A Novel Experimental Method for Penile Augmentation Urethroplasty With a Combination of Buccal Mucosa and Amniotic Membrane in a Rabbit Model.

OBJECTIVE: To investigate the results of penile urethral reconstruction using amniotic membrane (AM) and buccal mucosa (BM) grafts, and the simultaneous use of both in a rabbit model. MATERIALS AND METHODS: A total of 28 male rabbits were divided into 4 groups according to grafting style: group 1 (AM), group 2 (BM), group 3 (BM + AM), and group 4 (sham). A standardized urethral defect was created in the 3 initial groups. The sham group underwent only a ventral vertical urethral incision and primary re-suturation. AM grafts were used in group 1, and BM grafts were used in groups 2 and 3. AM grafts were affixed to the BM grafts in group 3 as a covering tissue. Urethrography and endoscopy were performed after the 1st and 2nd months of grafting. The penises were subjected to histopathologic and immunohistochemical assessment for fibroblast growth factor and vascular endothelial growth factor expression. RESULTS: Dehiscence and fistula developed in group 1, whereas 2 fistulas were observed in group 2. No complications developed in group 3. Epithelization at urethras was observed at 4 weeks in all groups, but transformation to urothelial epithelialization occurred at 8 weeks. Marked amelioration and epithelial transformation were observed in group 3. The most prominent fibroblast growth factor expression was observed in group 3. Vascular endothelial growth factor expression was completely negative in group 3 at 8 weeks, indicating complete healing. CONCLUSION: The simultaneous use of AM and BM for ventral onlay penile urethroplasty provides better tissue healing and lower complication rates in comparison to BM alone. Further animal studies or clinical applications are needed.

Do anxiety, stress, or depression have any impact on pain perception during shock wave lithotripsy?

INTRODUCTION: The most important adverse effect during shock wave lithotripsy (SWL) is pain perception. In this study, we evaluated the effect of anxiety, stress, and depression on pain perception during SWL. METHODS: From November 2013 to December 2014, 189 consecutive patients undergoing SWL for kidney stones were evaluated prospectively. Patient characteristics (age, sex, body mass index [BMI], urologic intervention history, the presence of a double-j catheter, and stone-related parameters) were also recorded. Anxiety, stress, and depression states were assessed before the first procedure using the Depression, Anxiety, and Stress Scales (DASS-42), which is a self-report scale. The degree of pain perception was evaluated with a 10-point Visual Analogue Scale (VAS) at the end of the first SWL session. RESULTS: There were no statistically significant differences in terms of VAS scores during SWL between patients with and without anxiety, stress, or depression (p >0.05). Furthermore, no statistically significant relationships were found between VAS scores and patient age, sex, side of the stone, presence of a double-j stent, number of stones, and SWL experience (p >0.05). CONCLUSIONS: According to our findings, anxiety, stress, or depression seemed to have no impact on pain perception during SWL.

Atypical Testicular Torsion: We Must be Cautious in the Course of Manual Detorsion.

Testicular torsion is a common important urological emergency. Testicles usually undergo various degrees of rotation in a medial (inward) direction. Manual detorsion is a critical maneuver, allowing to prevent testis viability in patients with delay to get into the operation room. Testis torsion rarely occurs in lateral direction. It is important for patients undergoing manual detorsion. Hereby, we present a case of atypical lateral (outward) torsion who performed preoperative manual derotation.

Comparison of shockwave frequencies of 30 and 60 shocks per minute for kidney stones: a prospective randomized study.

OBJECTIVE: One of the factors that determines the treatment success of shockwave lithotripsy (SWL) is the frequency of the shockwaves during the procedure. This study compared the efficacy and pain perception of shockwave frequencies at 30 versus 60 shocks/min for kidney stones. MATERIALS AND METHODS: From August 2013 to May 2015, 160 patients with solitary, radiopaque kidney stones were randomized to SWL at 30 shocks/min (group 1) or 60 shocks/min (group 2), with 80 patients in each group. The primary outcome measure was success rate at 3 months after the last SWL session. The secondary outcome measure was pain perception during the procedures. RESULTS: Of the 160 randomized patients, data for a total of 148 patients (74 patients in group 1 and 74 patients in group 2) were analyzed, after the exclusion of the patients lost to follow-up or who required secondary intervention within 3 months. There was no statistically significant difference between the two groups in terms of the success rate at 3 months (68.9% vs 71.6%, p = .719). However, the mean visual analogue scale scores of all the sessions were significantly higher in group 1 than in group 2 (5.83 vs 4.06, p < .05). Stone location, especially the lower calyceal location, was the only significant negative predictor for success according to multivariate logistic regression analysis. CONCLUSIONS: The success rate was similar between these two frequencies. However, pain perception was significantly higher at 30 than at 60 shocks/min.

