Is the Efficacy and Safety of Retrograde Flexible Ureteroscopy in the Elderly Population Different from Non-elderly Adults?

Background and objectives The population of elderly adults is increasing globally, and due to metabolic changes related to advanced age, many elderly adults experience kidney stones. Flexible ureteroscopy (f-URS) is a minimally invasive procedure to treat kidney stones, but it is not free of complications. The goals of this study were to analyze the efficacy and safety of f-URS in the management of kidney stones in patients aged ≥60 years and compare the outcomes of this surgery with the outcomes of the same surgery in a younger population. Materials and methods We retrospectively reviewed patient data from 1750 patients who met our inclusion criteria and received f-URS at the urology clinic of our hospital from 2012 to 2017. Patients were assigned into two groups: those aged ≥60 years (Group 1, n=291) and those aged 19-59 years (Group 2, n=1459). The perioperative results were evaluated comparatively. We performed multivariable analyses for factors predicting complications. Results When we compared the groups on demographic attributes, we noted statistically significant differences in gender, body mass index (BMI), and American Society of Anesthesiologists scores. Stone size and operation time were higher in the ≥60-year age group (Group 1). Other stone characteristics and operative features were similar. Stone-free rates (SFR) after the first procedure were 88.0% in Group 1 and 89.2% in Group 2. SFR and success rates at three months were similar for both groups. The complication rates were similar, and multivariable regression analysis revealed the most important factor affecting the complications was the presence of residual stones in both groups. The second most important factor affecting the complication was the operation time in Group 1 and the number of stones in Group 2. Conclusion In our study, there were no significant differences in terms of results and complications among elderly and young patients after f-URS except for the duration of the operation. The prolongation of operation time results in worse outcomes in terms of perioperative complications in patients aged ≥60 years. f-URS is a relatively safe and efficient procedure, with a small risk of minor complications even in the elderly population, with increased comorbidity.

A different perspective for morbidity related to Fournier's gangrene: which scoring system is more reliable to predict requirement of skin graft and flaps in survivors of Fournier's gangrene?

PURPOSE: To identify the prognostic factors that might predict morbidity related to Fournier's gangrene (FG) and particularly requirement of skin grafting and flaps. We also evaluated the validities of different severity indexes. METHODS: Thirty male patients with complete data who were treated for FG between January 2012 and December 2018 were retrospectively evaluated. Fournier's Gangrene Severity Index (FGSI), Uludag Fournier Gangrene Severity Index (UFGSI) and Age-Adjusted Charlson Comorbidity Index (ACCI), Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, the Combined Urology and Plastics Index (CUPI) and neutrophil-lymphocyte ratio (NLR) were calculated for 27 surviving patients. These patients were divided into two groups: Group I (14 patients with primary skin closure) and Group II (13 patients with requiring skin grafting and flaps). RESULTS: Body temperature (p = 0.026), heart rate (p < 0.001), respiratory rate (p = 0.029), creatinine (p = 0.002), white blood cell count (p = 0.014), hemoglobin levels (p = 0.018), involvement of pelvic floor or beyond (p = 0.018), length of hospital stay (p = 0.049), previous endourologic instrumentation (p = 0.035), requirement of cystostomy (p = 0.041), colostomy (p = 0.046), orchiectomy (p = 0.034) and intensive care unit (p = 0.046) were found to be significantly higher in Group II. All six different scoring systems were significantly higher in the patients who underwent skin grafting and flaps. In multivariate analysis, heart rate, FGSI, UFGSI, NLR, requirement of colostomy and intensive care unit were determined as independent factors for predicting requirement of skin grafting and flaps. CONCLUSION: FGSI, UFGSI and NLR are more reliable parameters for predicting skin reconstruction method (with the threshold values of 4.5, 5.5, and 7.87, respectively).

A comparison of standard PCNL and staged retrograde FURS in pelvis stones over 2 cm in diameter: a prospective randomized study.

The aim of the study was to compare percutaneous nephrolithotomy (PCNL) and staged retrograde flexible ureteroscopy (FURS) methods used in the treatment of kidney stones of 2 cm or more in diameter. The study comprised a total of 60 patients with a diagnosis of kidney pelvic stones more than 2 cm in diameter, for whom surgery was planned between January 2013 and January 2014. The patients were randomly allocated to two groups as staged retrograde FURS (Group A) and PCNL (Group B). Comparison of the groups was made with respect to operating time, number of procedures, total treatment time, length of hospital stay, stone-free rates and complications according to the Clavien-Dindo classification. In Group A, the total operating time of multiple sessions was 114.46 min. In Group B, a single session of PCNL was applied to all patients and the mean operating time was 86.8 min (p = 0.014). Mean total treatment time was 2.01 weeks in Group A and 1 week in Group B (p < 0.01). The mean total hospitalization time was 3.66 days in Group A and 3.13 days in Group B (p = 0.037). At the end of the sessions, clinically insignificant residual fragments were observed in ten patients of Group A and one patient of Group B (p = 0.03). No statistically significant difference was determined between the groups in terms of stone-free rates or complications. Although current technology with FURS is effective on large kidney stones, it has no superiority to PCNL due to the need for multiple sessions and long treatment time.

