Impact of robotic partial nephrectomy with and without ischemia on renal functions: experience in 34 cases.

OBJECTIVE: In this study we aimed to compare renal functions in patients who underwent robotic partial nephrectomy (RPN) with on-clamp and zero- ischemia techniques. MATERIAL AND METHODS: Between 2009 and 2015, 12 off-clamp and 22 on-clamp RPN procedures were performed on a total of 34 patients in two centers. The main outcome parameters examined were serum creatinine, and estimated glomerular filtration rate (eGFR) during preoperative, immediate postoperative periods, and at postoperative 3rd months. RESULTS: There were no statistically significant differences between on-clamp and zero- ischemia groups regarding age, ASA score, BMI, PADUA and R.E.N.A.L. nephrometry scores, operation time and tumor size (p>0.05). Significant differences were found in the duration of hospital stay (3.8±0.9 days vs. 3.0±0.9 days) and amount of blood loss (85.9±49.6 mL vs. 183.3±176.2 mL) between the on-clamp and zero-ischemia groups (p<0.05). Statistically significant differences were found between preoperative and immediate post-operative periods, in terms of eGFR and serum creatinine levels in both groups. Moreover, statistically significant differences were found between preoperative and postoperative 3rd month periods, in the on-clamp group in terms of eGFR and serum creatinine levels. In the zero-ischemia group, the decrease in eGFR and serum creatinine levels at postoperative 3rd month relative to the preoperative period was not statistically significant. CONCLUSION: Off-clamp RPN technique is superior, in short-term outcomes involving renal functions, compared to on clamp approach. However, long- term data regarding the renal functions should be evaluated to arrive at a definitive decision.

The first recurrent intravascular papillary endothelial hyperplasia (Masson's tumor) of the kidney.

Intravascular papillary endothelial hyperplasia (IPEH, Masson's Tumor) of the kidney is an unusual, benign vascular lesion. A rare case of recurrent IPEH in the kidney was presented in this article. A 50-year-old male with a diagnosis of a suspicious mass in the left kidney was referred to our center for robotic partial nephrectomy. Robotic zero ischemia partial nephrectomy was performed due to the suspicion of a renal malignancy. On the basis of the histopathological results, the patient was diagnosed as IPEH. A urinary ultrasound was performed on the 3(rd) postoperative month and a hyper echoic solid lesion, which was in the same localization, was detected. Due to the previous atypical pathological result, computed tomography (CT) guided fine-needle aspiration biopsy from the left renal mass was performed but malignant cytology was not confirmed with this biopsy. On follow-up CT done 6 months later, a persistent suspicious left renal mass, measuring 40 × 30 cm in size was detected with no change in its dimensions and appearance. Additionally, magnetic resonance imaging (MRI) scan revealed a bone lesion of 15 × 10 mm in the left hip, which was not present on previous MRI/CT scans. In view of the solid masses in the left kidney, and left hip on CT and MRI scan suspicious for a probably metastatic renal neoplasm, left radical nephrectomy via a left subcostal transperitoneal incision was performed. The ultimate pathological report of the patient was also supported the diagnosis of Masson's tumor and any renal malignancy was not encountered The patient was discharged on the 4(th) postoperative day and has been followed up for 4 months without any problems. In this case, we discuss the clinical features, histopathological characteristics, and the management of Masson's tumor of the kidney in the light of the current literature.

Robotic partial nephrectomy for clinical stage T1 tumors: Experience in 42 cases.

