Nation-wide analysis of the impact of Covid-19 pandemic on daily urology practice in Turkey.

OBJECTIVE: To present a nation-wide analysis of the workload of urology departments in Turkey week-by-week during Covid-19 pandemic. METHODOLOGY: The centres participating in the study were divided into three groups as tertiary referral centres, state hospitals and private practice hospitals. The number of outpatients, inpatients, daily interventions and urological surgeries were recorded prospectively between 9-March-2020 and 31-May-2020. All these variables were recorded for the same time interval of 2019 as well. The weekly change of the workload of urology during pandemic period was evaluated, also the workload of urology and the distributions of certain urological surgeries were compared between the pandemic period and the same time interval of the year 2019. RESULTS: A total of 51 centres participated in the study. The number of outpatients, inpatients, urological surgeries and daily interventions were found to be dramatically decreased by the 3rd week of pandemics in state hospitals and tertiary referral centres; however, the daily urological practice were similar in private practice hospitals throughout the pandemic period. When the workload of urology in pandemic period and the same time interval of the year 2019 were compared, a huge decrease was observed in all variables during pandemic period. However, temporary measures like ureteral stenting, nephrostomy placement and percutaneous cystostomy have been found to increase during Covid-19 pandemic compared with normal life. CONCLUSIONS: Covid-19 pandemic significantly affected the routine daily urological practice likewise other subspecialties and priority was given to emergent and non-deferrable surgeries by urologists in concordance with published clinical guidelines.

Comparison of functional outcomes of off-clamp laparoscopic partial nephrectomy access techniques: A preliminary report.

OBJECTIVE: This study aims to compare renal functional outcomes of access techniques in patients who underwent off-clamp (Off-C) laparoscopic partial nephrectomy (LPN). MATERIALS AND METHODS: Thirty-four Off-C LPNs in patients with functioning contralateral kidney from March 2011 to June 2018 were included in the study. Twenty-two patients underwent transperitoneal, 12 patients underwent retroperitoneal Off-C LPN. The primary outcome was glomerular filtration rate changes over time, postoperatively. The secondary outcome was the evaluation of trifecta and pentafecta rate. RESULTS: Preoperative demographics, tumor size (26.59 vs. 22.83mm, p=0.790), RENAL score (5.45 vs. 5.33, p=0.990), operation time (79.95 vs. 81.33 min, p=0.157), blood loss (170.23 vs. 150.83mL, p=0.790) were similar in both groups. Although preservation of renal function was better in group 2 in the early period, similar results were found in both groups at the end of the first year, postoperatively. No positive surgical margin and postoperative major complications were detected in any patient. While trifecta goals were achieved in all the patients in the cohort, pentafecta rates were 90.9% and 91.7% in the transperitoneal and retroperitoneal groups, respectively. CONCLUSIONS: Transperitoneal and retroperitoneal access were found to have similar outcomes in terms of preservation of renal function at the end of the first year postoperatively. Off-C LPN may be considered as a safe and effective treatment option in patients having non-complex renal tumors.

The learning curve for pure retroperitoneoscopic donor nephrectomy by using cumulative sum analysis.

INTRODUCTION: This study aimed to identify a precise learning curve for pure retroperitoneoscopic donor nephrectomy (RDN). METHODS: Data from 172 consecutive kidney donors who underwent pure RDN between January 2010 and July 2019 were prospectively collected and evaluated. Cumulative sum (CUSUM) analysis was used for testing the operation time. Changepoints were determined by using the r program and BINSEG method. The cohort was divided into three groups - group 1: competence, including the first 10 cases; group 2: 11-48 cases as proficiency; and group 3: the subsequent 124 cases as expert level. Continuous variables were evaluated using one-way ANOVA, and categorical data were evaluated using the Chi-squared test. RESULTS: Right RDN was performed in 39 (22.7%) donors. The eighth patient was converted to open surgery due to vena cava injury and excluded from the CUSUM analysis. Depending on experience in pure RDN, a significant decrease was detected in operative time (p<0.001), warm ischemia time (p=0.006), and blood loss (p<0.001). Recipient complications and graft function were found to be statistically comparable. CONCLUSIONS: In our study, the attainment of expertise in pure RDN was observed after performing 50 cases. The transperitoneal technique, which is a feasible alternative, is far more widely used than pure RDN. We believe that understanding the learning curve associated with pure RDN could facilitate the adoption of this approach as a viable alternative to the transperitoneal approach.

