Catheterized uroflowmetry as a noninvasive test for detrusor acontractility.

OBJECTIVE: To evaluate the efficacy of uroflowmetry performed through an indwelling catheter on the differential diagnosis of detrusor acontractility. PATIENTS AND METHODS: 50 men aged between 51 and 85 years (mean 66 years) presenting to the outpatient urology department with indwelling catheters due to urinary retention were included in the study. In the supine position, 300 ml of saline was instilled into the bladder and the catheter was blocked; with the patient standing by the flowmeter, the catheter was opened, allowing the patient to void through the catheter. The evaluation continued with a cystometry and pressure-flow study (PFS). The patients were separated into two groups according to the results of the PFS--group 1 with positive detrusor pressure and group 2 with negative detrusor pressure (detrusor acontractility)--and the catheterized uroflow and PFS data were compared. RESULTS: Statistical significance was seen between detrusor acontractility and peak flow rate (Qmax) on catheterized uroflow when Qmax <10 ml/s was taken as a threshold value (p = 0). CONCLUSION: A quick, noninvasive and inexpensive means of assessing lower urinary tract function would improve the management of men needing PFS. This study reveals that catheterized uroflow is a very easy and useful test if the question is whether the bladder is acontractile or not.

Efficacy and safety of a new-generation shockwave lithotripsy machine in the treatment of single renal or ureteral stones: Experience with 2670 patients.

PURPOSE: To review the treatment efficacy and to assess the complications encountered in patients with single renal or ureteral calculi managed with a new-generation SWL machine, the Siemens Lithostar Modularis Uro-Plus. PATIENTS AND METHODS: The stone location, size, minimum and maximum energy used, localization technique, number of shockwaves, fluoroscopy time, and number of sessions were reviewed for 2670 patients. The medical records were consulted to identify post-SWL secondary treatments in order to calculate the efficacy quotient (EQ). RESULTS: The stone-free rate was 79%. Calculi in the renal pelvis and upper, middle, and lower ureter had success rates of 86%, 86%, 86%, and 85%, respectively (P < 0.05). Higher re-treatment rates were encountered for midureteral stones (P < 0.05). The major complications were renal hematoma, acute pyelonephritis, perirenal abscess, and acute pancreatitis. The overall EQ was 0.67. The EQ was higher for the renal pelvis (0.73) and upper ureter (0.71). CONCLUSION: Our experience has shown that this new lithotripter is safe and provides a 68% to 86% chance of stone clearance.

Comparison of nitinol urethral stent infections with indwelling catheter-associated urinary-tract infections.

BACKGROUND AND PURPOSE: To determine the efficacy of intraurethral metal stents in preventing or eradicating urinary-tract infections (UTI) during the management of bladder outlet obstruction (BOO) by comparing the frequency and nature of the infections with indwelling-catheter-associated UTI. PATIENTS AND METHODS: The SAS relative-risk test was used to compare the risks of UTI in 76 patients with temporary urethral stents, 60 patients with BOO who had never been catheterized nor stented, and 34 patients with a permanent indwelling urethral catheter (PIUC). Infection was assessed 1 month after placement of the devices. Scanning electron microscopy (SEM) of the proximal and distal pieces of the stents removed from five patients with and five patients without UTI was carried out in a search for predisposing changes on the surfaces. RESULTS: After insertion of the catheter, UTI developed in 79.4% of the patients who originally had sterile urine. However, after insertion of the stent, UTI developed in only 40.9% of the patients with sterile urine. In 21 (44.6%) of the catheterized patients who had infected urine, UTI was eradicated after stent insertion. The SEM analysis of the stents showed that a thick organic layer had formed only on the infected devices but with no sign of erosion. CONCLUSION: Urinary infection is a significant problem in patients with PIUC but is significantly less frequent and less severe in patients with urethral stents. This advantage of stents over the conventional urethral catheter, in addition to their obvious convenience for the patient, make them good alternatives to reduce the risk of UTI.

Calcification of the epididymis and the tunica albuginea of the corpora cavernosa in patients on maintenance hemodialysis.

