SUI in postmenopausal women: advantages of an intraurethral + intravaginal Er:YAG laser.

OBJECTIVE: This study aimed to compare the efficacy of concomitant application of an intraurethral (IU) + intravaginal (IV) non-ablative Erbium (Er):YAG laser with IV application in improving the symptoms of stress urinary incontinence (SUI) in women. METHODS: This observational retrospective cohort study included 122 patients with SUI, 60 women in the IU + IV laser arm and 62 in the IV laser arm. The primary outcome was the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form score at entry and at 3, 6 and 12 months from baseline. RESULTS: Demographic characteristics were comparable in both arms. Significant improvement in SUI symptoms was seen 3 months after the intervention and was sustained until the end of month 12 in both arms. The women who had severe SUI symptoms initially showed greater improvement. A higher number of women who initially had mild to moderate SUI symptoms were dry after treatment. Patients treated with IU + IV Er:YAG laser showed significant improvement in SUI symptoms compared to IV laser only, especially at postmenopausal state (p = 0.003). CONCLUSIONS: The Er:YAG laser appears to be an efficient treatment method for SUI. Concomitant application of an IU + IV Er:YAG laser is more effective in relieving SUI symptoms at postmenopausal state.

Effectiveness of erector spinae plane block in patients with percutaneous nephrolithotomy.

BACKGROUND: Percutaneous nephrolithotomy operation is a minimally invasive surgical procedure for the treatment of kidney stones. AIM: This study aimed to evaluate the effectiveness of ultrasound-guided erector spinae plane block (ESPB) on analgesic consumption in patients who underwent percutaneous nephrolithotomy. SUBJECTS AND METHODS: The data of 60 cases who underwent percutaneous nephrolithotomy operation between 01.01.2020 January and 12.01.2020 were retrospectively analyzed. Hemodynamic parameters, verbal analogue scale adjectives, total morphine consumption, additional analgesic and antiemetic need, duration of hospitalization, and patient satisfaction score were compared in patients who had ESPB and did not have block. RESULTS: Demographic data and hemodynamic parameters were similar between the two groups. Verbal rating scale values were lower for Group I at 2, 6, 12, and 24 h (P < 0.05). Patient satisfaction score was significantly higher in Group I over 24 h (P = 0.039). Total morphine consumption at postoperative 2nd, 6th, and 24th h was less than that of Group II (P < 0.05). Analgesia consumption in postoperative 24 h of group I was less than that of Group II (P = 0.001). The amount of fentanyl given intraoperatively was significantly higher in Group II (P = 0.001). Nausea and vomiting rates were significantly lower for Group I (P = 0.002). CONCLUSION: Ultrasound-guided ESPB reduced postoperative morphine consumption and the rate of nausea and vomiting.

Does lower urinary tract status affect renal transplantation outcomes in children?

BACKGROUND: Lower urinary tract dysfunction (LUTD), an important cause of end stage renal disease (ESRD) in children, can adversely affect renal graft survival. We compared renal transplant patients with LUTD as primary renal disease to those without LUTD. METHODS: The data of 60 children who underwent renal transplantation (RTx) between 2000 and 2012 were retrospectively reviewed. All patients with LUTD were evaluated with urodynamic tests preoperatively; 15 patients required clean intermittent catheterization and 9 patients underwent augmentation cystoplasty before RTx. RESULTS: There were 25 children with LUTD. The mean follow-up for LUTD (+) and LUTD (-) groups were 63 (22-155) and 101 months (14-124), and graft survival were 76% for LUTD (+) and 80% for LUTD (-), respectively (P = .711). On the other hand, creatinine levels at last follow-up were significantly higher in the LUTD (+) group (1.3 ± 0.3 mg/dL vs 0.96 ± 0.57 mg/dL, P < .001). Infectious complications and postoperative urinary tract infection incidences were also higher in the LUTD (+) group (68% vs 25.7%, P = .002 and 60% vs 11.4%, P < .01). CONCLUSION: UTI is significantly higher after kidney transplantation in patients with LUTD. Despite the higher risk of UTI, renal transplantation can be performed safely in those patients with careful patient selection, preoperative management, and close postoperative follow-up. Restoration of good bladder function is the key factor in the success of kidney transplantation in those patients.

