Surgery in patients with von Willebrand disease.

Von Willebrand disease (vWD) is the most common inherited bleeding disorder. The biggest challenge in the management of vWD is the difficulty in performing surgical procedures because of bleeding. Treatment guidelines recommend the use of pure von Willebrand factor or von Willebrand factor/factor VIII (vWF/FVIII) concentrate in patients with type 2 or type 3 vWD undergoing surgery, in patients with type 1 vWD undergoing surgery who are unresponsive, and in patients for whom desmopressin acetate is contraindicated. However, there is no consensus on the dosage and optimum levels of these factors to date. The aim of this study was to evaluate the perioperative management of patients with vWD during surgical procedures. Data pertaining to surgical procedures performed at our center from 2003 to 2014 were analyzed retrospectively. All operations, except one appendectomy, were elective, and a plan for the management of hemostasis was prepared for each patient. During this period, 37 surgical procedures (major, minor, and dental) were performed in 23 patients with vWD. Complications occurred in four out of 37 procedures (10.8%). No deaths or life-threatening bleeding occurred during any of the operations and no thromboembolic events were observed. The results from this retrospective study indicate that surgery can be safely performed by providing adequate and timely hemostasis during and after the procedure in patients with vWD. Perioperative and postoperative bleeding complications are rare when patients are closely and carefully monitored.

Comparison of cystoscopy with diffusion-weighted magnetic resonance images used in the diagnosis and follow-up of patients with bladder tumors.

PURPOSE: To compare diffusion-weighted magnetic resonance imaging (DW-MRI) with cystoscopy in the diagnosis and follow-up of patients with bladder tumor and to investigate any histopathological correlation. MATERIALS AND METHODS: Totally 59 patients, between 31-85 years (mean age 60∓13) referred to our clinic due to a hematuria complaint were enrolled and evaluated by upper urinary system pathology and then DW-MRI (average 7 days) and cystoscopy. Apparent diffusion coefficients (ADCs) of images were calculated. RESULTS: While a mass in bladder was determined with cystoscopy in 43 out of 59 patients,the mass was not determined in 16 of the patients (n=34 malign, n=9 benign). While a mass was determined in 40 out of 59 patients with DW-MRI,the mass was not determined in 19 of the patients(n=40 malign, n=19 benign). Regarding ADC values, mean ADC values of 34 patients who were diagnosed with a bladder tumor (1.05∓0.22x10(-3) mm2/s), were significantly lower than the mean ADC values obtained from the normal bladder wall (1.830∓0.18x10(-3) mm2/s) whereas a statistically significant difference was found (p<0.001). ADC values in 9 patients with a benign lesion (1.73∓0.12x10(-3) mm2/s), were not found statistically different from the mean ADC values obtained from the normal bladder wall (1.78∓0.2x10(-3) mm2/s) (p>0.05). A significant difference was determined between ADC values of benign lesions and the ADC values of malign lesions (p<0.001). CONCLUSIONS: According to cystoscopy, values of DW-MRI's related with sensitivity, specificity and accuracy were found, respectively 90%, 93% and 91%. As the DW-MRI is a non-invasive and a rapid technique, and does not contain ionized radiation and because it is accepted as an important marker of tumor cellularity, it may be used as an alternative in future diagnosis and follow-up of bladder tumors.

Is prophylactic breast radiotherapy necessary in all patients with prostate cancer and gynecomastia and/or breast pain?

PURPOSE: We investigated the efficacy of prophylactic radiotherapy for gynecomastia/breast pain induced by 150 mg bicalutamide in a prospective, randomized, multi-institutional trial. MATERIALS AND METHODS: After definitive treatment for localized prostate cancer 125 patients were randomized to 12 Gy radiotherapy before bicalutamide as prophylactic radiotherapy (53) or bicalutamide only for nonprophylactic radiotherapy (72). The incidence of gynecomastia, breast pain and tenderness, and discomfort perceived by the patients was assessed by physical examination and direct questioning at 3, 6 and 12 months of followup. RESULTS: At the end of 12 months the gynecomastia rate was 15.8% in the prophylactic group and 50.8% in the nonprophylactic group (p <0.001). On patient evaluation the breast enlargement rate was 34.4%. The severity of breast pain and tenderness was not different between the groups. The breast pain rate was 36.4% and 49.2% by 12 months in the prophylactic and nonprophylactic groups, and the rate of patients who felt discomfort from gynecomastia was 11.4% and 29.5%, respectively. CONCLUSIONS: In this prospective study the incidence of gynecomastia was not as high as previously believed. Although prophylactic breast irradiation seemed to decrease the gynecomastia rate in patients on 150 mg bicalutamide, our study proves that not all patients need prophylaxis since only 52% were significantly bothered by gynecomastia. Thus, individual assessment is needed to select patients who need prophylactic radiation while on 150 mg bicalutamide.

