Pelvic dimensions do not impact on complications and operative difficulty in radical cystoprostatectomy and orthotopic neobladder.

BACKROUND: To evaluate the factors including pelvic dimensions, which might influence operative difficulty and complications after open radical cystoprostatectomy and orthotopic neobladder reconstruction in men. METHODS: A total of 198 RC patients operated in our institution with preoperative magnetic resonance (MRI) were analyzed were included in the study. Pelvic dimensions, including interspinous distance (ISD), bony femoral - (BFW) and soft tissue width (SW), apical prostate depth (AD), upper conjugate (UC), lower conjugate (LC) were measured by preoperative MRI. BFW, ISD, and SW indexes were defined as BFW/AD, ISD/AD, and SW/AD, respectively. Complicatons were classified according to the Clavien-Dindo classification system. As indicators of surgical difficulty; transfusion rate (TR), estimated blood loss (EBL), operative time (OT) and hospital stay (HS) were assessed. SPSS version 17.0 was used for statistical analyses. RESULTS: A total of 239 complications developed in 143 of the 198 patients (72.2%). Correlation analysis revealed a significant indirect relationship between TR and SW/AD (P=0.023). For EBL, there were significant indirect correlations between the SW/AD, BFW/AD and ISD/AD indexes (P=0.026, P=0.05, P=0.009; respectively). Additionally, OT was directly correlated body mass index (BMI) (P=0.001); and indirectly correlated with UC, SW/AD, and BFW/AD (P=0.047, P=0.038, P=0.016, respectively). On multivariate logistic regression analyses higher American Society of Anesthesiologist (ASA) score was associated with major complications. Multivariate analyses revealed that pathological stage was a significant predictor of EBL. CONCLUSIONS: Patients with smaller pelvises might undergo more difficult surgeries. However, it seems that small sized pelvis does not impact on operative difficulty and complication rate in radical cystoprostatectomy and orthotopic neobladder.

An Open Radical Prostatectomy Approach that mimics the Technique of Robot-assisted Prostatectomy: A Comparison of Perioperative Outcomes.

PURPOSE: To report on an ascending radical retropubic prostatectomy (RRP) technique and determine whether this technique has better perioperative, oncological and functional outcomes than the standard RRP technique applied in our clinic Material and Methods:The perioperative and functional outcomes of the 246 patients that underwent standard RRP (N = 150) or modified RRP (N = 96) were evaluated, retrospectively. In the modified RRP technique the dorsal vasculare complex (DVC) was controlled at first. Thereafter, the bladder neck was incised at the prostate-vesical junction. After seminal vesicles and vasa were exposed, posterior dissection was continued until to the apex. Finally, the urethra was divided. To assess the differences between the two groups the independent sample T-test and chi-square test were used. RESULTS: The mean volume of  estimated blood loss (EBL) was significantly longer in the standard RRP group than in the modified RRP group (610 vs. 210 ml, respectively; P= .001). The mean operative time (OT) was significantly less in the modified RRP group (177 vs. 134 min, respectively; P = .003), as were the transfusion rate TR (P = .041). With regard to the rate of postoperative complications, a statistically significant difference was observed between the two groups (P = .014). Continence rates after 3 and 12 months postoperatively were 98.95% and 98.95 % in the modified RRP group, and 97.33% and 98.66% in the standard RRP group, respectively ( P = .83). CONCLUSION: We observed that the EBL, TR and OT were significantly lower when we applied the modified RRP technique to patients. This modified technique might be applicable for institutions as an alternative procedure for the standard RRP technique.

Hand-assisted laparoscopic and laparoscopic donor nephrectomy: A comparison of surgical outcomes from two centres.

OBJECTIVE: The aim of the study was to compare the different surgical approaches of two centers on outcomes of live donor laparoscopic nephrectomy. MATERIAL AND METHODS: The first 98 patients of each centre who underwent laparoscopic donor nephrectomy (LDN) or hand-assisted laparoscopic donor nephrectomy (HALDN) were included in the study. The following data were used for analyses: donor age, weight, height, body mass index (BMI), transfusion requirement, operative time, ischemia time and postoperative complications. RESULTS: Median age, BMI, operation time and estimated blood loss (EBL) was 47.29 years, 27.91 kg/m2, 110.73 minutes, and 78.95 mL, respectively. Operation time was significantly shorter in the HALDN group (t=-3.554, p<0.01). EBL was not significantly different between the two groups. The difference in hospitalization time and warm ischemia times (WIT) was not significant between the two surgical technique groups (t=-1.554, t=1.258; p>0.05). No statistically significant difference was detected in the intraoperative and postoperative complication rates between two groups (p>0.05). The postoperative complication rate was 7.14% (n=7) and 6.12% (n=6) in the LDN and HALDN groups, respectively. There were two patients with conversion to open surgery in the HALDN group because of lumbar vein injury. CONCLUSION: The operative and postoperative outcomes for the two techniques were found to be similar. The HALDN technique preserves the benefits of minimally invasive surgery. In experienced urologic laparoscopy centres both techniques promise similar success rates.

