Failure of ureteral access sheath insertion in primary flexible ureteroscopy for renal stones: is there any relation with inflammation?

PURPOSE

To investigate the relationship between failure to insert a ureteral access sheath (UAS) with inflammation and other clinical parameters in patients treated with flexible ureteroscopy for renal stones.

METHODS

This study included patients who underwent flexible ureteroscopy for the treatment of renal stones in our centre between 2015 and 2020. Patients who underwent any surgical procedure on the ipsilateral ureter and had a history of spontaneous stone passage were excluded. Patients were divided into two groups based on UAS insertion success (group 1) or failure (group 2). Both groups were compared with a view to clinical characteristics, preoperative neutrophil, lymphocyte, monocyte and platelet counts and ratios of these counts, all being considered inflammatory markers. A multivariate logistic regression analysis was performed to determine the independent variables affecting UAS insertion success.

RESULTS

There were 113 (59.1%) patients in group 1, while group 2 consisted of 78 (40.9%) patients. The rates of male gender, coronary artery disease and preoperative ipsilateral hydronephrosis were significantly higher in group 2, while platelet counts and platelet-lymphocyte ratios were significantly lower. Our analysis revealed four independent predictors for UAS insertion failure: female gender (odds ratio [OR]=2.1) increased the rate of UAS insertion success, while hydronephrosis (OR=1.6), low platelet counts and PLR increased the rate of UAS insertion failure (OR=0.99, OR=0.98, respectively).

CONCLUSION

Our results suggest that male gender and ipsilateral hydronephrosis are associated with increased UAS insertion failure. Although we found a relationship between relatively low platelet levels and UAS insertion failure, we think that further studies are needed to investigate this matter.

The role of preoperative ultrasound in the diagnosis of penile fractures and the effect of tunica defect length on postoperative functional outcomes

PURPOSE

This study aimed to investigate the rate of tunica defect detection by postoperative penile ultrasound (US) and the effect of tunica defect length (TDL) on functional outcomes.

METHODS

Forty-six patients who underwent early penile fracture surgery in our hospital between July 2010 and December 2018 were included in the study. Each diagnosis was made via history, physical examination and US. Functional outcomes were assessed at 3, 6 and 12 months postoperatively. The International Index of Erectile Function-5 (IIEF-5) score was used to assess erectile function. US detection rates for tunica defects, as well as whether the rates changed according to TDL, were also analysed. The TDL cut-off value for US detection was determined to be 11 mm using the receiver operating characteristic curve. The impact of TDL on functional outcomes was also evaluated using this cut-off value.

RESULTS

The main cause of fractures in 34 patients (74%) was sexual intercourse. One patient (2.2%) had penile curvature, and 16 (34.8%) had penile nodules in the follow-ups. US had a higher detection rate in the group with TDL >11mm (94% vs 25%). IIEF-5 scores at the postoperative third month were statistically lower in patients with TDL >11mm (n = 34) compared with those with ≤11 mm (n = 12). The rate of penile nodules was found to be statistically higher in the group with TDL >11mm at the end of the 1-year follow-up period (44.1% vs 8.3%).

CONCLUSIONS

US is a valuable tool for the detection of tunica defects especially with >11mm length. In addition, TDL >11 mm in penile fractures is associated with lower IIEF-5 scores in the early postoperative period and higher rates of penile nodules.

The fate of paratesticular masses: 13 years' experience in a tertiary referral centre

OBJECTIVE

Paratesticular neoplasms exhibit different behaviours, depending on the embryological tissue of origin. Treatment modalities can depend on the differential diagnosis. The aim of this study is to present the clinical, morphological and histopathological features of patients with paratesticular masses and their follow-ups and is intended to increase awareness of the issues.

METHODOLOGY

We included 31 excisions of paratesticular masses, after radiological diagnosis as paratesticular mass in our hospital between 2007-2020. Information on treatment modalities, tumour recurrence, metastasis, and survival rates were obtained from hospital archives. All patients were evaluated by taking patients' history, physical examination, scrotal ultrasound, chest radiography, and serum tumour markers. Treatment modality was selected according to intraoperative findings. Haematoxylin-eosin sections were examined, and immunohistochemical analyses were performed for smooth muscle actin, desmin, Ki67, CD34, S100, and myogenin. Ten high-power fields were counted to document Ki67 and p53 nuclear positivity rates.

RESULTS

A total of 31 operations were performed with recurrence in three patients. Histomorphological and immunohistochemical examination revealed eleven malignant masses; eight rhabdomyosarcomas, a leiomyosarcoma, a liposarcoma and a large B cell lymphoma. Other excised masses were benign and infective lesions.

CONCLUSION

Paratesticular masses are heterogeneous tumours that follow different clinical courses. Clinicians must be aware of this histological diversity in order to plan a treatment pathway. This study is one of the largest published series, with a long follow-up period. It shows that the most critical features in determining prognosis are histopathological subtype and tumour grade.

