Surgical reintervention requirements following GreenLight PVP: A single-center experience using three different laser device models.

Objective: To assess the incidence, risk factors, and timing of specific causes of reoperations following PVP. Material and Methods: A retrospective analysis of data on men who underwent GreenLight PVP between 2004 and 2019 in a single center and required surgical intervention for bladder neck contracture (BNC), urethral stricture (US), or persistent/recurrent prostate adenoma. Results: The overall rate of reoperations was 13.8% during a 61-month median follow-up of 377 patients. Reoperations were due to BNC, US, and adenoma in 7.7%, 5.6%, and 4.8% of cases, respectively. The median interval until reoperation for US (11 months) was significantly shorter. None of the risk factors had any relevance to US. In patients who underwent reoperation for BNC, lasing time and energy were significantly lower, and the prostate volume was smaller; however, the multivariate analysis only identified shorter lasing time as a predictor. In patients who had reoperation for persistent/recurrent adenoma, the PSA was increased, while the prostate volume was non-significantly high, and performance by less-experienced surgeons was associated with a higher rate of reoperations (p < 0.05). A longer lasing time predicted an increased risk of reoperation for adenoma in multivariate analysis. Conclusions: An unselective utilization of PVP may result in a relatively high rate of reoperations. The correlation of BNC with shorter lasing time may imply a higher risk after PVP of smaller prostates. A longer lasing time predicts an increased risk of reoperation due to persistent/recurrent adenoma, which may be related to higher prostate volumes and inefficient PVP by less-experienced surgeons.

Suboptimal Prediction of Clinically Significant Prostate Cancer in Radical Prostatectomy Specimens by mpMRI-Targeted Biopsy.

OBJECTIVE: To investigate the correlation of multiparametric magnetic resonance imaging targeted (TBx) and/or systematic prostate biopsy (SBx) in predicting the presence of clinically significant (cs) prostate cancer (PCa) in radical prostatectomy (RP) specimens. Concordance of mpMRI and RP specimen lesions was also investigated in terms of tumor localization and histopathological features. METHODS: A total of 70 male patients with PCa and treated with robot-assisted RP were included in this study between January 2016 and December 2019. All patients underwent mpMRI-TBx and concomitant SBx. Suspicious lesions on mpMRI were scored according to Prostate Imaging-Reporting and Data System version 2 (PI-RADS) criteria. TBx was performed for all suspicious lesions with a PI-RADS score ≥3. RESULTS: The median age was 67 (43-77) years. Presence of csPCa in prostatectomy specimens was missed by TBx and SBx specimens in 25.4% and 19.4% of the cases, respectively (P<.001, for each). Combination of both biopsy (CBx) results improved detection by missing only 4.5% of csPCa (P = .250). International Society of Urologic Pathology grade group concordance with RP specimens were 50%, 54.3% and 67.1% for SBx, TBx, and CBx, respectively. There was a statistically significant correlation in terms of tumor localization and histopathological features between prostatectomy specimens and the first 3 lesions, particularly for the index lesions. CONCLUSIONS: CBx improved detection rate of csPCa. We propose TBx of 3 lesions with highest PI-RADS score(s) and a combination with SBx for the highest correlation with prostatectomy histopathology.

Correlation of Prostate-Imaging Reporting and Data Scoring System scoring on multiparametric prostate magnetic resonance imaging with histopathological factors in radical prostatectomy material in Turkish prostate cancer patients: a multicenter study of the Urooncology Association.

BACKGROUND: Histopathological features after radical prostatectomy (RP) provide important information for the prognosis of prostate cancer (PCa). The possible correlations between Prostate-Imaging Reporting and Data Scoring System (PIRADS) scores in multiparametric magnetic resonance imaging (mpMRI) may also be predictive for prognosis. In this study, we aimed to evaluate the correlation of PIRADS scores with histopathological data. METHODS: A total of 177 patients who underwent preoperative mpMRI and RP for PCa from eight institutions were included in the study. Correlation of PIRADS score in preoperative mpMRI with adverse histopathological factors in RP specimen was investigated using univariate and multivariate analyses. RESULTS: The relationship between PIRADS score and postoperative extracapsular extension, lymphovascular invasion, and seminal vesicle involvement was significant (P < 0.001, P = 0.032, and P = 0.007, respectively). Although the PIRADS score was significantly correlated with the number of dissected lymph nodes (p = 0.026), it had no significant correlation with the number of positive nodes (P = 0.611). Total Gleason score, extracapsular extension, seminal vesicle invasion, and number of lymph nodes were found to be independent factors, which correlated with high PIRADS scores in ordinal logistic regression analysis. CONCLUSION: PIRADS scoring system in mpMRI showed a statistically significant correlation with adverse histopathological factors in RP specimen. A higher PIRADS score may help to predict a higher Gleason score, indicating clinically important PCa as well as poor prognotic factors such as extracapsular extension, lymphovascular invasion, and seminal vesicle invasion that may indicate a higher risk of recurrence and the need for additional treatment.

