Fluid dynamics within renal cavities during endoscopic stone surgery: does the position of the flexible ureteroscope and ureteral access sheath affect the outflow rate?

PURPOSE

To evaluate the impact of ureteroscope position within renal cavities as well as different locations of the tip of the ureteral access sheath (UAS) on fluid dynamics during retrograde intrarenal surgery (RIRS).

MATERIALS AND METHODS

A prospective observational clinical study was performed. Measurements with a flexible ureteroscope placed in the upper, middle and lower calyces were obtained with the tip of the UAS placed either 2 cm below the pyelo-ureteric junction (PUJ), or at the level of the iliac crest.

RESULTS

74 patients were included. The outflow rates from the middle and upper calyxes were statistically significantly higher compared to the lower calyx, both with the UAS close to the pyelo-ureteric junction and at the iliac crest. When the UAS was withdrawn and positioned at the level of the iliac crest, a significant decrease in outflow rates from the upper (40.1 ± 4.3 ml/min vs 35.8 ± 4.1 ml/min) and middle calyces (40.6 ± 4.0 ml/min vs 36.8 ± 4.6 ml/min) and an increase in the outflow from the lower calyx (28.5 ± 3.3 ml/min vs 33.7 ± 5.7 ml/min) were noted.

CONCLUSIONS

Our study showed that higher fluid outflow rates are observed from upper and middle calyces compared to lower calyx. This was true when the UAS was positioned 2 cm below the PUJ and at the iliac crest. Significant worsening of fluid dynamics from upper and middle calyces was observed when the UAS was placed distally at the level of the iliac crest. While the difference was statistically significant, the absolute change was not significant. In contrast, for lower calyces, a statistically significant improvement was documented.

Trends in the use of radiation protection and radiation exposure of European endourologists: a prospective trial from the EULIS-YAU Endourology Group

INTRODUCTION

Due to the radiation exposure for the urology staff during endourology, our aim was to evaluate the trends of radiation protection in the operation room by endourologists from European centers and to estimate their annual radiation.

METHODS

We conducted a multicenter study involving experienced endourologists from different European centers to evaluate whether the protection and threshold doses recommended by the International Commission on Radiation Protection (ICRP) were being followed. A 36-question survey was completed on the use of fluoroscopy and radiation protection. Annual prospective data from chest, extremities, and eye dosimeters were collected during a 4-year period (2017-2020).

RESULTS

Ten endourologists participated. Most surgeons use lead aprons and thyroid shield (9/10 and 10/10), while leaded gloves and caps are rarely used (2/10 both). Six out of ten surgeons wear leaded glasses. There is widespread use of personal chest dosimeters under the apron (9/10), and only 5/10 use a wrist or ring dosimeter and 4 use an eye dosimeter. Two endourologists use the ALARA protocol. The use of ultrasound and fluoroscopy during PCNL puncture was reported by 8 surgeons. The mean number of PCNL and URS per year was 30.9 (SD 19.9) and 147 (SD 151.9). The mean chest radiation was 1.35 mSv per year and 0.007 mSv per procedure. Mean radiation exposure per year in the eyes and extremities was 1.63 and 11.5 mSv.

CONCLUSIONS

Endourologists did not exceed the threshold doses for radiation exposure to the chest, extremities and lens. Furthermore, the ALARA protocol manages to reduce radiation exposure.