Rare Causes of Hydronephrosis in Adults and Diagnosis Algorithm: Analysis of 100 Cases During 15 Years

Introduction Hydronephrosis (HN) is a common pathology that is with/without obstruction. HN should be promptly addressed; otherwise, it progresses to cause impaired kidney function. This study was conducted to define the diagnosis algorithm and poor prognostic parameters used to evaluate unknown HN. Materials and Methods This study enrolled 100 patients who were over 20 years of age and were admitted to the center between 2001 and 2015 for the diagnosis and treatment of HN. Although initial diagnostic tests were applied, the HN etiology of the patients could not be found in ambulatory conditions; therefore, they were hospitalized to seek the causes for their HN. Patients who had a malignancy or tuberculosis or any previous ureteral injury were excluded. Results Of these cases, 29 were on both sides, whereas 42 were on the left side. Despite further investigations, the etiology was not determined in five patients. The frequency of malignancy in patients with hematuria (5/15) was two times higher than in patients without hematuria (33% vs. 17.6%; p = 0.01). Additionally, the malignancy rate was significantly higher in patients with weight loss (100%) than those without weight loss (OR: 6.25; p < 0.001). Conclusions Further investigation is recommended to define the precise etiology of HN. Hematuria and weight loss should be considered poor predictive factors during diagnosis.

The learning curve of sting method for endoscopic injection treatment of vesicoureteral reflux

Objective:

To identify how many endoscopic injection (EI) procedures, STING method, must be performed before reaching an ideal success rate when simulation training has not been received.

Materials and Methods:

The EI procedures performed by two pediatric urology fellows were investigated. The study excluded patients without primary VUR and those with previous EI or ureteroneocystostomy, lower urinary tract dysfunction, and/or duplicate ureters. The EIs used dextranomer hyaluronate and the STING method, as described by O’Donnell and Puri. Groups number was determined by multiple statistical trials. Statistically significance differences were achieved with one combination that had 35 EI procedures each and with 3 different combination of patients, having 12, 24, and 36 patients, respectively. Therefore, groups were established 12 patients. The first fellow performed 54 EIs, and the second performed 51. Therefore, each of the first fellow's three groups contained 18 EI procedures, and each of the second fellow's 17.

Results:

The study included 72 patients and 105 ureter units. When the data from both fellows were combined, each of the three groups contained 35 procedures. For the first fellow, the success rates in the first, second, and third groups were 38.3%, 66.6%, and 83.3% (p = 0.02), respectively, and for the second fellow, the success rates were 41.2%, 64.7%, and 82.3% (p = 0.045), respectively. The increased success rates for both fellows were very similar.

Conclusions:

An acceptable rate of success for EI may be reached after about 20 procedures and a high success rate after about 35-40 procedures.

Lower urinary tract dysfunction in pediatric patients after ureteroneocystostomy due to vesicoureteral reflux: Long-term follow-up

OBJECTIVE

The aim of the present study was to evaluate long-term lower urinary tract dysfunction (LUTD) in pediatric patients who underwent ureteroneocystostomy due to vesicoureteral reflux.

METHODS

The present retrospective study was performed on 61 patients. Patients were divided into 3 groups: Group 1 (n = 26), did not have LUTD; Group 2 (n = 23), had LUTD; and Group 3 (n = 12), was not toilet trained preoperatively. Patients were reassessed regarding de novo LUTD or the persistence of LUTD at least 7 years after the ureteroneocystostomy.

RESULTS

Mean patient age was 7 years (range 1-15) when ureteroneocystostomy was performed and the surgery was associated with a 92% success rate. The mean follow-up period was 10 years (range 7-12 years). Postoperative LUTD was present in 6 (23%), 12 (52%), and 1 (8.3%) patients in Groups 1, 2, and 3, respectively. The presence of LUTD before surgery and bilateral repair in the same setting were predictive risk factors for the presence of LUTD during the long-term follow-up. LUTD occurred at higher rate in Group 2 than in Groups 1 and 3 (52% vs. 23% and 8.3%, respectively; P = .015). The presence of de novo LUTD was significant in Group 1 compared with the presence of preoperative and postoperative LUTD (P = .031, Wilcoxon analysis).

CONCLUSIONS

LUTD may not resolve after a ureteroneocystostomy, and additional therapy could be necessary. Due to the probability of damage to the ureterovesical nerve and/or disturbed bladder dynamics, de novo LUTD may occur in patients with bilateral high-grade reflux without LUTD before a ureteroneocystostomy.

Evaluation of per-operative cough stress test during transobturator mid-urethral sling surgery

PURPOSE

Currently, it is unclear how the mesh tension should be adjusted on the transobturator tape surgery (TOT) for improving continence. The aim of this study was to evaluate the effects of per-operative cough stress test on TOT.

