Predictive factors for prostatic involvement by transitional cell carcinoma of the bladder.

PURPOSE: To evaluate the predictive factors for prostatic involvement according to the bladder transitional cell carcinoma (TCC) characteristics in a prospective study. MATERIALS AND METHODS: Hundred patients with the bladder TCC who had undergone standard radical cystoprostatectomy were enrolled in this study. A number of factors, including vascular and perineural invasion, number of tumors, maximum diameter of the tumor, presence of carcinoma in situ, distance between the tumor and the bladder neck, grade, and local stage of the tumor were recorded, and their relationships with prostatic involvement were studied. In addition, hydronephrosis and age of the patients were included in the analysis. RESULTS: The mean age of the patients was 62.6 ± 10.8 years. Of a total of 100 patients, 21 (75%) were found to have prostatic involvement with TCC. Univariate statistical analysis showed that vascular invasion and the distance between the tumor and the bladder neck were significantly related to the prostatic involvement (P = .001 and P < .001) and tumor stage had relatively low P value (P = .08). In the logistic regression, only the distance between the tumor and the bladder neck was found to be significantly related to the prostatic involvement (P = .004). CONCLUSION: This study demonstrated that distance between the tumor and the bladder neck is a predictive factor for prostatic involvement; hence, prostate-sparing or capsule-sparing cystectomy in patients with tumors in short distances from prostatovesical junction is not rationale and should be avoided.

Familial relations and recurrence pattern in nephrolithiasis: new words about old subjects.

PURPOSE: While medical and surgical approaches to urolithiasis are different for single and recurrent stone former (RSF), the RSF definition itself is commonly overlooked. Moreover, despite consensus on association between family history (FH) and urolithiasis, more epidemiologic evidence is required to clarify the nature of this relationship. Our purpose was to propose a more precise definition of RSF, and also to investigate how family history may affect urolithiasis. MATERIALS AND METHODS: Using a multistage stratified sampling in 4 seasonal phases, 6127 subjects with imaging-proven urolithiasis were detected in 12 Iranian regions. The FH of urolithiasis and the average interval between episodes (cycles) were determined by an informed interview. RESULTS: Of 6127 patients with the mean age of 41.8 +/- 15.1 years, 42% had FH, and 22.2% were RSF of whom 61% were men. The patients with FH had a greater chance of recurrence (OR = 1.2, 95% Confidence Interval (CI), 1.1 to 1.4). Furthermore, patients with positive FH had more episodes (P = .0001), comparable cycles and younger ages at the onset (P = .02) than those patients without a FH. In the RSF group, the 90th percentiles of the cycle were 60 months and the estimated mean stone cycle for the population was 25.34 months (99% CI, 23.0 to 27.7). CONCLUSION: Family history seems very common in Iranian population and is a risk factor for recurrence. Moreover, RSF could be identified by the estimated average cycle in the population (25.3 months) or by the percentiles.

Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: a new approach to crossing vessels, crossing vein division, and upward transposition of the crossing artery.

OBJECTIVE: To demonstrate the role of the laparoscopic approach for management of primary ureteropelvic junction obstruction (UPJO) using two different techniques in the pediatric age group. MATERIAL AND METHODS: From April 2005 to October 2008, 63 pediatric patients underwent treatment of primary UPJO via a laparoscopic approach. Dismembered pyeloplasty was elected in 56 renal units while nine patients were managed by upward transposition of accessory renal artery after division of accessory renal vein. No JJ stent was required in these nine patients. RESULTS: Mean age of patients was 61 (2-180) months. Mean operative time was significantly lower in those managed by transposition of aberrant vessels compared with dismembered pyeloplasty. The mean hospital stay was 6.4 (2-14) days for the dismembered technique and 2.1 (1-4) days for the vascular transposition approach. Significant improvement of obstruction was achieved in all of the patients who underwent the modified Hellstrom technique and in 92.81% of the renal units undergoing dismembered pyeloplasty. CONCLUSION: The technique of laparoscopic transposition of crossing renal artery without violating collecting system may have a role in minimally invasive management of UPJO in selected pediatric patients. Further research with larger samples and a longer follow-up period is required.

