Oncologic results, functional outcomes, and complication rates of robotic-assisted radical prostatectomy: multicenter experience in Turkey including 1,499 patients.

BACKGROUND: Robot-assisted radical prostatectomy (RARP) is a rising minimally invasive treatment of localized prostate cancer (PC). We present our multicenter experience of 1,499 consecutive cases with an analysis of complication rates, oncologic, and functional outcomes. PATIENTS AND METHODS: From March 2005 through December 2012, details of 1,499 patients were retrospectively analyzed. Transperitoneal approach using a da-Vinci robotic system was used to perform RARP. Perioperative characteristics and postoperative oncologic and functional outcomes are reported. RESULTS: The mean age was 61.3 years (37-77). Mean PSA level was 8.3 ng/ml. According to D'Amico classification, the percentage of patients with low-, intermediate-, and high-risk disease cases were 65.0, 30.1, and 4.8 %, respectively. Mean operative time was 181.9 min. Mean estimated blood loss was 225.4 cc (30-1,250). Positive surgical margin (PSM) was detected in 212 (14.1 %) patients. PSM rates in pT2, pT3, and pT4 stages were 6.1, 37.1, and 100 %, respectively. The overall complication rate due to modified Clavien classification was 6.1 %. Mean follow-up time was 26.7 months. Continence, potency, and biochemical recurrence rates were 88.7, 58.2, and 2.9 %, respectively. CONCLUSIONS: Our analyses including high-volume centers, which is the first largest series in Turkey, show that RARP is a safe procedure, has low PSM rates, high continence, and potency rates for the treatment of localized PC at experienced centers.

The role for active monitoring in urinary stones: a systematic review.

BACKGROUND AND PURPOSE: All urinary stones may not need prompt active treatment. The aim of our study was to identify urinary stones that can be actively monitored safely. MATERIALS AND METHODS: We performed a systematic review of the natural history and the role of active monitoring for urinary stones. RESULTS: Thirty-seven studies have selected. Of symptomatic ureteral calculi <4 mm, 38% to 71% will pass spontaneously while only 4.8% of stones <2 mm will need intervention during surveillance. Follow-up with history, physical examination, urinalysis, and plain radiography every 2 weeks for 1 month is necessary. If spontaneous passage does not occur within this period, intervention is recommended. When shockwave lithotripsy for caliceal stones is prospectively compared with observation, there is no difference in stone-free rates (28% vs 17%), need for additional treatment (15% vs 21%), or visits to a general practitioner (18.5% vs 20.8%). Patients under observation may need more invasive procedures and may be more commonly left with residual stone fragments >5 mm (58% vs 30%). Isolated, nonuric acid calculi <4 mm may be most amenable to active monitoring. Physical examination, urinalysis, and CT scan performed on an annual basis up to year 2 or 3, followed by intervention, are recommended. Lower pole stones <10 mm could be actively monitored on an annual basis by alternating ultrasonoraphy with CT scan, provided the patients are adequately informed. Up to 58.6% and 43% of patients with residual fragments after shockwave and percutaneous lithotripsy, respectively, may become symptomatic or require intervention during follow-up. Noninfected, asymptomatic fragments, <4 mm postextracorporeal lithotripsy, and <2 mm postpercutaneous surgery could be followed expectantly on an annual basis, in combination with medical therapy. CONCLUSION: Active stone monitoring has a certain role in the treatment of patients with urinary stones. The success is largely dependent on the stone size, location, and composition, as well as the time after the diagnosis. Medical therapy is a useful adjunct to observation.

The relationship between antioxidant enzymes and bladder cancer.

Carcinogenesis proceeds through at least three distinct stages - initiation, promotion and progression. Free radicals play an important role in the multistep complex course of carcinogenesis. Urinary bladder has been recognized as a target organ for many carcinogens, including benzidine, beta-napthylamine, 2 napthylamine, 4-aminobiphenyl. Antioxidants have been shown to inhibit both initiation and promotion in carcinogenesis. The aim of presented study was to determine and compare the oxidant and antioxidant status in different clinical stages of bladder cancer and of control groups. Study was conducted in fifty-two (n=52) patients with transitional cell epithelial cancer of bladder and in twenty-four (n=24) healthy adults as plasma and erythrocyte controls. Malondialdehyde levels (4.636+/-1.118, 2.853+/-0.576 / 262.112+/-61.772, 203.788+/-35.340) were significantly higher and erythrocyte glutathione levels (6.272+/-1.708, 7.523+/-1.346) were significantly lower in bladder cancer patients group than in control group. Erythrocyte glutathione reductase and glutathione peroxidase (3.935+/-1.155, 5.481+/-1.626 / 8.729+/-1.614, 12.362+/-1.707) activities were significantly lower in cancer patients. In the other hand, glutathione S-transferase activities (3.100+/-1.177, 1.071+/-0.471) were found significantly increases. We suggest that the values of glutathione S-transferase enzyme activity can be used for a tumor detection approach and even as an indicator of the biological behavior of the bladder carcinoma.

