic between 1996 and 2005, 56 (14%) were diagnosed with secondary tethering of the spinal cord (median age at diagnosis 4.1 years). The diagnosis was based on urological and neuro-orthopedic deterioration in 58% and 42% of children, respectively. Preoperative urological findings were compared with 6-month postoperative findings. RESULTS: Febrile urinary tract infection, upper tract dilatation and vesicoureteral reflux were preoperatively documented in 48.2%, 19% and 30% of the 56 children, respectively. At 6 months postoperatively urine cultures were sterile in 34% of patients and upper tract dilatation completely resolved in 45%. For all grades of vesicoureteral reflux complete resolution occurred in 47% of patients. Urodynamic parameters in terms of cystometric bladder capacity and detrusor leak point pressure substantially improved 6 months after untethering surgery (125 vs 170 ml and 69.1 vs 47.5 cm H2O, respectively, p < 0.05). Assessment of urodynamic findings in 19 children at 1 year failed to demonstrate a significant change in these parameters. A subgroup analysis according to patient age at untethering surgery revealed urodynamic improvement was more significant in children who were diagnosed and treated before age 7 years. CONCLUSIONS: Secondary tethering of the spinal cord is a major risk factor for urological and neurological deterioration in children with myelomeningocele. Close urological surveillance remains the most valuable tool in the early diagnosis. Our study shows that secondary untethering surgery may significantly improve urological outcome.

The timing of primary neurosurgical repair significantly affects neurogenic bladder prognosis in children with myelomeningocele.

PURPOSE: The correlation between timing of the primary neurosurgical repair and urological prognosis in infants with open spinal dysraphism remains unknown. We investigated the impact of primary repair timing on neurogenic bladder prognosis in children with myelomeningocele. MATERIALS AND METHODS: We retrospectively reviewed the records of 401 children with myelomeningocele followed at our multidisciplinary clinic between 1996 and 2005. Among these patients 129 were included in the study based on the availability of urological followup data at age 3 years, which was chosen as an ideal point for the standardization of urological findings. Children were assigned to 1 of 2 groups-those who underwent primary neurosurgical repair within 72 hours of delivery (group 1) and those undergoing repair after 72 hours (group 2). We compared the incidence of febrile urinary tract infections, hydronephrosis, vesicoureteral reflux and secondary tethering of the spinal cord at age 3 years, as well as cystometric bladder capacity and detrusor leak point pressure between the 2 groups. RESULTS: Urological followup data at age 3 years revealed significantly increased incidence of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering of the spinal cord in children in group 2 compared to group 1 (chi-square, p < or =0.05 for all comparisons). Urodynamic assessment also showed a significantly lower bladder capacity and a substantially higher detrusor leak point pressure in children who received primary repair at later than 72 hours (t test, p <0.05). A subgroup analysis of group 1 comparing children who underwent repair before and after 24 hours following delivery failed to demonstrate any significant difference in terms of febrile urinary tract infections, vesicoureteral reflux, hydronephrosis and secondary tethering (chi-square, p >0.05 for all comparisons), whereas mean bladder capacity was significantly higher (t test, p <0.05) and mean detrusor leak point pressure was lower (t test, p = 0.08) in children undergoing repair within 24 hours of delivery. CONCLUSIONS: The timing of primary neurosurgical repair has a significant impact on neurogenic bladder prognosis in children with myelomeningocele. Closure of the spinal lesion on the first day of life seems to provide the best chance for favorable lower urinary tract function.

Intravesical stone formation on intrauterine contraceptive device.

Since more than 30 years, intrauterine contraceptive devices (IUCD) have been used for a contraceptive opportunity. Although they are termed to be a safe and effective method for contraception, they also have some type of complications and uterine perforation, septic abortion, pelvic abscess are the serious complications of these devices. The incidence of uterine perforation is very low, but in the literature nearly 100 cases were reported about the extra uterine localization of IUCD. Migration may occur to the adjacent organs. We here in describe a case of a 31 year-old woman who had an IUCD with stone formation in the bladder. In the literature all of the cases were reported as IUCD migration, but although it seems technically impossible, IUCD placement into the bladder should also be considered in misplaced IUCDs.

Cervical lymph node enlargement on the right side as the initial manifestation of metastatic prostate cancer.

OBJECTIVES: Cervical lymph node enlargement (LAP) due to metastatic spread is an uncommon manifestation of prostatic adenocarcinoma. In case of non-regional lymphatic spread, left supraclavicular region was found to be the most common site (1,2,3) whereas right sided metastatic lymph node involvement has been extremely uncommon. METHODS: We here in describe a case of a 75 year-old man who had an enlarged cervical lymph node for a year which subsequently proved to be involved by metastatic adenocarcinoma of the prostate. CONCLUSIONS: Although, prostate cancer rarely metastasize to the cervical lymph node chain it should always be considered in the differential diagnosis of metastatic lymph node enlargement in the cervical area of elderly men.

Anterior urethropexy according to lapides: how effective is it in the treatment of genuine female stress incontinence?

OBJECTIVES: Anterior urethropexy, introduced by Lapides, is a retropublic suspension procedure in which the anterior urethral wall is secured to the posterior surface of the symphysis pubis by full thickness trans-urethral sutures. Little information exists in the literature about its effectiveness and morbidity as a surgical treatment option for female stress incontinence. In this study, the outcome of this technique in the treatment of anatomic genuine stress urinary incontinence has been evaluated. METHODS: Thirty women with urodynamically-proven anatomic stress urinary incontinence underwent anterior urethropexy and 27 of them were followed up for a minimum of 12 months with a mean period of 28.9 months. RESULTS: A complete dry rate of 52% and a significant improvement of 11% were achieved at the mean follow up period. No postoperative retention or other significant complication was observed in the study group. De novo urge incontinence was noted in 2 patients and managed by anticholinergic treatment. CONCLUSION: Anterior urethropexy is found to be a safe retropubic suspension technique with a considerably low morbidity but revealed a relatively lower success rate compared other open bladder neck suspension techniques.