The use of unaltered appendix transfer in ileal continent reservoir: 10 years experience, a novel technical modification.

INTRODUCTION: We report a new modified technique of unaltered appendix transfer to ileal pouch and preserving ileocecal segment. This modification enables us to use ileum as the popular type of enteric segment instead of ileocecal segment while using appendix as a catheterizable stoma. MATERIALS AND METHODS: Forty-five patients (30 men) who needed reconstruction of the lower urinary tract were enrolled for using appendix as a catheterizable stoma. Reservoir was reconstructed using ileal segment. The appendix was circumcised from its base over its pedicle. The spatulated appendix tip was exteriorized as a catheterizable stoma to the skin, preferably umbilicus, and its base was implanted to the ileal pouch. RESULTS: Follow-up records of 38 of 45 patients were available. The median follow-up period was 29 months. The mean intermittent catheterization interval was 4.19 +/- 1.6 hours. Urodynamic parameters were evaluated for 18 out of 38 patients. The median maximal pouch capacity determined as 380 mL. The median appendiceal closure pressure was 61 cm H2O. No pouch perforation occurred. Stomal stenosis occurred in 3 patients. They did not catheterize their appendiceal stoma because they restarted catheterization through the urethra. CONCLUSION: This novel approach enabled us to use ileum as today's more popular type of bowel segment to reconstruct enteric pouch rather than using ileocecal segment, while using appendix as a catheterizable stoma. One of the unique advantages of this technique is that the postponement of clean intermittent catheterization will not result in pouch perforation since the urine will leak when the pouch becomes overfill.

Early continence after open and laparoscopic radical prostatectomy with sutureless vesicourethral alignment: an alternative technique, 8 years' experience.

INTRODUCTION: We reviewed urinary outcomes after sutureless vesicourethral alignment in open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). MATERIALS AND METHODS: Charts of 324 patients who underwent sutureless ORP (n = 188) and LRP (n = 136) were reviewed. After prostatectomy, a 22- to 24-F silicon Foley catheter was passed into the bladder via the preserved bladder neck. The Foley balloon was filled, and mild traction was applied to appose the bladder neck to the urethral stump. The Foley catheter was fixed to the patient's leg. No cystostomy was placed. RESULTS: The follow-up period ranged from 12 to 60 months. The mean operative time was 65 minutes in ORP and 260 minutes in LRP. Blood transfusion was significantly less frequent with LRP (9.6% versus 19.7%, P = .02). The mean postoperative catheterization durations were 12 days in ORP and 13 days in LRP. Complete continence was achieve in 293 patients (90.4%) after 3 months of follow-up (88.9% in LRP and 91.5% in ORP, P = .78). The continence rate improved to 96.3% in LRP and 95.2% in ORP at 1 year (P = .52). Bladder neck stricture rate was 13.6% (12.8% in ORP versus 14.7% in LRP, P = .87). CONCLUSION: Sutureless vesicourethral alignment during ORP and LRP is a promising approach with minimum urinary extravasation, a high rate of continence, and an acceptable rate of stricture. This technique could be considered as an alternative in anatomically demanding situations.

Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old.

OBJECTIVE: We present our experience with percutaneous nephrolithotomy (PCNL) for management of large renal calculi in children less than 5 years old, and determine its safety and efficacy when using an adult-size device. PATIENTS AND METHODS: Twenty patients younger than 5 years old underwent PCNL between August 2003 and July 2008. After retrograde catheterization, the nephrostomy tract dilated up to 26Fr. Then a 24-Fr rigid nephroscope was used and stones were fragmented with a pneumatic lithotripter. RESULTS: Twenty patients with a mean age of 3.1 years underwent 26 PCNL procedures on 24 renal units. Four patients had bilateral renal stones. Five patients (20%) had staghorn stones, as did five of the other cases with multiple stones. Four patients had undergone previous stone surgery on the same side. All of the patients were managed with only one tract. The mean stone size was 33 (20-46)mm and average operative time was 93.25 (78-174)min. Stones were completely cleared in 79.16% of patients, which increased to 91.67% with adjunctive shockwave lithotripsy. The overall complication rate was 15.38% and mean hospital stay was 5.26 (3-8) days. CONCLUSION: PCNL is an effective and safe treatment for renal calculi in children less than 5 years old, even when using instruments designed for adults.