The relationship between platelet-lymphocyte ratio and severity of erectile dysfunction.

The prognostic importance of platelet-lymphocyte ratio (PLR) is already known for various artery diseases. In this study, the relationship between PLR and severity of erectile dysfunction (ED) is examined in patients with impotence. The data from patients suffering from erection problems was screened retrospectively. Detailed medical history, age, International Index of Erectile Function-5 (IIEF-5) scores, fasting blood glucose, lipid, whole blood count, and hormone profile values were examined. Patients with no ED were selected as the control group. All men answered the IIEF-5 questions and were then classified according to their scores. Patients were determined to have severe ED (scores 5-7), moderate ED (scores 8-16), or mild ED (scores 17-21). An IIEF-5 score greater than 21 was accepted for the control group. The PLR values from both patient and control groups were evaluated. Demographic data were similar in both groups. Mean PLR value was 104 in control and 118 in the patient group (p < 0.001). PLR value increased depending on the severity of ED. Mean PLR values were 108 in mild, 116 in moderate, and 130 in severe ED groups. Compared with the control group, this value was statistically significant for patients with moderate and severe ED (p = 0.04 and p < 0.001). PLR showed weak negative but significant correlation with IIEF-5 scores (r = -0.27 and p < 0.001). The PLR value was found to be higher in patients with ED. PLR value may be related to ED and its severity in patients with impotence.

Chromosomal aberrations in benign prostatic hyperplasia patients.

PURPOSE: To investigate the chromosomal changes in patients with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: A total of 54 patients diagnosed with clinical BPH underwent transurethral prostate resection to address their primary urological problem. All patients were evaluated by use of a comprehensive medical history and rectal digital examination. The preoperative evaluation also included serum prostate-specific antigen (PSA) measurement and ultrasonographic measurement of prostate volume. Prostate cancer was detected in one patient, who was then excluded from the study. We performed conventional cytogenetic analyses of short-term cultures of 53 peripheral blood samples obtained from the BPH patients. RESULTS: The mean (±standard deviation) age of the 53 patients was 67.8±9.4 years. The mean PSA value of the patients was 5.8±7.0 ng/mL. The mean prostate volume was 53.6±22.9 mL. Chromosomal abnormalities were noted in 5 of the 53 cases (9.4%). Loss of the Y chromosome was the most frequent chromosomal abnormality and was observed in three patients (5.7%). There was no statistically significant relationship among age, PSA, prostate volume, and chromosomal changes. CONCLUSIONS: Loss of the Y chromosome was the main chromosomal abnormality found in our study. However, this coexistence did not reach a significant level. Our study concluded that loss of the Y chromosome cannot be considered relevant for the diagnosis of BPH as it is for prostate cancer. Because BPH usually occurs in aging men, loss of the Y chromosome in BPH patients may instead be related to the aging process.

A Novel Approach to Penile Augmentation Urethroplasty Using Buccal Mucosa and Amniotic Membrane: A Pilot Study in a Rabbit Model.

OBJECTIVE: To evaluate and compare the success of amniotic membrane (AM) and buccal mucosa (BM) grafts and simultaneous use of both in penile augmentation urethroplasty in rabbits. MATERIALS AND METHODS: A total of 12 New Zealand rabbits were divided into 3 groups by grafting style: Group 1 (AM), Group 2 (BM), and Group 3 (simultaneous use of BM and AM). In all animals, a standardized urethral defect was created. BM and AM were obtained from the rabbits. Solely AM grafts were affixed to the defects in Group 1, solely BM grafts were affixed to the urethral defects in Group 2, and simultaneous AM + BM grafts were affixed in Group 3. At 4 and 8 weeks, the penises were subject to histological assessment of subepithelial fibrosis, epithelial transformation, and inflammatory reaction. RESULTS: Stenosis was detected in none of the groups. A dehiscence was developed in one rabbit in Group 1 and a fistula was developed in one rabbit in Group 2. After 4 weeks, minimal subepithelial fibrosis and inflammatory reaction were observed in Group 2, while subepithelial fibrosis was not in Groups 3. After 8 weeks, subepithelial connective tissue proliferation was moderate in Group 2, at both 4th and 8th weeks in Group 2. After 8 weeks, the best epithelial transformations were observed in Group 3. CONCLUSION: In an animal model, the simultaneous use of AM and BM grafts following acute urethral injury may be feasible for penile augmentation urethroplasty. Further study is needed.