Normotensive, Oversized Pheochromocytoma in Twin-Pregnancy: Analysis of Therapeutic Challenges in a Rare Case.

An asymptomatic, normotensive 36-year-old woman in the second trimester of a twin-gestation was diagnosed with a 11 cm adrenal pheochromocytoma. Considering the hemodynamic stability of the patient, tumor size, and gestational age, the therapeutic decision of a multidisciplinary team ensued open surgical excision without any preoperative antihypertensive preparation. Following successful removal of pheochromocytoma, the patient had a normal subsequent course of pregnancy and cesarean section delivery of healthy twins at term. This unique case of a normotensive, incidental, large-sized pheochromocytoma in a twin-pregnancy illustrates that the decisions of management in such a rare occurrence should be based on individual features of the patient. Our experience supports that α-adrenergic blockade may not be essential in normotensive pheochromocytoma in pregnancy and open-surgery remains as a safe approach in the management of large adrenal tumors in twin-pregnant patients following a multidisciplinary consultation.

Clinical Case Discussion: Bilateral Synchronous Testicular Cancer and Organ-sparing Surgery.

In cases of bilateral synchronous testicular cancer, organ-sparing surgery can be performed safely, if appropriate surgical rules are respected and if a stringent follow-up protocol is obeyed. If fertility is a concern, a simultaneous TESE procedure can be performed.

Bilateral same-session ureterorenoscopy: A feasible approach to treat pan-urinary stone disease.

OBJECTIVES: To assess treatment effectiveness and safety of bilateral same-session ureterorenoscopy (BSSU) for the management of stone disease involving the entire urinary system. PATIENTS AND METHODS: We reviewed the records of 64 patients who underwent BSSU for the treatment of bilateral ureteric and/or kidney stones. Size, number, location per side, and the total burden of stones were recorded. Data on stenting, lithotripsy, and stone retrieval, and details of hospital stay and operation times were investigated. Treatment results were assessed using intraoperative findings and postoperative imaging. The outcome was considered successful in patients who were completely stone-free or who had only residual fragments of ≤2 mm. RESULTS: The outcome was successful in 82.8% of the patients who received BSSU (54.7% stone-free and 28.1% insignificant residual fragments). The success rate per renal unit was 89.8%. There were no adverse events in 73.4% of the patients. The most common intraoperative complication was mucosal injury (36%). The complications were Clavien-Dindo Grade I in 9.4% and Grade II in 7.8%. Grade IIIa and IIIb (9.4%) complications required re-treatments. Statistical evaluation showed no association between complication grades and stone, patient, or operation features. Stone burden had no negative impact on BSSU results. The presence of impacted proximal ureteric stones was significantly related to unsuccessful outcomes. CONCLUSION: BSSU is safe and effective for the management of bilateral urolithiasis. BSSU can prevent recurrent surgeries, reduce overall hospital stay, and achieve a stone-free status and complication rates that are comparable to those of unilateral or staged bilateral procedures.

An unusual cause of Grade IIIb Clavien complication of percutaneous nephrolithotomy: Broken and retained Malecot nephrostomy catheter.

Percutaneous nephrolithotomy (PCNL) is a relatively safe operation with low rates of major complications. Clavien-Dindo classification is a validated system to record complications, although still needing standardization in reporting and scoring of complex and rare events. We report an unusual adverse incident that required interventional management and impacted the postoperative course. The case of a broken re-entry Malecot nephrostomy catheter as it was being removed on the third postoperative day of an otherwise uneventful PCNL is described. The retained part was removed by open-surgery under general anesthesia. This incident has upgraded the minimally invasive surgery to a Grade IIIb complicated procedure according to the modified Clavien classification. Patient data, procedure conditions, and surgical retrieval of the catheter are detailed. Although far from being life-threatening, this rare complication due to a broken and retained drainage catheter is regarded as a high-grade complication according to the Clavien system.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

BACKGROUND: The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. PATIENTS AND METHODS: Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. EXCLUSION CRITERIA: The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. RESULTS: (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) and at the end of surgery (0.29±0.05) as well. CONCLUSION: We did not demonstrate any significant mesenteric-splanchnic ischemia which could be detected by serum IMA levels during robotic radical prostatectomies performed under steep Trendelenburg position and when IAP is maintained in between 11-14 mmHg.

Simple Renal Cysts: Prevalence, Associated Risk Factors and Follow-Up in a Health Screening Cohort.