Urologic Disorders in Living Renal Donors and Outcomes of Their Recipients.

BACKGROUND: There is an expanding gap between the number of patients listed for kidney transplantation and the number of kidney transplantations performed annually. The use of sensitive imaging methods results in increased discovery of many urologic asymptomatic problems, such as urolithiases, renal cysts, and solid renal masses. This result has brought the question of whether all donors with these urologic disorders should be rejected for donation. METHODS: We retrospectively analyzed donor and recipient records of all living kidney transplantations performed from 2004 to 2014. RESULTS: Among 251 living-related donor kidney transplantations, 51 donors (20.3%) had urologic disorders. Mean donor age was significantly higher in donors with urologic disorders than in the standard donor group (50 y vs 41 y). The identified disorders were 32 renal cysts, 8 urolithiases, 3 renal tumors, 6 adrenal adenomas, and 2 microscopic hematurias. After nephrectomy, the graft kidneys with cysts were inspected carefully and all of the cortical-peripheral cysts were decorticated. Renal tumors were excised in 3 renal units. Transplantations had proceeded after the confirmation of low malignancy potentials of the lesions with safe surgical margins. Two out of 8 patients had undergone stone removal with ex vivo ureteroscopy and 1 by means of pyelotomy incision because of calix neck stenosis. None of those donors and recipients developed clinically significant renal stone disease with a mean follow-up of 28 months. Neither donors nor recipients of asymptomatic microscopic hematuria patients developed any problem with a mean 28 months' follow-up period. CONCLUSIONS: Asymptomatic urologic problems are very common. The significance of these asymptomatic pathologies is unclear. Our results suggest that in a selected group, at least some of these candidates can be accepted for donation.

Preoperative evaluation of hilar vessel anatomy with 3-D computerized tomography in living kidney donors.

OBJECTIVES: Digital subtract angiography is the gold standard for anatomic assessment of renal vasculature for living renal donors. However, multidetector-row computerized tomography (MDCT) is less invasive than digital subtract angiography and provides information of kidney stones and other intra-abdominal organs. In this study, preoperative MDCT angiography results were compared with the peroperative findings to evaluate the accuracy of MDCT for the evaluation of renal anatomy. METHODS: From December 2002 to May 2007, all 60 consecutive living kidney donors were evaluated with MDCT angiography preoperatively. We reported the number and origin of renal arteries, presence of early branching arteries, and any intrinsic renal artery disease. Renal venous anatomy was evaluated for the presence of accessory, retroaortic, and circumaortic veins using venous phase axial images. The calyces and ureters were assessed with delayed topograms. The results of the MDCT angiography were compared with the peroperative findings. RESULTS: A total of 67 renal arteries were seen peroperatively in 60 renal units. Preoperative MDCT angiography detected 64 of them. The two arteries not detected by MDCT had diameters less than 3 mm. Anatomic variations were present in nine veins, five of which were detected by CT angiography. Sensitivity of MDCT angiography for arteries and veins was 95% and 93%, respectively. Positive predictive values were 100% for both arteries and veins. CONCLUSION: MDCT angiography offers a less invasive, rapid, and accurate preoperative investigation modality for vascular anatomy in living kidney donors. It also provides sufficient information about extrarenal anatomy important for donor surgery.

Coronary artery calcifications in hemodialysis patients and their correlation with the prevalence of erectile dysfunction.

INTRODUCTION: Our aim in this study was to investigate the prevalence and correlation with coronary artery calcium scores (CACS) and erectile dysfunction (ED) among hemodialysis patients. PATIENTS AND METHODS: Thirty-five male patients with chronic renal failure were selected to participate in this study. All patients underwent examinations for CACS using 16-channel multidetector computed tomography. The presence and severity of ED were determined by calculating the erectile function domain of the self-administered International Index of Erectile Function (IIEF). RESULTS: The patients' ages ranged from 22 to 78 with a mean of 51.6 years. The mean duration of hemodialysis was 75.7 months (range = 12 to 232). Twenty-six patients had a history of one or more systemic diseases. The prevalence of any level of ED was 82.9% for all hemodialysis patients, and severe ED, 40%. The CACS was significantly higher among patients with severe ED (P = .032). The IIEF-5 score was also shown to have a moderate negative correlation with the CACS (r = -.420, P = .012). Age, duration of hemodialysis, body mass index, diabetes mellitus, hypertension, coronary heart diseases, hyperlipidemia, thyroid disease, depression, tobacco consumption, and medication were not associated with the presence of ED (P > .05). CONCLUSION: ED is prevalent in hemodialysis patients. Although many possible factors contribute to ED, the severity of ED increases with greater CACS.

