Comparison of laparoscopic and open ureterolithotomy in impacted and very large ureteral stones.

PURPOSE: To compare the efficacy of laparoscopic and open ureterolithotomy in patients with ureteral stones. MATERIALS AND METHODS: Patients who had undergone open or laparoscopic ureterolithotomy between 2001 and 2013 in our clinic were enrolled in the study.Ureterolithotomy was performed due to the following reasons: failure to position the patient for ureteroscopy, unreachable stone with ureteroscopy also use of balloon dilatation, high stone volume, and the need for removal of kidney stones at the same session.. The patients' demographic data, the volume of the stones, the duration of the operation and the hospital stay, the amount of analgesics administered after the operation, and the need for another procedure were compared. RESULTS: Of study subjects 32 patients had undergone open and 20 patients had undergone laparoscopic ureterolithotomy. When the two groups were compared, there was no statistically significant difference with regard to the mean age (44.5-44 years), the body mass index (26-24.7 kg/m²), the stone volume (420-580 mm³), the duration of operation (122-123 min), the need for another procedure and complications. The mean amount of analgesics administered after the operation (3.6 and 1.81 doses, P = .02) and the mean hospital stay (6.1 and 2.9 days, P = .01) were significantly lower in the laparoscopic ureterolithotomy group. CONCLUSION: Laparoscopic ureterolithotomy is a good alternative with less need for analgesia and a shorter hospital stay when compared with open ureterolithotomy.

Montelukast prevents testes against ischemia-reperfusion injury through suppression of iNOS expression.

OBJECTIVE: To elucidate the mechanism of a possible protective effect of montelukast against testicular ischemia/reperfusion (I/R) injury. MATERIAL AND METHODS: Fifty-one adult male Wistar-Albino rats were randomly assigned into 6 groups; sham + saline (S), sham + montelukast (M), I/R + S, I/R + S 30', I/R + M and I/R + M 30'. Saline or montelukast (10 mg/kg) was intraperitoneally administered 30 minutes prior to (S 30', M 30') and during detorsion (I/R + S, I/R + M) in the I/R groups. The I/R groups underwent 2 hours of ischemia followed by 4 hours (early-term) of reperfusion in unilateral testes. Half of the rats underwent 24 hours (late-term) of reperfusion to investigate long-term effects. Testicular tissue samples were examined for biochemical and histopathological parameters. Germ cell apoptosis was evaluated using apoptosis-activating factor 1 (Apaf-1). Inducible nitric oxide synthase (iNOS) activity was analyzed in late-term reperfusion groups. Spermatogenic functions were assessed for each testis based on the Johnsen criteria. RESULTS: Unilateral I/R caused a significant increase in serum TNF-α levels in the early-term group compared to the sham groups. Malondialdehyde levels and myeloperoxidase activity were found to be elevated in the I/R groups and accompanied with a significant decrease in glutathione levels when compared to the sham groups. I/R significantly increased iNOS activity and germ cell apoptosis compared to the sham groups. Montelukast treatment significantly reversed all of these parameters and achieved comparable results with the sham groups. Finally, spermatogenic indices were similar for the bilateral testes between all groups. CONCLUSION: Montelukast exerts protective effects against testicular I/R injury by inhibiting neutrophil activity, reversing the oxidative stress markers, decreasing iNOS activity and attenuating apoptosis.

"Snodgraft" technique for the treatment of primary distal hypospadias: pushing the envelope.