PURPOSE: To investigate the prevalence of simple renal cysts in an adult health-screening cohort, and to evaluate clinical characteristics, associated risk factors and the natural course. MATERIALS AND METHODS: Between April and November 2008, a thousand individuals diagnosed with simple renal cyst by ultrasonography in a check-up program were chart-reviewed for demographic-clinical characteristics and cyst features. Follow-up was done via electronic patient records. Univariate and multivariate analyses to evaluate the relationship of outcomes and correlation analysis were done to measure the degree of association between parameters. RESULTS: The prevalence was 7.7%. There were 123 cysts in 77 patients, followed for 3.5 years (mean). Individuals with cysts were older (P < .01). Prevalence rates were 2.7% in individuals younger than 40 years and 23.9% in older than 60. The cysts were predominantly (94.8%) detected in males and most (63.6%) were solitary. No relation with Body Mass Index and total cholesterol levels was found but serum creatinine values were significantly increased in individuals with cysts (P < .01). There was no difference in the diagnosis of hypertension and microscopic hematuria in patients with renal cysts, however diabetes/hyperglycemia were more common and increasing age correlated with higher number of cysts (all P < .05). Follow-up revealed that the number of cysts were increased and/or the same in 86.5%; the sizes of cysts were larger and/or the same in 78.4% of patients, while in 14% of patients the cyst disappeared. CONCLUSION: In a cohort of adults undergoing a health-screening, the prevalence of simple renal cyst was found 7.7% by ultrasonography. Renal cysts were more common in males and elders, and associated with increased levels of serum creatinine and diabetes.

Ischemia modified albumin: does it change during pneumoperitoneum in robotic prostatectomies?

ABSTRACT Background The unique positioning of the patient at steep Trendelenburg with prolonged and increased intra-abdominal pressure (IAP) during robotic radical prostatectomy may increase the risk of splanchnic ischemia. We aimed to investigate the acute effects of IAP and steep Trendelenburg position on the level of ischemia modified albumin (IMA) and to test if serum IMA levels might be used as a surrogate marker for possible covert ischemia during robotic radical prostatectomies. Patients and Methods Fifty ASA I-II patients scheduled for elective robotic radical prostatectomy were included in this investigation. Exclusion criteria The patients were excluded from the study when an arterial cannulation could not be accomplished, if the case had to be converted to open surgery or if the calculated intraoperative bleeding exceeded 300ml. All the patients were placed in steep (45 degrees) Trendelenburg position following trocar placement. Throughout the operation the IAP was maintained between 11-14mmHg. Mean arterial blood pressure (MAP), cardiac output (CO) were continuously monitored before the induction and throughout the surgery. Blood gases, electrolytes, urea, creatinine, alanine transferase (ALT), aspartate transferase (AST) were recorded. Additionally, IMA levels were measured before, during and after surgery. Results (1) MAP, CO, lactate and hemoglobin (Hb) did not significantly change in any period of surgery (p>0.05); (2) sodium (p<0.01), potassium (p<0.05) and urea (p<0.05) levels decreased at postoperative period, and no significant changes at creatinine, AST, ALT levels were observed in these patients; (3) At the end of surgery (180 min) pCO2, pO2, HCO3 and BE did not change compared to after induction values (p>0.05) but mild acidosis was present in these patients (p<0.01 vs. after induction); (4) IMA levels were found to be comparable before induction (0.34±0.04), after induction (0.31±0.06) ...

Defining the Pathways of Parental Decision-making and Satisfaction Levels About Newborn Circumcision in a Setting Where Traditional Male Circumcision is Prevalent: An Online Survey Study.

OBJECTIVE: To investigate the decision-making attitudes, course of informed consent, and satisfaction levels of parents who opted for newborn circumcision (NC) in a societal setting where the timing of circumcision is generally determined by tradition. METHODS: Online questionnaire was sent to 1235 parents of boys who had NC. RESULTS: The response rate was 50.4%. The final decision of newborn circumcision depended on the mother in 51.47%. Nearly 75% of circumcisions were performed before hospital discharge. The most common (70.65%) reported reason for parents' choice was medical/hygienic. When evaluating their decision, 93.05% refused any feelings of regret and 96.26% stated they would decide the same if they had another son. The source of information on newborn circumcision was mostly physicians (39.27%), followed by friends and family (31.2%). Parental preference, having nonreligious motives, and being previously informed about the procedure by experienced peers appeared as significant factors on the decision regarding timing of NC. In total, 79.90% ranked their satisfaction level as "very satisfied" on a Likert scale. The mean rate of satisfaction was significantly higher in parents who acquired previous information from healthcare providers and who acknowledged sufficient preprocedural counseling before giving consent. CONCLUSION: In a society where the timing of circumcision is usually determined by faiths and traditions, parental decision-making on newborn circumcision is greatly influenced by personal choices of parents, based on timely, accurate, and adequate information received from peers and healthcare providers. Medical providers play an important role on the informed decision of parents and impact on satisfaction with prior decision and outcomes of newborn circumcision.