The aim of this study was to evaluate outcomes of robotic partial nephrectomy (RAPN) procedures. At two centers, 42 patients underwent RAPN. Radius, Exo/Endophytic, Nearness, Anterior/Posterior, Location (R.E.N.A.L.) nephrometry and PADUA scores of patients were calculated by computed tomography (CT) or magnetic resonance imaging (MRI). Intra- and perioperative (0-30 days) complications were evaluated using modified Clavien classification. A four-arm da Vinci-S robotic surgical system was used and outcomes were evaluated retrospectively. Mean age of the patients was 52.3 ± 6.5 years. Mean tumor size was 3.1 ± 1.0 (1.4-6.6) cm. R.E.N.A.L. nephrometry and PADUA scores were 6.0 ± 1.5 and 7.5 ± 0.9, respectively. Mean surgical time was 127.7 ± 18.7 minutes and estimated blood loss was 100 ± 18.1 cc. Mean warm ischemia time was 16.0 ± 8.9 (0-30) minutes. Intraoperative complications did not develop in any patient. Median hospital stay was 3.0 (2-6) days. Except for 17 patients, hilar clamping was performed in 25 patients. Histopathology results included 34 renal cell carcinoma (22 clear cell, 7 chromophobe cell, 4 papillary cell, and 1 clear papillary cell). Oncocytoma (n = 4), adenoma (n = 1), fibroadipose tissue (n = 1), papillary epithelial hyperplasia (n = 1), and chronic pyelonephritis (n = 1) were present. Surgical margins were negative in all patients. During a median follow-up period of 15.5 ± 10.9 (3-46) months, neither local recurrence nor distant metastasis was detected. In conclusion, RAPN is a safe, minimally invasive surgical approach, with excellent surgical and oncological outcomes in T1 kidney tumors. Zero ischemia off-clamp RAPN is also safe in selected masses with the advantage of avoiding complete renal ischemia.

Flexible Ureteroscopy Can Be More Efficacious in the Treatment of Proximal Ureteral Stones in Select Patients.

Purpose. We aimed to compare and evaluate the outcomes and complications of two endoscopic treatment procedures, semirigid ureteroscopy (SR-URS) and flexible ureteroscopy (F-URS), in the treatment of proximal ureteral stones (PUS). Methods. SR-URS (group 1) was done on 68 patients whereas 64 patients underwent F-URS (group 2) for the treatment of PUS. Success rate was defined as the absence of stone fragments or presence of asymptomatic insignificant residual fragments < 2 mm. Outcomes and complications were recorded. Results. The differences were statistically not significant in age, gender, body mass index (BMI), and stone characteristics between groups. Mean ureteral stone size was 9.1 ± 0.4 mm and 8.9 ± 0.5 mm for groups 1 and 2. Mean operative time was 34.1 ± 1.5 min and 49.4 ± 2.3 min for groups 1 and 2 (p = 0.001). SFRs were 76.5% and 87.5% for groups 1 and 2 (p = 0.078). Two major complications (ureteral avulsion and ureteral rupture) occurred in group 1. Conclusion. F-URS is safer and less invasive than SR-URS in patients with PUS. There is no statistically significant difference in the efficacy of either technique. Nonetheless we recommend F-URS in the management of PUS as a first-line treatment option in select cases of proximal ureteral calculi.

Retrograde Intrarenal Surgery in Patients Who Previously Underwent Open Renal Stone Surgery.

Purpose. To ascertain whether retrograde intrarenal surgery (RIRS) is as effective in patients treated previously with open renal stone surgery (ORSS) on the same kidney as in patients with no previous ORSS. Methods. There were 32 patients with renal stones who had previous ORSS and were treated with RIRS in the study group (Group 1). A total of 38 patients with renal stones who had no previous ORSS and were treated with RIRS were selected as the control group (Group 2). Recorded data regarding preoperative characteristics of the patients, stone properties, surgical parameters, outcomes, SFRs (no fragments or small fragments <4 mm), and complications between groups were compared. Results. Mean age, mean BMI, mean hospital stay, and mean operative time were not statistically different between groups. Mean stone size (10.1 ± 5.6 versus 10.3 ± 4.2; p = 0.551) and mean stone burden (25.4 ± 14.7 versus 23.5 ± 9.9; p = 0.504) were also similar between groups. After the second procedures, SFRs were 100% and 95% in groups 1 and 2, respectively (p = 0.496). No major perioperative complications were seen. Conclusion. RIRS can be safely and effectively performed with acceptable complication rates in patients treated previously with ORSS as in patients with no previous ORSS.

Combined ureterorenoscopy for ureteral and renal calculi is not associated with adverse outcomes.