Malfunctioned and Fractured Penile Prosthesis Caused by Cross Placement: Case Report.

Penile prosthesis is a functional option for patients who have erectile dysfunction after failed medical and intracavernosal treatments. Malleable penile prosthesis is a good alternative. Penile prosthesis implantation is a surgical process. Seldomly complications occur. In this study we presented a 61 y old man who has malfunctioned and broken penile prosthesis due to cross implantation.

Comparison of complications associated with standard and totally tubeless percutaneous nephrolithotomy according to modified Clavien grading: a multicenter retrospective study.

The aim of this study was to compare the complications of standard and totally tubeless percutaneous nephrolithotomy (PCNL) based on the modified Clavien complication grading system. We retrospectively evaluated the complications of 290 consecutive patients who had undergone standard or totally tubeless PCNL at four institutes between January 2010 and August 2012 based on the modified Clavien scale. The totally tubeless cases were classified as Group 1 and the cases to which a Malecot re-entry catheter was applied were classified as Group 2. The postoperative complications were recorded according to the modified Clavien complication grading system. Statistically significant differences were observed only in the first-degree injury class between the two groups based on the modified Clavien classification. The requirement for blood transfusion and prolonged percutaneous access site leakage were more frequent in Group 2, but these differences were not statistically significant. We also performed a pain evaluation by monitoring postoperative analgesia demands. In Group 1, the analgesic demand rates in the 1(st) and 6(th) postoperative hours were 64.6% and 31.5%, respectively. In Group 2, the analgesic demand rates were 87.5% and 58.75% in the 1(st) and 6(th) postoperative hours, respectively. The mean ± standard deviation of analgesic doses in the first 6 hours was 0.96 ± 0.7 and 1.46 ± 0.6 in Groups 1 and 2, respectively. These differences were statistically significant. Based on our results, we can conclude that the tubeless technique has fewer complications, improved postoperative patient comfort, shorter hospitalization times, and a reduced need for analgesics, suggesting that tubeless PCNL should be the standard approach. For suitable cases, this technique may be used safely as the standard PCNL approach.

Prognostic significance of neuroendocrine differentiation in prostate adenocarcinoma.

Much progress has been made toward an understanding of the development and progression of prostate cancer (PC) and the factors that drive the development of androgen independence. Neuroendocrine (NE) cells may provide an intriguing link between NE cell differentiation (NED) and tumor progression in PC. NED in PC generally confers a more aggressive clinical behavior and less favorable prognosis than conventional PC. In this article, we review the known functions of NE cells in PC and discuss the current knowledge on stimulation of cancer proliferation, invasion, apoptosis resistance, serum and immunohistochemical markers, and the prognostic significance of NED in human PC.

Diagnostic value of a urine-based tumor marker for screening lower urinary tract in low-risk patients with asymptomatic microscopic hematuria.

BACKGROUND: To evaluate the use of NMP22 BladderChek® (NMP22BC) as an initial test in comparison to voided urine cytology for screening subjects with asymptomatic microscopic hematuria (AMH); those who are <40 years of age and have a low risk for bladder cancer based on a non-smoking history, and by discussing the guidelines on this subject. METHODS: From October 2005 to September 2007, 164 patients (56 male, 108 female) were evaluated. Patients with risk factors according to AUA Best Practice Policy Recommendations on AMH were strictly excluded from the study. For upper urinary tract imaging, ultrasonography (USG) was performed and prior to the cystoscopic procedure freshly voided urine was sampled for urine cytology and NMP22BC assay in all patients. Biopsy was performed if suspicious lesions were seen or positive cytology was obtained. RESULTS: The mean age was 30.8 years. As some benign urological pathologies were detected in 21 patients by USG, NMP22BC was positive in 26 patients where the cytology was confirmed as atypia in 5. Two TaG1 tumors were detected cystoscopically in a 39-year-old man and a 33-year-old woman where the NMP22BC test was positive and the cytology was negative in both patients. NMP22BC tests sensitivity, PPV and NPV values were detected to be higher compared to cytology and the likelihood ratio was 6.75. CONCLUSION: We recommend in evaluation of low-risk patients with AMH that, as an initial test, two non-invasive and cost-effective methods be chosen: an upper tract imaging by USG as recommended by guidelines, followed by an NMP22BC test for lower tract investigation instead of urine cytology.