Renal hydatid cyst treatment: retroperitoneoscopic "closed cyst" pericystectomy.

Cystic hydatid disease is an endemic disease caused by the larval form of Echinococcus spp. Isolated renal involvement is extremely rare. The treatment methods for renal hydatid disease require some form of intervention, ranging from traditional open techniques to laparoscopic techniques. Herein, we present a large hydatid cyst in the lower pole of the left kidney in a 43-year-old male patient who was treated by the "closed cyst" method via the retroperitoneal laparoscopic approach to prevent soiling of the peritoneal cavity. To our knowledge, this is the first case of a renal hydatid cyst treated by preserving the renal parenchyma by pericystectomy via the retroperitoneoscopic laparoscopic approach in an adult patient. No complications occurred during the perioperative and postoperative periods. After 9 months of follow up, the patient was asymptomatic with no evidence of clinical recurrence. Retroperitoneoscopic laparoscopic closed cyst pericystectomy can be an alternative minimally invasive treatment technique for the treatment of renal hydatid disease.

Which Is the Best Predictor to Achieve Trifecta in Patients Undergoing Elective Laparoscopic Partial Nephrectomy with Global Hilar Clamping? Comparative Analysis in Patients with Clinical T1a and T1b Renal Tumors.

Background: Partial nephrectomy (PN) is the standard of treatment in patients with cT1 renal tumors. Current guidelines recommend PN as a standard of treatment in patients with cT1 renal tumors. However, the commonly accepted criteria for which surgical outcomes are evaluated both functionally and oncologically are not yet clear. The aim of this study was to evaluate compounding factors that affect the operative and functional outcomes for laparoscopic partial nephrectomy (LPN) in patients with cT1 renal tumors. Methods: This study was registered at NCT04213157 for patients who underwent LPN with the diagnosis of clinical T1 renal tumors. Between November 2009 and August 2018, 292 patients were included in the study. The patients were allocated into two groups according to the tumor size: T1a (n = 215) and T1b (n = 77). Demographic features, clinical tumor characteristics, and intraoperative and postoperative outcomes were analyzed. A negative surgical margin, warm ischemia time of <20 minutes, and no postoperative major complications were accepted to achieve the trifecta outcomes. Pentafecta was defined as trifecta criteria plus >90% preservation of baseline renal function (RF) and no stage upgrade of chronic kidney disease at 12 months after surgery. Univariate and multivariate analyses were used to identify factors predicting trifecta and pentafecta. Results: Preoperative variables including age, gender, and baseline RF were similar between the two groups. The warm ischemia time was 13.4 vs 15.9 minutes (P = 0.001). The positive margin rate was 0.9% vs 2.6% (P = 0.284), and the major complication rate was 3.3% vs 2.6% (P = 0.548). The achievement of the trifecta rate was 88.4% vs 75.3% (P = 0.006) and pentafecta rate was 72.6% vs 42.9% (P = 0.001). Multivariate analysis showed that tumor complexity, baseline RF, and diabetes mellitus are independent predictors of achieving pentafecta outcomes. Conclusion: LPN is an effective and reliable method for renal tumors even in T1b with satisfying surgical and functional outcomes.

Strategies to Perform Pure Retroperitoneoscopic Donor Nephrectomy: A Single-Center Cohort Study.