The aims of this study were to determine the incidence rates of genital calcification in male hemodialysis patients based on ultrasonography findings and to identify risk factors for this condition. Twenty-three male end-stage renal disease (ESRD) patients (mean age, 51.4 +/- 12.1 years) who were on maintenance hemodialysis underwent penile and scrotal ultrasonography. For each case, we recorded the underlying renal disease and measured serum levels of phosphorus, intact parathormone, and calcium x phosphorus product. Patients were also questioned about erectile dysfunction. The control group consisted of 22 consecutive patients (mean age, 51 years) with type 2 diabetes mellitus with normal renal function who underwent penile and scrotal ultrasonography for various reasons. In the ESRD group, ultrasound revealed calcification of the tunica albuginea of the corpora cavernosa in 15 patients (65%) and calcification of the epididymis in 16 patients (70%; 14 bilateral and 2 unilateral cases). Twenty patients (87%) showed calcification of the epididymis and/or the tunica, and 10 (43%) showed calcification of both these tissues. The rates of epididymal and penile calcification in the ESRD patients and the controls were significantly different (P <.001 for both). There were no significant differences between patients with and without penile and epididymal calcification with respect to age, hemodialysis duration, frequencies of elevated serum phosphorus, elevated serum intact parathormone, elevated calcium x phosphorus product, and frequency of erectile dysfunction (ED) (P >.05 for all). Ultrasonography revealed high rates of penile (tunica albuginea of the corpora cavernosa) and epididymal calcification (65% and 70%, respectively) in the ESRD patients studied, but no association was found between risk factors such as age, underlying renal disease, hemodialysis duration, frequencies of elevated serum phosphorus, elevated serum intact parathormone, and elevated calcium x phosphorus product.

Carcinosarcoma and squamous cell carcinoma of the renal pelvis associated with nephrolithiasis: a case report of each tumor type.

Both squamous cell carcinoma and carcinosarcoma of the renal pelvis are uncommon. We report on two cases, one carcinosarcoma and one squamous cell carcinoma of the renal pelvis. In the patient with squamous cell carcinoma of the left kidney, the tumor was neither detectable on preoperative radiological evaluation nor grossly visible in the surgical specimen. This patient, a 56-year-old man, presented with left lumbar pain, hematuria, fever, 4-5 kg weight loss, and untreated nephrolithiasis of the left kidney that had been diagnosed 20 years earlier. The second patient, an 87-year-old woman, also had a long history of left kidney nephrolithiasis and presented with left lumbar pain and hematuria. Both patients underwent nephrectomy for removal of the non-functioning hydronephrotic left kidney. In both cases, microscopic examination of the surgical specimen revealed squamous metaplasia and dysplasia in the pelvicalyceal mucosa, and islands of atypical squamous cells in the renal parenchyma. In the second case, the kidney also showed sarcomatous changes in the pelvis.

Papillary renal cell carcinoma within a renal oncocytoma: Case report of very rare coexistence.

Renal oncocytomas accounts for 3% to 9% of primary renal neoplasms. The coexistence of renal cell carcinoma (RCC) within the oncocytoma is extremely rare. We report the case of an asyptomatic 74-year-old man with papillary RCC within oncocytoma managed with left radical nephrectomy.

Percutaneous nephrolithotomy for staghorn kidney stones in elderly patients.

PURPOSE: We retrospectively analyzed the results of percutaneous nephrolithotomy operations for treatment of staghorn kidney stone disease in elderly patients and compared surgical parameters and outcomes with a control group of young adult patients. PATIENTS AND METHOD: Between 2002 and 2010, 300 consecutive patients underwent percutaneous nephrolithotomy operation for treatment of staghorn kidney stone disease. Forty-five of the patients were older than 65 years and considered to be in elderly group. Thirty-seven of the patients were between the ages 18 and 36 years and considered to be the control group. Surgical parameters and outcomes were compared between groups. RESULTS: There were no significant differences between groups for stone area, operation time, difference in hemoglobin levels before and after surgery, blood transfusion rate, and length of hospital (P = 0.230, P = 0.106, P = 0.395, P = 0.691, and P = 0.690, respectively). Success rates after the operations were 53% in elderly group and 38% in young adult group. The difference for the outcomes of the operations was statistically insignificant (P = 0.365). Thirty-three (73%) of the patients had associated comorbid diseases in elderly group, while no patients had any comorbid disease in control group. Statistical analyses revealed no significant relation between the presence of comorbid diseases or ipsilateral renal surgery with success rate of the operation in the elderly group (P = 0.26 and P = 0.222, respectively). CONCLUSIONS: The management of kidney stone disease by percutaneous nephrolithotomy in elderly patients is an adequate treatment modality even in the presence of complete staghorn calculi, comorbid diseases or previous ipsilateral renal surgery.