The significance of Y chromosome microdeletion analysis in subfertile men with clinical variocele.

INTRODUCTION: The aim of study is determining the cost-effectiveness of detection analysis in the presence of exceptional patients who have mild semen disorders, and beware of unnecessary varicocele repairs; and to ascertain whether patients with clinical varicocele should undergo Y chromosome (Yq) microdeletion analysis as a routine procedure. MATERIAL AND METHODS: Varicocele with reflux was diagnosed in 51 male patients with subfertility symptoms upon physical examination (PE), confirmed by scrotal colour-Doppler ultrasound (CDU). After cytogenetic examination, Yq microdeletion analysis was performed on the peripheral blood samples using Promega Y Chromosome Deletion Detection System Version 2. Varicocele repair was performed under general anaesthesia with optical magnification (3-fold) through a subinguinal approach. RESULTS: The mean age of the patients was 27.9. Values of semen concentration ranged from 0 to 72 million/ml, motility from 0 to 65% (A + B) and Kruger from 0% to 18%. The PE revealed normal size and consistency in the bilateral testicles. All patients were cytogenetically normal. However, Yq microdeletion was detected in 2 patients, 1 with mild oligoteratozoospermia and partial AZFb deletion (sY121) and the second patient with severe oligozoospermia and partial AZFc deletion (sY254 and sY255), and they were not subjected to varicocelectomy. CONCLUSIONS: The routine performance of pre-operative Yq microdeletion analysis in patients with clinical varicocele does not seem to be cost-effective but the omission of patients with mild oligozoospermia would have subjected them to an unnecessary varicocelectomy and/or further ICSI applications and also would have caused the failure of referral for genetic counselling.

Predictive value of urinary interleukin-8 cutoff point for recurrences after transurethral resection plus induction bacillus Calmette-Guérin treatment in non-muscle-invasive bladder tumors.

BACKGROUND: This study was designed to investigate whether there is a correlation between interleukin (IL)-8 secretion rate and recurrences in induction bacillus Calmette-Guérin (BCG) immunotherapy following transurethral resection (TUR) in cases of primary non-muscle-invasive bladder cancer (NMIBC). PATIENTS AND METHODS: A total of 41 patients with NMIBC were randomized to receive a 6-week course with a standard dose of 81 mg intravesical BCG. Voided urine samples were collected immediately before and after (at 2 and 4 hours) BCG instillation. IL-8 was measured using enzyme-linked immunosorbent assay. Patients were monitored according to European Association of Urology Guidelines. RESULTS: Patients were monitored for a mean duration of 21.0 +/- 13.86 months. The mean time to recurrence for the 15 patients who had recurrences was 11.2 months. After adjusting for risk factors, the change in IL-8 levels at 2 hours after the first BCG compared with the levels before BCG instillation was found to be significantly predictive of recurrence (P = .047), and the best cutoff point was estimated as 112 pg/mL. The sensitivity of this measure for prediction of recurrences was 53.3%, specificity was 88.5%, positive predictive value was 72.7%, and negative predictive value was 76.7%. Comparison of patients who had values below and above this cutoff point revealed that the recurrence-free survival rate was 76.7% versus 27.3%, and the expected recurrence-free survival time was 34.9 months versus 18.8 months (P = .006). CONCLUSION: Besides numerous other prognostic factors that have been suggested so far, a cutoff point of 112 pg/mL for IL-8 levels measured 2 hours after the first BCG instillation appears to be a good predictive factor for successful outcome in BCG treatment following TUR.

The effectiveness of transdermal electromotive administration with verapamil and dexamethasone in the treatment of Peyronie's disease.