The effect of thermochemotherapy with mitomycin C on normal bladder urothelium, an experimental study.

PURPOSE: To investigate the effects of thermochemotherapy with mitomycin C (MMC) on normal rabbit bladder urothelium and to compare it with standard intravesical MMC and hyperthermia with normal saline. METHODS: Twenty-four male New Zealand rabbits, with a mean weight of 2.7 kg (in weight of 2.1­4.3 kg), were divided into three groups, each containing eight rabbits. Thermotherapy with only normal saline was performed in the first group, standard intravesical MMC was performed in the second group, and thermotherapy with MMC was performed in the last group. A week after the primary procedure, total cystectomy was performed and tissue samples were evaluated. RESULTS: The presence of epithelial vacuolar degeneration (p = 0.001), epithelial hyperplasia (p = 0.000), subepithelial fibrosis (p = 0.001) and hemorrhagic areas in the connective tissue (p = 0.002) was observed statistically significantly higher in the standard MMC group than in thermotherapy with normal saline group. There was almost a significant difference among standard MMC and normal saline group in terms of vascular congestion in the connective tissue (p = 0.08). Presence of epithelial vacuolar degeneration (p = 0.002), epithelial hyperplasia (p = 0.002), subepithelial fibrosis (p = 0.030), hemorrhagic areas (p = 0.011) and vascular congestion (p = 0.36) in the connective tissue was observed statistically significantly higher in the thermochemotherapy with MMC group than in standard intravesical MMC group. Polymorphonuclear cell infiltration was not considerable in any of the groups, and there was no significant difference between each groups (p = 0.140). CONCLUSION: Administration of intravesical MMC causes a toxic effect on the normal urothelium of the bladder rather than an inflammatory reaction. Heating MMC significantly increased this effect.

A novel approach for manual de-torsion of an atypical (outward) testicular torsion with bedside Doppler ultrasonography guidance.

A 17-year-old boy presented with right testicular torsion to the lateral side. Torsion was diagnosed by physical examination; the colour Doppler ultrasonography (CDU) confirmed right testicular torsion with minimal peripheral hydrocele. Transverse and longitudinal examination of the spermatic cord with ultrasound and CDU revealed a counter-clockwise testicular torsion. Manual de-torsion was performed in a clockwise direction (720o) and testicular blood flow and the neutral position of the spermatic cord were confirmed by CDU. We did not encounter a residual twist of the spermatic cord upon surgical exploration. In our experience, ultrasound and CDU may predict the direction of testicular torsion and may allow appropriate management of cases prior to surgery.

Does resectoscope size play a role in formation of urethral stricture following transurethral prostate resection?

BACKGROUND AND AIMS: To investigate the possible effect of resectoscope size on urethral stricture rate after monopolar TURP. MATERIALS AND METHODS: A retrospective study of 71 men undergoing TURP was conducted at two centers' from November 2009 to May 2013. The patients were divided into one of two groups according to the resectoscope diameter used for TURP. Resectoscope diameter was 24 F in group 1 (n=35) or 26 F in group 2 (n=36). Urethral catheter type, catheter removal time and energy type were kept constant for all patients. Urethral stricture formation in different localizations after TURP was compared between groups. RESULTS: There was no significant difference between the two groups in terms of age, pre-operative prostate gland volume (PV), prostate-specific antigen (PSA), maximal urinary flow rates (Qmax), International Prostate Symptom Score (IPSS) and post-voiding residual urine volume (PVR). The resection time and weight of resected prostate tissue were similar for both groups (p>0.05). A statistically significant higher incidence of bulbar stricture was detected in group 2 compared to group 1 (p=0.018). CONCLUSIONS: The use of small-diameter resectoscope shafts may cause a reduction in the incidence of uretral strictures in relation to urethral friction and mucosal damage.

Is it possible to distinguish testicular torsion from other causes of acute scrotum in patients who underwent scrotal exploration? A multi-center clinical trial.