Emerging Trends in AI and Radiomics for Bladder, Kidney, and Prostate Cancer: A Critical Review

This comprehensive review critically examines the transformative impact of artificial intelligence (AI) and radiomics in the diagnosis, prognosis, and management of bladder, kidney, and prostate cancers. These cutting-edge technologies are revolutionizing the landscape of cancer care, enhancing both precision and personalization in medical treatments. Our review provides an in-depth analysis of the latest advancements in AI and radiomics, with a specific focus on their roles in urological oncology. We discuss how AI and radiomics have notably improved the accuracy of diagnosis and staging in bladder cancer, especially through advanced imaging techniques like multiparametric MRI (mpMRI) and CT scans. These tools are pivotal in assessing muscle invasiveness and pathological grades, critical elements in formulating treatment plans. In the realm of kidney cancer, AI and radiomics aid in distinguishing between renal cell carcinoma (RCC) subtypes and grades. The integration of radiogenomics offers a comprehensive view of disease biology, leading to tailored therapeutic approaches. Prostate cancer diagnosis and management have also seen substantial benefits from these technologies. AI-enhanced MRI has significantly improved tumor detection and localization, thereby aiding in more effective treatment planning. The review also addresses the challenges in integrating AI and radiomics into clinical practice, such as the need for standardization, ensuring data quality, and overcoming the "black box" nature of AI. We emphasize the importance of multicentric collaborations and extensive studies to enhance the applicability and generalizability of these technologies in diverse clinical settings. In conclusion, AI and radiomics represent a major paradigm shift in oncology, offering more precise, personalized, and patient-centric approaches to cancer care. While their potential to improve diagnostic accuracy, patient outcomes, and our understanding of cancer biology is profound, challenges in clinical integration and application persist. We advocate for continued research and development in AI and radiomics, underscoring the need to address existing limitations to fully leverage their capabilities in the field of oncology.

Ethanolic extract of cotinuscoggygria leaves attenuates crystalluria and kidney damage in ethylene glycol-induced urolithiasis in rats

OBJECTIVE

Nephrolithiasis is a common cause of kidney insufficiency. Nephrolithiasis is proven to be the result of various biochemical and inflammatory processes that result in crystal formation and subsequent aggregation. Cotinuscoggygria L. (CCog) is a plant extract which has been used as a Turkish remedy for kidney stones. With this study, we planned to evaluate the effects of CCog extract in ethylene glycol (EG)-induced nephrolithiasis model in rats.

METHODS

The study group comprised 32 Wistar albino rats which were divided into Control (C), EG, CCog Prophylaxis (CC+EG+CC), and CCog Treatment (EG+CC) groups. Stone formation was induced by adding EG (0.75%) into rat's drinking water. Normal drinking water was given to Control group for 8 weeks. Throughout the study period of 8 weeks, EG group was given only EG (0.75%) and CC+EG+CC group was given both EG and CCog. In EG+CC group, EG (0.75%) was given for 8 weeks whereas CCog was given for the past 4 weeks. After the 8th week, 24-h urine samples were collected. Rats were then sacrificed and kidney tissue samples were harvested.

RESULTS

Metabolites (calcium, citrate) and creatinine in 24 h urine samples were decreased in CC+EG+CC and EG+CC groups. While hyperoxaluria was observed in the EG group, oxalate levels were similar to control levels in the P-CCog and C-CCog groups. The N-acetyl-β-glucosaminidase and myeloperoxidase activities were both increased in EG group and these parameters were significantly decreased on CCog treatment.

CONCLUSION

We can conclude that C. coggygria extract can have beneficial effect on lowering concentration of stone-forming metabolites in urine and consequently protect renal tissues from damage due to nephrolithiasis. C. coggygria extract can be considered as a potential prophylactic and therapeutic option in high-risk stone formers. Furthermore, our data confirm ethnobotanical use of CC against nephrolithiasis.

Radiation exposure during different percutaneous renal puncture techniques: A YAU endourology & urolithiasis study

PURPOSE

Radiation exposure is affected by C-arm fluoroscopy device positioning during percutaneous renal puncture. Our aim was to compare the exposure of surgeon's lens, hand and chest with a fluoroscopy protocol replicated in different C-arm positions.