PURPOSE: "Snodgraft" modification has been proposed to reduce the risk of meatal/neourethral stenosis in distal hypospadias. We applied the Snodgraft technique by using inner preputial graft in primary distal hypospadias repair. MATERIALS AND METHODS: A total of 102 consecutive patients undergoing the Snodgraft procedure were prospectively studied between 2006 and 2011. Mean patient age was 7.2 years. Localization of the meatus was glanular in 5 patients, coronal in 49, subcoronal in 45 and mid penile in 3. In all patients the posterior urethral plate was incised, and the graft harvested from the inner prepuce was sutured from the old meatus to the tip of the glans. A neourethra was created over a urethral catheter using 6-zero polyglactin suture. An interpositional flap was laid over the urethra as a second barrier. All patients were followed at 3 to 6-month intervals for cosmetic and functional results. RESULTS: At a mean of 2.4 years of followup no patient had meatal stenosis or diverticulum at the inlay graft site. However, urethrocutaneous fistula was observed in 10 patients (9.8%). A slit-like appearance of neomeatus was achieved in all patients. During followup no obstructive urinary flow pattern was detected, and early and long-term maximum urine flow rates were comparable. CONCLUSIONS: No meatal/neourethral stenosis was observed in any patient undergoing a Snodgraft procedure. A randomized trial will be needed to prove that the incidence of meatal/neourethral stenosis is lower after Snodgraft repair compared to routine tubularized incised plate repair.

Revisiting the predictive factors for intra-operative complications of rigid ureteroscopy: a 15-year experience.

PURPOSE: To revise the predictive factors for intra-operative complications of rigid ureteroscopy in the treatment of ureteral calculi. MATERIALS AND METHODS: During a 15-year period (1993 to 2008), a total of 1496 consecutive patients who had undergone 1660 ureteroscopy procedures were retrospectively reviewed. After exclusion of the cases for diagnostic purposes, diseases other than ureteral calculi, and repeated ureteroscopy procedures, 1189 patients were left as the study population. Those patients were then divided into two groups based on the presence of the complications: complication-positive (group 1, n = 57) and complication-negative (group 2, n = 1132). Both groups were statistically compared regarding patients' age and gender, stone surface area, lateralization and localization of the stone, impaction of the stone, type of the ureteroscope, necessity of ureteral orifice dilation, and use of a catheter during and after the procedure. Furthermore, the effect of leaving the fragmented stones in situ small enough to pass spontaneously (break'n'leave) on occurring of the complications has been investigated. RESULTS: The complication rate was recorded as 4.7%. Success rate after a single intervention was 86.3%, whereas increased to 94.1% after ancillary procedures. Stone surface area, lateralization, and type of lithotripter used were comparable between the groups, but impacted stones and the stones located at the upper ureters were associated with significantly increased complication rates. Furthermore, significantly less complication has been observed in cases where we performed break'n'leave. Furthermore, multivariate analysis revealed that stone impaction and failure to adhere to the "break'n'leave" principle were the independent predictors of occurring of the complications. CONCLUSION: Ureteroscopy is safe and effective in the treatment of ureteral calculi. Careful attention for the patients having a potential for occurrence of the complications and selection of the techniques are of importance for reducing untoward events.

Hyperoxaluria-induced tubular ischemia: the effects of verapamil and vitamin E on apoptotic changes with an emphasis on renal papilla in rat model.

An experimental study in rats was performed to evaluate the presence and the degree of both tubular apoptotic changes and crystallization at cortical, medullar and papillary regions of the kidney during hyperoxaluric phase and assess the possible protective effects of vitamin E and verapamil on these pathologic changes (particularly in papillary part of the affected kidneys). A total of 32 rats have been included into the study program. Hyperoxaluria was induced by continuous administration of ethylene glycol (0.75%). In addition to hyperoxaluria induction, animals in Groups 2 and 3 did receive a calcium channel-blocking agent (verapamil) and vitamin E, respectively. Histologic alterations of the kidneys including crystal formation together with apoptotic changes were evaluated on days 1, 14 and 28, respectively. Both apoptotic changes and the presence and degree of crystallization were assessed separately in renal cortical region, medulla and particularly papillary parts of the removed kidneys. Although verapamil did well limit the degree of crystal formation and apoptosis and brought it to the same levels observed in control group animals in all parts of the kidneys during intermediate phase, addition of vitamin E was failed to show the same protective effect during both intermediate and late phase evaluations. As demonstrated in our study, the limitation of both crystal deposition and apoptotic changes might be instituted by calcium channel-blocking agents. Clinical application of such agents in the prophylaxis of stone disease might limit the formation of urinary calculi, especially in recurrent stone formers.

Twelve-year experience with Hinman-Allen syndrome at a single center.