Minimally invasive approach for the management of urological complications after renal transplantation: single center experience.

BACKGROUND: The aim of the study was to characterise urological complications after renal transplantation and to evaluate the role of minimally invasive management for urological complications. METHODS: A total of 920 kidney transplantations were performed between 2008 and 2015. All patients were followed up for at least 1 year after transplantation. Complications regarded as urological were urinary leakage, ureteral stricture, urinary malignancy, bladder outlet obstruction (BOO) and urinary calculi. We evaluated data from the time of occurrence of urological complications and the type of the management prescribed. RESULTS: Among 920 transplantations performed in our clinic, 41 (4.4%) urological complications arose. Twenty (48.8%) of the complications occurred during the first 3 months and 21 (51.2%) occurred after 3 months, postoperatively. Ureteral strictures were found in 14 (34.1%) patients, urinary tract stones in seven (17%), BOO in 6 (14.6%) and urinary leakage was observed in 5 (12.1%) patients. Ureteral stricture was managed with endoscopic approach in eight (61.3%) patients. Urinary tract stones and urinary leakage were managed in 7 (100%) and 4 (75%) patients with endoscopic approach. Overall 29 (70.7%) of 41 urological complications were managed with endourological approaches. CONCLUSIONS: It is likely that the importance of open surgery could decrease in the future. Endoscopic management of urological complications have come to have an important role in the treatment of urological complications after transplantation.

Outcome of penile prosthesis implantation: are malleable prostheses an appropriate treatment option in patients with erectile dysfunction caused by prior radical surgery?

The aim of our study was to evaluate the outcome of penile prosthesis implantation in patients with various comorbidities as a cause of erectile dysfunction (ED). The data of 181 patients who underwent surgery between 1998 and 2012 in two centers were evaluated. The mean age of the patients was 52.2 years (range: 31-71 years). The study group contained 162 patients (89.5%) with malleable prostheses and 19 (10.5%) with inflatable implants. All patients were re-evaluated 1 month later to assess prosthesis function and complications, and further re-examinations were performed if needed. Satisfaction was defined as having satisfactory intercourse and happiness with the device in general. The follow-up period was at least 12 months for each patient. The postoperative complication rate was 32% (n = 58). The number of complications with inflatable and malleable prostheses was 7 (3.9%) and 51 (28.1%), respectively. Overall, 21 prostheses (11.6%) had to be removed because of various complications and patient dissatisfaction. Patients with prior radical surgery had higher extraction rates (ƛ = 14.606, P < 0.05, Chi-square test). The main reasons for removal were erosion (n = 11; 6.1%) and infection (n = 3; 2.1%). With respect to satisfaction during intercourse, we found that 104 (57.5%) patients described themselves as very satisfied with the prosthesis, while 21 (11.6%) were unsatisfied. The high explantation rate in patients with prior surgery was remarkable in our study. Our results revealed that a malleable prosthesis should not be the preferred type of implant for patients with prior surgery.

Salvage urethroplasty using skin grafts for previously failed long-segment urethral strictures.

The aim of this study was to describe a technique using full-thickness skin grafts (FTSGs) from different parts of the body for salvage urethroplasties and the present outcomes. A total of 24 men underwent urethroplasties for strictures averaging 7.7 cm (range, 5-17 cm) in length, using FTSGs from the inner arm, inner thigh, or abdominal skin. Each of these cases had at least one failed urethroplasty. Twenty-four patients underwent surgery for 26 urethral strictures, with a mean follow-up period of 23.2 (5-44) months and a mean operation time of 140 (115-180) minutes. Reconstruction of the urethra with skin grafting was successful in 18 out of the 26 procedures during the first attempt (69%). A "redo" skin grafting was performed for the eight failed cases, with four successful procedures (50%). Overall, the success rate was 84% (22 out of 26 urethral strictures); however, the failed cases developed abscesses and later, ureterocutaneous fistulas. No hair formation from the skin grafts was seen. Skin grafts provide useful alternative graft sources for previously failed long-segment urethral strictures in which the buccal mucosae are not available or are insufficient for salvage urethroplasties with an acceptable success rate.

The management of total avulsion of the ureter from both ends: Our experience and literature review.