INTRODUCTION: To assess the clinical presentation of patients who underwent surgical exploration for acute scrotum and to investigate the potentially related factors for differential dignosis. MATERIAL AND METHODS: We retrospectively analyzed the medical records of 97 patients who underwent surgical exploration for acute scrotum between May 2007 and July 2013. The patients were divided into two groups as follows: Group1 included patients with testicular torsion (TT) and Group 2 contained patients with acute scrotal pathologies other than TT, including torsion of the testicular appendage, epididymo-orchitis, trauma and Henoch-Schönlein purpura. The physical examination findings, colour Doppler ultrasound (CDUS) and laboratory findings for the groups were compared. RESULTS: In total, 97 scrotal explorations were carried out for acute scrotum. Group 1 included 72 patients (74.2%) and Group 2 included 25 patients (25.8%). Group 2 was comprised of patients with torsion of the testicular appendage (n = 13), epididymo-orchitis (n = 8), testicular trauma (n = 2) and Henoch-Schönlein purpura (n = 2). In Group 1, 32 cases (44.4%) presented to a hospital less than 6 hours after onset of pain. More than half (64%) of Group 2's cases presented more than 24 hours after pain onset. Fever and pyuria appeared more frequently in Group 2 than in Group 1 and the results reached statistical significance (p = 0.001 and p = 0.044, respectively). Group 1 had more testicular tenderness than Group 2 (p <0.001). Our testicular salvage rate was 59.7%, and 40.3% of patients underwent orchiectomy. CONCLUSIONS: CDUS predicted the diagnosis of TT (sensitivity 98.6%). Furthermore, clinical findings may also play a substantial role in the differential diagnosis of acute scrotum.

Does resectoscope size play a role in formation of urethral stricture following transurethral prostate resection?

ABSTRACTBackground and aims:To investigate the possible effect of resectoscope size on urethral stricture rate after monopolar TURP.Materials and Methods:A retrospective study of 71 men undergoing TURP was conducted at two centers’ from November 2009 to May 2013. The patients were divided into one of two groups according to the resectoscope diameter used for TURP. Resectoscope diameter was 24 F in group 1 (n=35) or 26 F in group 2 (n=36). Urethral catheter type, catheter removal time and energy type were kept constant for all patients. Urethral stricture formation in different localizations after TURP was compared between groups.Results:There was no significant difference between the two groups in terms of age, pre-operative prostate gland volume (PV), prostate-specific antigen (PSA), maximal urinary flow rates (Qmax), International Prostate Symptom Score (IPSS) and post-voiding residual urine volume (PVR). The resection time and weight of resected prostate tissue were similar for both groups (p>0.05). A statistically significant higher incidence of bulbar stricture was detected in group 2 compared to group1 (p=0.018).Conclusions:The use of small-diameter resectoscope shafts may cause a reduction in the incidence of uretral strictures in relation to urethral friction and mucosal damage.

Predictive role of hematologic parameters in testicular torsion.

PURPOSE: To evaluate the predictive role of the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet count (PLT) in the diagnosis of testicular torsion (TT) and testicular viability following TT. MATERIALS AND METHODS: We analyzed two study groups in this retrospective study: 75 patients with a diagnosis of TT (group 1) and 56 age-matched healthy subjects (group 2). We performed a complete blood count as a part of the diagnostic procedure, and NLR, PLR, MPV, and PLT values were recorded. We compared the patient and control groups in terms of these parameters. Then, TT patients were divided into two subgroups according to the time elapsed since the onset of symptoms. Subsequently, we evaluated the relationship between the duration of symptoms and these parameters. RESULTS: There were significant differences between groups 1 and 2 in NLR, PLR, and PLT (p<0.001 for all). There was no predictive role of MPV in the diagnosis of TT (p=0.328). We determined significantly high sensitivity and specificity levels for NLR in the prediction of TT diagnosis (84% and 92%, respectively). Furthermore, NLR was significantly related to the duration of symptoms in TT patients (p=0.01). CONCLUSIONS: NLR may be a useful parameter in the diagnosis of TT. Furthermore, NLR may be used as a predictive factor for testicular viability following TT.

Combination of the buccal mucosa and amniotic membrane: a novel approach for graft augmentation urethroplasty.

Today, complicated and long-segment stricture is usually treated by augmentation urethroplasty with buccal mucosa (BM) as the grafted tissue. Augmentation urethroplasty is applied in different parts of the urethra with varying success. Success rate is quite low in one-step penile ventral urethra rehabilitations due to weak subcutaneous tissue in the penile urethra tissue. The amniotic membrane (AM) is a biologically compatible tissue with growth factors, antimicrobial qualities, and immunoregulatory activity that minimizes tissue rejection and scarring. Due to these characteristics, it has been used in various surgical areas, particularly in ophthalmology, with success for more than 50 years. According to our hypothesis, when AM is combined with BM, the success rates in penile ventral augmentation urethroplasty would be increased by decreasing postoperative complications. New evidence could be added to the literature by using AM and BM in combination on an animal model. The positive results of this combined method would give a new point of view to reconstructive urethral surgery practice.