Long-term renal function and stone recurrence after percutaneous nephrolithotomy in patients with renal insufficiency.

PURPOSE: We analyzed long-term results after percutaneous nephrolithotomy (PCNL) in patients with impaired renal function. PATIENTS AND METHODS: Nineteen (6.3%) of 300 patients who underwent PCNL had serum creatinine values above 1.4 mg/dL before surgery and were considered to have impaired renal function. Success rate of operation, recurrence rate, and renal functional status were evaluated. RESULTS: Mean follow-up time was 51.1 +/- 10.1 months. Sixteen patients completed the study, but three patients were lost to follow-up. The results of the operation were as follows: stone free in 50%, clinically insignificant residual fragments in 25%, and clinically significant residual fragments in 25% of the patients. Mean serum creatinine value was 2.30 +/- 0.56 mg/dL before surgery and 2.67 +/- 1.41 mg/dL at the end of follow-up (p = 0.386). Creatinine values decreased to normal range in six patients (37.5%). Six patients (37.5%) had stable renal function (creatinine: 1.4-4 mg/dL). Creatinine values increased (>4 mg/dL) in four patients (25%) who required renal replacement therapy. Three new patients progressed to end-stage renal failure. These three had insulin-dependent type II diabetes mellitus and one also had solitary kidney and atherosclerosis. Two patients (12.5%) had recurrences, one of these had hypercalciuria, and the other had infection stone. CONCLUSION: Our results indicated that most patients presenting with kidney-stone disease and renal insufficiency experience improvement or stabilization of renal function after PCNL. The patients with solitary kidney and those with conditions such as diabetes and atherosclerosis might be at greater risk for deterioration of renal function. Patients with metabolic abnormalities and infection stones might be at higher risk for recurrence.

Percutaneous nephrolithotomy in patients with normal versus impaired renal function.

This study aimed to compare the results of percutaneous nephrolithotomy (PCNL) in patients with impaired renal function (IRF) and normal renal function (NRF). Records of 300 consecutive patients who underwent PCNL from July 2002 to July 2005 were retrospectively reviewed. Nineteen patients (6.3%) had serum creatinine values higher than 1.5 mg/dl before surgery (IRF Group). Nineteen gender and age matched patients with normal renal function were chosen as controls (NRF Group). The surgical parameters, outcome, and complication rates were compared. The effect of PCNL on the renal function was assessed in patients with IRF. There were 13 male and 6 female patients in both groups. In the IRF group, seven patients had a solitary kidney and three had bilateral stones. Thus, PCNL was performed on 22 kidneys. No patients in the NRF Group had solitary kidney or bilateral stones and PCNL was performed on 19 kidneys. There were no statistically significant differences between the two groups for success and complication rates (P = 0.376 and P = 0.184, respectively). In a mean follow-up of 15.6 months, mean serum creatinine decreased from 2.8 to 2.6 mg/dl (P = 0.273) in patients of the IRF group. Similar stone clearance and complication rates were obtained with PCNL in patients with impaired and normal renal function. Surgery does not cause biochemical deterioration in patients with compromised renal function before treatment.

Effects of selective alpha-1-adrenergic receptor blockers on bladder weight.