MATERIALS AND METHODS

Between March 2007 and December 2011, 206 women with SUI were enrolled in this study. Patients were randomly categorized to treatment with TOT (96) or TOT with cough stress test (110). The IIQ-7 and the UDI-6 were used to identify satisfaction level. At the end of 1st year, two groups were compared patient characteristics, operation time, duration of hospital stay, cure and complication rates.

RESULTS

The cure rate was 84.37% 81/96) versus 83.63% (92/110) in TOT and TOT with cough test groups, respectively. Postoperatively ten patient (10/110, 9.09%) suffered voiding difficulties (&gt; 250 ml residual urine) in TOT with cough stress test group. Five patients were discharged with transurethral catheter, whereas, in traditional TOT group, two patients (2/96, 2.1%) had transient postoperative voiding difficulty and two patients were treated with repeated catheterization for 1 week (p &lt; 0.05). Postoperative groin pain was present in 7/96 (8%) versus 24/110 (22%) in TOT and TOT with cough test groups, respectively (p &lt; 0.05). TOT with cough stress test group had an higher rate of complications like, retention of urine, necessitating to cut the tape, mesh erosion and pain in groin or leg. No patient had resistant voiding difficulty or prolonged urinary retention (&gt; 1 week) in traditional TOT group.

CONCLUSIONS

We believe that per-operative cough stress test leads to overtreatment of stress urinary incontinence when the complication rates were considered.

Does maternal exposure during pregnancy to higher ambient temperature increase the risk of hypospadias?

INTRODUCTION

The association between ambient temperature that the mother is exposed to during pregnancy and hypospadias has not been investigated by the studies, although the recent studies showed the correlation between some congenital malformations (congenital heart disease, neural tube defect, etc.) and ambient temperature.

OBJECTIVE

The aim was to investigate the relation between hypospadias and the ambient temperatures that the mother is exposed to during her pregnancy.

METHODS

The data of patients with hypospadias that had their gestational periods in Ankara and Istanbul regions, and had other urological treatments (circumcision, urinary tract infection, pyeloplasty, nephrolithotomy, etc.) between January 2000 and November 2015 were analyzed retrospectively. The ambient temperature at 8-14 weeks of gestation was investigated for each patient by reviewing the data of the General Directorate of Meteorology, since this period was risky for development of hypospadias. The data including ambient temperature that the pregnant mother was exposed to, maternal age, parity, economical status, gestational age at birth, and birth weight were compared between two groups. The retrospective nature of the study may be a potential source for selection bias.

RESULTS

The data of 1,709 children that had hypospadias repair and 4,946 children that had other urological treatments between 2000 and 2015 were retrospectively analyzed. There were no differences between the groups for maternal age, parity, economical status, gestational age at birth, and birth weight (Table). Analysis of exposed maximum and average ambient temperatures at 8-14 weeks of gestation revealed that July and August, hot periods in summer time, were more prevalent in the hypospadias group (p = 0.01). The average and maximum monthly ambient temperatures during summer increased the risk for hypospadias (OR, 1.32; 95% CI, 1.08-1.52; and OR, 1.22; 95% CI, 0.99-1.54, respectively.

CONCLUSIONS

In this paper, we evaluated the relation between hypospadias and the ambient temperatures that the mother is exposed during her pregnancy. The results of this study indicated that the high ambient temperatures the mother and fetus are exposed to at 8-14 weeks of gestation increased the risk of hypospadias in the offspring.

Comparison of laparoscopic and open ureterolithotomy in impacted and very large ureteral stones

PURPOSE

To compare the efficacy of laparoscopic and open ureterolithotomy in patients with ureteral stones.

MATERIALS AND METHODS

Patients who had undergone open or laparoscopic ureterolithotomy between 2001 and 2013 in our clinic were enrolled in the study.Ureterolithotomy was performed due to the following reasons: failure to position the patient for ureteroscopy, unreachable stone with ureteroscopy also use of balloon dilatation, high stone volume, and the need for removal of kidney stones at the same session.. The patients' demographic data, the volume of the stones, the duration of the operation and the hospital stay, the amount of analgesics administered after the operation, and the need for another procedure were compared.

RESULTS

Of study subjects 32 patients had undergone open and 20 patients had undergone laparoscopic ureterolithotomy. When the two groups were compared, there was no statistically significant difference with regard to the mean age (44.5-44 years), the body mass index (26-24.7 kg/m²), the stone volume (420-580 mm³), the duration of operation (122-123 min), the need for another procedure and complications. The mean amount of analgesics administered after the operation (3.6 and 1.81 doses, P = .02) and the mean hospital stay (6.1 and 2.9 days, P = .01) were significantly lower in the laparoscopic ureterolithotomy group.

CONCLUSION

Laparoscopic ureterolithotomy is a good alternative with less need for analgesia and a shorter hospital stay when compared with open ureterolithotomy.