MATERIALS AND METHODS

A standardized fluoroscopy protocol was created using water-equivalent solid phantoms to replicate a surgeon and patient. 111 mGy radiation (360 s) was applied in standard fluoroscopy mode (91 kVp, 2.7 mA/mAs). Dosimeters were placed on lens, chest and hand of surgeon and patient phantom models. 7 different C-arm positions were created: 0°, mediolateral (ML) +90°, ML -90°, ML +30°, ML -15°, craniocaudal (CC) +30°, CC +15°. Measurements were evaluated separately for different positions.

RESULTS

The highest radiation exposure was measured on patient dosimeter (2.97 mSv). The highest exposure on surgeon was recorded on finger dosimeter in all C-arm positions; highest dose was recorded in ML +90° position (2.88 mSv). In finger dosimeters, lowest exposure was recorded in 0° position (0.51 mSv). The lowest exposure of all positions was measured in chest dosimeter in ML -90° position (0.24 mSv).

CONCLUSIONS

In positions where X-ray generator of the C-arm was facing towards the surgeon, radiation exposure measured in all dosimeters was higher compared to positions where the generator was facing away. The hand radiation exposure in all positions was higher than chest and lens. Special care must be taken to avoid facing the X-ray generator tube and hands should be as well-protected as chest and eyes with special protective gear.

Practices and utility of imaging among urological communities for urolithiasis, observations, and inferences from a targeted survey

To evaluate the general practice among urologists about the use of various radiological imaging and measurement tools, and to compare the different preferences in radiological evaluations between Turkish and European urologists. Our study was designed as a survey study. The survey comprised 22 questions which evaluated the epidemiological information, caseload of participants, general preferences of participants on CT image slice thickness, basic radiologic workup routines prior to surgery, use of special tools and measurements on CT. Data collection was conducted with both an online poll and printed copies. A total of 222 urologists from 23 different countries responded to the survey. The most performed endourologic surgery was semi-rigid URS which was performed more than 25 times/year by 90.1% (n = 200) of the participants. Although PCNL was performed more commonly by Turkish urologists (39.7%) compared to their European (17.3%) colleagues (p < 0.001), it was still the least often performed endourological surgery among all participants (31.5%). The stone size evaluation was the most performed measurement performed by the participants. Although the group of surgeons used size measurement tools, there were differences between the two groups. Turkish urologists used size measurement before PCNL (85.7%) as opposed to European urologists who used it mostly before URS (91.4%). Non-contrast CT images for urolithiasis are mainly evaluated by urologists themselves and a considerable number of urologists do not use additional measurement tools in evaluating CT images. Although there are similarities in the knowledge of various radiological tools, there are distinct regional differences.

Comparison and outcomes of dusting versus stone fragmentation and extraction in retrograde intrarenal surgery: results of a systematic review and meta-analysis

INTRODUCTION

Lithotripsy during retrograde intrarenal surgery (RIRS) can be achieved either by fragmentation and extraction or dusting with spontaneous passage. We aimed to perform a systematic review on the safety and stone-free rate after RIRS by comparing the techniques of dusting vs fragmentation/extraction.

MATERIAL AND METHODS

This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The inverse variance of the mean difference and 95% Confidence Interval (CI), Categorical variables were assessed using Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR) and 95% CI. Statistical significance was set at p <0.05.

RESULTS

There were 1141 patients included in 10 studies. Stone size was up to 2.5 cm All studies used holmium laser for lithotripsy. Meta-analysis showed no significant difference in surgical time (MD -5.39 minutes 95% CI -13.92-2.31, p = 0.16), postoperative length of stay (MD -0.19 days 95% CI -0.60 - -0.22, p=0.36), overall complications (OR 0.98 95% CI 0.58-1.66, p = 0.95), hematuria (OR 1.01 95% CI 0.30-3.42, p = 0.99), postoperative fever (OR 0.70 95% CI 0.41-1.19, p = 0.19) and sepsis (OR 1.03 95% CI 0.10-10.35, p = 0.98), immediate (OR 0.40 95% CI 0.13-1.24, p = 0.11) and overall stone-free rate (OR 0.76 95% CI 0.43-1.32, p = 0.33), and retreatment rate (OR 1.35 95% CI 0.57-3.20, p = 0.49) between the groups.