Background: Considering the increase in a number of vascular complications, right laparoscopic donor nephrectomy is less preferred due to achieving not only shorter renal vein but also longer renal artery. However, recent studies have indicated that the side of the surgery would not affect the outcomes. Aim: The aim of this study is to evaluate the outcomes and strategies to increase the safety of pure retroperitoneoscopic donor nephrectomy (RDN). Methods: We analyzed the prospectively collected medical records of 158 kidney donors who underwent RDN from January 2010 to August 2018. The patients were divided into two groups based on their side of surgery. Right- and left-sided RDNs were compared in terms of demographics, intraoperative, and postoperative data, including the development of incisional hernia (IH). The outcomes of the recipients were also evaluated. Results: Right RDN was performed in 40 (25.3%) and left RDN was performed in 118 (74.7%) donors. Operation time (P = .593), warm ischemia time (P = .271), blood loss (P = .787), and length of hospital stay (P = .908) were statistically similar in right and left RDN groups. Intraoperative and postoperative complications were statistically showed no difference between right and left RDNs. No IH was observed in any group. One-year and five-year patient survival and graft survival rates were 100% versus 97% (P = .299) and 100% versus 95% (P = .126) on both sides, respectively. Conclusion: Right RDN is an effective and safe method as on the left side. RDN has an additional advantage in the absence of IH. Experience with other retroperitoneoscopic urological interventions may have had a positive effect on the outcomes of pure RDN.

Laparoscopic Partial Nephrectomy in Allograft Kidney.

The incidence of renal tumor on the allograft kidney is relatively rare. There is no standard treatment available for the management of such cases. However, if technically feasible nephron-sparing surgical approaches, whether open or minimally invasive, should be preferred for the management of these challenging cases. To our knowledge, there is no pure laparoscopic technique reported in the literature but only 3 cases of robot-assisted partial nephrectomy. In this article, we aimed to present the application of pure transperitoneal laparoscopic partial nephrectomy for the management of a renal mass on the allograft kidney.

Clinical Effectiveness of Single Pigtail Suture Stent on Patient Comfort: A Double-Blind Prospective Randomized Trial.

Background: A double-pigtail ureteral stent (DPUS) can cause untoward symptoms, such as urgency, frequency, urinary incontinence, hematuria, and body pain that are bothersome to patient's quality of life (QoL). By reducing the quantity of material in the bladder, it could be reasonable to decrease stent-related symptoms (SRSs). We aimed to evaluate the tolerability of single pigtail suture stent (SPSS) with a validated questionnaire after uncomplicated retrograde semirigid ureteroscopic lithotripsy (URSL). Materials and Methods: A total of 130 patients who underwent ureteral stent placement after URSL for unilateral symptomatic ureteral stones with <15 mm diameter were randomized prospectively into two groups. Polyurethane ureteral stent (6 Fr, 24 or 26 cm) was placed in all patients, which was removed postoperatively with a mean of 14 days. There were 65 patients in both groups. All subjects completed the ureteral stent symptoms questionnaire (USSQ), which explores the SRSs. The questionnaires were conducted on the day of stent removal (at week 2) with the stent in situ and 4 weeks after removal (at week 6, poststent). The severity of SRSs and QoL were compared between the two groups. Results: SPSS was associated with perfect effect on all domains of USSQ, except from sexual and general health index scores. Pain index scores, visual analog scores (VAS), and analgesic requirements in SPSS group were found significantly low compared with those in the DPUS group. The QoL scores were significantly better in patients indwelling SPSS. Conclusion: SPSS is a potentially beneficial option to minimize ureteral SRSs after uncomplicated URSL.

Bladder-sparing Approach in a Woman with Muscle-invasive Primary Bladder Melanoma.

Primary bladder melanoma (PBM) is an extremely rare tumor. Herein, we present a 39-year female evaluated for a history of dysuria and hematuria for one month and a solid mass of 23x15 mm detected on the left lateral wall of the bladder. The transurethral resection (TUR) of the tumor revealed muscle-invasive malignant melanoma. Laparoscopic partial cystectomy (LPC) and bilateral pelvic lymph node dissection (BPLND) were performed since other sites of melanoma were excluded. In this article, the effects of tumor characteristics and minimally invasive treatment options on survival are discussed in a patient with muscle-invasive PBM.

Laparoscopic Bladder-Sparing Approach in Patients with Prostatic Rhabdomyosarcoma: A Case Series of Two Pediatric Patients.

