Live surgery: highly educational or harmful?

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.

Fournier's gangrene: an analysis of 80 patients and a novel scoring system.

BACKGROUND: To create a better scoring system for outcome prediction for patients with Fournier's gangrene in order to design more appropriate and feasible management strategies. METHODS: Using logistic regression, the medical records of 80 patients who underwent surgery for Fournier's gangrene in the last 10 years were reviewed using a prospectively maintained database, and a novel scoring system was adopted combining this data with the Fournier's gangrene severity index (FGSI). The new system consists of a physiological score, an age score, and an extent of gangrene score. RESULTS: The mortality rate of the 80 patients was 21%. Using the new scoring system (UFGSI), at a threshold value of 9, there was a 94% probability of death with a score greater than 9 and an 81% probability of survival with a score of 9 or less (P < 0.001). The receiver operating characteristics (ROC) analysis concluded that the new scoring system was more powerful than the FGSI (P = 0.002). CONCLUSIONS: The power of the novel scoring system introduced in this study proves that in patients with Fournier's gangrene, the extent of the gangrene as well as the patient's age and physiological status have a significant effect on the outcome.

CPAP treatment in the coexistence of obstructive sleep apnea syndrome and metabolic syndrome, results of one year follow up.

OBJECTIVE: To investigate the effect of one year continuous positive airway pressure (CPAP) treatment on metabolic syndrome (MS) prevalence and components in patients diagnosed with both obstructive sleep apnea syndrome (OSAS) and metabolic syndrome. METHODS: This was a single center, observational prospective cohort study. 38 patients who were diagnosed with OSAS after polysomnographic analysis in sleep laboratory and diagnosed with MS according to National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guideline and underwent CPAP treatment were followed for one year. After the 1 year of follow up period on CPAP treatment, the prevalence of MS was evaluated again. RESULTS: 20 (13 male, 7 female) of 38 patients completed the entire study. Mean age was 50+/-7.7.4 patients were under treatment for diabetes mellitus (DM), 9 for hypertension (HT). After one year of follow up on CPAP treatment, the prevalence of MS decreased by 45%. When each components of MS were evaluated, no significant difference was found in fasting blood glucose, triglyceride levels and systolic and diastolic blood pressure after treatment (p>0.05). However, significant difference was observed in waist circumference (p=0.002), HDL cholesterol (p=0.001) and BMI (p=0.01) after treatment. DISCUSSION: If MS accompanies OSAS, which is a cardiovascular risk factor by itself, treatment indications of CPAP should be reevaluated. Thus, if OSA patients meet the criteria of MS even though they do not have obvious DM, HT and hyperlipidemia, initiating CPAP treatment at lower AHI levels may contribute to the prevention and development of cardiovascular disease.

Cytokine gene polymorphisms can alter the effect of Bacillus Calmette-Guérin (BCG) immunotherapy.

Various types of cancer are more frequent in men than women, and bladder cancer is one of the most common of these. Intravesical instillation of Bacillus Calmette-Guérin (BCG) after transurethral resection is the most effective treatment for superficial bladder cancers. The main aim of this study was to investigate for possible links between cytokine gene polymorphisms and different outcomes after BCG immunotherapy. Sixty patients who had been diagnosed with transitional cell cancer were investigated. All genotyping experiments were performed using polymerase chain reaction sequence-specific primers and a commercially available kit. The genes investigated were those that code for interleukin (IL)-1alpha, IL-1beta, IL-1R, IL-1RA, IL-4RA, IL-2, IL-4, IL-6, IL-10, IL-12, interferon-gamma (IFN-gamma), transforming growth factor-beta (TGF-beta), and tumor necrosis factor-alpha (TNF-alpha). Analyses of the data identified TGF-beta codon 25 GG (92.85% vs. 64.44%, p=0.04, OR=7.17), IL-4 -1098 GG (16.6% vs. 0.0%, p=0.05, OR=18.33), IL-10 -1082 GG (28.5% vs. 6.8%, p=0.05, OR=5.47), and IL-10 -1082 GCC/GCC (28.57% vs. 4.5%, p=0.025, OR=8.4) polymorphisms as risk factors for progression of bladder cancer.

An unusual cause of ureteral obstruction in a renal transplant recipient: ureteric aspergilloma.

Mycotic infections in various organ transplant recipients represent severe and often fatal complications. Aspergillosis isolated from the urinary tract occurs quite infrequently in renal transplant recipients. Besides, fungus balls are rare causes of ureteral obstruction. We report a 51-year-old patient with the diagnosis of ureteral obstruction caused by aspergillosis in the early post-renal transplant period, who unfortunately died with the clinical picture of disseminated infection and its complications.