INTRODUCTION: We intended to evaluate the feasibility and effectiveness of the simultaneous rigid and flexible ureteroscopic treatment of symptomatic ureteral and ipsilateral small simultaneous calyceal stones. Outcomes of combined therapy were compared with monotherapy alone. MATERIAL AND METHODS: In this retrospective study, group 1 consisted of 45 patients with middle or lower ureteral and ipsilateral small simultaneous calyceal stones treated by combined therapy. Group 2 included 45 patients with middle or lower ureteral stones only and treated by monotherapy. Stone characteristics, operative time, hospital stay, stone free rates, and complications were compared between groups 1 and 2. Stone free status was defined as no fragments and/or the presence of asymptomatic fragments smaller than 4 mm. RESULTS: Mean BMI were 29.3 ±0.9 kg/m(2) and 27.6 ±0.6 kg/m(2) in groups 1 and 2, respectively. Mean ureteral stone size (7.6 ±0.4 mm vs. 8.0 ±0.4 mm, p = 0.261) and ureteral stone burden (56.0 ±5.5 mm(2) vs. 54.8 ±6.1 mm(2), p = 0.487) were similar between groups. Mean renal stone size and renal stone burden for group 1 were 7.1 ±0.8 mm and 83.7 ±11.3 mm(2). The mean operative time was significantly longer (for a mean of 32.5±1.2 minutes) for group 1 (p = 0.001). Ureteral stents were left in 38 (84.4%) and 19 (42.2%) patients in group 1 and group 2 (p = 0.001). Hospital stay and complication rates were similar between groups. SFRs were 100% for ureteral stones in both groups and 88.9% for renal stones within group 1. CONCLUSIONS: Simultaneous ureteroscopic treatment of the ureteral and ipsilateral small calyceal stones prolongs operative time and increases use of ureteral stent without leaving any residual renal stones.

RIRS is equally efficient in patients with different BMI scores.

The objective of the study was to ascertain whether flexible ureteroscopy with holmium laser lithotripsy and/or extraction of stone fragments is as effective in obese patients as in non-obese patients. The patients were divided into four groups (group 1: normal weight = 79 procedures, group 2: overweight = 123 procedures, group 3: obese = 87 procedures, and group 4: morbidly obese = 20 procedures) according to BMI cohorts. Patient charts were retrospectively reviewed and relevant data collected. A total of 309 operations were included in the present study. The overall mean ± SD (range) age was 41 ± 12 years (18-82), BMI 29 ± 6 kg/m(2) (18-52), operative time 64 ± 29 min (20-200), hospital stay 25 ± 11 h (4-168), stone number 3 ± 2 (1-15), stone burden 21 ± 14 mm (4-98), and internal stenting time 26 ± 8 days (2-60). Mean stone size was 10 ± 6, 9 ± 5, 11 ± 8, and 11 ± 8 mm for groups 1 through 4, respectively. There were no differences among groups regarding patients and stone characteristics, and perioperative parameters including patient age, operative time, hospital stay, and complications. Overall SFRs were similar between groups (81, 87, 87.4, and 85%, respectively; χ(2)=3.304, p=0.770) as were the complication rates (12-16%). Our contemporary Retrograde Intrarenal Surgery (RIRS) series showed that operative times, hospital stays, ancillary equipment use (internal stent, basket, etc.), SFRs, and complication rates were independent of BMI. Therefore, RIRS can be performed as efficiently and efficaciously in obese patients as in non-obese patients.

Renoprotective effect of aliskiren on renal ischemia/reperfusion injury in rats: electron microscopy and molecular study.

