Comparison of Bipolar Electrocautery-Based Vascular Sealers with Conventional Ligation in Iliac Vessel Preparation of Renal Transplant Recipients.

BACKGROUND: Post-transplant lymphocele is a common complication with a potentially severe course and may require percutaneous drainage or open/percutaneous surgical intervention. Closure of the lymphatics around the iliac vessels is paramount in avoiding lymphocele formation. This study aimed to evaluate the effectiveness of bipolar electrocautery-based vascular sealers (BSD) in the dissection and/or ligation of lymphatic vessels in terms of the development of lymphoceles and postoperative kidney functions in live donor kidney transplants at our center. METHODS: A total of 63 patients who underwent kidney transplantation (KTx) between January and December 2021 were included in the study. Data, including postoperative creatinine values and postoperative ultrasonography follow-up, were recorded. Thirty-seven patients who were operated on using conventional ligation for iliac vessel preparation were included in group 1. Twenty-six patients treated using BSD for iliac vessel preparation were included in group 2. Statistical analysis was performed to compare these groups. This study complied with The Helsinki Congress and The Declaration of Istanbul. RESULTS: There was no significant difference between the groups in terms of postoperative first-week creatinine values (1.176 mg/dL vs 1.203 mg/dL), first-month creatinine values (1.061 mg/dL vs 1.091 mg/dL), first-week collection volume (33.240 mL vs 33.430 mL), and third-month collection volume (23.120 mL vs 23.430 mL) (P > .05). CONCLUSIONS: In KTx surgery, BSD is as safe as and faster than conventional ligation in preparation of the recipient's iliac vessels.

Standardization of Laparoscopic Donor Nephrectomy Technique in Minimizing Ureteral Complications in Renal Transplant Recipients: 10-Year Experience of a Single Center.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) is the preferred method for kidney retrieval in live donor kidney transplantation. The surgical technique of LDN has improved over the years, but ureteral complications are still common after kidney transplantation. The relationship between the surgical technique in LDN and ureteral complications has been debated. This study aims to discuss ureteral complications and risk factors in kidney transplantation in a group of patients performed with a standard technique. MATERIALS AND METHODS: A total of 751 live donor kidney transplantations were included in the study. Age, sex, body mass index, concomitant metabolic diseases, nephrectomy side, multiple renal arteries, and several complete or incomplete duplicated ureters of donors were recorded. The recipient's age, sex, body mass index, duration of dialysis, the daily volume of urine before transplantation, accompanying metabolic diseases, and postoperative ureteral complications were also recorded. RESULTS: Of the 751 patient donors included in the study, 433 (57.7%) were female, and 318 (42.3%) were male. Of the 751 recipients, 291 (38.7%) were female, and 460 (61.3%) were male. In the 751 recipients, there were 8 (1.0%) ureteral complications, all of which were ureteral strictures. No ureteral leaks or urinomas were noted in this series. There was no statistically significant relation between donor age, donor body mass index, donor side, presence of hypertension in the donor, presence of diabetes mellitus in the donor, or ureteral complications. The mean duration of dialysis and preoperative daily urine volume were associated with increased ureteral complications with statistical significance. CONCLUSION: Recipient factors may affect ureteral complication rates in live donor kidney transplantation, donor nephrectomy technique, and gonadal vein preservation.

The Predictive Value of Donor Renal Functions, Graft Weight, Recipient Body Mass Index, and Human Leucocyte Antigen Match Regarding Early Graft Functions.