A renal transplant recipient with pulmonary tuberculosis and visceral leishmaniasis: review of superimposed infections and therapy approaches.

Visceral leishmaniasis (VL) is an acute or subacute disease that is almost invariably fatal if untreated. It is a rare disease in renal transplant recipients and frequently reported together with other infectious agents. A 39-year-old renal transplant patient was admitted to hospital for elective coronary surgery. In the post-operative period, he developed spiking fever and non-productive cough and his general condition deteriorated. While he was taking medication for non-specific pneumonia, a cavitary lesion occurred in his lung, and he had the diagnosis of pulmonary tuberculosis and antituberculous treatment was started. Despite treatment, his fever continued. As the patient developed pancytopenia and splenomegaly, a bone marrow aspiration was done. Evaluation of bone marrow aspirate indicated Leishmania parasites. He was successfully treated with a more intensive liposomal amphotericin (L-AmB). Complete cure was achieved during follow-up period of 10 months without clinical relapse. In the existence of fever and long-standing pancytopenia, VL should be suspected although the patient had another proved infection and did not live or visit an endemic area. L-AmB usage can be safely preferred for treatment of selected renal transplant recipients with VL as first-line therapy.

Role of ejaculation in the treatment of chronic non-bacterial prostatitis.

BACKGROUND: Chronic non-bacterial prostatitis (NBP) is the most common prostatitis syndrome. Prevention and cure are not possible because the cause of NBP is unknown. However, patients may benefit from supportive measures. The impact of the frequency of ejaculation alone on the course of NBP was evaluated in the present study. METHODS: Thirty-four single male patients who avoided masturbation and extramarital sexual intercourse for personal and/or religious beliefs and who did not respond to a clinical trial of doxycycline hydrochloride therapy (200 mg daily for 4 weeks) directed against mycoplasmas, chlamydiae and ureaplasmas were enrolled in the study. They were encouraged to masturbate regularly at least twice a week and were re-evaluated at the end of a 6 month period, including a complete inquiry regarding their sexual function during this time. Response was assessed by a symptom severity index. RESULTS: Clinical and laboratory re-evaluation could be performed in 28 patients. Of 18 patients who adhered to the recommendations, two (11%) experienced complete relief of symptoms, whereas six (33%) had marked improvement, six had moderate improvement and four (22%) did not benefit. In contrast, three of seven patients who masturbated less frequently reported partial improvement. Three patients who did not ejaculate other than during wet dreams had a worse prognosis. CONCLUSIONS: Young men who are single and suffering from NBP must be informed about their illness in detail and, if they are not doing so, they should be encouraged to ejaculate regularly, for example by masturbation in the absence of a sexual relationship with a partner. We believe that normal sexual activity decreases the incidence of NBP in some cases.

Renal cell carcinoma with solitary synchronous pancreaticoduodenal and metachronous periprostatic metastases: report of a case.

We report herein the case of a patient who underwent successful resection of a solitary metachronous periprostatic metastasis 12 months after undergoing a right radical nephrectomy with pylorus-preserving pancreaticoduodenectomy for renal cell carcinoma (RCC) with a synchronous pancreaticoduodenal metastasis. At present the patient is free of any signs of recurrence 12 months after removal of the metachronous mass in the periprostate. This case report supports the opinion that an aggressive surgical approach is appropriate for RCC metastasis.

Pneumatic lithotriptor--a useful tool for challenging renal stone surgery.

Open surgical measures may be undertaken in the treatment of some complex calculi and manoeuvres such as extended pyelolithotomy or nephrolithotomy may be necessary. In an attempt to improve surgical results with less morbidity and maximum ease, we used the Swiss Lithoclast to disintegrate large stones presenting as hard cases. Five patients with renal pelvic stones associated with calyceal stones in two and two further cases with staghorn stones were treated surgically using the pneumatic lithotriptor probe with less dissection and without nephrotomy. Only one of the patients with staghorn stones had residual fragments which were then treated with ESWL. We believe that when open surgical treatment is considered in hard cases, especially in those with small renal pelvises, the best results may be achieved with minimum surgical intervention if it is combined with pneumatic lithotripsy.

A very long foreign body in the bladder.

We report on a 58-year-old man in whom a very long rubber catheter was self-inserted for the purpose of increasing rigidity during erection. Eight years elapsed between insertion of the catheter and its retrieval. The foreign body was removed from the bladder by endoscopy.

Percutaneous suprapubic transvesical route: a new and comfortable method of intraprostatic injection.