PURPOSE: To determine the protective effect of aliskiren on ischemia-reperfusion (I/R) injury in a rat renal (I/R) model. METHODS: Rats were randomly divided into five groups: sham control group; sham control with aliskiren pretreatment; I/R group and I/R with two doses of aliskiren pretreatment. Rats were unilaterally nephrectomized and subjected to 45 min of renal pedicle occlusion followed by 24 h reperfusion. Aliskiren (50 and 100 mg/kg) was administered orally by gavage 24 and 1 h prior to ischemia. After 24 h reperfusion, kidney samples were taken for the determination of malondialdehyde (MDA) level, superoxide dismutase (SOD), glutathione (GSH) activity and histological evaluation. The level of serum creatinine (SCR) and blood urea nitrogen (BUN), renin and angiotensin II (AT-2) was measured in serum samples. RESULTS: Kidneys from I/R groups showed significant increase in MDA level and significant decrease in GSH, and SOD activity. IL-1ß, iNOS and NFkB gene expression significantly increased in the I/R groups in the rat kidney tissue. Aliskiren treatment showed a significant down-regulatory effect on IL-1ß, iNOS and NFkB mRNA expression. Compared with the sham group, SCR and BUN, renin and AT-2 were significantly increased in the I/R rats, accompanied by histopathological damage to the kidney. CONCLUSION: Pretreatment with aliskiren ameliorated I/R-induced renal injury through decreasing nitric oxide and AT-2 levels and by the reduction of injury induced by I/R injury and ameliorated renal histopathological molecular and biochemical changes.

Does anterior prostatic fat tissue removed during robotic radical prostatectomy contain any lymph nodes?

INTRODUCTION: We investigated whether anterior periprostatic fat (APPF) tissue removed during robotic radical prostatectomy (RARP) contains any lymph nodes (LNs). MATERIAL AND METHODS: APPF tissues removed during RARP in 129 patients were evaluated histopathologically. Correlation with postoperative pathologic stage was made. Patients with a history of previous prostate or bladder surgery and radiation therapy were excluded. RESULTS: Mean patient age, serum prostate specific antigen (PSA), prostate weight and body mass index (BMI) were 62.2 ±5.5 (range 45-74), 9.3 ±6.3 ng/dl (range 0.26-30.3), 60.3 ±27.2 grams (range 11.0-180) and 26.6 ±1.9 kg/m(2) (range 20.0-30.3), respectively. Overall, LNs in APPF tissues were detected in 14 (10.9%) patients with a mean LN yield of 1.1 ±0.7 LNs (range, 1-3). Among those found, no metastatic LN was detected. Of the patients with pT2a (n = 22), pT2b (n = 15), pT2c (n = 62) and pT3a (n = 21) disease, LNs in APPF tissues were detected in 1 (4.6%), 1 (6.7%), 11 (17.7%) and 1 (4.8%) patient in each group, respectively. Among the patients, LNs in APPF tissues were detected in 0 (0%), 5 (35.7%), 8 (57.1%) and 1 (7.1%) patients of underweight, optimal weight, overweight and obese patients due to body mass index, respectively. CONCLUSIONS: In our series, LNs were detected in around 10% of the patients. Therefore, this fat should, not be pushed back during RARP but should be removed and sent for pathologic evaluation. Although no metastatic LN was detected in our series, the presence of metastatic LNs might have an impact on the oncologic outcomes of the patients and warrants further research.

Endourological treatment of foreign bodies in the urinary system.

BACKGROUND AND OBJECTIVES: In this retrospective study, nature, clinical presentations, diagnostic modalities, and endoscopic treatment of urinary system foreign bodies were evaluated. METHODS: A total of 8 cases were treated with endoscopic surgery between February 15, 2007 and June 12, 2012. Clinical findings, radiologic diagnosis, and management were reviewed. RESULTS: We observed that urinary tract foreign bodies were generally secondary to iatrogenic causes; however, bladder/urethral foreign bodies could also be due to self-insertion. Clinical findings were different secondary to their location in the urinary system. All foreign bodies were treated endoscopically. CONCLUSIONS: Foreign bodies of the urinary system can successfully be treated with endoscopic modalities without any complications.

Simultaneous robot assisted laparoscopic radical nephroureterectomy; genital tract and paravaginal nerve sparing radical cystectomy; superextended lymph node dissection and intracorporeal Studer pouch reconstruction for bladder cancer: Robotic hat-trick.