OBJECTIVE: To report the long-term follow-up results of patients with Hinman-Allen syndrome (HAS) at our institution. METHODS: The data from 22 children with HAS were retrospectively analyzed. The patients were followed up every 3-6 months with serial physical examinations, voiding charts, urine culture, postvoid residual urine volume determination, serum creatinine measurement, and urinary imaging. The follow-up time was calculated from the day of the first visit to the day of the latest dimercaptosuccinic acid scan. Urotherapy, pharmacotherapy, clean intermittent catheterization, biofeedback therapy, and surgery were performed sequentially and/or combined, depending on the disease course. Renal deterioration was defined as any presence of a new scar or cortical thinning compared with the findings from the first dimercaptosuccinic acid scan. Upper urinary tract deterioration was defined as the persistence or progression of hydronephrosis on ultrasonography. RESULTS: The mean age at referral was 9.18 ± 3.36 years (range 2-14), and the mean follow-up period was 80.90 ± 19.57 months (range 54-144). Conservative therapy resulted in improvement of the bladder function in 14 patients; however, 8 patients required surgery owing to failure of this approach. Asymptomatic bacteriuria developed in one half of the children (n = 11, 50%), and in 6 (22.7%), ≥1 febrile urinary tract infection developed. None of the patients had upper urinary tract deterioration; however, renal deterioration developed in 3 patients (13.6%). The mean creatinine levels had remained stable at the end of the follow-up. CONCLUSION: Close follow-up at a single institution and proactive treatment resulted in successful stabilization of HAS in most of our children with HAS.

Emergency ureteroscopic removal of ureteral calculi after first colic attack: is there any advantage?

OBJECTIVE: To comparatively evaluate the efficacy of ureteroscopic stone treatment immediately after the first colic attack and in an electively planned manner. METHODS: A total of 145 patients underwent semirigid ureteroscopic removal of obstructive ureteral calculi using 2 different approaches (group 1, 69 patients, and group 2, 76 patients). The 69 patients in group 1 were treated with appropriate medical therapy for a period of ≥7 days for colic pain and subsequently underwent either semirigid ureteroscopy or pneumatic lithotripsy in a planned manner. The 76 patients in group 2 underwent semirigid ureteroscopy after the first colic attack. The stone-free status, auxiliary procedures, and complications were evaluated between the 2 groups using the Mann-Whitney U test; for qualitative data, Fisher's exact test was used. RESULTS: Of the 145 patients who underwent semirigid ureteroscopy, the mean stone size was 11.80±3.95 mm and 8.32±2.08 mm in the 2 groups. No patient experienced a major complication during or after the procedure. The stone-free rate was 87% and 90.7% in groups 1 and 2, respectively. The mean readmission rate to the emergency department for the management of a colic attack was 3.03±2.84 in group 1; no patient in group 2 required readmission. CONCLUSION: Ureteroscopic stone removal immediately after the first colic attack in the cases of obstructive ureteral stones proved to be safe and effective. It has the main advantage of offering both immediate stone fragmentation and the relief of acute onset colic pain causing extreme discomfort.

Comparison of ureteroscopic procedures with rigid and semirigid ureteroscopes in pediatric population: does the caliber of instrument matter?

OBJECTIVES: To compare the results of two different ureteroscopes in pediatric ureteroscopy (URS) procedures. PATIENTS AND METHODS: Sixty-five consecutive URS procedures in pediatric population (39 males, 26 females) were retrospectively evaluated. The subjects were divided in two groups according to the type of ureteroscope used: Group 1 (n = 32, Wolf 8F) and group 2 (n = 33, ACMI 6.9F). All the procedures performed in both groups were statistically compared regarding patient age, gender, lateralization, complication rates, whether the procedure was diagnostic or therapeutic, and whether a guide-wire was used. Additionally, in cases with ureteral stones, stone clearance rate and the necessity of a stone extractor were also compared between the groups. All data were statistically analyzed using chi-square and t tests, where appropriate. A p value less than 0.05 was considered as significant. RESULTS: Mean age of the groups were comparable (9.44 +/- 4.3 and 8.67 +/- 3.9, p = 0.456). There was no statistically meaningful difference between the groups regarding patients' gender, lateralization rates, whether the procedure was diagnostic or therapeutic, the need for a guide-wire use, and complication rates (p > 0.05). In cases with ureteral stones, both groups exhibited statistically comparable results in stone clearance rates and the use of a stone extractor (p > 0.05). CONCLUSIONS: Data on this comparison demonstrated that both ureteroscopy devices in pediatric population can be used safely in URS procedures. Neither the diameter nor the rigidity is significantly affecting the outcomes and success rates