Renal transplantation in children with lower urinary tract dysfunction of different origin: a single-center experience.

INTRODUCTION: Renal transplantation in patients with lower urinary tract dysfunction (LUTD) of various origins is a challenging issue in the field of pediatric transplantation. We report our single-center experience to evaluate patient and graft survivals as well as the risks of the surgery and immunosuppressive therapy. PATIENTS AND METHODS: Among 70 pediatric transplant patients, 11 displayed severe LUTD. Videourodynamic tests were performed on all patients preoperatively as well as postoperatively if required. The cause of urologic disorders were neurogenic bladder (n = 5) and urethral valves (n = 6). Clean intermittent catheterization (CIC) was needed in six patients to empty the bladder. To achieve a low-pressure reservoir with adequate capacity pretransplantation augmentation ileocystoplasty was created in four patients and gastrocystoplasty in one patient. Three of the patients received kidneys from cadaveric and eight from living donors. All patients were treated with calcineurin-based immunosuppressive therapy. RESULTS: The mean age at transplantation was 15 +/- 4.7 years. The median follow-up after transplantation was 36 months (6 to 62 months). At their last visit the median creatinine level was 0.95 mg/dL (0.8 to 2.4 mg/dL). Three patients had recurrent symptomatic urinary tract infections who had augmented bladder on CIC. One patient with ileocystoplasty who developed urinary leak and ureteral stricture in the early postoperative period was treated by an antegrade J stent. CONCLUSION: Severe LUTD carried high risks for the grafted kidney. However, our data suggested that renal transplantation is a safe and effective treatment modality, if the underlying urologic diseases properly managed during the transplantation course. Since surgery and follow-up is more complicated, patient compliance and experience of transplantation team have significant impacts on outcomes.

Utility of the Doppler ultrasound parameter, resistive index, in renal transplant histopathology.

BACKGROUND: Doppler ultrasonography is routinely used by many clinicians during long-term follow-up to identify high-risk patients without diagnosing the exact cause of graft dysfunction. Despite a number of studies showing a correlation between intrarenal resistive index (RI) and renal function in patients with kidney diseases, correlations between RI and renal histopathologic characteristics have not been sufficiently evaluated in renal transplant recipients. The aim of this study was to examine this relationship in grafted kidneys. PATIENTS AND METHODS: The intrarenal RI was retrospectively compared with biopsy findings in 28 kidney recipients. All renal biopsy specimens were reviewed by light microscopy and immunofluorescence staining. For glomerulosclerosis, we considered the percentage of glomeruli showing this change; for interstitial fibrosis/tubular atrophy and interstitial infiltration, we graded abnormalities according to the methods of Kliem et al (Kidney Int 49:666, 1996). RESULTS: The percentage of globally sclerosed glomeruli was significantly greater among patients with RI values higher than 0.75 than below this level (23% vs 47%; P = .022). Patients with grade 1 interstitial fibrosis and tubular atrophy (n = 14) showed lower RI values (0.68 +/- 0.03 vs 0.74 +/- 0.06; P = .047) than those with grade 3 fibrosis (n = 12). Similarly, lower RI values (0.66 +/- 0.02 vs 0.73 +/- 0.05; P = .014) were observed among patients with grade 1 (n = 13) compared with grade 3 interstitial infiltration (n = 13). CONCLUSION: RI seemed to provide a prognostic marker for the graft rather than yielding an exact diagnosis of renal graft dysfunction.

Outcome of primary glomerular disease in pediatric renal transplantation: a single-center experience.