"Snodgraft" technique for the treatment of primary distal hypospadias: pushing the envelope

PURPOSE

"Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair.

MATERIALS AND METHODS

A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results.

RESULTS

At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable.

CONCLUSIONS

No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

Twelve-year experience with Hinman-Allen syndrome at a single center

OBJECTIVE

To report the long-term follow-up results of patients with Hinman-Allen syndrome (HAS) at our institution.

METHODS

The data from 22 children with HAS were retrospectively analyzed. The patients were followed up every 3-6 months with serial physical examinations, voiding charts, urine culture, postvoid residual urine volume determination, serum creatinine measurement, and urinary imaging. The follow-up time was calculated from the day of the first visit to the day of the latest dimercaptosuccinic acid scan. Urotherapy, pharmacotherapy, clean intermittent catheterization, biofeedback therapy, and surgery were performed sequentially and/or combined, depending on the disease course. Renal deterioration was defined as any presence of a new scar or cortical thinning compared with the findings from the first dimercaptosuccinic acid scan. Upper urinary tract deterioration was defined as the persistence or progression of hydronephrosis on ultrasonography.

RESULTS

The mean age at referral was 9.18 ± 3.36 years (range 2-14), and the mean follow-up period was 80.90 ± 19.57 months (range 54-144). Conservative therapy resulted in improvement of the bladder function in 14 patients; however, 8 patients required surgery owing to failure of this approach. Asymptomatic bacteriuria developed in one half of the children (n = 11, 50%), and in 6 (22.7%), ≥1 febrile urinary tract infection developed. None of the patients had upper urinary tract deterioration; however, renal deterioration developed in 3 patients (13.6%). The mean creatinine levels had remained stable at the end of the follow-up.

CONCLUSION

Close follow-up at a single institution and proactive treatment resulted in successful stabilization of HAS in most of our children with HAS.

Factors affecting complication rates of ureteroscopic lithotripsy in children: results of multi-institutional retrospective analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSE

We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi.

MATERIALS AND METHODS

We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates.

RESULTS

A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate.

CONCLUSIONS

Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Bowel preparation and peri-operative management for radical cystectomy in Turkey: Turkish Urooncology Association multicenter survey

PURPOSE

To investigate the preferences and practice patterns of urooncologic surgeons in Turkey on bowel preparation and peri-operative management for radical cystectomy.

MATERIALS AND METHODS

This study was conducted by Turkish Urooncology Association as a multicenter survey. Participants were asked to fill in questionnaires dispensed at annual oncologic meeting or using internet access to the website of Urooncology Association. The questionnaire consisted of multiple choice or open-ended questions related to frequency of cystectomy, surgical technique and type of diversion, bowel preparation protocol, nasogastric tube applications, antibiotic prophylaxis, and deep vein thrombosis prophylaxis. Collected data from the survey were presented descriptively.

RESULTS

Forty-four questionnaires from 44 surgeons of different centers were evaluated. All participants answered that they always perform bowel preparation before cystectomy. Four participants reported that they had an experience of cystectomy without bowel preparation. Bowel preparation methods included long conservative methods, short enema protocols, and Golytely, but there were significant differences in application of each method. Of participants, 88.6% perform diversion by themselves whereas others ask help from a general surgeon. Antibiotic prophylaxis is preferred mostly by 2 agents using third-generation cephalosporins and metronidazole for a period of 5 days or more in the majority. Type, duration, and dosage of deep vein thrombosis prophylaxis differed among participants.

CONCLUSION

There are significant individual differences in peri-operative management of radical cystectomy, which render deficient and sometimes inadequate patient care. There is a need to establish standard protocols for bowel preparation and adequate peri-operative management for radical cystectomy.

Do lifestyle changes work for improving erectile dysfunction?

The main cause of erectile dysfunction (ED) is organic in nature, with vascular etiologies being the most common risk factors. Although there have been sufficient data on the relationship between ED and several well-recognized risk factors, including aging, coronary artery disease, atherosclerosis, diabetes mellitus, dyslipidemia, high blood pressure, and pelvic surgeries, little attention has been paid by the urologists to the role of lifestyle factors in ED. However, accumulating data from basic science and clinical studies have determined a link between the occurrence of ED and a number of lifestyle factors, such as smoking, obesity, alcohol consumption, and lack of physical activity. The application of findings from animal and human studies to the clinical practice regarding the modification of lifestyle factors could help improving ED as well as reducing the risks of developing cardiovascular diseases. This communication addresses the impact of lifestyle factors on erectile function and the potential benefits of modifying these factors to improve ED in respect to the current evidence.

Double-Blind, Placebo-Controlled, Randomized Clinical Trial of Sublingual or Intramuscular Piroxicam in the Treatment of Renal Colic

AIMS

To investigate the therapeutic effect of the fast-dissolving dosage form (FDDF) of sublingual piroxicam on renal colic compared with the intramuscular (IM) injection form of the same agent in a randomized, double-blind, placebo-controlled clinical trial.