OBJECTIVE: To evaluate the treatment modalities of total ureteral avulsion and to clarify the risk factors of this serious complication. METHODS: This study retrospectively analyzed the data of 3 patients with complete ureteral avulsion during ureteroscopy. Of the three patients, two had distal ureteral complete avulsion, and one total ureteral avulsion on both ends. Ureteroneocystostomy (UNC) was immediately performed after distal ureteral avulsion cases. Ileal ureter substition was performed on the same session after the total ureteral avulsion in both ends. Two of the patients were under chronic use of corticosteroid treatment due to diagnosis of idiopathic trombocytopenic purpura and myastenia gravis and all patients had unsuccesful shockwave litotripsy (SWL) treatment history with at least 1 month period before surgery. RESULTS: The patient who had ileal ureter substitution was followed at 3-month intervals by ultrasonography and renal function tests and she was uneventful after a 2 year follow-up period. The patients treated with UNC were followed up at 3 month interval by ultrasonography and renal function tests. They had normal renal function 1 year after the operation CONCLUSION: Complete ureteral avulsion is a rare but severe complication. Treatment modality can vary and ileal ureter can be applied succesfully in the total ureter avulsion in both ends when bladder capacity is not enough for a Boari flap. Failed SWL and/or corticosteroid treatment history of patients seems to increase the risk of the ureteral avulsion.

Evaluation of various active surveillance protocols in prostate cancer.

OBJECTIVE: This study aims to investigate whether pathology results obtained by radical retropubic prostatectomy (RRP) were correlated with active surveillance (AS) criteria defined by Klotz, Soloway and D'Amico. MATERIALS AND METHODS: In our clinic we evaluated 211 patients with diagnosis of localized prostate cancer who underwent RRP between 2007 and 2012. AS criteria defined by Soloway (cT ≤ T2, PSA ≤ 15 ng/dl, Gleason ≤ 6), Klotz (cT1c-T2a; if age ≥ 70 PSA ≤ 15 ng/dl, if age < 70 PSA ≤ 10 ng/dl; if age ≥ 70 Gleason ≤ 7(3+4), if age < 70 Gleason ≤ 6) and D'Amico (cT1c-T2a, PSA ≤ 10 ng/dl, Gleason ≤ 6) were used in our study. Pathological stages and Gleason scores were evaluated with coherence to AS protocols, mis-staging rates, biochemical recurrence (BC) of the mis-staged patients and death due to prostate cancer Data was analyzed using NCSS 2007 & PASS 2008 Statistical Software (Utah, USA). Chi square test and Mann-Whitney U test were applied for analyzing qualitative data. Significance was determined as p < 0.05. RESULTS: 137 (64.9%) patients were coherent with Soloway AS criteria, 118 (55.9%) with Klotz AS criteria and 108 (51.1%) with D'Amico AS criteria. Histopathological results of the patients grouped according to Soloway, Klotz and D'Amico AS protocols showed high stage prostate cancer in 40 (29.2%), 32 (27%) and 27 (24.9%) patients, respectively. High grade prostate cancer rates in Soloway, Klotz, D'Amico groups were 55 (40.2%), 46 (38%) and 39 (36.1%); respectively. Misstaging rates of Soloway, Klotz and D'Amico AS protocols were determined as 65 (47.4%), 54 (45.5%) and 46 (42.5%), respectively. In the Soloway group BC rate was 21.9% in those with high stages. Relation between BC and high stage was found to be statistically significant (p < 0.05). CONCLUSION: Misstaging rates were relatively high in the three groups and there was no difference between the three groups in BC rates. Randomized studies with adequate follow up are needed.

The effectivity of periprostatic nerve blockade for the pain control during transrectal ultrasound guided prostate biopsy.

AIM: Transrectal ultrasound (TRUS) guided prostete biopsy is accepted as a standard procedure in the diagnosis of prostate cancer. Many different protocoles are applied to reduce the pain during the process. In this study we aimed to the comparison of two procedure with intrarectal lidocaine gel and periprostatice nerve blockade respective- ly in addition to perianal intrarectal lidocaine gel on the pain control in prostate biop- sy by TRUS. METHODS: 473 patients who underwent prostate biopsy guided TRUS between 2008-2012 were included in the study. 10-point linear visual analog pain scale(VAS) was used to evaluate the pain during biopsy. The patients were divided into two groups according to anesthesia procedure. In Group 1, there were 159 patients who had perianal-intrarectal lidocaine gel, in Group 2 there were 314 patients who had periprostatic nerve blockade in addition to intrarectal lidocain gel. The pain about probe manipulation was aseesed by VAS-1 and during the biopsy needle entries was evalu- ated by VAS-2. Results were compared with Mann-Whitney U and Pearson chi-square test. RESULTS: Mean VAS-2 scores in Group 1 and Group 2 were 4.54 ± 1.02 and 2.06 ± 0.79 respectively. The pain score was determined significantly lower in the Group 2 (p = 0.001). In both groups there was no significant difference in VAS-1 scores, patient's age, prostate volume, complication rate and PSA level. CONCLUSION: The combination of periprostatic nerve blockade and intrarectal lidocain gel provides a more meaningful pain relief compared to group of patients undergoing intrarectal lidocaine gel.