The case of a simultaneous robotic radical nephroureterectomy, genital tract and paravaginal nerve-sparing robotic radical cystectomy, super-extended pelvic lymph node dissection and intracorporeal Studer pouch construction on a 57-year old female patient with muscle invasive bladder and distal ureteral tumors, along with a hydroureteronephrotic nonfunctioning right kidney is presented. The entire surgery was completed through a total of 8 ports in 9.5 hours. The patient was discharged home on postoperative day-6 and a JJ-stent attached to the urinary catheter was removed altogether on postoperative day-21. This complex surgery can be done safely robotically with excellent oncological outcomes and no surgical and wound complications in the short term.

Effectiveness of Flexible Ureterorenoscopy and Laser Lithotripsy for Multiple Unilateral Intrarenal Stones Smaller Than 2 cm.

Purpose. To evaluate the safety and efficacy of RIRS for the treatment of multiple unilateral intrarenal stones smaller than 20 mm. Methods. Between March 2007 and April 2013, patients with multiple intrarenal stones smaller than 20 mm were treated with RIRS and evaluated retrospectively. Each patient was evaluated for stone number, stone burden (cumulative stone length), operative time, SFRs, and complications. Results. 173 intrarenal stones in 48 patients were included. Mean age, mean number of stones per patient, mean stone burden, and mean operative time were 40.2 ± 10.9 years (23-63), 3.6 ± 3.0 (2-18), 22.2 ± 8.4 mm (12-45), and 60.3 ± 22.0 minutes (30-130), respectively. The overall SFR was 91.7%. SFRs for patients with a stone burden less and greater than 20 mm were 100% (23/23) and 84% (21/25), respectively (χ (2) = 26.022, P < 0.001). Complications occurred in six (12.5%-6/48) patients, including urinary tract infection or high-grade fever >38.5°C in three cases, prolonged hematuria in two cases, and ureteral perforation in one case, all of whom were treated conservatively. No major complications occurred. Conclusions. RIRS is an effective treatment option in patients with multiple unilateral intrarenal stones especially when the total stone burden is less than 20 mm.

Same-session bilateral retrograde intrarenal surgery for upper urinary system stones: safety and efficacy.

PURPOSE: We present our experience with same-session retrograde intrarenal surgery (RIRS) for the management of bilateral upper urinary system stones (UUSS) in terms of clearance of stones, operative times, duration of hospital stay, and complications. MATERIALS AND METHODS: Between November 2007 and January 2013, a total of 44 simultaneous bilateral RIRS were performed at our hospital. Initially, symptomatic sides of the patients were operated on, and, when asymptomatic, the greater stone burden was treated first. Having completed stone fragmentation with a holmium:YAG laser, larger fragments were extracted with a nitinol basket. All patients underwent noncontrast CT scanning or urinary ultrasonography 2 months after the removal of the stent to detect any residual fragments. The stone-free status was defined as no fragments and/or the presence of asymptomatic fragments <4 mm in the urinary system. RESULTS: The total stone number was 201 with a mean stone burden per patient of 30.0±15.4 mm (range 10-85 mm). The overall stone-free rate (SFR) was 88.6% after all procedures. The patients in this study were divided into two groups according to stone burden: Although the overall SFR was 100% for a stone burden <25 mm, the SFR was 80% for a stone burden ≥25 mm (P=0.006). A Double-J stent was not placed in two patients, and they developed postoperative anuria; both cases were treated with Double-J stent placement. CONCLUSION: Bilateral same-session RIRS is a safe and effective procedure that can be considered a first-line treatment for bilateral UUSS in select patients. The SFR is satisfactory, especially in patients with a stone burden <25 mm. At minimum a unilateral Double-J stent should be placed in patients undergoing bilateral RIRS to avoid postrenal failure.

Gleason score at the margin can predict biochemical recurrence after radical prostatectomy, in addition to preoperative PSA and surgical margin status.