Background and objective Graft performance is the most important postoperative parameter for patients undergoing kidney transplantation (KTx). The renal function of the donor is reported to be correlated with graft function after KTx. The body mass index (BMI) is also one of the important parameters involved in the prediction of graft function. The aim of this retrospective study was to examine the relationship between early postoperative graft function in patients undergoing KTx and donor cystatin C and estimated glomerular filtration rate (e-GFR) levels, graft weight/recipient BMI (G/B) ratio, and human leukocyte antigen (HLA) tissue compatibility. Materials and methods A total of 215 cases (215 donors, 215 recipients) who underwent KTx at our center between January 2018 and December 2022 were included in the study. Patients' age, sex, BMI, preoperative donor serum cystatin C and e-GFR levels, HLA tissue compatibility, graft weights, and recipient creatinine levels were recorded one week postoperatively. The Kolmogorov-Smirnov test and histogram plots were used to analyze the conformity of the variables to the normal distribution and Spearman's correlation test was used to analyze the relationship between variables. Results A negative correlation was identified between recipient creatinine level and G/B ratio and donor e-GFR (r = -0.256 and -0.137, respectively). Donor cystatin C level showed a positive correlation with recipient creatinine level (r = 0.242). No significant correlation was noted in terms of tissue matching rates (p = 0.616). Conclusion Although these three parameters are correlated with early graft functions, the graft weight/recipient BMI ratio has the strongest correlation.

Is 'Omega Sign' anatomical endoscopic enucleation of the prostate technique reproducible?

We aimed to evaluate the learning curve of the surgically standardised 'Omega Sign' anatomical endoscopic enucleation (AEEP) of the prostate surgery technique for junior surgeons. This study is a retrospective comparison of cases that underwent AEEP by a mentor surgeon and three junior surgeons who have completed their learning curve. A video-based laser enucleation of the prostate assessment tool (LEAT) composed of 8 steps of the technique was used to assess a senior surgeon and junior surgeons' surgical compatibility and consistency. The surgeon who defined Omega Sign technique was determined as group 1, and cases by three junior surgeons were identified as group 2. The end points were to assess the reproducibility and repeatability and operative post-operative outcomes of the technique. 55 patients' videos were rated by five experienced endourologists. There was no significant difference in LEAT scores between the groups among all steps. The most symmetry was found in the 1st and 3rd steps. Inter-rater consistency was also high for each step, with no statistically significant difference between the evaluators. The standardised anatomical 'Omega Sign' technique is reproducible for the junior surgeons. The operative steps can be performed with high consistency, and the functional and perioperative outcomes are comparable with the senior surgeon.

Laser enucleation for prostates larger than 100 mL: Comparison of HoLEP and ThuLEP.

Recently, with the advancements in laser technology, Holmium laser enucleation of the prostate (HoLEP) and Thulium laser enucleation of the prostate (ThuLEP) have come to the fore in the surgical treatment of benign prostatic hyperplasia (BPH). We aimed to evaluate and compare the outcomes of HoLEP and ThuLEP in patients with >100 ml prostate volume. Patients who underwent HoLEP and ThuLEP between July 2017 and March 2020 were reviewed retrospectively. The patients were divided into two groups as HoLEP (Group 1, n = 121) and ThuLEP (Group 2, n = 104). Perioperative parameters, functional outcomes, continence status, intra and post-operative complications were compared between groups in the post-operative 1st and 6th month. No significant difference was found in terms of total laser energy (TLE), morcellation efficiency (ME), enucleated tissue weight (ETW), complication rates (CR) and continence status of patients between both groups (p > .05). In favour of ThuLEP group, there were statistically significant differences regarding total operation time (TOT), laser efficiency (LE), enucleation time (ET) and enucleation efficiency (EE) between groups (p ≤ .05). HoLEP and ThuLEP can be used safely and effectively in prostates larger than 100 ml.

The effects of bladder neck sparing with an additional anterior urethral fixation on postoperative continence after robot-assisted radical prostatectomy.