Vesicovaginal reflux: recognition and diagnosis using ultrasound.

BACKGROUND: Vaginal reflux is a functional voiding disorder seen in prepubertal girls without anatomical or neurological abnormality. When not associated with urinary tract infections (UTI), asymptomatic bacteriuria, post-void dribbling or daytime enuresis it may be considered a normal finding. OBJECTIVE: To review the radiographic features of vesicovaginal reflux based on multiple imaging modalities. MATERIALS AND METHODS: Three girls aged 11, 13 and 5 years were referred for pelvic US for daytime incontinence, post-void dribbling, frequency and urgency. One girl also had recurrent UTIs treated with antibiotics and was investigated for vesicoureteric reflux with US and voiding cystourethrogram (VCUG). All three were examined with MRI. RESULTS: Imaging appearance common to all three girls was a fluid-filled mass posterior to the bladder that disappeared after voiding. A previous VCUG in one girl had shown contrast medium refluxing into the vagina which disappeared after bladder emptying. Pelvic MRI confirmed the findings in all three girls. CONCLUSION: US examination of a distended bladder followed by a post-void study easily provides the correct diagnosis of vesicovaginal reflux by identifying the vagina as the fluid-filled mass. Treatment involves behavioural modifications. Though well known to urologists, this may be a perplexing pathology for the inexperienced trainee radiologist.

Splenogonadal fusion in a 13-year-old boy with contralateral displaced intra-abdominal testis.

Splenogonadal fusion is a rare congenital malformation characterized by intrauterine fusion of the spleen and gonad. We present a 13-year-old boy referred to our clinic, with left scrotal mass and impalpable testis on the right. The scrotal mass was diagnosed histologically as discontinuous-type splenogonadal fusion and intra-abdominal displaced right testis as germ cell aplasia (Sertoli cell only).

[Evaluation of patients with urogenital trauma managed in a urology clinic]. / Klinikte tedavi edilen ürogenital travma hastalarinin degerlendirilmesi.

BACKGROUND: Ten percent of all traumas, responsible for 14% of all deaths, involve the urogenital system. We retrospectively evaluated the patients with genitourinary trauma who underwent any kind of management modality in our clinics. METHODS: We retrospectively evaluated 108 patients (92 males, 16 females; mean age 35.8+/-17.5 years; range 6 to 87 years) with urogenital trauma between 2003 and 2007 according to age, gender, type of trauma, affected organ, grade of trauma, accompanying other-organ injuries, radiological imaging techniques, and treatment. RESULTS: Sixty-eight patients (63%) had blunt, 25 (24%) had penetrating, and 12 (11%) had iatrogenic trauma, and 3 patients (3%) had spontaneous organ injury. When we considered the affected organ, renal trauma was determined in 34 patients (32%), ureteral trauma in 11 (10%), bladder injuries in 18 (17%), urethral trauma in 27 (25%), testicular trauma in 6 (6%), and penile trauma in 12 (10%) patients. Seventeen patients (50%) had grade 3, 11 (32%) had grade 4 and 6 (18%) had grade 5 renal injury; 6 patients of these cases underwent surgical treatment. CONCLUSION: Our results were parallel to those available in the literature. Due to the lack of sufficient information about urogenital trauma rates in our country, it would be highly useful for reference centers to evaluate and publish their own data.

Correlation between duration of varicocele and apoptosis in testicular tissue in an experimental model.