Traditionally, the standard treatment of bladder-prostate rhabdomyosarcoma (BP-RMS) is being implemented to be total cystoprostatectomy and urinary diversion. However, current multimodal treatment approaches emphasize the importance of bladder-sparing surgery. In this case series, it was aimed to indicate the results of the laparoscopic bladder-sparing approach of two pediatric patients with BP RMS. They have admitted to the emergency department due to acute urinary retention (AUR). The tumors located in the prostate causing AUR were detected by Magnetic resonance imaging (MRI) and the pathological diagnosis was confirmed by biopsy. The patients were managed in a prosperous manner by implementing laparoscopic surgery with the cause of detection of a significant decrease in the size as well as the enhancement pattern of the tumors following neoadjuvant chemotherapy. No urinary incontinence, tumor recurrence or metastasis was observed at 36 and 28 months follow-up in case 1 and case 2, respectively. Laparoscopic bladder-sparing approaches may have an advantage in patients with BP RMS to decrease morbidity and mortality related to radical surgery. To our knowledge, these are the first cases of laparoscopic bladder-sparing approach in the treatment of pediatric prostate-derived embryonal RMS (PDERMS).

Unilateral Synchronous Multiple Kidney Tumors Managed by Laparoscopic Partial Nephrectomy: Five-year Follow-up.

Unilateral synchronous multifocal renal tumors are rare. Due to the limited data in the literature and challenges in the technique, there is still doubt on the application of laparoscopic partial nephrectomy (LPN) for the management of such tumors. Herein, we report a 36-year male patient presenting with right-sided flank pain and microscopic hematuria. Abdominal computed tomography (CT) revealed five solid masses, the largest of which was 27 x 18 mm. The patient underwent LPN and the largest mass was resected with the control of segmental artery of the lower pole of the right kidney. The remaining four masses were resected by zero-ischemia technique. Final pathology revealed renal cell carcinoma in all masses. Postoperative period was uneventful. No recurrence was detected during a 5-year follow-up.

Evaluation of early and late-term infections after renal transplantation: Clinical experiences of Sanko University Medical Faculty Transplantation Center.

OBJECTIVE: Infections play an important part in post-transplantation causes of morbidity and mortality. The purpose of this study is to evaluate short-, and long-term infections encountered in after renal transplantations. MATERIAL AND METHODS: Two hundred and thirteen cases that consisted of both living and cadaver donors, who suffered from late period renal insufficiency and had renal transplant between June 2011 and January 2016 at the Transplantation Center of Sanko University School of Medicine were included in the study. In this study the short-, and long-term infections seen in post renal transplantation were examined retrospectively. Infection types, frequency and periods of infection, infection agents and predisposing factors were determined as the examination parameters. RESULTS: Of the 213 patients who received renal transplant, 139 were males (65.3%) and 74 were women (34.75%) and the mean age was 42±11,8 (range, 14-70) years. Twelve (5.6%) patients exited after renal transplantation. Post-transplant infections were seen in 49 patients (23.1%) within 1-6 months; in 13 patients (6.1%) within 6-12 months; and in 5 patients (2.4%) after the 12th month. The most common infections after renal transplantation were associated with urinary tract (70 patients, 34.3%). The most frequently isolated agents were E. coli (n=66; 30.9%), Kebsiella spp. (n=18; 8.4%) and Enterococci (n=18; 8.4%) respectively. The renal transplants from the cadavers were observed to contract infections 1.78 times more frequently compared to the living donors (OR=1.78, 95% CI=1.03-3.09). CONCLUSION: The most common complication after renal transplantation are infections. The majority of the infections are seen within the first year especially between 1-6 months. Post-transplant infections are often related to urinary system. E.coli is the most frequently isolated agent and it may be responsible for urosepsis in renal transplant patients. Infection more often seen in renal transplantations from cadavers.

Percutaneous nephrolithotomy in pediatric age group: Assessment of effectiveness and complications.