OBJECTIVE: Urinary incontinence remains one of the main problems affecting the quality of life after radical prostatectomy. Along with the improved understanding of the precise anatomy of the prostate, urethra and their surrounding structures, minimally invasive surgical techniques have been refined and described, aiming to improve functional outcomes without oncological compromise. This study aimed to investigate the impacts of anterior urethral fixation (AUF) and bladder neck sparing (BNS) on the early continence success after Robot-assisted Radical Prostatectomy (RALP). METHODS: This retrospective study included 120 patients who underwent RALP between January 2018 and June 2019. Patients were allocated to one of two groups; group 1 (n=60) underwent RALP with BNS, group 2 (n=60) underwent RALP with both AUF and BNS. The patient continence status was measured at baseline on day 7 and in the 1st, 3rd, and 6th months postoperatively. RESULTS: Concerning Incontinence Impact Questionnaire-7 form, statistically significant better results in group 2 were recorded in all visits, but the last (month 6) (p=0.023). Following catheter removal, postmicturition symptoms, including incomplete emptying and post-micturition dribble rate, were significantly higher in group 1 after catheter removal and in the 1st month (13.3% vs. 0 p=0.006). This difference was not recorded at the next visits (months 3 and 6). CONCLUSION: Our findings showed that the combination of AUF and BNS significantly increases early continence rates and decreases post-mictional symptoms after RALP without hampering oncologic outcomes.

Comparison of outcomes of Holmium enucleation of the prostate for small- and moderate-sized prostates.

There is an ongoing discussion in the literature on the surgical treatment option for small prostate size benign prostate hyperplasia (BPH) patients. This study aimed to evaluate the efficacy of Holmium laser enucleation of the prostate (HoLEP) surgery in small (<30 ml) and moderate (30-80 ml) prostate size as accepted in European Association of Urology guideline. We retrospectively analysed our database between May 2016 and May 2019 and patients who underwent HoLEP surgery. Patients who have prostate size <80 ml were included the study. These patients were divided into two group: group 1 with prostate size <30 ml (n: 64) and group 2 with prostate size 30-80 ml (n: 101). Enucleation time (ET), morcellation time (MT), total operation time (OT), enucleation efficiency (EE), morcellation efficiency (ME), intra- and post-operative complications were analysed. While EE and Hb drop were better in favour of group 2; PSA drop, ET, MT, OT and ME were superior in favour of group 1. In group 1, intra-operative complications were higher (6 vs. 2; p < .05) and post-operative complications did not differ statistically between groups (p = .14). No statistically significant finding was found between groups regarding incontinence. In conclusion, HoLEP is a reliable method in terms of its results in patients with small prostates.

Impact of diabetes mellitus on urinary continence after holmium laser enucleation of the prostate due to lower urinary tract symptoms: a retrospective study.

INTRODUCTION: Diabetes mellitus (DM) is known as a risk factor of stress urinary incontinence after Holmium laser enucleation of the prostate (HoLEP). We aimed to compare the postoperative continence status of patients with and without DM, after HoLEP surgery. MATERIAL AND METHODS: A total of 214 patients who underwent HoLEP between January 2017 and January 2020 were retrospectively assessed. Functional outcomes, perioperative total operation time (TOT)(min), enucleation time (ET)(min), enucleation efficiency (EE)(g/min), enucleated tissue weight (ETW)(g), morcellation efficiency (ME)(g/min), morcellation time (MT)(min), continence status, intraoperative and postoperative complications according to Clavien-Dindo classification were recorded. RESULTS: A total of 96 patients had DM additional to benign prostate hyperplasia (BPH) (Group 1), while 118 patients had only benign prostate hyperplasia without DM (Group 2). When comparing preoperative and postoperative functional outcomes, a statistically significant improvement was observed in both groups from baseline to the 1st and 6th month follow-up (p ≤0.001). There were no statistically significant differences between groups in postoperative stress urinary incontinence at postoperative months 1 and 6 (1.7% vs 2.1%, p = 1 and 0.8% vs 1%, p = 1; respectively). There was no significant difference between groups in intraoperative and postoperative complications (p >0.05). CONCLUSIONS: HoLEP is safe to perform in patients with DM at low complication and urinary incontinence rates.

HoLEP after prostate biopsy: does it have any impact?