Extracorporeal shockwave lithotripsy for stones in abnormal urinary tracts: analysis of results and comparison with normal urinary tracts.

PURPOSE: We reviewed our experience with SWL for stones in abnormal urinary tracts and compared the results with those in normal urinary tracts. PATIENTS AND METHODS: The study group was composed of 2566 renal units (RU) treated on the Siemens Lithostar lithotripter at our SWL unit whose treatment and follow-up at 10 to 12 weeks were completed. Sixty-eight RUs (2.7%) belonged to 52 patients who had congenital upper urinary tract abnormalities. Logistic regression analysis was performed to analyze the impact of age, stone size, location, and the type of abnormality on the outcome of the SWL in the abnormal RU. The student t-, chi-square, and Fisher's exact tests were used for the comparison of stone load, number of treatment sessions, catheter placement, and success rates of the patients with normal and abnormal RU. Results of long-term follow-up for available patients (38 RU; 56%) were also evaluated. RESULTS: Age, stone load, stone location, and the type of abnormality did not have a statistically significant impact on the outcome of SWL for abnormal RU. The average stone load was 2.1 +/- 2.8 cm2 in the abnormal and 1.4 +/- 1.3 cm2 in the normal RU. Thus, the stone load was significantly higher in the abnormal RU (P < 0.05). In the abnormal group, 56% of the RU became stone free, 37% had nonobstructive and noninfectious clinically insignificant residual fragments < or = 4 mm (CIRF), and SWL failed in 7%. In the normal group, 78% of the RU became stone-free, 18.5% had CIRF, and SWL failed in 4%. There was no significant difference in the success rates in the groups if success was defined as stone free and CIRF together (P > 0.05). However, there was significant a difference when stone-free, CIRF, and failure rates were evaluated separately (P < 0.05). Recurrence, regrowth, and retreatment rates in abnormal RU were 50%, 37%, and 34%, respectively. CONCLUSIONS: Although the fragmentation rates were similar, clearance of the fragments was hampered in abnormal urinary tracts. Thus, especially for large stones, other endourologic treatment options should be considered. High recurrence and regrowth rates warrant careful monitoring and consideration for medical treatment during follow-up.

Metastatic adenocarcinoma of the prostate to the uvea as the initial presenting symptom in a 49-year-old man.

We report a case of a 49-year-old man who presented with symptoms related to his right eye. Subsequent workup revealed carcinoma of the prostate metastatic to the uvea. On ophthalmologic evaluation, choroidal metastasis was noted. His prostate was firm on digital rectal examination, and the serum prostate-specific antigen level was 124 ng/mL. Prostate biopsy was consistent with adenocarcinoma, Gleason score 9. The patient was treated with total androgen blockade and radiation to the eye. Although his ocular lesions disappeared, the patient died of hormone-refractory disease 32 months after the diagnosis. The first case of prostate cancer metastatic to the uvea was reported more than 1 century ago; however, only a few cases have been reported subsequently. To our knowledge, we present the first published report in the urological literature of a patient in whom ocular complaints were the presenting symptoms that led to the diagnosis of prostate cancer. The urologist should be cognizant of the distinct possibility of ocular metastasis if a patient with prostate cancer presents with complaints related to the eye.

Complications of the Mainz pouch II (sigma rectum pouch).

OBJECTIVE: The complications of the sigma rectum pouch were analyzed. METHODS: A total of 60 patients who underwent a construction of the Mainz pouch II was analyzed retrospectively. Data on early complications was available for all patients, while long-term follow-up data was available for 50 patients. RESULTS: Perioperative mortality was nil. Early complications were encountered in 2 (3.3%) patients. Oral alkalizing supplementation therapy was required in 30 (60%) of the patients; 3 (6%) patients needed hospitalization for severe acidosis and hypokalemia. Hydronephrosis developed in 5 (5%) of 98 renoureteral units anastomosed. Acute pyelonephritis was observed in 3 (8%) patients. All of the patients were continent except for 1 female patient who had had previous radiotherapy to the pelvis. The mean voiding frequency during the day and night was 5.1+/-1.1 and 1.9+/-0.7, respectively. The psychological state and general health of 2 patients became progressively worse until they died of probable malnutrition and metabolic abnormalities. Mechanical bowel obstruction developed in 1 patient 2 years after surgery. CONCLUSION: The complication rate of the Mainz pouch II appears to be acceptable with a median follow-up of 31 months. Patient selection and cooperation are of paramount importance for a successful outcome.

Removal of urolume endoprosthesis using holmium:YAG laser.

A potential complication of UroLume endoprosthesis is migration, which may necessitate removal of the stent. Stent removal may be associated with complications such as urethral injury, bleeding, and external sphincter trauma. We report a patient in whom a holmium:yttrium-aluminium-garnet (Ho:YAG) laser was used to cut the UroLume endoprosthesis into fragments, which led to easy and uneventful stent removal.