Anti TNF-α therapy might be responsible for an increased incidence of varicocele in patients with ankylosing spondylitis.

AIM: To evaluate the effects of anti-tumor necrosis factor-alpha (TNF-α) therapy on the frequency of varicocele in patients with ankylosing spondylitis (AS) using color Doppler ultrasound. MATERIALS AND METHODS: The patients were divided into 2 groups: patients with AS who were on anti-TNF-α treatment and patients with AS who were not regularly taking any antiinflammatory drugs. Thirty-one healthy volunteers were included as controls. RESULTS: Left-sided varicocele was determined in 14 patients of Group 1 (44%), 10 patients of Group 2 (33%), and 7 of the controls (23%). There was a statistically significant difference only between Group 1 and controls (P = 0.009). However, right-sided varicocele was determined in 12 patients of Group 1 (38%), 2 patients of Group 2 (6%), and 2 of the controls (6%) (P = 0.01 vs. Group 2, P = 0.005 vs. controls). CONCLUSION: The present study shows that patients with AS who were taking anti-TNF-a therapy had an increased prevalence of right- sided and bilateral varicocele compared to patients with AS who were not taking any disease-modifying antirheumatic drugs and the healthy control group.

Distal ureteral stricture: An unexpected complication of further adjuvant intravesical mitomycin C thermotherapy.

We present a case of distal ureteral obstruction in relation to further adjuvant intravesical thermochemotherapy with mitomycin C (MMC) for non-muscle invasive bladder cancer (NMIBC). We also discuss the diagnostic procedures and management of this recurrent case.

The relationship between lower urinary tract symptoms associated with benign prostatic hyperplasia and erectile dysfunction: the role of autonomic hyperactivity.

BACKGROUND/AIM: To investigate whether autonomic nervous system (ANS) hyperactivity may be a potential cause for the relationship between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED). MATERIALS AND METHODS: Twenty-four patients were recruited for this study. Complete physical examinations, urine analysis, uroflowmetry, and postvoid residual urine volume (PVRU) analysis were performed. The potential impact of some factors such as hyperglycemia, obesity, and hyperlipidemia were analyzed. These values were correlated with the various symptom scores. We performed an electromyographic and an electrocardiographic evaluation. The alterations after treatment with 2 different alpha-blockers were also analyzed. RESULTS: The electromyographic and electrocardiographic assessments revealed a minimal increase in ANS activity and it did not change significantly after treatment (P > 0.05). After treatment, maximum flow rate increased and PVRU decreased significantly (P < 0.001 and P < 0.001, respectively); total and free testosterone levels increased significantly (P = 0.0068 and P = 0.0071, respectively). There was a statistically significant difference between the 2 treatment groups regarding the outcomes of the Danish Prostate Symptom Score questionnaire (P = 0.047). CONCLUSION: This current study suggested that the effect of ANS hyperactivity is not the fundamental factor underlying the relationship between LUTS and ED.

Radical perineal prostatectomy: Our initial experience.

OBJECTIVE: Radical prostatectomy is the standard treatment modality for localized prostate cancer. Minimally invasive surgery, especially robotic surgery, has attracted interest in the last 10 years, and open surgery has been less preferred. Among the open surgical procedures, the perineal approach is the least preferred by urologists, which may be related to their perception of its overall difficulty. In this study, we aimed to present our initial experience with learning and performing radical perineal prostatectomy (RPP) and to draw attention to this method. MATERIAL AND METHODS: After a short training period between November 2011 and May 2013, RPP was performed on 9 patients with localized prostate cancer. The patients were evaluated as for medical, and perioperative and major postoperative complications. RESULTS: The mean age of the patients was 60.4±5.3 (50-68) years, the mean preoperative prostate-specific antigen (PSA) value was 5.8±1.3 (4.0-7.6) ng/mL and the mean prostate volume was 38.8±7.7 (28-54) cc. The biopsy Gleason score ranged from 5 to 7. The median follow-up period was 14 (3-30) months. Anastomotic stricture did not occur in any of the patients. Of the 9 patients, 4 (44%) were immediately continent after catheter removal, while the remaining patients were continent at the end of three months. Of the 7 patients who underwent nerve-sparing surgery, 2 had postoperative spontaneous erections. Erectile function was maintained with phosphodiesterase 5 (PDE-5) inhibitor treatment in 3, and with intracavernosal injection in 1 patient. Penile prosthesis implantation was performed in 1 patient. CONCLUSION: RPP has been a promising procedure at the start with its favorable oncologic and functional outcomes. This method should be considered by urologists, although it has been previously perceived as a challenging surgical procedure to perform.