BACKGROUND/AIM: To evaluate the relation between biochemical recurrence (BCR) of prostate cancer and the extent of positive surgical margins (PSMs), Gleason score (GS) of the tumor at the margins, and preoperative prostate-specific antigen (PSA) levels. MATERIALS AND METHODS: A total of 94 patients who underwent radical prostatectomy were recruited for this study and received postoperative follow-up care for 2 years. All specimens were evaluated for surgical margin status, PSM length, GS at positive margin, size of tumor, multifocality, invasion of seminal vesicle, lymphovascular invasion, and perineural invasion. PSM was defined as a prostate tumor. RESULTS: Out of 94 patients, 34 patients (36.2%) had PSMs and 46 patients (48.9%) had BCR. A statistically significant relation between having a high risk of BCR of prostate cancer and having high preoperative PSA levels (P < 0.001), PSMs (P < 0.001), or a high GS at the surgical margin (P = 0.024) was found. CONCLUSION: High preoperative PSA levels, PSMs, and tumors with high GS at the margins have a poor prognostic impact, and they correlate with a higher rate of BCR. Close follow-up of patients with PSMs with high GS and high levels of preoperative PSA is recommended.

Metachronous periadrenal Fatty tissue metastasis from contralateral renal cell carcinoma.

Contralateral adrenal metastases from renal cell carcinomas are not commonly seen. To our knowledge, we are presenting the first case of extraadrenal metastasis in the English literature, from the contralateral RCC 6 months after radical nephrectomy. Patient was treated with robotic right adrenalectomy for continuous growing of a de novo right adrenal mass of 6 × 4 × 3 cm in diameter. Tissue between vena cava, renal capsule, and inferior diaphragmatic surface was removed en block. Pathological evaluation revealed renal cell carcinoma within the fatty tissue abutting the adrenal capsule from outside with negative surgical margins. Our experience dictates that removing adrenal tissue only after identifying the adrenal borders may sometimes result in insufficient tumor removal. Therefore, adrenal containing tissue within the anatomic boundaries should be removed en block, if surgical removal is planned for metachronous tumor metastasis in the treatment of renal cell carcinoma.

Right-sided hydronephrosis secondary to swallowing a headscarf pin.

A majority of foreign objects ingested pass through the gastrointestinal tract without any complications. Sometimes, complications such as perforation and adhesions of the neighboring organs occur and surgical treatment becomes necessary. We report the case of a 22-year-old female who was admitted with right flank pain. Past medical history revealed that the patient had accidentally swallowed a headscarf pin 11 months earlier. A computed tomography scan confirmed the swallowed foreign body posterior to and around the ileocecal region. The headscarf pin, causing stenosis and proximal ureteral dilatation, was removed surgically. To the authors' knowledge there has been no previous report of such ureteral obstruction published in the English literature.

Photoselective vaporization of the prostate in men with a history of chronic oral anti-coagulation.

PURPOSE: A considerable percentage of patients with benign prostatic hyperplasia (BPH) also have additional cardiac pathologies, which often require anticoagulant therapy. The aim of this study was to evaluate the efficacy and safety of photoselective vaporization of the prostate (PVP) for BPH in cardiac patients receiving anticoagulant therapy. MATERIALS AND METHODS: A total of 67 patients suffering from BPH and high risk cardiac pathologies were operated on using laser prostatectomy. All patients had cardiac pathologies with bleeding disorders requiring anticoagulant use, and underwent standard urologic evaluation for BPH. Patients were treated with laser prostatectomy for relief of the obstruction using the KTP/532 laser energy at 80 W. RESULTS: The mean patient age was 71.4 years (range 55-80). Mean prostate volume on transrectal ultrasonography was 73.2 mL (range 44-120). Operation time ranged from 40 to 90 min, with an average value of 55 min. The average hospital stay was 48 hours (range 12-72) and the Foley catheters were removed within 48 hours, with a mean catheterization time of 34.2 +/- 5.9 hours (0-48). No patient required an additional procedure due to severe bleeding necessitating intervention during the early postoperative phase. Mean International symptoms scoring system (IPSS) values and post voiding residual volume decreased and peak urinary flow rate increased (p < 0.001). Our results showed that the mean prostate volume had decreased by 53% at 6 months. CONCLUSIONS: High-power photo selective laser vaporization prostatectomy is a feasible, safe, and effective alternative for the minimal invasive management of BPH, particularly in cardiac patients receiving anticoagulant therapy.