Sixteen-slice multidetector computed tomographic virtual cystoscopy in the evaluation of a patient with suspected bladder tumor and history of bladder carcinoma operation.

PURPOSE: The purpose of this study was to evaluate the use of virtual cystoscopy performed with multidetector computed tomography (CT) in patients with suspected bladder tumors and histories of bladder carcinoma operation. MATERIAL AND METHODS: Thirty-six patients (29 men and 7 women) with a mean age of 66 years (range, 24-88 years) with suspected bladder tumors and histories of bladder carcinoma operation were included in this prospective study. Virtual cystoscopy was performed by 16-slice multidetector CT scanner. The bladder was filled with diluted contrast material solution through a Foley catheter. Then, all patients underwent conventional cystoscopy examination. RESULTS: Two reviewers found 18 lesions detected by virtual cystoscopy by consensus, whereas 19 lesions were depicted by conventional cystoscopy. At virtual and conventional cystoscopies, the conditions of 3 patients, 2 with chronic inflammations and 1 with foreign body reaction, were wrongly diagnosed as tumors. At conventional cystoscopy, one patient's result was wrongly interpreted as normal. In pathologic evaluation, all tumors were diagnosed as transitional cell carcinoma. CONCLUSIONS: Bladder tumor can be noninvasively diagnosed using virtual cystoscopy. Use of virtual cystoscopy should be considered inpatients who present with hematuria or have histories of bladder carcinoma operation and are for follow-up because of its lesser complication risk and its being a less invasive, easily applied procedure without need of anesthesia. In the future, owing to the development of the CT technology and image processing technique, virtual cystoscopy may have a part in the detection of bladder cancer.

Photoselective potassium titanyl phosphate (KTP) laser vaporization versus transurethral resection of the prostate for prostates larger than 70 mL: a short-term prospective randomized trial.

OBJECTIVES: To compare the short term outcomes of photoselective vaporization (PVP) and transurethral resection of the prostate (TURP) for glands larger than 70 mL in a prospective randomized trial. METHODS: Seventy-six consecutive patients with enlarged prostatic adenomas of 70 to 100 mL were randomly assigned for surgical treatment with TURP (n = 37) or PVP (n = 39). International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) scores, maximum flow rates (Qmax), postvoid urine residues (PVR), and transrectal ultrasound (TRUS) volumes were recorded. Operative data, complications, catheter removal, and hospitalization periods were also recorded. Patients were reassessed at 3 and 6 months. RESULTS: Baseline characteristics of both groups were similar. Mean preoperative TRUS volume was 88 +/- 9.2 mL in the TURP group and 86.1 +/- 8.8 mL in the PVP group. The procedure was significantly shorter for the TURP group (51 +/- 17.2 minutes versus 87 +/- 18.3 minutes, P <0.05), catheter removal (3.9 +/- 1.2 days and 1.7 +/- 0.8 days, P <0.05), and hospital stay (4.8 +/- 1.2 days versus 2 +/- 0.7 days, P <0.05) were shorter in the PVP group. A significant difference in IPSS, Qmax and PVR values was observed within the follow-up period in favor of the TURP. The percentage volume reduction was significantly higher in TURP group. Reoperation was necessary in 7 patients in PVP but none in TURP group. CONCLUSIONS: Although PVP offers advantageous over TURP with regard to intraoperative and perioperative safety, early functional results of TURP are superior to PVP in patients with enlarged prostates larger than 70 mL.

A case of primary lymphoma of the bladder managed with multimodal therapy.