INTRODUCTION: The recurrence of primary disease in transplantation is a well-known problem. We report our single-center experience to assess the frequency of the recurrence of primary glomerulonephritis in children after renal transplantation. PATIENTS AND METHODS: Medical reports of 14 children with primary glomerular disease were evaluated. Among the 14 grafts were 10 from living related and four from cadaveric donors. Ten were diagnosed as focal segmental glomerulosclerosis (FSGS), two membranoproliferative glomerulonephritis (MPGN), and two polyarteritis nodosa (PAN). The original diagnosis was biopsy-proven in every case. All patients were treated with calcineurin-based immunosuppressive therapy. RESULTS: The mean age was 15.5 +/- 5.4 years. The median transplantation duration was 47 months; however, one of the FSGS patient had hyperacute rejection. Five years later she received a second graft with a serum creatinine of 0.7 mg/dL at 7 years after transplantation. Posttransplant recurrence of FSGS was confirmed in two patients (20%), who were treated with plasmapheresis with no improvement of proteinuria, two FSGS patients had thromboses after transplantation. One had a cardiac thrombosis with heterozygote MTHFR mutation and one, a renal artery thrombosis and loss of graft with prothrombin 20210A mutation. They all have functioning grafts except these two. We did not observe recurrence of PAN or MPGN in patients. CONCLUSION: Although the number of patients is quite small, our recurrence rate was compatible with the previous reports. Additionally, we strongly recommend evaluation of all risk factors for thrombosis and give appropriate anticoagulation.

Utility of c2 monitoring in prediction of diastolic dysfunction in renal transplant recipients.

BACKGROUND: A number of experimental studies have suggested that cyclosporine (CsA) toxicity induces cardiac modifications which may cause diastolic dysfunction over the course of time. Doppler echocardiography with tissue Doppler imaging (TDI) could consistently detect diastolic dysfunction. The purpose of this study was to assess diastolic dysfunction using C2 monitoring of CsA exposure in stable renal transplant patients. PATIENTS AND METHODS: Seventy-eight kidney recipients including 42 men and 36 women of overall mean age of 52 +/- 9 years were obtained in 47 living and in 31 cases from cadaveric donations over 12 or more months after transplantation using cases from CsA, mycophenolate mofetil, and steroid. C2 levels were measured by an enzyme multi-immune assay technique. The patients underwent conventional and Doppler echocardiography with TDI. RESULTS: The patients were divided into 2 groups according to C2 levels less than 500 mug/L (group 1, n = 40) versus greater than 500 mug/L (group 2, n = 38). The demographic parameters, serum creatinine and lipid levels, systolic and diastolic blood pressures, number and type of antihypertensive medications, and conventional echocardiographic parameters did not differ significantly between the groups. However, group 1 patients showed significantly higher isovolumic relaxation time (109 +/- 27 vs 86 +/- 14 ms), early diastolic deceleration time (189 +/- 52 vs 137 +/- 59 ms), and lower values of E velocity (56 +/- 32 vs 92 +/- 27 cm/s) and E/A ratios (0.81 +/- 0.23 vs 1.15 +/- 0.46) than group 2. TDI studies revealed significantly lower E'/A' (0.76 +/- 0.25 vs 1.09 +/- 0.32, P < .05) in group 1 versus group 2. CONCLUSION: The data suggested that the higher C2 levels may induce diastolic dysfunction in the hearts of kidney recipients without impairment of contractile performance.

Semen variables and hormone profiles after kidney transplantation during adolescence.

Our aim was to investigate the semen variables and hormone profiles among transplant patients who received kidneys during adolescence. Seven postpubertal transplant patients who underwent successful renal transplantation during adolescence (13-19 years; 3 were preemptive) were enrolled in our clinical follow-up. Serum levels of prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone were checked together with the semen analysis. The ages of the patients ranged from 18 to 25 years (median, 22 years). The median age was 15 years (range, 12-18 years) at initial presentation. The median time between initial diagnosis and transplantation was 12 months (range, 2-60 months). The median follow-up after transplantation was 51 months (range, 23-134 months). Three of the seven patients had unilateral low testicular volume. The renal function tests were within normal limits, as well as serum levels of prolactin, FSH, LH, and testosterone. Sperm counts ranged from 0.2 to 55 million/mL (median, 1.7 million/mL). Only 1 patient (14.2%) had normal sperm parameters. Oligoteratozoospermia (low sperm count and defects in morphology) was observed in 1/7 (14.2%), asthenoteratozoospermia (low levels of motility and defects in morphology) in 1/7 (14.2%), and all parameters were abnormal in 4/7 (57.1%) cases. Our data suggest that in contrast to adult patients, semen variables are severely affected and spermatogenesis does not improve after renal transplantation when the patient was subjected to uremia before or during adolescence, the crucial period for spermatogenesis.