OBJECTIVES: To experimentally demonstrate the negative effect of a waiting period for treatment in patients with varicocele. METHODS: A varicocele group of 30 rats and a sham group of 10 were used. All rats in the varicocele groups underwent ligation in the left testicle proximal to the site at which the internal spermatic vein drains into the renal vein to constrict the vein by 50%. In the sham group, the renal vein was dissected but not ligated. One month later, the first 15 rats in the experimental group and the first 5 rats in the sham group underwent laparotomy and bilateral orchiectomy. At 2 months postoperatively, the same procedures were performed on the second group of rats (15 varicocele rats and 5 sham rats). The apoptotic index was evaluated by group and interval after varicocele or sham operation. For apoptosis detection, modification of in situ end labeling was used. RESULTS: At 1 and 2 months after creation of the varicocele or sham operation, the apoptosis rate in the left varicocele group was significantly greater than in the sham group (P <0.001) or in the right testicles (P <0.001). Although an increase in the apoptosis rate was seen in the second month compared with the first month, the difference was not statistically significant (P = 0.875). The histopathologic finding of atrophy was more significant in the second month than in the first month in the varicocele group. CONCLUSIONS: The results of our study have indicated that the increase in apoptosis at the end of the first month in the varicocele group was significant and that this apoptosis continued with time. Because the histopathologic injury, which is parallel to apoptosis, increased, we believe that treatment in the early phase of varicocele is important for prevention of probable injury.

The long-term results of transurethral vaporization of the prostate using plasmakinetic energy.

OBJECTIVE: To assess the long-term efficacy and the safety of plasmakinetic vaporization of prostate (PKVP, Gyrus Medical Ltd., Bucks, UK) against standard transurethral resection of the prostate (TURP) for symptomatic prostatic obstruction. PATIENTS AND METHODS: Of 75 patients admitted to our clinic with symptomatic prostatic obstruction between 2001 and 2003, 40 who were randomized to undergo either TURP or PKVP, and who had returned for the follow-up, were included in this study. All treated patients completed the 36-months of follow-up; 25 had had PKVP and 15 a standard TURP. After surgery the treatment outcome was evaluated using the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Q(max)) and long-term complications of surgery. RESULTS: The two groups had similar baseline characteristics. The improvement in both groups was statistically significant for the IPSS and Q(max) at 24 and 36 months vs the baseline values (P < 0.05). The mean (sd) IPSS decreased from 21 (3.4) to 7.1 (1.5) and 7.6 (1.4) after PKVP and from 22 (3.8) to 5.2 (1.1) and 5.7 (1.2) after TURP, at 24 and 36 months, respectively. The mean Q(max) for the both groups increased significantly from baseline values at 2 and 3 years, respectively, at 20.8 (2.4) and 21.8 (3.1) mL/s after TURP, which was statistically significantly better than after PKVP, at 12.5 (2.1) and 14.4 (2.6) mL/s, respectively (P < 0.05). Although three patients (12%) in the PKVP group had TURP at 14, 20 and 36 months, respectively, for residual adenoma tissue, one patient had an additional operation after TURP. Bulbar urethral strictures occurred in one patient in each group, requiring internal optical urethrotomy. Erectile dysfunction was reported by three patients after PKVP (12%) and by two of 15 after TURP who were potent before surgery (P > 0.05). The retrograde ejaculation rates in patients with erectile function were similar in both groups (56% and nine of 15, respectively; P > 0.05). In the PKVP and TURP groups, 12 (48%) and nine of 15 patients were satisfied overall. CONCLUSIONS: Although early results showed that PKVP was a good alternative technique among the minimally invasive methods for surgically managing prostatic obstruction, the clinical outcome of PKVP in the long term was not comparable to the results after TURP.

The effects of human chorionic gonadotrophin on normal testicular tissue of rats: dose-dependence and reversibility.

OBJECTIVE To investigate the effect of human chorionic gonadotrophin (hCG) on rat testicular tissue, and its reversibility and dose dependence. MATERIALS AND METHODS Male Wistar rats were assigned to groups (10 rats/group) receiving 10, 30 or 50 IU/kg hCG subcutaneously once daily for 15 days; 10 controls received subcutaneous isotonic saline. At 1 and 3 months later, five rats in each group were killed and their testes removed. The testes were examined histologically to measure seminiferous tubular diameter and germinal membrane thickness. RESULTS At 1 month after hCG administration, the mean germinal membrane thickness in the testicular tissues of the hCG-treated rats was significantly less than in control rats, and was also significantly different between all of the hCG-treated groups (P < 0.05). However, at 3 months after hCG administration, all histological variables were similar to those in control rats (P > 0.05), and the mean germinal membrane thickness at 3 months after hCG administration was larger than that at 1 month (P < 0.05). There were no significant differences in the mean seminiferous tubular diameter between hCG-treated rats and control rats. CONCLUSION hCG impairs seminiferous tubule histology in the 'normal' descended testes of rats. This effect was dose-dependent, and the changes were reversed at 3 months after treatment. Thus, although hCG therapy might affect the seminiferous tubules of contralateral descended testes in cryptorchid boys, these effects might be reversible.