CONCLUSIONS

This systematic review infers that urologists can safely use either option of fragmentation and basket extraction or dusting without extraction to achieve similar outcomes as both techniques are similar for efficacy and safety.

How reliable is endoscopic stone recognition? A comparison between visual stone identification and formal stone analysis

OBJECTIVE

To assess the diagnostic accuracy and intra-observer agreement of endoscopic stone recognition compared with formal stone analysis.

INTRODUCTION

Stone analysis is a corner stone in the prevention of stone recurrence. Although X-ray diffraction and infrared spectroscopy are the recommended techniques for reliable formal stone analysis, this is not always possible, and the process takes time and is costly. Endoscopic stone recognition could be an alternative as it would give immediate information on stone composition.

MATERIAL AND METHODS

Fifteen endourologists predicted stone composition based on 100 videos from ureterorenoscopy. Diagnostic accuracy was evaluated by comparing the prediction from visual assessment with stone analysis by X-ray diffraction. After 30 days, the videos were reviewed again in a random order to assess intra-observer agreement.

RESULTS

The median diagnostic accuracy for calcium oxalate monohydrate was of 54% in questionnaire 1 (Q1) and 59% in questionnaire 2 (Q2), whereas calcium oxalate dihydrate had a median diagnostic accuracy of 75% in Q1 and 50% in Q2. The diagnostic accuracy for calcium hydroxyphosphate was 10% in Q1 and 13% in Q2. The median diagnostic accuracy for calcium hydrogen phosphate dihydrate and calcium magnesium phosphate was 0% in both questionnaires. The median diagnostic accuracy for magnesium ammonium phosphate was in 20% in Q1 and 40% in Q2. The median diagnostic accuracy for uric acid was 22% in both questionnaires. Finally, there was a diagnostic accuracy of 60% in Q1 and 80% in Q2 for cystine. The intra-observer agreement ranged between 45-72%.

CONCLUSION

Diagnostic accuracy of endoscopic stone recognition is limited and intra-observer agreement is below the threshold of acceptable agreement.

Percutaneous Nephrolithotomy in Horseshoe Kidneys: Results of a Multicentric Study

Objective: To report the outcomes of percutaneous nephrolithotomy (PCNL) in horseshoe kidneys (HSK) in 12 institutions worldwide and evaluate the impact of patient position during operation. Methods: We carried out a retrospective analysis of PCNL procedures performed between 2008 and 2018 in patients with HSK. Pre-, peri-, and postoperative data were collected, and a subgroup analysis was performed according to patient position. Success was defined as an absence of >4-mm fragments. Values of p < 0.05 were considered significant. Results: We analyzed 106 procedures. The transfusion, complication, and immediate success rates (ISRs) were 3.8%, 17.5%, and 54.7%, respectively. The final success rate (FSR) increased to 72.4% after a mean of 0.24 secondary procedures. Logistic regression showed that higher body mass index (BMI) and stone size were significantly associated with residual fragments ≥4 mm. Sixty-seven patients (63.2%) were treated in prone and 39 (36.8%) in supine position. The prone group had a significantly higher BMI than the supine group (30.1 vs 27.7, p = 0.024). The transfusion, complication, and ISRs between the prone and supine groups were 4.5% vs 2.6% (p = 0.99), 16.9% vs 18.4% (p = 0.99), and 52.5% vs 69.2% (p = 0.151), respectively. Surgical time was significantly longer in the prone group (126.5 vs 100 minutes, p = 0.04). Upper pole was the preferred access in 80.3% of the prone group and 43.6% of the supine group (p < 0.001). The prone group had significantly more Clavien 2 complications than the supine (p = 0.013). The FSR in the prone and supine groups increased to 66.1% and 82.1% after 0.26 and 0.21 secondary procedures, respectively. No complications higher than Clavien 3 occurred. Conclusion: PCNL in patients with HSK is safe and effective with a low complication rate. Higher BMI and stone size negatively impacted outcomes. Supine PCNL may be an option for treating kidney stones in patients with HSK.