How does the presence of urologic problems change the outcome of kidney transplantation in the pediatric age group.

PURPOSE: We retrospectively reviewed the impact of functional and anatomic urologic disorders on kidney transplantation outcomes in terms of the surgical and long-term results of pediatric renal transplantation. MATERIALS AND METHODS: Of the 55 kidney transplantations in the pediatric age group, end-stage renal disease (ESRD) was secondary to genitourinary disorders in 23 patients (42%). The urologic abnormalities were vesicoureteral reflux in 13 patients (59%), neurogenic bladder in 4 patients (18%), posterior urethral valves in 3 patients (14%), renal stone disease in 4 patients (18%), bilateral ureterovesical junction obstruction in 3 patients (14%), and unilateral renal agenesis with concomitant contralateral ureteropelvic junction obstruction in 1 patient (4%). RESULTS: Of the 23 patients with urologic problems, 19 (83%) had functioning grafts with a mean follow-up of 49 months (range, 7-120 months). In the other 32 patients, 26 (81%) had functioning grafts with a mean follow-up of 43 months (range, 1-144 months). The graft survival, mean serum creatinine, and urinary tract infection rates of the patients did not differ between the two groups. CONCLUSIONS: The presence of functional urologic disorders as the cause of ESRD did not seem to change the outcome of renal transplantation in terms of graft survival when compared with patients without any urologic disorders. Urinary tract infections seem to be a little more common and yet clinically not significant in those patients. Reflux does not always need to be corrected before transplantation, unless it is causing symptoms or infection.

Renal transplantation in children with augmentation enterocystoplasty.

INTRODUCTION: We report our experience with renal transplantation in patients with severe bladder dysfunction who underwent prior augmentation cystoplasty. PATIENTS AND METHODS: Among 58 pediatric patients, three underwent bladder augmentation prior to renal transplantation. The patients' ages at transplantation were 10, 13, and 17. The etiologies of bladder dysfunction were posterior urethral valves in two patients and contracted bladder in one patient. Vesicoureteral reflux was concomitantly present in three patients. Pretransplant ileocystoplasty was created in two patients and gastrocystoplasty in one patient. All patients received kidneys from cadaveric donors and were treated with calcineurin-based immunosuppressive therapy. RESULTS: The patients had normal renal function without hydronephrosis of the transplanted kidney at 13, 22, 49 months follow-up. No patients had morbidity due to technical complications. All the patients were continent. Two of three patients required clean intermittent catheterization from a Mitrofanoff conduit, while one patient spontaneously voids without significant residual urine. Urinary tract infections observed in two patients were successfully treated without any permanent deterioration in graft kidney function. CONCLUSIONS: Our data suggest that augmentation cystoplasty is a safe and effective option to treat patients with end-stage renal disease undergoing kidney transplantation. Experience of the transplantation team with a qualified pediatric urologist is essential due to the potentially high risk of surgical complications during the long term management of these patients.

A novel surveillance protocol for stage I nonseminomatous germ cell testicular tumours.