The effects of pelvic dimensions on radical retropubic prostatectomy.

INTRODUCTION: To determine the effects of pelvic dimensions on margin status, preoperative and postoperative estimated blood loss (EBL), operative time and transfusion rate (TR) during radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Data from 94 patients with preoperative prostate MRI were analyzed. Pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth, upper conjugate (UC), lower conjugate (LC) were measured by preoperative MRI. Indexes for pelvic dimensions (PDI), bony width (BWI) and soft-tissue width (SWI) were defined as ISD/AD, BFW/PD, and SW/AD, respectively. As indicators of surgical difficulty, TR and EBL were assessed. SPSS version 17.0 was used for statistical analyses. RESULTS: Correlational analysis revealed no significant relationship between pelvic dimensions and parameters reflecting operative difficulty (p > 0.05). For EBL, there were significant indirect correlations between the BFW/AD, ISD/AD, and SW/AD indexes (p < 0.01, p < 0.01, p < 0.05; respectively). Additionally, the correlations between AD and TR (p < 0.05) and between AD and EBL (p < 0.05) were significant. Consequently, TR was significantly correlated with BFW/AD, ISD/AD and SW/AD (p < 0.01, p < 0.05, p < 0.01; respectively). Correlational analysis revealed that prostate volume (PV) was significantly correlated with EBL and TR (p < 0.01). Multivariate analyses revealed that PV was a significant predictor of TR (p = 0.06). None of the pelvic dimensions were significantly associated with recovery of urinary continence (RUC) (p > 0.05). CONCLUSIONS: Analyses of pelvic dimensions as significant factors influencing operative difficulty during RRP yielded mixed results. PV seems to be the strongest factor related to operative difficulty. Future studies about pelvic dimensions should be conducted.

Importance of the number of retreived lymph nodes during cystectomy.

PURPOSE: To evaluate the effect of the number of dissected lymph nodes (LNs) during radical cystectomy on survival outcomes. MATERIALS AND METHODS: Medical files of 211 patients who underwent cystectomy between 1996 and 2009 were retrospectively evaluated. Seventy-four patients were included in the study and divided into two groups regarding the median number of retrieved LNs (median number = 13); 36 patients in the 1st and 38 in the 2nd group. Radical cystectomy, urinary diversion, and pelvic LN dissection were done in all the patients. When necessary, adjuvant chemotherapy was applied. Kaplan-Meier survival analysis was performed to compare survival outcomes of the groups. RESULTS: Of 74 patients, 67 (90.5%) were men and 7 (9.5%) were women, with the mean age of 61.7 years (range, 39 to 83 years). Age distribution, pathologic stages, carcinoma in situ occurrence, adjuvant chemotherapy rates, LN involvement, and median follow-up period were similar in both groups. Mean dissected LNs number in the 1st and 2nd groups was 6.17 (range, 1 to 12) and 21.6 (range, 13 to 41), respectively. Five-year estimated overall survival rates were 24.5% and 60.5% (P = .002) while five-year estimated disease-specific survival rates were 43.7% and 74.4% (P = .049), respectively. CONCLUSION: Although exact guidelines are not described, it seems that dissection of high number of LNs during radical cystectomy is crucial.

Bilateral renal choriocarcinoma in a postmenopausal woman.

Choriocarcinoma is the most malignant tumor of gestational trophoblastic neoplasia. It grows rapidly and metastasizes to the lung, liver, and less frequently, the brain. Metastases to the kidney are rare in the literature, and bilateral involvement is even more scarce. Renal involvement of choriocarcinoma is highly exceptional and may mimic renal cell carcinoma. Here we report a case of bilateral renal choriocarcinoma presenting 5 years after a history of a total anterior hysterectomy because of a hydatidiform mole.

Superficial dorsal vein rupture imitating penile fracture.

Dorsal vein rupture of the penis is a rare condition, and few cases have been reported in the literature. Herein we report a 41-year-old man who presented with mildly painful and acute swollen penis, which initially imitated a penile fracture but was surgically explored and shown to be a superficial dorsal vein rupture.