Melatonin prevents deterioration of erectile function in streptozotocin-induced diabetic rats via sirtuin-1 expression

A review of the literature indicated that sirtuin-1 expression, a regulator of nitric oxide bioavailability in erectile dysfunction (ED) after melatonin therapy, has not yet been investigated. The objective of this study was to evaluate the protective effects of melatonin for erectile function with sirtuin-1 protein expression in type 1 diabetic rat models. Fifty male Sprague Dawley rats were placed into five groups. Except for those in the control group (C), each animal received a single dose (60 mg/kg) of streptozotocin to induce diabetes. The animals were placed into the diabetes (D) group, insulin (I) group (6 U/kg/day), melatonin (Mel) group (10 mg kg^-1  day^-1 ) and combined treatment (I + Mel) group. Ten weeks later, the serum testosterone levels, intracavernosal pressure (ICP), mean arterial pressure (MAP), malondialdehyde (MDA), cyclic guanosine monophosphate (c-GMP), 8-hydroxydeoxyguanosine (8-OHdG), nitric oxide synthase (NOS), caspase-3 activity, sirtuin-1 and endothelial nitric oxide synthase (eNOS) protein expression and histological findings were assessed. The mean ICP/MAP ratio for the D group was lower than the mean ratios for the other groups. The treatment groups, particularly the I + Mel group, exhibited lower 8-OHdG and MDA levels and caspase-3 activity than the D group. The sirtuin-1 and eNOS expression and cavernosal tissue (CT) histology seemed to have been preserved by the melatonin and/or insulin therapy. These results were indicative of a profound protective effect of melatonin by the activation of sirtuin-1 protein expression against hyperglycemia-induced oxidative CT injury.

Simultaneous and synchronous bilateral endoscopic treatment of urolithiasis: a multicentric study

Introduction

The general prevalence of bilateral urolithiasis has risen to 15% and bilateral non-simultaneous treatment has been reported to have good outcomes. The objective of this study was to evaluate the effectiveness and safety of simultaneous bilateral endoscopic surgery (SBES).

Material and methods

An international multicenter analysis was performed between May 2015 and December 2017. All patients with bilateral stone disease that underwent SBES were included. Patients were treated under general anesthesia in either the supine or lithotomy position. Demographic, clinical, intraoperative and postoperative data were analyzed.

Results

A total of 47 patients were included. Mean age was 53.8 years and 70% of the patients were males. The mean American Society of Anesthesiology (ASA) score was 2. The mean diameter of right- and left-sided stones was 29.43 mm (2–83 mm) and 31.15 (4–102 mm), respectively. Staghorn stones were treated in 18 cases (8 right-sided and 10 left-sided), four of them were defined as complete staghorn. The procedures performed were 42 cases of bilateral URS and PCNL and ureteroscopy. Additionally, 5 bilateral flexible ureteroscopy (fURS) cases were described. Intraoperative complications occurred in five patients: four of them were classified as Clavien-Dindo (CD) I and one as CD II. Postoperatively, there were two cases with CD I, 6 with CD II and one CD IIIa.

The stone-free status was 70%. Residual stones (30%) were detected only on the side treated for high-volume (complete) staghorn calculi.

Conclusions

SBES is a feasible, effective and safe procedure. It may potentially avoid repeated anesthetic sessions as needed for staged procedures and reduce the length of patients' hospital stay.