INTRODUCTION: This study was undertaken to investigate the effects of two different alpha(1)-adrenergic blockers on bladder hypertrophy using ultrasound-estimated bladder weight (UEBW) and to assess the relation between changes in UEBW and other objective and subjective parameters of disease severity in patients with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: 41 men were enrolled in the study and they were subjected to either watchful waiting (group 1) or alpha(1)-adrenergic receptor blocker therapy (group 2 with alfuzosin; group 3 with tamsulosin). The patients were investigated by symptom evaluation using the International Prostate Symptom Score (IPSS) and quality of life score (QOL), uroflowmetry and UEBW. The parameters were assessed again 3 months after initiation of treatment and compared with the initial values. RESULTS: While the mean UEBW increased in group 1 (42.2 +/- 10.3 to 52.5 +/- 12.2 g), it decreased in both the other groups that received alpha-blocker therapy (61.3 +/- 18.7 to 41.1 +/- 13.2 and 59.4 +/- 17.2 to 43.5 +/- 17.6 g, respectively). In groups 2 and 3, the mean UEBW, post-void residual urine, IPSS and QOL values decreased, and the mean maximum flow rate increased. All of the changes in group 2 and all except QOL in group 3 were statistically significant (p < 0.05). The changes correlated well with each other with regard to treatment success. The highest decreases in UEBW were encountered in patients with heavier bladders. CONCLUSIONS: UEBW decreases with alpha(1)-adrenergic receptor blockers. When used together with the other objective and subjective parameters, UEBW is a promising quantitative parameter as a follow-up tool and can be useful in monitoring the therapeutic effects of alpha(1)-adrenergic receptor blockers.

Adenosquamous carcinoma of the prostate.

Adenosquamous carcinoma of the prostate is an unusual histological variant of prostate cancer. The histogenesis of this tumor remains uncertain. The stimulus for the development of the squamous metaplastic cells had been thought to be related to hormone and/or radiation therapy. This report presents a case of adenosquamous carcinoma of the prostate with abscence of previous hormone or radiation therapy. The case showed negative prostate-specific antigen and high molecular weight cytokeratin staining of the adenocarcinoma component, and negative prostate-specific antigen and positive high molecular weight cytokeratin staining of the squamous cell carcinoma component. The adenocarcinoma component stained intraluminally with periodic acid schiff. The staining features and the distinct localizations of the components with intermingling, but no transition, are against the collision-type tumor theory and support the theory that the adenocarcinoma and squamous components arise de novo from pluripotent stem cells. The patient had a rapid downhill clinical course and died 3 weeks after the diagnosis was made.

Does ischemia-induced prostate damage during cardiac surgery involving cardiopulmonary bypass cause bladder outlet obstruction?

OBJECTIVE: This study sought to investigate whether ischemia-induced prostate damage during cardiac surgery involving cardiopulmonary bypass causes bladder outlet obstruction. MATERIALS AND METHODS: The study involved 37 men who underwent elective cardiac surgery involving cardiopulmonary bypass. Prostate-specific antigen (PSA) levels were determined preoperatively (baseline) and on postoperative days 1, 5, and 30. In 4 cases, the PSA level after the operation was unchanged from the preoperative level, so these 4 men were excluded from the study. In the remaining 33 patients, symptoms of bladder outlet obstruction were assessed using the International Prostate Symptom Score. Each subject completed this test preoperatively and 3, 6 and 9 months postoperatively, and the means scores at these time points were compared. The effects of patient age, operative time, CPB time, and aortic clamping time on postoperative increases in PSA levels were investigated. RESULTS: Thirty-three (89.2%) of the 37 men exhibited increased postoperative PSA levels compared to baseline. The mean PSA level for the 33 cases on day 5 was significantly higher than the baseline mean, but the mean levels on postoperative days 1 and 30 were comparable to baseline. Nine (24.3%) of the 33 men had postoperative PSA levels greater than 4.0 ng/dl (the upper normal limit). There was no significant difference between preoperative and postoperative International Prostate Symptom Scores. CONCLUSION: The study indicates that men's PSA levels are, indeed, increased after cardiac surgery with cardiopulmonary bypass. However, in 9 months of follow-up, there was no association between this PSA rise and development of BOO, according to International Prostate Symptom Scores.