METHODS

80 patients were assigned to one of two treatment groups: Group 1 received 40 mg piroxicam FDDF sublingual tablets and IM injection of 2 ml distilled water. Group 2 received an IM injection of 40 mg piroxicam and two sublingual tablets of placebo. At baseline and 30 min after the medication, vital signs were recorded and the pain intensity was evaluated by the patient using a numeric rating scale.

RESULTS

The overall efficacy of the treatment was 90%. There was no significant difference with respect to the required rescue treatment (p = 0.328), pain relapse within 24 h (p = 0.434) and the decrease in vital signs and numeric rating scale in both groups (p > 0.05).

CONCLUSION

The piroxicam FDDF tablet was found to be as effective as the IM injection form of the same agent in the treatment of renal colic. The FDDF is a good alternative to the parenteral form because of its earlier onset of action and ease of self-administration which increases patient compliance.

Healing of the Urethral Plate after Deep Incision: Does Catheterization Change the Course of This Process?

BACKGROUND

We aimed to evaluate the sequence of healing process as well as possible effects of stent placement on the healing process after deep urethral plate incision.

METHODS

A deep urethral plate incision was done at the 12 o'clock position. After that, in the first group (n = 14) the anterior urethra was stented with a silicon catheter. Animals in the second group (n = 14) underwent the same incision procedure, however no stent was placed after this operation. All animals in both groups were again divided into three groups with respect to the follow-up period (7-14 and 21 days). Partial penectomy was performed in all subgroups and histopathologic evaluation performed.

RESULTS

In the first group after 7 days, limited neovascularization and granulation tissue formation could be noted far away from the epithelial lumen. Evaluation of these specimens during the long-term follow-up (21 days) demonstrated an almost completely healed tissue with a remarkable neovascularization and well-developed granulation tissue. In the second group during 14-21 days, evaluation progression of tissue healing along with increasing vessel formation and re-epithelialization were demonstrated. Although the incision edges did show evident approximation, no sign of fibrosis could be demonstrated in these specimens.

CONCLUSION

We may say that tissue healing with a desired and complete re-epithelialization could be achieved without inserting a catheter. Prevention of re-approximation along with the limited urinary extravasations to the subepithelial area might be responsible for tissue protection that will limit the long-term aforementioned adverse effects of the procedure.

The learning curve in the training of percutaneous nephrolithotomy

OBJECTIVES

To investigate the learning curve in the training of percutaneous nephrolithotomy (PCNL).

METHODS

A total of 104 PCNL cases were included in this evaluation to define the learning curve of a surgeon with no previous experience at performing solo PCNL. Two parameters of expertise were reviewed, namely the operation and fluoroscopic screening times. The operation time was calculated as the beginning of access with the needle until the nephrostomy tube was placed and secured. PCNL procedures were analyzed in seven sets of 15 cases regarding the operation and fluoroscopy times, stone size, stone clearance rate, blood transfusion rate, and estimated blood loss.

RESULTS

The mean operation time was 2.4 h for the first 15 patients. It decreased to a mean of 1.5 h for cases 46 through 60. No further decrease in the operation time was observed after case 60. The fluoroscopic screening time was a peak of 17.5 min in the first 15 cases, whereas it dropped to a mean of 8.9 min for cases 46 through 60. The decline in the mean fluoroscopy screening time continued in cases 61 to 104, but the decline was not significant. There was no significant difference in stone size, stone clearance rate, blood transfusion rate, and estimated blood loss among each set of cases.

CONCLUSIONS

This study suggests that the surgical competence in PCNL can be reached after 60 cases. PCNL and fluoroscopy times drop to a steady-state level after performing 60 procedures.

Single stage Fowler-Stephens orchidopexy: a preferred alternative in the treatment of nonpalpable testes

In this present study we aimed to discuss the surgical efficacy of single stage Fowler-Stephens orchidopexy (FSO) technique, with an emphasis on its practical and logical application that may be kept in mind during a standard orchidopexy procedure. Twenty-two children have undergone a single stage FSO procedure for nonpalpable testes during the last 9 years in our department. Surgical procedure was initiated with a standard inguinal oblique incision keeping in mind that depending on the position and the anatomic features of the testes a FSO method might be needed. While an excellent result was defined as a testis with good scrotal position, size and adequate blood flow on Doppler sonogram, acceptable result was a palpably normal sized testis in a high scrotal position with adequate blood supply and lastly an unacceptable result was the atrophy of the testis with compromised blood supply. During regular follow-up visits although some cases revealed testicular atrophy; long-term examination (12 months) did show that majority of the testes maintained their normal position and tissue consistency (21/24, 87.5%). Due to the necessity of surgical approach either in the evaluation or the treatment of nonpalpable testes in most cases along with the unsatisfactory data of the time consuming and invasive radiological procedures; we believe that a classical orchidopexy approach together with further single stage FSO will be a rational and satisfactory algorithm in the majority of such cases.