The new Avicenna Roboflex: How does the irrigation system work? Results from an in vitro experiment

Introduction: Since 2012 Elmed has been working on a robot specifically designed for flexible ureteroscopy. After the first version of Avicenna Roboflex, a second version was developed in 2015, with significant changes especially in the irrigation system. We consider mandatory for the endourologist that works with the Avicenna Roboflex be aware of the functioning of the irrigation system. Materials and Methods: We connected a container to the pump’s irrigation system and measured the quantity of saline per second delivered by each speed setting, with/without the flush in five different modalities: pump on its own, pump with ureteroscope, with two laser fibers, with 1.9 Fr basket, and with a Terumo guidewire. Results: The highest mean flow-rates were observed in the 200- micrometer laser fiber, after the pump on its own. Median flowrates for all speed settings were significantly higher for the pump on its own than for the URS in both flushed and nonflushed modes (p = 0.045, p = 0.039 respectively). There was no statistically significant difference in median flow-rates between the guide wire and basket in all of the speed settings (p = 0.932 and p = 0.977). For both laser fibers there was no statistically significant difference between the median flow rate on both nonflush and flush modes. (p = 0.590 & p = 0.590). There was a linear correlation between the speed setting and the increase measured with the flush-option for pump only measurements (r = 0.602, p = 0.038). There was no statistically significant difference between laser fibers and the pump on its own on the increase of flow rate with flush mode. (p = 0.443 for the 272- micrometer fiber and p = 0.219 for the 200-micrometer fiber). Conclusion: The irrigation system of the new Avicenna Roboflex is optimized compared to the previous version. However other more complex studies concerning the live flow/pressure relationship are needed before firm conclusions can be made.

Ureteroscopy in pregnant women with complicated colic pain: Is there any risk of premature labor?

OBJECTIVE

Clinical presentation of ureteral stones during pregnancy is generally with renal colic pain. The aim of this study is to present our experience in the management of renal colic during pregnancy in emergency settings.

MATERIALS AND METHODS

208 pregnant patients who presented to emergency department with renal colic pain and underwent ureteroscopy (URS) due to failed conservative therapy were enrolled in the study. Urinary tract stones were diagnosed either with ultrasound (US) examination or during URS. Laser lithotripsy and double J (DJ) stent placement were routinely done in all patients with ureteral stones. The incidence of infective complications and premature uterine contractions (PUC) due to URS were compared.

RESULTS

No stone was identified in 36.1% (n = 75) of patients with using US and diagnostic URS. Of the remaining 133 patients, 30 (22.6%) had no stone at US but stones were diagnosed during diagnostic URS. The type of anesthesia had no significant effect on PUC. An increased risk of sepsis and PUC was found in patients with fever at the initial presentation. Interestingly, PUC was more frequent in patients with lower serum magnesium levels. There was a significant correlation with time delay until the intervention and the risk of urosepsis and PUC, individually.

CONCLUSIONS

Ureteroscopy is a safe option for evaluation of pregnant patients with unresolved renal colic. According to the current findings, timing of the operation is the most important factor affecting the septic risks and abortion threat. Surgical intervention with URS must be planned as soon as possible.

Effects of platelet-rich plasma against experimental ischemia/reperfusion injury in rat testis

BACKGROUND

Testicular torsion is a common problem and, to date, there is no agent to preserve testicular function following detorsion. Platelet-rich plasma (PRP), with its rich growth factor composition, has proven beneficial in regenerative therapy. It is believed that PRP has not been studied in testis for ischemia/reperfusion (I/R) injury.

OBJECTIVE

This study investigated the effect of PRP in an I/R rat model 1 month after detorsion.

STUDY DESIGN

Of 24 adult male Sprague-Dawley rats, 18 were randomly assigned into three groups, with six in each: control, I/R and I/R + PRP. The PRP was prepared from the remaining six. Each group underwent right orchiectomy. Ischemia was performed by rotating the left testis 720° and fixing with a nylon suture for 4 h. Reperfusion occurred 4 h later by removing the suture, and PRP was administered at a dose of 10 μl (2000 × 10⁹/l) into the left testis via the intraparenchymal route. Animals were sacrificed at the fourth week, and testes were taken for malondialdehyde (MDA), glutathione (GSH), superoxide dismutase (SOD), myeloperoxidase (MPO), transforming growth factor β (TGF-β), and caspase-3 measurements.