Laparoscopic anatrophic nephrolithotomy for managing large staghorn calculi.

OBJECTIVES: To evaluate the efficacy of a laparoscopic approach for managing large staghorn renal calculi. PATIENTS AND METHODS: Laparoscopic transperitoneal anatrophic nephrolithotomy was used to duplicate open anatrophic nephrolithotomy in five patients (three men) with large staghorn renal stones unsuitable for percutaneous nephrolithotomy. Only the renal artery was clamped, using a bulldog clamp. The stone was removed through a nephrotomy incision on the Brodel line, which was closed using 3/0 polyglactin continuous sutures, and sutures were buttressed by haemostatic clips instead of knots. Intraoperative ultrasonography was used in the last two patients to evaluate residual stones. RESULTS: The mean (range) stone size was 53 (45-65) mm, the patient age was 53 (45-58) years, and the warm ischaemia and operative duration were 32 (29-35) and 170 (120-225) min, respectively. No blood transfusion was needed during or after surgery. All of the procedures were uneventful and there was no urine leakage after surgery. Only an 8-mm and a 6-mm residual stone remained in the first and third patients, in the lower and middle calyces, respectively. Both of them were subsequently treated with shock wave lithotripsy. An intravenous pyelogram after surgery showed a functional corresponding renal unit, with a significant improvement in obstruction in all patients. CONCLUSION: Laparoscopic anatrophic nephrolithotomy is a promising alternative for patients who are candidates for open surgery, with an acceptable stone-free rate. While offering a minimally invasive approach, it can minimize the need for secondary invasive interventions. Further patients and a longer follow-up are needed before this is suggested as the preferred method in selected patients in the future.

How to improve the safety of polymer clips for vascular control during laparoscopic donor nephrectomy.

PURPOSE: To evaluate the use of a new modification of the technique for controlling the renal pedicle during laparoscopic donor nephrectomy (LDN) with Hem-o-Lok clips. PATIENTS AND METHODS: From July 2005 to January 2007, 241 candidates for left LDN were enrolled in the study. There were 175 men, and the mean age of the patients was 27.84 +/- 4.96 years. At the end of procedure for renal-artery closure, one 10-mm Hem-o-Lok clip was applied a few millimeters distal to the root from the aorta, and a medium-large titanium clip was applied distal to the Hem-o-Lok clip using a non-automatic firing applier to exert sufficient closing pressure to the titanium clip to ensure adequate tightness. Then the renal vein was doubly ligated with one 12-mm and one 10-mm Hem-o-Lok clip. RESULTS: With these modifications, there were no intraoperative or perioperative bleeding complications, clip dislodgments, or slippages. The conversion rate was zero, and the mean warm-ischemia time was 7.50 +/- 0.71 minutes (range 3-17 minutes). Graft function was excellent, with a mean serum creatinine concentration of 1.42 +/- 0.46 mg/dL after 12 months of follow-up and no renal-artery or -vein thrombosis in any of the grafts. CONCLUSION: With this technique, there is more security on the arterial closure, and sufficient pedicle length can be obtained for anastomosis. The warm-ischemia time is within an acceptable range. Also, this approach is less expensive than the use of endovascular staplers.

Blind puncture in comparison with fluoroscopic guidance in percutaneous nephrolithotomy: a randomized controlled trial.