Operative Failure during Ureteroscopic Pneumatic Lithotripsy: Factors Affecting Successful Outcome

AIM

We aimed to evaluate the predictive factors that would in turn indicate stone migration and the effects of these factors on the ultimate success of the intervention.

METHOD

Patients were divided into two groups with respect to the migration of the stone treated. Group I: patients demonstrating stone migration during manipulation; group II: no migration of the stones noted. In the second phase of the study, the results of ureteroscopic management in 433 patients were evaluated with respect to the success rates obtained. Parameters such as stone size, stone burden, experience of the surgeon, length of the ureter proximal to the stone treated, and lastly transverse diameter of the ureter were noted in all patients as possible risk factors for stone migration.

RESULTS

Statistical analysis of ureteroscopic success in all patients revealed that there was a meaningful correlation with respect to the length of the proximal ureteral portion (p < 0.0001) and surgeon's experience (p = 0.004). p value for the correlation between stone burden and operative success was 0.056. There was no significant correlation between stone size (p = 0.51), ureter diameter (p = 0.78), and operative success.

CONCLUSION

Stones that are close to the renal pelvis and treated by inexperienced physicians are the ones most likely to migrate to the renal pelvis during manipulation with pneumatic lithotripsy.

Testicular blood flow measurements and mean resistive index values after microsurgical and high ligation varicocelectomy

OBJECTIVES

To compare the effects of the two most commonly used surgical methods in the management of varicocele disease, namely, microsurgery and high-ligation varicocelectomy, on testicular blood flow changes and mean residual index values in a prospective randomized study.

METHODS

A total of 56 patients clinically diagnosed with varicocele were randomized into two groups: 28 were selected for high-ligation surgery and 28 for microsurgery. The testicular blood flow was evaluated in all patients before and 7 days after surgery, and the maximal flow velocity (Vmax), minimal flow velocity, and resistive index were measured. The data assessment was performed using the paired t test, and independent t test was used in comparison of the two groups.

RESULTS

No significant difference was detected between the preoperative resistive index, Vmax, and minimal flow velocity of the two groups. The values of the same parameters measured 7 days postoperatively were also not significantly different. The preoperative and postoperative comparison of the three parameters within the microsurgery group revealed no difference, although the postoperative Vmax was significantly lower than the preoperative Vmax in the high-ligation group.

CONCLUSIONS

Our data have shown that no significant impairment in testicular circulation results after low microsurgical varicocele repair compared with high ligation.

Accessory scrotum with multiple skeletal abnormalities

Accessory scrotum is very uncommon. Here we report a 5-year old Caucasian boy presenting with an accessory scrotum localized to the left side of the pubic area. The penis and the primary scrotum were completely normal, containing two dependent testicles. On the right side of the body there was type B proximal femoral focal deficiency and there was also diastasis of the symphisis pubis. As observed in this case, abnormalities of two different embryological organ systems (accessory labioscrotal fold and proximal femoral focal deficiency) may occur concurrently at the same intrauterine time point as part of an overall embryologic mesenchymal disorder.

Evaluation of bone mineral density after ileocystoplasty in children with and without myelomeningocele

We evaluated the bone mineral density (BMD) after ileal augmentation cystoplasty in a group of children with and without myelomeningocele. Between 1996 and 2003, eight patients with neurogenic bladder and seven patients with non-neurogenic bladder underwent augmentation ileocystoplasty. Preoperative and postoperative serum creatinine and electrolytes were measured. All patients underwent clinical evaluation, supine height measurement, blood gas analysis, and BMD measurement using a dual energy X-ray absorptiometry (DEXA) postoperatively. BMD was measured at L1-L4 and femoral neck, and compared to age- and sex-matched population. Follow-up time was calculated from the day of surgery to the day of DEXA performance. A total of eight boys and seven girls with the mean age of 10.2 +/- 4.1 years were evaluated with respect to BMD measurement. Mean age was 9.8 years in neurogenic group and 10.5 in non-neurogenic group. Mean follow-up was 728 and 616 days in neurogenic and non-neurogenic groups, respectively. There were no significant differences between ages, follow-up times, preoperative and postoperative creatinine levels, pH and bicarbonate values, and supine heights. Mean BMD at L1-L4 was 55.7% in neurogenic group and 83.8% in non-neurogenic group. There was a statistically significant difference between the two groups (P = 0.02). Mean BMD at femoral neck was 72% in neurogenic group and 86.2% in non-neurogenic group. The difference was also statistically significant (P = 0.028). After augmentation ileocystoplasty, the BMD in early postoperative period of patients with myelomeningocele is lower than the patients with non-neurogenic neurogenic bladder, which have the same clinical characteristics except the neurologic pathology. In the light of our findings and the reported literature data as well, we may claim that BMD decrease after augmentation ileocystoplasty depends more on the underlying neurologic pathology and its locomotor consequences rather than the enterocystoplasty itself.