RESULTS

Ischemia/reperfusion caused a significant increase in MDA, MPO and caspase-3 activity, and significant decrease in GSH levels and SOD activity. The PRP treatment helped correct the alterations in SOD, caspase-3, and MPO activities and MDA levels. However, the mean MDA level and MPO activity were not totally restored compared with the controls. Serum testosterone levels of the I/R group were significantly lower compared with the control and I/R + PRP groups. TGF-β and caspase-3 protein expressions were significantly higher in the I/R group compared with the control group and were low with PRP administration compared with I/R groups (summary Table).

DISCUSSION

The findings of the present study suggest that PRP, by inhibiting neutrophil infiltration and oxidative stress and increasing antioxidant defense, exerts protective effects on testicular tissues against I/R. This study had some limitations: a scoring system was not used in the assessment of spermatogenesis in the histopathological findings and specific testis cell types were not histologically assessed.

CONCLUSIONS

In light of the biochemical, histological and, especially, hormonal findings, intraparenchymal PRP injection may have a protective effect in testicular tissue against I/R injury.

Thulium laser vaporesection of the prostate: Can we operate without interrupting oral antiplatelet/anticoagulant therapy?

Purpose

Thulium vaporesection of the prostate (ThuVARP) is a new and safe approach for patients receiving anticoagulant therapy in whom transurethral resection of the prostate (TURP) may possess a high bleeding risk. We aimed to demonstrate the efficacy and safety of ThuVARP in patients receiving oral antiplatelet/anticoagulant (OAP/OAC) therapy.

Materials and Methods

A total of 103 patients who underwent ThuVARP between 2011 and 2013 were enrolled in the study. Patients were divided into 2 groups. Group A consisted of 47 patients who underwent low molecular weight heparin (LMWH) bridging and group B consisted of 56 patients who were operated on while receiving OAP/OAC therapy.

Results

The drop in hemoglobin levels in the pre- and postoperative periods was significantly higher in group A than in group B. When subgroups were analyzed, the mean drop in hemoglobin was significantly lower in the warfarin and ticlopidine subgroups of group B than in group A. International Prostate Symptom Scores were significantly lower 3, 12, 18, and 24 months after surgery in group A than in group B. Quality of life scores, maximal flow rate values, and postmicturition residual urine volumes (mL) were similar between the 2 groups. A total of 38 and 41 patients in groups A and B, respectively, had no complications.

Conclusions

Our study showed the safety profile of continuing different OAP/OAC therapies in terms of bleeding problems in patients undergoing ThuVARP. We strongly recommend abandoning LMWH bridging and maintaining the OAP/OAC regimen patients are already receiving.

The Effects of Melatonin on Ethylene Glycol-induced Nephrolithiasis: Role on Osteopontin mRNA Gene Expression

OBJECTIVE

To evaluate the protective effects of melatonin (Mel) on an ethylene glycol (EG)-induced nephrolithiasis model in rats.

MATERIALS AND METHODS

Thirty-two Wistar albino rats were divided into 4 groups: control, EG, prevention Mel (Mel + EG + Mel), and therapeutic Mel (EG + Mel). EG (0.75%) was added to drinking water to create nephrolithiasis model. The EG group received EG and the Mel + EG + Mel group received both EG and Mel for 8 weeks. In the EG + Mel group, EG is given for 8 weeks and Mel is given for the last 4 weeks of the experiment. At the end of experimental period, urine, blood samples, and tissues were collected.