Management of complete ureteral obstructions with a transluminal puncture technique.

INTRODUCTION: The traditional delayed treatment of iatrogenic complete ureteral obstruction is open surgery. An easy endourological technique, transluminal re-canalization of the ureter by guide-wire puncture under fluoro-endoscopic control, which has been performed on 4 patients, is described. SURGICAL TECHNIQUE: With the guidance of C-arm fluoroscopy, by moving the C-arm to different planes, the tip of the ureteroscope is directed to the correct plane to meet the obliterated proximal end of the ureter and under direct vision, transluminal puncture is performed using the stiff end of a 0.035-inch guide wire. Once the stiff end of the guide-wire is in the lumen of the proximal ureter, an ureteral catheter is introduced over the guide wire, the guide wire is then removed and reinserted through the ureteral catheter with its soft end leading and a double J catheter is inserted. Ureteral stricture, if later encountered, is treated with balloon dilatation. RESULTS: Continuity of the ureter was restored in all 4 patients. The double J stents were removed 6 weeks later and a retrograde pyelography revealed resolution of the hydronephrosis without extravasation of urine. CONCLUSION: Although a very satisfactory result was achieved in our cases, more cases are needed to show if it can be an alternative to conventional surgical repair. However, we believe that this minimally invasive technique can be used for short obliterated ureteral segments and neither delays nor does it preclude further management using open surgery.

Sterile vesicoureteral reflux decreases tubular cell apoptosis in rat kidney.

OBJECTIVES: To assess the possible role of apoptosis in reflux-related renal scarring by investigating how sterile vesicoureteral reflux affects apoptosis of glomerular and tubular cells in the rat kidney. METHODS: Twenty-nine rats were assigned to one of three groups: group 1, reflux (n = 10); group 2, sham surgery (n = 9); and group 3, controls (n = 10). All rats underwent bilateral nephrectomy 42 days later. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling was used to detect the apoptotic cells, and separate apoptotic index values for glomerular cells (GCAI) and tubular cells (TCAI) were calculated in each kidney (left and right from each animal). RESULTS: The mean TCAI value in the left kidney from groups 1, 2, and 3 was 0.86% +/- 0.26%, 1.20% +/- 0.18%, and 1.19% +/- 0.14%, respectively. The corresponding TCAI values for the right kidneys were 0.77% +/- 0.21%, 1.10% +/- 0.34%, and 1.06% +/- 0.15%. The mean GCAI value in the left kidney from groups 1, 2, and 3 was 0.26% +/- 0.14%, 0.28% +/- 0.08%, and 0.20% +/- 0.10%, respectively. The corresponding GCAI values for the right kidneys were 0.23% +/- 0.06%, 0.26% +/- 0.06%, and 0.22% +/- 0.12%. Analysis revealed no significant differences among the groups with respect to GCAI in the left kidneys (P = 0.258) or right kidneys (P = 0.618). The mean TCAI values in group 1 were significantly lower than the corresponding values in groups 2 and 3 for the left (P = 0.001) and right (P = 0.012) kidneys. CONCLUSIONS: This is the first study to have shown that sterile vesicoureteral reflux decreases apoptosis in tubular cells in rat kidneys with vesicoureteral reflux.

Follow-up of testicular microlithiasis for subsequent testicular cancer development.

INTRODUCTION: To demonstrate the relationship between testicular microlithiasis and testicular tumor development. PATIENTS AND METHODS: Between January 1996 and March 2004, bilateral testicular microlithiasis was found in 40 of the 5,263 patients who underwent scrotal ultrasonography yielding a prevalence of 0.76%. Of the 40 patients, 4 patients with concomitant testicular tumors were excluded from the study. The remaining 36 patients were enrolled into the study and followed by ultrasonography at 6-month intervals. RESULTS: Patient ages ranged between 1 and 69 years (mean 31 +/- 14 years). The median ultrasonography follow-up was 34 months (range, 1-96). Testicular tumor development was not observed in any of these 36 patients during the follow-up period. CONCLUSIONS: Extensive evaluation including computerized tomography, testicular tumor markers and testicular biopsy of patients with testicular microlithiasis is unnecessary and also increases patient anxiety. Yet annual ultrasonography and physical examination should be performed if ever until testicular microlithiasis is completely accepted as a nonpremalignant disease.