PURPOSE: Holmium laser enucleation of the prostate (HoLEP) has recently become the recommended treatment for prostate in all sizes in benign prostate hyperplasia surgery. A recent prostate biopsy performed prior to the HoLEP procedure can make surgeons concerned about the surgery. We aimed to investigate the per- and postoperative outcomes of the HoLEP procedure in patients who underwent prostate biopsy and to evaluate the most appropriate surgery time after biopsy. METHODS: The data of 160 patients who underwent HoLEP by a single surgeon between March 2017 and December 2019 were retrospectively reviewed. The patients were divided into two groups, Group 1 consisted of 80 patients without prostate biopsy and Group 2 consisted of 80 patients with prior prostate biopsy. All HOLEP procedures in group 2 were performed at least 2 weeks following biopsy. Per- and postoperative outcomes, complications were evaluated. RESULTS: No significant differences were found between groups in terms of by enucleation time, efficiency of laser, efficiency of enucleation, hospitalization time, and catheterization removal time. Only morcellation time was shorter in biopsy naïve patients. There were no statistical differences in postoperative outcomes. Previous prostate biopsy did not affect the continence status in our study group. There were not any Clavien grade 4 or higher complications. Urinary tract infection was higher in early post-biopsy period, there was no difference among the groups. CONCLUSiON: Our study confirms that HoLEP is a safe and efficient surgical procedure for the patients with prior prostate biopsy. We believe that it can be safely performed 2nd week following prostate biopsy.

A Ureteral Inguinoscrotal Hernia from a Pelvic Kidney.

A 74-year-old male patient with prostate cancer under remission was admitted with left inguinoscrotal swelling. He underwent scrotal ultrasound demonstrating a giant in-guinoscrotal hernia. Contrast-enhanced computerized tomography of the abdomen and pelvis demonstrated a left pelvic kidney associated with severe hydroureteronephrosis secondary to a ureteral inguinoscrotal hernia. Upon exploration with left inguinal incision, a paraperitoneal ureteral in-guinoscrotal hernia and a hypertrophic left spermatic cord were observed. The elongated and tortuous left ureter, being pulled down to the scrotum by the hernia, was released from the herniating tissues fullfilling left hemiscrotum. The ureter was tapered followed by ureteroureterostomy. The accompanying left spermatic cord was excessively elongated and curled, necessitating cordectomy. The hernia was repaired with prolene mesh after removal of herniating peritoneal tissue. This is a rare case of a paraperitoneal ureteral inguinoscrotal hernia of the left pelvic kidney.

Factors effective on survival after radical prostatectomy: To what extent is pre-operative biopsy Gleason scoring is confident in predicting the prognosis?

In the present study, the effect of different grades on independent survival from the biochemical relapse was investigated through comparison of the histological grades of the biopsy and prostatectomy materials in patients undergoing radical prostatectomy (RP). A total of 152 patients undergoing RP following biopsy were retrospectively investigated in an attempt to reveal the effect of discordance between needle biopsy Gleason score and RP Gleason score on prostate specific antigen relapse-free survival. Accordingly, while 58.3% (14/24) survival was seen in the patients in Group 1 (high-graded) with Gleason score 7, 93.7% (15/16) survival has been seen in the patients in Group 2 (low-graded) and Group 3 (same Gleason scores) with Gleason score 7. The difference in-between has been statically found significant (P < 0.001). Similarly, while a 10% (1/10) survival is seen in the patients in Group 1 with Gleason score 8 and above, 75% (3/4) survival has been observed in the patients in Group 2 and 3 with Gleason score 8 and above. Also in this comparison, the difference in-between has been statically found significant (P = 0.041). Eventually, different grading, particularly determination of Gleason score higher than the RP specimen biopsy also bring about bad pathologic parameters and shortened survival periods.

Metastatic transitional cell carcinoma presenting with skin metastasis.