Management of kidney stone disease in pediatric population is a challenging condition in urology practice. While the incidence of kidney stone is increasing in those group, technological innovations have conrtibuted to the development of minimally invasive treatment of urinary stone disease such as mini-percutenous nephrolitotomy (mini-PCNL), micro-PCNL, ultra mini-PCNL. In this review we tried to evaluate the effect of new teratment techniques on pediatric kidney stones.

Comparison of functional outcomes of off-clamp laparoscopic partial nephrectomy access techniques: A preliminary report

ABSTRACT Objective: This study aims to compare renal functional outcomes of access techniques in patients who underwent off-clamp (Off-C) laparoscopic partial nephrectomy (LPN). Materials and Methods: Thirty-four Off-C LPNs in patients with functioning contralateral kidney from March 2011 to June 2018 were included in the study. Twenty-two patients underwent transperitoneal, 12 patients underwent retroperitoneal Off-C LPN. The primary outcome was glomerular filtration rate changes over time, postoperatively. The secondary outcome was the evaluation of trifecta and pentafecta rate. Results: Preoperative demographics, tumor size (26.59 vs. 22.83mm, p=0.790), RENAL score (5.45 vs. 5.33, p=0.990), operation time (79.95 vs. 81.33 min, p=0.157), blood loss (170.23 vs. 150.83mL, p=0.790) were similar in both groups. Although preservation of renal function was better in group 2 in the early period, similar results were found in both groups at the end of the first year, postoperatively. No positive surgical margin and postoperative major complications were detected in any patient. While trifecta goals were achieved in all the patients in the cohort, pentafecta rates were 90.9% and 91.7% in the transperitoneal and retroperitoneal groups, respectively. Conclusions: Transperitoneal and retroperitoneal access were found to have similar outcomes in terms of preservation of renal function at the end of the first year postoperatively. Off-C LPN may be considered as a safe and effective treatment option in patients having non-complex renal tumors.

Effect of urinary stone disease and its treatment on renal function.

Urolithiasis is a common disease that affects urinary tract in all age groups. Both in adults and in children, stone size, location, renal anatomy, and other factors, can influence the success of treatment modalities. Recently, there has been a great advancement in technology for minimally invasive management of urinary stones. The epoch of open treatment modalities has passed and currently there are much less invasive treatment approaches, such as percutaneous nephrolithotomy, ureteroscopy, shockwave lithotripsy, and retrograde internal Surgery. Furthermore, advancement in imaging technics ensures substantial knowledge that permit physician to decide the most convenient treatment method for the patient. Thus, effective and rapid treatment of urinary tract stones is substantial for the preservation of the renal function. In this review, the effects of the treatment options for urinary stones on renal function have been reviewed.

Horseshoe kidney: does it really have any negative impact on surgical outcomes of percutaneous nephrolithotomy?

OBJECTIVES: To compare the stone-free rate and complications between horseshoe and normal kidneys. METHODS: Between December 1997 and June 2008, a total of 2401 patients with 2618 renal units underwent percutaneous nephrolithotomy (PCNL). During this period, we retrospectively reviewed the data of 46 patients with 50 (1.9%) renal units with horseshoe kidneys treated by PCNL. We compared the success and complication rate in horseshoe kidney and normal kidney. RESULTS: Fifty PCNL were performed in the above-mentioned 46 patients with a mean age of 41.6 years. The average stone burden ranged from 100 to 4900 mm(2) (mean, 644 +/- 135 mm(2)). The stones were located in the renal pelvis in 13 (26%), calices in 17 (34%), and in both in 11 kidneys (22%). A single tract was used in 42 kidneys (84%), and 2 tracts were created in the remaining 8 (16%). Major complications were seen in 8 PCNL procedures (16%). A detailed comparison between horseshoe and normal kidneys showed that stone burden, operation time, stone-free rates, and auxiliary procedure rates were similar. The only statistically significant difference was detected in the number of access, which is more in normal kidneys. Logistic regression analysis did not reveal that horseshoe kidney did not have any negative effect on success after PCNL. CONCLUSIONS: Despite the anatomic abnormalities, PCNL is a safe and effective treatment option for calculi both in the horseshoe kidney and the normal kidney with the similar success and complications rates.