Giant desmoid tumor in a case of ileal neobladder.

Aggressive fibromatosis or desmoid tumor, is a histologically benign entity with unknown etiology that may present a serious clinical course. Due to its high tendency to recur and local aggressive behavior and as there is no established effective medical treatment, complete surgical excision remains the sole management. To our knowledge, we describe the first case of giant desmoid tumor which arised from ileal neobladder mesenterium in a bladder cancer patient with orthotopic substitution.

General anesthesia versus epidural and general anesthesia in radical cystectomy.

INTRODUCTION: The aim of this study is to compare two different anesthetic techniques in radical cystectomy with regard to blood loss, transfusional requirements, intraoperative complications and the quality of analgesia. MATERIALS AND METHODS: 50 patients scheduled for radical cystectomy were randomized to two groups: group GA - general anesthesia, n = 25 and group CEGA - combined epidural and general anesthesia. The patients were monitored and hemodynamic changes, intraoperative bleeding, transfusional requirements, quality of analgesia and postoperative complications were evaluated. RESULTS: There were no significant differences between the demographic characteristics of the two groups. Intraoperative bleeding which was 874.8 +/- 190.7 ml in the CEGA group and 1,248.3 +/- 343.4 ml in the GA group was statistically different (p < 0.05). Significantly more intraoperative blood transfusions in terms of units were required in the GA group. Analgesia was better in the CEGA group, with VAS values at 0, 1, 2, 4, 6, 12 and 24 h significantly (p < 0.05) lower than those observed in the GA group. No significant differences in intraoperative hemodynamic parameters or postoperative complications were noted between the two groups. CONCLUSIONS: Statistically significant differences in intraoperative bleeding were observed between the two groups: CEGA provides lower intraoperative bleeding and a better postoperative analgesia. Major operations such as radical cystectomy, which also is associated with considerable blood loss, a combination of general and epidural anesthesia may allow for less blood loss, with a better postoperative analgesia and without any increase in complications.

Erectile dysfunction under age 40: etiology and role of contributing factors.

The aim of this study was to evaluate the etiology of erectile dysfunction (ED) in patients under the age of 40 years. Eighty one patients were included in this study. All patients underwent a multidisciplinary diagnostic approach by color Doppler ultrasonography, dynamic pharmacocavernosometry (optional), selective pudendal pharmaco-arteriography (optional) and nocturnal penile tumescence monitoring by a Rigi-Scan (optional). Mean age of the population was 32 years. Psychogenic impotence was diagnosed in 50% of the patients and organic impotence was diagnosed in 45%. After the 3rd decade of life, a vasculogenic etiology was the most common cause of impotence. Smoking and hypertension played a major role as chronic contributing factors in the overall study population. Primary impotence was diagnosed in 11 patients who were unmarried. The rate of organic causes was 45% in this group (all vasculogenic in nature). Erectile dysfunction in younger patients and in patients with primary impotence is due mainly to organic causes, usually vascular in origin.

Effect of extracorporeal shockwave lithotripsy on serum prostate specific antigen concentration.

PURPOSE: We investigated the effect of extracorporeal shockwave lithotripsy (SWL) on the serum prostate specific antigen (PSA) concentration. PATIENTS AND METHODS: A total of 22 male patients with a mean age of 52.9 years (range 37-67 years) were treated with SWL for distal ureteral calculi close to the ureteral orifice. Serum samples were drawn for measurement of PSA values just before (PSA-1) and 45 minutes (PSA-2) and 7 days (PSA-3) after the session. None of the patients had urinary tract infection or any abnormal finding on digital rectal examination. The SWL sessions were performed with the Wolf piezoelectric 2300 lithotripter that has a therapeutic focus of 3 x 11 mm. The mean number of shockwaves per patient was 2204. Student's t-test was used for statistical analysis. At 1 year, all patients completed a questionnaire concerning recent diagnosis of prostate cancer. RESULTS: The mean total PSA concentration before SWL was 3.13 ng/mL and rose to 3.91 ng/mL 45 minutes after the session. The mean PSA-3 value was 3.76 ng/mL. The mean free PSA values were 0.80, 0.83, and 0.77 ng/mL, respectively. The difference between PSA-1 and PSA-2 was statistically significant; all of the other differences were not significant. None of the patients reported prostate cancer at 1 year. CONCLUSION: Shockwave lithotripsy affects prostate epithelial cells and may cause a minor rise in total serum PSA values. However, this rise does seem to impair the value of PSA in patients with undiagnosed prostate cancer.