To assess the efficacy and safety of the percutaneous suprapubic transvesical route (STR) for intraprostatic antibiotic injections and compare it with the transperineal route (TPR), a total of 37 patients suffering from chronic bacterial prostatitis, resistant even to treatment with fluoroquinolones, were randomized to intraprostatic amikacin injections using either STR (n = 19) or TPR (n = 18). Follow-ups were done at weeks 4, 12, 24 and 52. Patients found to have failures at the first follow-up were given an additional injection using the initial route. At the 24th week, 15 patients from both groups were given another injection using the alternative route and were asked to report any subsequent voiding difficulties and compare the discomfort and pain experienced. At the end of 52 weeks, bacteriological cure rates did not differ significantly (44.4 vs. 47.3%). Overall improvement rates in the severity of symptoms and signs were similiar. Considerable difficulty in directing the needle to the prostate due to an excessive amount of subcutaneous fat was experienced, and more than 1 skin puncture was necessary in 5 of the STR group, whereas in the TPR group 7 patients with external hemorrhoids and 1 patient with a rectal fissure had prominent discomfort and pain during the transperineal procedures. Complications such as dysuria or hemospermia were encountered infrequently in both groups, but hematuria was observed more frequently in the STR group (85 vs. 54%). Less discomfort (p < 0.01) and pain (p < 0.01) were reported during access to the prostate by STR, but pain during the injection of the drug did not differ significantly. In conclusion, the percutaneous STR may well be used efficiently and comfortably as an alternative method to TPR when intraprostatic injections are needed in a limited number of cases such as those with a known hypersensitivity to fluoroquinolones or with a history of failure despite long-term systemic treatment with these agents.

The effects of ejaculation on serum prostate-specific antigen (PSA).

To determine the effects of ejaculation on serum PSA, we measured serum levels just before masturbation and 24 hours and 5 days later in a study group (n=25) aged between 23 and 25 years. In the study group, 16 cases showed a decrease (mean 22.37%, range 10-50%) in serum PSA levels 24 hours after ejaculation, while 6 had higher levels (mean 38.33%, range 21-67%) and 3 had no changes. No relation was found between seminal plasma levels or total amounts expelled of this marker and the difference in serum levels due to ejaculation. In the control group free of ejaculation in the same period determinations of serum PSA levels revealed no significant changes between days 0, 1 and 5. As compared with the control group, the changes in the study group were found to be statistically insignificant. These results may indicate that ejaculation has an insignificant effect on serum PSA levels.

Intracorporeal pneumatic lithotripsy for ureteral and vesical calculi.

To evaluate the effectiveness of pneumatic lithotripsy, 92 patients with 98 lower or mid-ureteric calculi and 8 with vesical calculi were treated with pneumatic lithotripsy (Swiss Lithoclast) under spinal anaesthesia. Successful stone fragmentation was achieved in 96 patients. In two patients their stones migrated to the upper ureter and renal pelvis during the procedure and so they were referred for extra corporeal shock wave lithotripsy. Total ureteral avulsion occurred in one patient and in another case attempts to dilate the stenotic ureteral orifice failed. In both cases, ureterolithotomy and ureteral reimplantation were performed. Pneumatic lithotripsy is found to be an easy, reliable and cost-effective method of endoscopic lithotripsy.

Treatment of catheter-associated Candiduria with fluconazole irrigation.

OBJECTIVE: To examine the safety and efficacy of fluconazole in patients with a permanent nephrostomy or suprapubic catheter in the prevention of candiduria. PATIENTS AND METHODS: Twenty patients with a nephrostomy or suprapubic catheter who had at least two positive urine cultures with a minimum of 15,000 col/mL Candida counts were studied. The catheters were irrigated with fluconazole solution prepared as 1 mg/mL with normal saline. Repeated urine cultures were obtained. RESULTS: In 17 patients Candida was eradicated from the urine by the third to sixth day of irrigation. No side-effects were noted. CONCLUSION: Fluconazole as an irrigant is effective and safe in the treatment of catheter-associated candiduria, which can be eliminated without changing the catheter.

Seasonal variation of prostatic acid phosphate and prostate-specific antigen in patients without prostatic malignancy.

The seasonal pattern of prostatic acid phosphatase (PAP) and prostate specific antigen (PSA) in nonmalignant males was investigated. Serum levels were measured in 1,540 men during a 3-year period with radioimmunoassay methods using monoclonal antibody techniques. All of the tested individuals were free of prostatic malignancy. During each of the 3 years, PAP ans PSA showed a rise, especially in spring. The mean PSA level in spring showed a statistically important difference when compared with winter, fall and summer mean levels (p less than 0.05). However, no significant difference of PAP levels was estimated seasonally in the 3 years, which shows that an important marker of prostatic cancer can vary with seasons.