Transitional cell carcinomas (TCC) of upper urinary system account for 5% of all TCCs. The incidence of such metastases ranges from 0.18% to 2%. Experimental studies reported a general unsatisfactory survival time following skin metastasis. We report in this paper a case of metastatic urinary system TCC, which had become evident with a skin lesion in the right hypogastric region. A 60-year-old female patient with a history of being operated upon due to renal pelvic TCC was admitted to our outpatient clinic with complaints of red skin lesion in the near vicinity of the operational incision scar for 3 months. Her medical history revealed nothing but nephroureterectomy operation on the upper urinary system; moreover, it was learned that she had been ignoring what was recommended to her for routine controls. Thoraco-abdominal computed tomographic (CT) examination performed on the basis of aforementioned findings depicted a mass lesion of 24*20 mm dimension with high contrast uptake detected within the subcutaneous fat tissue in the right abdominal wall. The skin lesion depicted in CT was surgically excised. The pathological examination of the excised material was reported to be compatible with TCC. The patient was referred due to abdominal lesion to medical oncology after the operation. Followed up under chemotherapy protocol, the patient died 3 months after the metastasectomy operation. Skin metastasis of upper urinary system TCCs, especially renal pelvic TCCs, are quite rare conditions. Among the likely skin sites of metastasis for genitourinary system TCCs are head, face, extremities, suprapubic region and abdomen. Taking into consideration the low survival rates, the importance of early diagnosis of recurrences and/or distant metastases should be better appreciated. These patients die soon after the skin metastasis even with the administration of aggressive therapy. Similarly, our patient died 90 days after the diagnosis of skin metastasis despite the oncologic therapy.

Importance of neutrophil/lymphocyte ratio in prediction of PSA recurrence after radical prostatectomy.

BACKGROUND: The aim of this study was to research the importance of the neutrophil to lymphocyte ratio (NLR) in prediction of PSA recurrence after radical prostatectomy, which has not been reported so far. MATERIALS AND METHODS: The data of 175 patients who were diagnosed with localised prostate cancer and underwent retropubic radical prostatectomy was retrospectively examined. Patient pre-operative hemogram parameters of neutrophil count, lymphocyte count and NLR were assessed. The patients whose PSAs were too low to measure after radical prostatectomy in their follow-ups, and then had PSAs of 0,2 ng/mL were considered as patients with PSA recurrence. Patients with recurrence made up Group A and patients without recurrence made up Group B. RESULTS: In terms of the power of NLR value in distinguishing recurrence, the area under OCC was statistically significant (p<0.001) .The value of 2.494 for NLR was found to be a cut-off value which can be used in order to distinguish recurrence according to Youden index. According to this, patients with a higher NLR value than 2.494 had higher rates of PSA recurrence with 89.7% sensitivity and 92.6% specificity. CONCLUSIONS: There are certain parameters used in order to predict recurrence with today's literature data.We think that because NLR is easy to use in clinics and inexpensive, and also has high sensitivity and specificity values, it has the potential to be one of the parameters used in order to predict biochemical recurrence in future.

Sarcomatoid carcinoma of the prostate.

Sarcomatoid carcinoma of the prostate is among the rarest malignant neoplasm types and has been well known for its aggressive clinical course. Patient was admitted with the symptoms of lower urinary tract. Transurethral resection of prostate (TUR-P) was carried out. Revealing Gleason 5 + 3 = 8 prostate adenocarcinoma in TUR-P material. Thereby, a Radical Prostatectomy procedure was planned. In operation, frozen examination revealed adenocarcinoma metastasis to the obturator lymph node. The operation was terminated. In the postoperative 3rd month, the patient was re-admitted with acute urinary system symptoms. A cystoscopy performed and complete resection of the mass was performed. The pathological examination reported that the tumor was compatible with undifferentiated adenocarcinoma owing to presence of poorly differentiated tumoral cells and detection of adenocarcinoma in a relatively small (<1%) focus. 4 month after the operation, the patient underwent another cyctoscopic examination which revealed the prostatic lounge and most of the bladder lumen to be filled with tumoral tissue. The tumoral tissues was resected incompletely. This material was diagnosed to be "Sarcomatoid Malignant Tumor" upon the new evidences of progressive dedifferentiation and predominant sarcomatoid appearance, compared with the former TUR-P materials. Subsequent PET-CT scan depicted multiple metastasis. The patient was referred to oncology department. In conclusion, sarcomatoid carcinoma is a malignant variant that brings along diagnostic and treatment difficulties.