RESULTS

In 24-hour urine samples, calcium, citrate, and creatinine levels were decreased and oxalate levels were increased in the EG group, whereas Mel prevention and Mel treatment reversed these parameters back to control levels. Malondialdehyde, glutathione activities, myeloperoxidase, superoxide dismutase levels, and caspase-3 activity showed improvements in the Mel-treated groups when compared with the EG group. 8-Hydroxydeoxyguanosine, matrix metalloproteinase 9 levels, N-acetyl-β-glucosaminidase activity, and osteopontin mRNA expression were elevated in the EG group and decreased back to control levels in the Mel + EG + Mel and EG + Mel groups. Histological examination showed improvement in the Mel-treated groups when compared with the EG group.

CONCLUSION

Mel can prevent crystalluria and kidney damage due to crystal formation and aggregation. It can be considered as a potential prophylactic and protective agent in high-risk patients with urinary stone formation or recurrence if supported by further clinical studies.

Differentiation of ureteral stones and phleboliths using Hounsfield units on computerized tomography: a new method without observer bias

To differentiate ureteral stones and phleboliths by measuring density [as Hounsfield unit (HU)] and volume (as mm³) of the opacities in the bony pelvis on unenhanced computerized tomography (U-CT). A total of 52 patients, who underwent semirigid ureteroscopy and laser lithotripsy for distal ureteral stone and had isochoronous phleboliths in U-CT, were included. Images were reviewed for density and volume of the opacities. Data were compared, and a cut-off value was defined with receiver operating characteristics curve analysis to differentiate the nature of the opacity. Using the cut-off values of 171 mm³ for volume (sensitivity 75 %, specificity 100 %) and 643 HU for density (sensitivity 75 %, specificity 93 %), differentiation between stone and phlebolith was achieved. Differentiation of pelvic opacities needs meticulous observation with certain signs on U-CT. On the other hand, our study offers a new method, with certain cut-off values, such as 643 HU and 171 mm³, which can be used to precisely predict the actual nature of opacities of interest.

Resistant pediatric priapism: A real challenge for the urologist

Priapism in pediatric patients is a rare entity. We present an 8-year-old boy with known cerebral palsy. He came to the emergency department with sustained painful erection for 12 hours. Physical examination showed rigid penis. Blood count and biochemical analysis were normal. Although penile Doppler ultrasound revealed normal arterial and venous flow, cavernosal blood gas was hypoxic. A total of 50 mL of dark blood was aspirated, and 2 mL of 0.001% adrenalin solution was applied to both corpus cavernosum, twice within 20 minutes, which eventually did not achieve detumescence. A distal Winter shunt was performed at the end of which the penis was semi-flaccid. By the 18th hour of surgery, the penis re-gained painful erection status, so an Al-Ghorab shunt was performed. After the Al-Ghorab shunt, the penis was still in the semi-flaccid state. The next day, an angiography was performed and an arteriovenous fistula was discovered and treated by embolization. The flaccid state was achieved and the patient was discharged the day after the embolization.

A guidewire introducer as a ureteral foreign body: A case report

A 63-year-old male, previously treated for a ureteral tumour by a right-sided segmental ureterectomy and end-to-end anastomosis of ureteral segments, was referred to our clinic for endoscopic follow-up. During his follow-up, he was diagnosed with partial right-sided ureteral stricture which eventually progressed to complete obstruction. During the ureteroscopy, as the stenotic segment did not allow passage of an hydrophilic guidewire, an antegrade-retrograde approach was decided. On the antegrade endoscopic view, a near-complete stenosis was diagnosed and a nephrostomy catheter (12 Fr) was placed. A second intervention was planned and from the nephrostomy tract, the ureteroscope was placed into the right pyelocaliceal system. The diagnostic ureteroscopy revealed a foreign object proximal to the stenotic area. Right-sided segmental ureterectomy of the stenotic segment with ureteroneocystostomy and removal of the foreign object was performed. This is the only case in literature to reveal a guidewire introducer as a ureteral foreign body. This case also highlights the importance of the fragility of the ureter, the importance of the equipment, of always being watchful during a surgery, and the importance of checking the integrity of the equipment at the end of each procedure.