Presentation and prognosis of female acute urinary retention: Analysis of an unusual clinical condition in outpatients.

OBJECTIVES: Acute urinary retention (AUR) in females is a poorly defined condition with undetermined epidemiology. This study aimed to evaluate female AUR in an outpatient population. PATIENTS AND METHODS: One hundred and thirty-eight adult female outpatients who presented to the emergency room with symptoms of urinary retention were retrospectively analyzed. The women who were ultimately diagnosed with true, complete AUR were systematically reviewed for clinical characteristics and management. RESULTS: In this outpatient cohort with urinary retention complaints, only 23% of the patients were diagnosed with objective AUR. Detailed medical and urological history in addition to urogenital, neurological, and pelvic examinations was essential; urine analysis and pelvic ultrasonography were necessary as baseline investigations. Further radiological and urodynamic tests were required in a minority. Specific etiology was established in 77% of the patients, whereas there was more than one probable cause in 16% of the patients, and no specific cause was found in 6.5% of the patients. Bladder decompression and correction of the underlying cause helped 92.6% of the reviewed patients to eventually achieve spontaneous micturition. CONCLUSIONS: The proportion of true, complete AUR among female outpatients presenting to the emergency department was 23% following urological evaluation. Acute condition was resolved by urgent catheterization in all, and the majority of women had eventually resumed spontaneous voiding.

Massive rectal bleeding after prostate biopsy controlled by endoclipping in a patient using acetylsalicylic acid.

A case of severe rectal bleeding following transurethral ultrasound (TRUS)-guided prostate biopsy is reported. Rectal bleeding is considered a minor, transient complication of this standard diagnostic procedure that can usually be controlled successfully by conservative measures. In this case where the patient had been taking acetylsalicylic acid (ASA), massive bleeding required hospitalization and blood transfusions. Conservative treatment attempts were not succesful, and profuse rectal bleeding was eventually treated by colonoscopy and endoclipping of the bleeding vessel. Although generally regarded as a less significant complication, rectal bleeding may rarely be encountered as a life-threatening situation. Furthermore, conservative therapeutic approach to this minor complication may be ineffective in patients taking ASA. Early endoscopic intervention may be necessary to prevent blood transfusion and prolonged hospitalization in severe rectal bleeding after TRUS biopsy.

Simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy in a patient with multifocal invasive urothelial carcinoma and previous contralateral nephroureterectomy.

We present a case of simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy with extended lymphadenectomy for multifocal invasive urothelial carcinoma in a patient with recurrent high-grade urothelial cancer and a previous right nephroureterectomy. The total urinary exenteration and extended lymphadenectomy was successfully performed with robot-assisted surgery in this unique case where the patient was rendered anephric at the end of the operation. We discuss the operative steps and the techniques performed to optimize the oncological results of robot-assisted surgery for invasive urothelial carcinoma, while attempting to preserve the renal function until the patient's urinary system was totally exenterated.

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.

Uretropexia anterior según la técnica dde Lapides: ¿Cuál es su efectividad en el tratamiento de la incontiencia de esfuerzo pura femenina? / Anterior urethropexy according to Lapides: how effective is it in the treatment of genuine female stress incontinence?

OBJETIVOS: La uretropexia anterior, introducida por Lapides, es una operación de suspensión retropúbica en la que se fija la pared anterior de la uretra a la superficie posterior de la sínfisis del pubis mediante puntos totales transuretrales. Hay poca información en la literatura sobre su eficacia y morbilidad como tratamiento quirúrgico de la incontinencia de esfuerzo femenina. En este estudio se han evaluado los resultados de esta técnica en el tratamiento de la incontinencia de esfuerzo femenina pura. MÉTODOS: Treinta mujeres con incontinencia de esfuerzo anatómica demostrada mediante estudio urodinámico fueron sometidas a uretopexia anterior y 27 de ellas fueron seguidas durante al menos 1 año con una media de 28.9 meses. RESULTADOS: Un 52 per cent de las pacientes estaban completamente secas y un 11 per cent habían mejorado significativamente en el momento de la evaluación. No aparecieron retenciones urinarias postoperatorias ni otras complicaciones importantes en el grupo de estudio. 2 pacientes desarrollaron urgencia incontinencia que fue tratada con medicación anticolinérgica. CONCLUSIONES: Se encuentra que la uretropexia anterior es una técnica de suspensión retropúbica segura con una morbilidad asociada considerablemente baja, aunque el porcentaje de éxitos se ha revelado relativamente bajo en comparación con otras técnicas abiertas de suspensión del cuello vesical. (AU)