Association of positive serum anti-p53 antibodies with poor prognosis in bladder cancer patients

AIMS

To assess the association of serum anti-p53 antibodies and overexpression of tumor p53 protein with survival and prognostic factors in patients with urinary bladder tumors.

METHODS

Seventy-six patients with transitional cell carcinoma of the urinary bladder were assessed prospectively (Ta, 18; T(1), 30; > or =T(2), 28). Serum anti-p53 antibodies were detected by enzyme-linked immunosorbent assay. Tumor p53 gene overexpression was assessed by immunohistochemical staining. The mean follow-up time was 34 months.

RESULTS

Serum anti-p53 antibodies were positive in 25 patients (33%). Overexpression of tumor p53 protein was positive in 41 patients (54%). There was an association between the presence of serum anti-p53 antibodies and tumor p53 gene overexpression (P = 0.001). The total survival of the patients with positive serum anti-p53 antibodies was shorter than the patients with positive tumor p53 gene overexpression (P < 0.001, P = 0.344, respectively). In the multivariate survival analysis, both tumor stage and serum-p53 antibodies were found to be independent survival predictors (P = 0.004, P = 0.006, respectively).

CONCLUSION

Serum anti-p53 antibody positive tumors had a worse prognosis than those with negative serum levels, regardless of the p53 status of the tumor.

Relation between serum anti-p53 antibodies and microvessel density in bladder cancer patients

INTRODUCTION

Etiology of serum anti-p53 antibodies in bladder cancer patients is still unknown. In this study we evaluated the relationship between serum anti-p53 antibodies and microvessel density in bladder cancer patients.

MATERIALS AND METHODS

Seventy-six patients with transitional cell carcinoma of the urinary bladder were assessed prospectively (18 Ta, 30 T1, 28 T2>or =). Serum anti-p53 antibodies were detected by enzyme-linked immunosorbent assay. Tumor p53 overexpression was assessed by immunohistochemical staining. Vessels were stained immunohistochemically using an antibody against platelet endothelial cell-adhesion molecule CD31. Spearman correlation test and t test were used for statistical analysis.

RESULTS

Serum anti-p53 antibodies were positive in 25 (60%) of 41 tumor p53-positive patients. While the mean (SD, range) microvessel density was found to be 43 (7.59, 8-99) in patients who had positive serum anti-p53 antibodies, it was found to be 23 (4.53, 6-98) in patients who had negative serum anti-p53 antibodies. There was a good correlation between serum anti-p53 antibodies and microvessel density (p<0.05). No correlation was found between tumor p53 expression and microvessel density (p>0.05).

CONCLUSIONS

We found that there is a significant correlation between the microvessel density and serum anti-p53 antibodies. This result may show the role of angiogenesis in the etiology of serum anti-p53 antibodies in bladder cancer patients.

Importance of serum p53 antibodies during follow-up after treatment of invasive bladder tumors

INTRODUCTION

To investigate the prognostic importance of the changes in serum p53 antibody titrations during follow-up of patients who had anti-p53 antibody-positive invasive bladder tumors with transitional epithelial cells.

MATERIALS AND METHODS

The study group consisted of 23 clinically T3</=, N0, M0 patients with positive serum anti-p53 antibodies before treatment. 23 cases with negative serum anti-p53 antibodies who were comparable in age, comorbidity and stage with the study group were selected as a control group. The cases whose serum anti-p53 titrations decreased to normal levels after treatment were compared for metastases, death rates and survival with cases who remained serum anti-p53-positive and those who were serum p53 antibody-negative before treatment. Serum anti-p53 antibody titration was determined by ELISA.

RESULTS

While serum anti-p53 antibody titrations became negative in 8 (35%) of the 23 seropositive patients, it did not change in 15 patients (65%). There was a correlation between the maintenance of seropositivity, local progression/metastasis and death (p < 0.05). Survival was found to be better in cases who were seronegative after treatment compared with cases who remained positive and also those who were seronegative before treatment (p < 0.05).

CONCLUSION

The normalization of serum anti-p53 antibody positivity after treatment of invasive bladder tumors seems to be a good and reliable prognostic indicator.

[The relationship between uretero-cloacal structure in birds and sigmoidorectal pouch surgery]

PURPOSE

The present study was planned to investigate morphological, functional and histological properties of the natural ureterocloacal for in birds as well as to provide an appropriate information which may contribute to rectosigmoidal pouch surgery and to decrease its complications.

MATERIALS AND METHODS

Thirty chickens (Gallus domesticus, 26 broilers, 4 layers) with a mean weight of 1870 +/- 88 g were used for this study. Histological and morphological evaluation of the cloaca was performed. Urethral reflux was estimated using X-rays.