Holmium laser ablation of recurrent strictures of urethra and bladder neck: preliminary results.

BACKGROUND: The management of patients with recurrent urethral strictures represents a challenge for the practicing urologist. PATIENTS AND METHODS: We used holmium:yttrium-aluminum-garnet (Ho:YAG) laser in the management of recurrent urethral strictures in 13 patients. The energy level was set at 1.0 at a frequency of 10 pulses/sec. No treatment complications were observed. The mean preoperative maximum flow rate by uroflowmetric analysis was 3.8 mL/sec. RESULTS: Nine patients (69%) continue to do well with no symptoms at a median follow-up of 27 months with a mean maximum flow rate of 19 mL/sec. Of the four patients in whom treatment failed, three were retreated with the Ho:YAG laser. One of them was managed by insertion of a permanent urethral stent, another continues to do well without any further treatment, and the other is managed with dilation by self-catheterization. One of the four failures underwent open reconstructive urethroplasty after recurrence following his first treatment with the Ho:YAG laser. CONCLUSION: Our preliminary results suggest that Ho:YAG laser ablation of urethral strictures is safe and might be a reasonable alternative endoscopic treatment for recurrent urethral strictures.

Multilocular cystic nephroma: an unusual localization.

We present a case of multilocular cystic nephroma with an unusual localization treated by a nephron-sparing procedure. A 21-year-old white woman presented with a history of hematuria and right lumbar pain. Imaging techniques revealed a multilocular cystic mass originating from the renal parenchyma but mainly involving the renal pelvis. The lesion was localized almost entirely within the renal pelvis at surgery and was treated by excision. Pathologic analysis was consistent with multilocular cystic nephroma. The patient remains free of recurrence with 10 years of follow-up. We conclude that multilocular cystic nephroma may present as a cystic lesion localized within the renal pelvis, and we advocate simple excision of these lesions.

Modified "pluck" nephroureterectomy for upper urinary tract disorders: combined endourologic and open approach.

Nephroureterectomy is the standard surgical approach for upper urinary tract transitional-cell carcinoma (TCC) and many other conditions. In 1952, a modification of the conventional method was described in which a transurethral resection of the ureteral meatus and intramural ureter is undertaken until the remaining ureter has no attachment to the bladder. The resected area and the distal tip of the ureter are coagulated, and the ureter is removed in continuity with the kidney through a single flank incision. Since January 1990, we have performed 12 nephroureterectomies with this technique (9 men and 3 women with an average age of 61.8 years, ranging from 35 to 73). Six of them were operated on for a TCC of the upper urinary tract, and the postoperative follow-up of these patients was from 6 to 54 months (mean 18.6). Within the follow-up period, tumor has not recurred either at the resected trigonal area or in the retroperitoneum, and only one patient has had a tumor distant from the site of ureteric resection. One patient with bladder TCC, who had a suspect kidney mass on the left side detected by CT, underwent nephroureterectomy with this technique. Five patients had primary renal disorders and upper tract calculous problems, in which nephroureterectomy was required. After the transurethral resection, an indwelling catheter was left in the bladder for 4 days. We believe that our experience confirms the feasibility of this technique in order to improve and simplify nephroureterectomy. Therefore, we recommend the modified "pluck" technique in all patients who are candidates for an operation requiring nephroureterectomy, as it gives considerable benefit to the patient.

Urinary excretion of glycosaminoglycans in patients with superficial bladder tumors.

Urinary glycosaminoglycan/creatinine (GAG/Cr) ratio was determined in 73 patients with superficial bladder tumors and 34 healthy volunteers. While the mean GAG/Cr value in the tumor group was higher than the control group (11.25 +/- 5.36 vs. 10.11 +/- 2.67) this difference was not statistically significant. However, comparing the urinary GAG/Cr ratio of T1, Grade III and recurrent tumors with the control group revealed statistically significant results (p < 0.01, p < 0.001 and p < 0.02 respectively). Therefore, the urinary GAG/Cr ratio determination in the follow-up of these patients may be used as noninvasive procedure and high levels may be signs of higher grade, higher stage disease.

Diffuse proliferative glomerulonephritis in Behçet's syndrome.

Renal involvement in Behçet's syndrome is infrequent and the reported cases of glomerulonephritis consisted mainly of patients with focal glomerulonephritis. A patient with Behçet's syndrome and diffuse proliferative sclerosing glomerulonephritis with predominant disposition of IgM is described.

Xanthogranulomatous pyelonephritis in children and adults.

Sixteen patients with xanthogranulomatous pyelonephritis (XGP) are reported. The preoperative diagnosis of XGP may be difficult because of its clinical and radiological similarities to various other renal lesions, but in four patients XGP was suspected pre-operatively. Nephrectomy is necessary in most patients, although medical treatment may help a few.