INTRODUCTION: Our aim was to evaluate blind puncture in percutaneous nephrolithotomy (PCNL) for decreasing the risk of radiation. MATERIALS AND METHODS: One hundred candidates for PCNL were randomly assigned into 2 groups. Blind access was performed for the patients in group 1 and the standard access using fluoroscopy for those in group 2. In group 1, displacement of the targeted calyx in the prone position was estimated by fluoroscopy comparing to the image on intravenous urography. Puncture of the calyx was attempted 3 cm to 4 cm below the marked site of the targeted calyx with a 30 angle. If the access to the collecting system was felt and urine came out, the site of puncture would be controlled by fluoroscopy. If the access failed, we would repeat puncturing up to 5 times. RESULTS: The mean time to access was 6.6 +/- 2.1 minutes and 5.5 +/- 1.7 minutes in groups 1 and 2, respectively (P = .008). The mean time of radiation exposure was 0.95 +/- 0.44 minutes in group 2. A successful puncture to the targeted calyx was achieved in 50% and 90% of the patients in groups 1 and 2, respectively (P < .001) and a successful calculus removal in 62% and 100% of the patients in groups 1 and 2 (P < .001). CONCLUSION: Although about half of the patients benefited from blind access in our study, this technique can not be solely relied on, and fluoroscopy or ultrasonography should be available for prevention of complications.

Varicocele in brothers of patients with varicocele.

INTRODUCTION: The aim of this study was to evaluate varicocele patients' brothers to determine whether they are at a higher risk of varicocele than the general population of men. MATERIALS AND METHODS: A total of 56 patients with varicocele and their 131 brothers (> 16 years old) were evaluated. The brothers had no complaints of infertility, pain, or cosmetic problems. They were all examined for varicocele. One hundred and fifty men who referred for employment medical examinations were considered as the control group. RESULTS: Of the subjects, 39 (69.6%) had grade III varicocele. Sixty (45.8%) of the brothers had varicocele. The grade of varicocele was III in 16 (26.7%) brothers. In the control group, varicocele was present in 15 (10%) which was grade III in 5 (33.3%). The frequency of varicocele was 4.5-fold greater in the brothers of the patients than the controls (P<.001). Also, the frequency of grade III varicocele was significantly more than grades I and II in the patients in comparison with their brothers and controls with varicocele (P<.001). There was no significant difference in the grades between the controls and the patients' brothers (P=.31). The frequency of bilateral varicocele was not statistically different between the three groups (P=.14). CONCLUSION: Our findings showed that a significant increase is seen in the prevalence of varicocele in the patients' brothers compared to men in the general population, warranting evaluation of the first-degree relatives of men who present with varicocele.

One-stage tract dilation for percutaneous nephrolithotomy: is it justified?

PURPOSE: To assess the feasibility of one-stage acute dilation of the nephrostomy tract with a 30F Amplatz dilator in patients who are candidate for percutaneous nephrolithotomy (PCNL) regardless of whether there is a previous renal scar to make the procedure less time consuming and more cost effective. PATIENTS AND METHODS: The outcomes of one-stage tract dilation for PCNL in 100 consecutive patients with and without a history of ipsilateral open stone surgery (OSS), treated by one surgeon, were examined prospectively. Forty-six patients (group 1) had a history of ipsilateral OSS, and 54 patients (group 2) did not have this history. Demographic data as well as intraoperative information, such as access time and radiation exposure time during access, were recorded. The success of the access technique and its bleeding complications were analyzed between the two groups. RESULTS: By applying a "one-stage" technique, the targeted calix could be entered with a success rate of 93%. There was no difference in the procedural success rate between groups 1 and 2 (93.5% v 92.6%, respectively). All seven failed attempts (7%; three with previous OSS) were managed successfully using an Alken dilator to gain access to the proposed calix in the same session. Previous OSS did not impact access time, radiation exposure time during access, postoperative hemoglobin drop, and bleeding complications. There were no visceral and vascular injuries. CONCLUSIONS: One-stage tract dilation for PCNL is a safe and effective method in almost every adult patient.