AIM: To determine the effectiveness of transdermal electromotive administration (TEA) of verapamil and dexamethasone in the treatment of Peyronie's disease (PD). METHOD: Totally, 51 patients with PD were prospectively included in the study. All patients were evaluated by history, subjective score scales, physical examination, photographs, and penile USG, before and after therapy. All patients were treated with TEA of the combination of verapamil and dexamethasone. The treatment plan included a total of 20 sessions (at 3-day intervals for a period of 2 months), each with a duration of 20 min. At the end of the study, improvements in penile plaques, penile deviation, pain on erection, and erectile dysfunction were determined. RESULTS: The findings in 41 of the 51 patients were eligible to present. Median patient age was 52 years. Median duration of disease at presentation was 8 months. Remarkable reduction in palpable plaques and in penile angulation was observed in 10 patients (24%) and 11 (26%) patients, respectively. There were significant decreases in median plaque volume from 72 mm(2) to 45 mm(2) (P < 0.001), and in median penile angulation from 25 degrees to 15 degrees (P < 0.001). Impaired sexual activity and pain on erection had completely resolved in 11 (55%) patients and in 16 (80%), respectively. CONCLUSION: The results of our study have shown that TEA of the combination of verapamil and dexamethasone is a more effective therapy for improving subjective symptoms rather than objective symptoms. Therefore, we think that this treatment can be individualized according to the clinical features of PD patients.

Case report: a novel and easy technique to remove stitched urethral foley catheter after radical retropubic prostatectomy.

The inability to remove a urethral catheter because of inadvertent stitching or entrapped sutures after radical retropubic prostatectomy is rarely reported in the literature. Various methods are recommended to solve this problem. Here, we discuss a method developed by using a pediatric optical urethrotome to remove endoscopically a Foley urethral catheter that was encircled by a vesicouretheral anastomotic suture.

Subureteral dextranomer/hyaluronic acid copolymer injection for vesicoureteral reflux in transplant candidates.

BACKGROUND AND PURPOSE: Endoscopic subureteral injection of tissue-augmenting substances has become an alternative to antibiotic prophylaxis and open surgery for the management of vesicoureteral reflux (VUR). Several injectable materials have been tried for this purpose. In this study, we tried to determine the efficacy of dextranomer/hyaluronic acid copolymer (Dx/HA) injection for the treatment of VUR in renal-transplant candidates. PATIENTS AND METHODS: A total of 21 transplant candidates (29 ureteral units; 13 females, 8 males) with a mean age of 20.2 years (range 14-26 years) underwent endoscopic correction of VUR with Dx/HA. Diagnosis of VUR was made by voiding cystourethrography. The efficacy of the treatment was assessed with voiding cystourethrography at 3 months and 1 year postoperatively. Renal transplantation with living related donor organs was performed in 11 of the 21 patients. RESULTS: Endoscopic treatment was performed without complication in all cases. Higher success rates were obtained in patients with low-grade reflux, the overall success rate in the series being 82.7%. The mean follow- up after renal transplantation was 21.8 months (range 5-45 months). In one patient, reflux recurred after renal transplantation and was treated successfully by a repeat Dx/HA injection. The urine cultures of all patients remained sterile. CONCLUSION: Transplant candidates with VUR can be treated with Dx/HA, which cured the majority of our patients after one or two treatments with few low side effects. Endoscopic subureteral injection of Dx/HA has become an alternative treatment for VUR in transplant candidates. Long-term results are needed before making a final statement about its value.

Rib resection for live-donor nephrectomy.

INTRODUCTION: Living-related kidney transplants yield more favorable results than cadaveric kidney transplant. Although multiple techniques have been described for living-related donor nephrectomy, operation is generally performed subcostally in lateral decubitis position or by an 11th or 12th rib resection. Recently laparoscopic donor nephrectomy is getting popular. The aim of this study is to determine the rib resection increase the morbidity or not. MATERIALS AND METHODS: Between 1997 and 2004 in our center 118 living donor nephrectomies were performed. 15 of these patients did not come to follow-up controls. This study consists of 103 patients: 11th rib resection (30 patients) determined as group I, 12th rib resection (52 patients) determined as group II, subcostal incision (21 patients) determined as group III. All these three groups were compared with each other according to operation time, pleural or peritoneal defect, pneumothorax, blood transfusion, wound infection, length of hospital stay, postoperative analgesic requirement, return to threshold activities and incisional hernia. RESULTS: Patients whose 11th rib was removed had the shortest operation time. But pain due to surgery continued more than others in this group of patients. The risk of developing incisional hernia was seen most in patients who had subcostal incision. In this group of patients incidence of incisional hernia was 4 (19%). None of the patients had wound infection. We also did not experience any pneumothorax and blood transfusion requirement. Peritoneal or pleural opening occurred in 4 out of 103 patients accidentally and there was no difference between groups. There was also no difference between groups in terms of returning back to daily activation. CONCLUSION: Morbidity of nephrectomy done with removal of 12th rib was less compared with other groups. Resection of 11th should be reserved for patients with high residing kidneys and also for those with a polar artery of the upper pole.