BACKGROUND: A 65-year-old female patient presented to a urology department with macroscopic hematuria, dysuria, urinary frequency and urgency. One year previously, she had visited a urologist because of a 1-month history of hematuria, dysuria, urinary frequency and urgency. She had subsequently undergone successful, simultaneous surgeries for resection of a basal cell carcinoma of the nasal skin and lymphoma of the bladder. INVESTIGATIONS: Physical examination, measurement of serum urea, creatinine and electrolyte levels, peripheral blood film evaluation, ultrasonography, intravenous pyelography, abdominal, thoracic and pelvic CT, bone marrow aspiration and biopsy, cystoscopy and pathologic examination. DIAGNOSIS: Primary lymphoma of the bladder. MANAGEMENT: Transurethral resection, chemotherapy, radiotherapy and follow-up comprising cystoscopy, biopsy, CT imaging and immunocytologic analyses of urine samples.

Do lifestyle changes work for improving erectile dysfunction?

The main cause of erectile dysfunction (ED) is organic in nature, with vascular etiologies being the most common risk factors. Although there have been sufficient data on the relationship between ED and several well-recognized risk factors, including aging, coronary artery disease, atherosclerosis, diabetes mellitus, dyslipidemia, high blood pressure, and pelvic surgeries, little attention has been paid by the urologists to the role of lifestyle factors in ED. However, accumulating data from basic science and clinical studies have determined a link between the occurrence of ED and a number of lifestyle factors, such as smoking, obesity, alcohol consumption, and lack of physical activity. The application of findings from animal and human studies to the clinical practice regarding the modification of lifestyle factors could help improving ED as well as reducing the risks of developing cardiovascular diseases. This communication addresses the impact of lifestyle factors on erectile function and the potential benefits of modifying these factors to improve ED in respect to the current evidence.

Healing of the urethral plate after deep incision: does catheterization change the course of this process?

BACKGROUND: We aimed to evaluate the sequence of healing process as well as possible effects of stent placement on the healing process after deep urethral plate incision. METHODS: A deep urethral plate incision was done at the 12 o'clock position. After that, in the first group (n = 14) the anterior urethra was stented with a silicon catheter. Animals in the second group (n = 14) underwent the same incision procedure, however no stent was placed after this operation. All animals in both groups were again divided into three groups with respect to the follow-up period (7-14 and 21 days). Partial penectomy was performed in all subgroups and histopathologic evaluation performed. RESULTS: In the first group after 7 days, limited neovascularization and granulation tissue formation could be noted far away from the epithelial lumen. Evaluation of these specimens during the long-term follow-up (21 days) demonstrated an almost completely healed tissue with a remarkable neovascularization and well-developed granulation tissue. In the second group during 14-21 days, evaluation progression of tissue healing along with increasing vessel formation and re-epithelialization were demonstrated. Although the incision edges did show evident approximation, no sign of fibrosis could be demonstrated in these specimens. CONCLUSION: We may say that tissue healing with a desired and complete re-epithelialization could be achieved without inserting a catheter. Prevention of re-approximation along with the limited urinary extravasations to the subepithelial area might be responsible for tissue protection that will limit the long-term aforementioned adverse effects of the procedure.

Sunitinib malate and sorafenib may be beneficial at the treatment of advanced bladder cancer due to their anti-angiogenic effects.

Due to the poor prognosis of advanced bladder carcinoma and the insufficient affects of the chemotherapy agents for this disease, the investigation of the novel genetic and pharmacologic agents including anti-angiogenic agents that can target pathway-specific molecules has been the subject of several publications especially for the last 2 years. Although the clinical trials of these agents are still lacking, the experimental and the preliminary studies are giving hope for the future treatment of advanced bladder carcinoma. Sunitinib malate and sorafenib are the novel food and drug administration (FDA) approved anti-angiogenic agents, which have recently been demonstrated to improve the progression-free survival in patients with metastatic renal cell carcinoma. The main mechanism of these two drugs are defined as preventing the tumor growth by the inhibition of angiogenesis and the induction of apoptosis and necrosis via acting on different types of vascular endothelial growth factor (VEGF) such as the several agents which have been demonstrated to be beneficial for bladder carcinoma. According to this knowledge we suggest that these two new agents may also increase the progression-free survival of the patients with advanced bladder carcinoma due to their anti-angiogenic and tumor cell apoptotic effects. We believe that the evaluation of the effects of these agents on bladder cancer population by clinical, prospective and placebo controlled studies may prove our hypothesis and add critical findings to the literature which is still lacking.