Unusual case of post-cesarean vesicouterine fistula (Youssef's syndrome).

Vesicouterine fistula without vaginal leakage of urine, cyclic hematuria and amenorrhea is a rare condition, referred to as Youssef's syndrome. The most common cause of this syndrome is trauma during a cesarean section. Herein a new case is reported.

p53 expression and apoptosis in varicocele in the rat testis.

PURPOSE: We investigated the presence of p53 expression and apoptosis in an experimental model of varicocele in the rat. MATERIALS AND METHODS: A total of 30 adult male Sprague-Dawley rats were studied in 3 groups, namely group 1-13 with varicocele, group 2-9 with sham operation and group 3-8 controls. All animals underwent orchiectomy after 30 days and sections of the left testis from each animal were studied. TUNEL was used to detect apoptotic germ cells and an apoptotic index (AI) was calculated for each testis specimen. p53 expression was determined immunohistochemically and graded according to the proportion of cells stained in each specimen. RESULTS: AI values in group 1 testes were 0% to 0.51% (mean 0.06% +/- 0.13%) and the corresponding range in group 2 was 0.04% to 0.69% (mean 0.25 +/- 0.21%). No group 3 control specimens showed TUNEL staining (AI 0% in all). Although the mean AI in group 1 was higher than that in controls, this difference was not statistically significant (p = 0.318). The mean AI value in group 2 was significantly higher than in the control group (p = 0.021) but it was comparable to that in group 1 (p = 0.099). Seven (53.8%) and 2 (22.2%) specimens in groups 1 and 2, respectively, showed p53 staining in germ cell nuclei. None of the specimens in group 3 showed nuclear p53 expression. The grade of p53 expression in group 1 was significantly higher than that in groups 2 (p = 0.042) and 3 (p = 0.011). Expression grades in groups 2 and 3 were not significantly different (p = 0.426). CONCLUSIONS: To our knowledge p53 expression that may reflect abnormal spermatogenesis has been documented for the first time in an experimental model of varicocele in the rat testis. In contrast to other investigations, no link between apoptosis and varicocele was detected.

Transurethral prostatectomy and inguinal hernia repair in a single session.

INTRODUCTION: We aimed at evaluating the outcomes of transurethral prostatectomy and inguinal hernia repair performed in a single session. PATIENTS AND METHODS: Fifty-six patients (mean age 68+/-8.3 years) in whom transurethral prostatectomy was performed combined with an inguinal hernia repair were included into the study. Type of anesthesia, technique of inguinal hernia repair, hospitalization time, and the complications encountered were recorded. Cost comparisons were made using the official price-lists of the Turkish Medical Association. All patients were asked whether they were satisfied with the outcome of both operations performed in one session. The data obtained from the patients who underwent both operations in one session were compared with those obtained from 56 patients who underwent transurethral prostatectomy only (control group). Statistical analysis was performed using the chi-square test corrected for continuity according to the Yates or the Fisher exact test. RESULTS: The operations were performed in 19 patients under general, in 20 patients under epidural, and in 14 patients under spinal anesthesia. Three patients were given general anesthesia and spinal anesthesia combined. In 6 patients bilateral and in 50 patients unilateral hernia repair was performed. In 11 repairs, polyprolene mesh grafts were utilized; in 2 repairs, a laparoscopic method was used, and in the remaining 49 repairs, one of the conventional techniques (McVay, Bassini, or Shouldice) was employed. There were no significant differences with regard to early and late postoperative complications and satisfaction between study group and control group (p>0.05). Combined prostatectomy and hernia repair allows approximately 30% cost profit. CONCLUSIONS: Performing transurethral prostatectomy and inguinal hernia repair in one session decreased the number of the operations and anesthesias, hospital stay, and thus health costs and did not cause an increase in operative and postoperative morbidity.