OBJECTIVES: To report the results of a novel surveillance policy for stage I nonseminomatous germ cell tumours (NSGCTs). PATIENTS AND METHODS: Between 1978 and 2000, 132 patients (median age 28 years, range 16-52) who were regularly followed were included in a new surveillance policy. All pathology specimens were studied retrospectively by the same pathologist for embryonal carcinoma, yolk sac tumour and lymphovascular invasion components. A loose surveillance protocol was designed in which computed tomography (CT) was used only for the first year. RESULTS: The median (range) follow-up was 38 (6-265) months; the relapse rate was 24% and all occurred before 23 months, with 87% diagnosed within the first year. Platinum-based chemotherapy was given to patients with relapse, and surgery used after chemotherapy in seven. Among all the risk factors, an embryonal carcinoma component was the only significant predictor of relapse. The overall survival rate was 99%. CONCLUSION: The presence of embryonal carcinoma in the primary pathology is the only risk factor determining the relapse rate of the present surveillance policy for stage I NSGCTs. The overall survival was no different from those reported for retroperitoneal lymph node dissection and primary chemotherapy. Decreasing the frequency of CT in the first year and totally eliminating it after 1 year reduces the cost of surveillance. The possible compliance problems of patients are also minimized, without changing the overall survival. This surveillance protocol for patients with stage I NSGCT has reduced costs and provided a better quality of life for the patients, without jeopardizing the final outcome.

Marsupialization for bilateral pararenal lymphatic cysts.

A case of bilateral pararenal lymphatic cysts associated with hypertension is described. The cysts surrounded the renal parenchyma and were located underneath the renal capsule. No vascular pathology explaining the cause of hypertension was diagnosed by radiological techniques. Hypertension improved following bilateral marsupialization.

Ureterocystoplasty: an alternative reconstructive procedure to enterocystoplasty in suitable cases.

PURPOSE: The objective of the report is to present the results of ureterocystoplasty in 6 children with megaureters and low-capacity, high-pressure bladders. METHODS: Of the 6 patients, 2 had valve bladders, 1 had Hinmann's syndrome, 1 had neuropathic bladder, and the remaining 2 with ureterocutaneostomy were mainly diverted because of refluxing megaureters. Nephrectomy was performed in both of the boys with posterior urethral valve because of vesicoureteral reflux dysplasia (VURD) syndrome, and the ipsilateral ureter was used for the augmentation. In 2 patients with ureterocutaneostomy and in 1 with Hinmann's syndrome, a transureteroureterostomy was carried out, and the distal part of the ureter was used to perform augmentation. The patient with neuropathic bladder had a nonfunctioning crossed ectopic left kidney with an associated ipsilateral, refluxing megaureter, and the ureter was used for augmentation after the nephrectomy. RESULTS: All of the patients are continent, and 4 patients who are neurologically normal void spontaneously without requiring clean intermittent catheterization (CIC). The average increase in bladder capacity is 263% (range, 190% to 340%). CONCLUSIONS: Ureterocystoplasty is the bladder augmentation of choice for patients with a nonfunctioning kidney with an associated ipsilateral, refluxing megaureter and for patients with kidneys both in good function and megaureters suitable for a transureteroureterostomy.

Intravesical ureteric plication and reimplantation for megaureters in children.

Historically, megaureters have always been a surgical dilemma for paediatric urologists. However, the evolution of modern diagnostic and surgical methods such as tailoring, folding and plication have made it possible to ensure successful correction in most patients. We report 17 megaureters (11 refluxing and 6 obstructing) in 11 children who were treated with intravesical plication and the trans-trigonal advancement technique between January 1986 and April 1991. Results were excellent in 11 ureters and satisfactory in 4. In one ureter additional surgery was needed because of obstruction at the implantation site and in another ureter reflux persisted. Intravesical plication and reimplantation is a good alternative procedure for grossly dilated ureters owing to its low morbidity and high success rate.

The fate of contralateral ureter after ipsilateral reimplantation in unilateral vesicoureteric reflux.

Four patients out of 23 girls and 7 boys who were treated by successful ureteroneocystostomies for unilateral reflux had postoperative contralateral reflux (13.33%). Three of these 4 refluxing ureters resolved with medical treatment. A second surgery was needed in only 1 case (3.33%) who did not respond to medical treatment. There was no correlation between the preoperative severity of ipsilateral reflux, intravenous urography findings and the onset of contralateral reflux after unilateral reimplantations. Data from this study and previous works indicated that bilateral reimplantations are not warranted for unilateral refluxing renal units unless there are position and shape anomalies at the ureterovesical angle and a very careful preoperative evaluation of the patients is mandatory in this regard.