The learning curve in the training of percutaneous nephrolithotomy.

OBJECTIVES: To investigate the learning curve in the training of percutaneous nephrolithotomy (PCNL). METHODS: A total of 104 PCNL cases were included in this evaluation to define the learning curve of a surgeon with no previous experience at performing solo PCNL. Two parameters of expertise were reviewed, namely the operation and fluoroscopic screening times. The operation time was calculated as the beginning of access with the needle until the nephrostomy tube was placed and secured. PCNL procedures were analyzed in seven sets of 15 cases regarding the operation and fluoroscopy times, stone size, stone clearance rate, blood transfusion rate, and estimated blood loss. RESULTS: The mean operation time was 2.4 h for the first 15 patients. It decreased to a mean of 1.5 h for cases 46 through 60. No further decrease in the operation time was observed after case 60. The fluoroscopic screening time was a peak of 17.5 min in the first 15 cases, whereas it dropped to a mean of 8.9 min for cases 46 through 60. The decline in the mean fluoroscopy screening time continued in cases 61 to 104, but the decline was not significant. There was no significant difference in stone size, stone clearance rate, blood transfusion rate, and estimated blood loss among each set of cases. CONCLUSIONS: This study suggests that the surgical competence in PCNL can be reached after 60 cases. PCNL and fluoroscopy times drop to a steady-state level after performing 60 procedures.

The risk of urolithiasis recurrence may be reduced with anti-nanobacterial therapy.

Urolithiasis is a common disorder responsible for serious human suffering and economic cost to society. Approximately 13% of men and 7% of women in the United States will be diagnosed with urolithiasis at some time in their lives with a recurrence rate of more than 50% in 5 years. Even if some risk factors are defined for stone formation, none of them can fully explain the etiopathogenesis. A controversial pathogen bacteria called 'nanobacteria' (NB) has been associated with several diseases including stone formation in some studies. It is thought to be the nidi for the stone formation after its' isolation from the renal stones and the occurrence of the stone after the percutaneus renal injection of NB. The clinical trials demonstrated that the eradication of NB prevented the calcifications in coronary arteries and prostate with an acceptable level by performing a novel combination therapy called 'ComET' which comprises a tetracycline antibiotic, nutraceutical and EDTA. Based on these findings, we hypothesize that the risk of urolithiasis recurrence may be reduced with combined anti-nanobacterial therapy. Long term prospective studies should be designed for evaluating the patients with positive NB cultures. If our hypotheses can be further supported with clinical trials it may change the approach of the medical management for urolithiasis.

Operative failure during ureteroscopic pneumatic lithotripsy: factors affecting successful outcome.

AIM: We aimed to evaluate the predictive factors that would in turn indicate stone migration and the effects of these factors on the ultimate success of the intervention. METHOD: Patients were divided into two groups with respect to the migration of the stone treated. Group I: patients demonstrating stone migration during manipulation; group II: no migration of the stones noted. In the second phase of the study, the results of ureteroscopic management in 433 patients were evaluated with respect to the success rates obtained. Parameters such as stone size, stone burden, experience of the surgeon, length of the ureter proximal to the stone treated, and lastly transverse diameter of the ureter were noted in all patients as possible risk factors for stone migration. RESULTS: Statistical analysis of ureteroscopic success in all patients revealed that there was a meaningful correlation with respect to the length of the proximal ureteral portion (p < 0.0001) and surgeon's experience (p = 0.004). p value for the correlation between stone burden and operative success was 0.056. There was no significant correlation between stone size (p = 0.51), ureter diameter (p = 0.78), and operative success. CONCLUSION: Stones that are close to the renal pelvis and treated by inexperienced physicians are the ones most likely to migrate to the renal pelvis during manipulation with pneumatic lithotripsy.