RESULTS

We found that the cloaca had three parts from cranial to caudal: coprodeum, urodeum and proctodeum respectively. A coprourodeal fold (CUF) between the coprodeum and urodeum and a uroproctodeal fold between the urodeum and proctodeum were detected. Settling of the muscle clusters both in the ureter and urodeum near the opening area appeared to be a strong sphincter structure and the ureters are opened to a structure covered by a transitional epithelium, which is similar to bladder in humans (connecting two identical epithelia). According to X-rays following the administration of a radio-opaque substance, there was no ureteral reflux in any of them.

CONCLUSIONS

The natural urointestinal structure in birds has a spontaneous ureterointestinal anti-reflux opening. The coprourodeal fold that prevents the mixing of faeces and urine, inhibits the effects of increased pressure and prevents the reflux of urine to the upper segments is provided with many of desired hinders properties for urointestinal diversion.

Neurapraxic complications in operations performed in the lithotomy position

In this study, we assessed the incidence and risk factors associated with lower extremity neurapraxia in operations performed in the lithotomy position. A total of 1170 patients, who were operated on in the lithotomy position, were evaluated retrospectively. During the post-operative neurological evaluation, those patients who developed neuropraxic complications were reviewed in detail to identify those with lower extremity sensory and motor deficiencies. The electromyographic (EMG) results of the patients with neurological deficiencies were evaluated. The patients were studied with respect to age, length of operation, type of operation and mode of anaesthesia. Fischer's Exact Probability Test was used for the statistical analyses. Post-operative neurapraxia complications developed in 12 of the patients (1.02%). Of these cases, two had irreversible neurological deficiencies. All other patients recovered without any treatment during the first post-operative month. No correlation was discovered between the type of anaesthesia used and neurapraxia (P> 0.05). However, it was found that age, type of operation and operation time contributed to neurapraxia developing (P < 0.05). Old age (older than 70), prolonged operation time (more than 180 min) and an inappropriate lithotomy position were seen as the main risk factors in developing post-operative neurapraxia. Mistakes in the positioning of the operating staff might be an additional contributing factor.

Rectodynamic and radiological assessment in modified mainz pouch II cases

OBJECTIVE

To evaluate the radiologic findings and to measure the pressure changes in a modified sigmoidorectal pouch (Mainz pouch II procedure).

METHODS

A total of 26 patients who had a radical cystectomy because of muscle-invasive bladder tumor underwent a Mainz pouch II procedure between 1993 and 1998. The differences from the original definition was a reverse ureteral anastomosis and a detubularized segment at least 30 cm in length. In all cases, sigmoidoscopy was done and sigmoidal pressure and capacity were measured preoperatively and at the 3rd and 6th months postoperatively besides the colon X-rays. The 24-hour pouch pressure changes called 'natural pouch pressure' was measured using a handmade system with a central venous pressure (CVP) manometer at the 3rd month postoperatively.

RESULTS

Preoperative colon X-rays showed a passage of opaque substance through the descending colon at an average volume of 150 ml (average sigma capacity), whereas postoperative anteroposterior and oblique pouch X-rays showed no passage up to an average volume of 520 ml (270-650) though the descending colon. The sigmoidal colon pressure that was on average 20 cm H(2)O at the preoperative evaluation was measured as 6 cm H(2)O at the 3rd month and 6.5 cm H(2)O at the 6th months during the postoperative period. 24 hour natural pouch pressure was found to be 8.7 cm H(2)O on average while the pressure was found to be 13.8 cm H(2)O on average when the patient felt abdominal discomfort, in other words the desire to defecat (miction).

CONCLUSIONS

A modified sigmoidorectal pouch procedure not only provides a reservoir with a higher capacity and lower pressure without a reflux to the upper urinary tract and descending colon with lower metabolic acidosis problem, but it is also a good alternative diversion procedure that whould be preferable especially in Muslim countries as it does not cause any difficulties in terms of Islamic worship.

Effect of long-term sitting on serum prostate-specific antigen levels

OBJECTIVE

The aim of this study was to evaluate the effect of long-term sitting on serum prostate-specific antigen (PSA) levels.

METHOD

The serum PSA levels of 50 bus drivers under the age of 45 (mean 37.7) years who worked at least 8 h a day for more than 3 weeks were compared with those of 50 healthy surgeons in similar age groups (mean 37.7 years) who spent most of their working time standing.

RESULTS

There was no statistically significant difference between the mean PSA level of the study group (1.211 +/- 0.96 ng/ml) and that of the control group (1.214 +/- 0.74 ng/ml; p > 0.05). The PSA levels returned to normal after a 5-day resting period in cases who had higher values than the anticipated 2.5 ng/ml for this age group at the initial determination.

CONCLUSIONS

These results suggest that there is no relationship between long-term sitting and serum PSA levels. A second PSA determination after a 5-day resting period may be helpful in cases with higher than normal initial values.