Adnan Gucuk

Effectiveness of Doxazosin in Treatment of Distal Ureteral Stones in Children

PURPOSE We evaluated the effectiveness of doxazosin in children with distal ureteral stones in terms of stone expulsion rates and time to expulsion. MATERIALS AND METHODS A total of 39 patients 2 to 14 years old with lower ureteral stones smaller than 10 mm were enrolled and randomly divided into 2 groups. Group 1 consisted of 20 controls receiving ibuprofen for pain and group 2 consisted of 19 patients receiving doxazosin. Doxazosin dose was approximately 0.03 mg/kg daily. All patients were evaluated with x-ray, ultrasound or spiral computerized tomography. Stone expulsion rates and time to expulsion between the groups were compared. Mean followup was 19 days. Effects of doxazosin were also evaluated by comparing subgroups with stones smaller than 5 mm and 5 to 10 mm. Results were also evaluated with special emphasis on gender and age. RESULTS Expulsion was observed in 14 patients (70%) in group 1 and 16 (84%) in group 2 (p >0.05). Mean expulsion times for groups 1 and 2 were 6.1 and 5.9 days, respectively (p >0.05). Although fewer pain episodes were observed in the treatment group, this finding could not be evaluated objectively. None of the patients experienced any adverse effects. CONCLUSIONS Administration of 0.03 mg/kg doxazosin daily in children to treat distal ureteral stones up to 10 mm is not superior to analgesic alone. This result is not affected by gender, stone size or patient age. However, additional randomized controlled studies, especially including larger stone volumes, and different doses of doxazosin and other alpha-blockers, might highlight the usefulness of alpha-blockers for ureteral stones in children.

Comparison of percutaneous nephrolithotomy, shock wave lithotripsy, and retrograde intrarenal surgery for lower pole renal calculi 10-20 mm.

Objective: To compare the results of percutaneous nephrolithotomy (PCNL), shock wave lithotripsy (SWL), and retrograde intrarenal surgery (RIRS) for 1- to 2-cm lower pole kidney stones. Patients and Methods: This retrospective study was based on data collected from the files of patients between January 2007 and May 2012. The files of 383 patients (221 SWL, 144 PCNL, 38 RIRS) were evaluated. The groups were compared for stone size, success rate, and complication rate using the modified Clavien grading system. Results: The stone burdens of the groups were similar (p = 0.36). The success rates were 76, 94, and 73%, respectively, in SWL, PCNL, and RIRS. The highest stone-free rate was in the PNL group (p < 0.05). When the complication rates were evaluated using the Clavien grading system, they were determined to be 13% in PCNL, 3% in SWL, and 5% in RIRS. Especially GII and GIII complications were more common in the PCNL group (p < 0.05). Conclusion: PCNL seems to be the most successful but most invasive method. However, with relatively low complication rates, SWL and RIRS are other techniques to keep in mind. To determine the first-line treatment, prospective randomized studies with larger series are needed.

LRIG2 Mutations Cause Urofacial Syndrome

Urofacial syndrome (UFS) (or Ochoa syndrome) is an autosomal-recessive disease characterized by congenital urinary bladder dysfunction, associated with a significant risk of kidney failure, and an abnormal facial expression upon smiling, laughing, and crying. We report that a subset of UFS-affected individuals have biallelic mutations in LRIG2, encoding leucine-rich repeats and immunoglobulin-like domains 2, a protein implicated in neural cell signaling and tumorigenesis. Importantly, we have demonstrated that rare variants in LRIG2 might be relevant to nonsyndromic bladder disease. We have previously shown that UFS is also caused by mutations in HPSE2, encoding heparanase-2. LRIG2 and heparanase-2 were immunodetected in nerve fascicles growing between muscle bundles within the human fetal bladder, directly implicating both molecules in neural development in the lower urinary tract.

Does the Hounsfield Unit Value Determined by Computed Tomography Predict the Outcome of Percutaneous Nephrolithotomy

PURPOSE We aimed to evaluate whether the Hounsfield unit (HU) value predicts outcome in percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS One hundred and seventy-nine patients who had undergone PCNL in our clinics in the last 4 years were included. Demographic and clinical data of the patients and complications, if any, were recorded. The mean age of the patients was 45.3 ± 14.3 years (range 5-82 y), and 111 of them were males (62%). The mean stone size and HU values were found to be 693.1 ± 628.0 (95-4200) mm(2) and 706.3 ± 245.0 (214-1325), respectively. RESULTS In logistic regression analysis, the size of the stone, the opacity of the stone, and the HU values were found to be independent predictors of the failure of the procedure (P<0.05). A cutoff value of 677.5 was used for the HU in the receiver operating characteristics analysis. Having a HU value under the cutoff value increased the likelihood of procedure failure by 2.65 times, whereas stones residing in the staghorn localization increased failure by 5.68. It was also observed that if the stones size was 485 mm(2) or more, the chance of failure increased by 1.9, whereas when the stone was nonopaque, failure increased by 6.04 times (P<0.05). There was a positive correlation between hematocrit decrease and a decrease in HU values (P<0.05), but no correlation was observed between the HU values and duration of surgery or fluoroscopy (P>0.05). CONCLUSION In addition to the size and location of the stones, the HU value determined in the unenhanced CT scan may be one of the parameters affecting PCNL outcomes. PCNL is a more efficient method in stones with higher HU values. Therefore, the HU values may be a useful tool for the selection of the treatment modality in patients with renal stones.

Comparison of Outcomes for Adjustable Bulbourethral Male Sling and Artificial Urinary Sphincter After Previous Artificial Urinary Sphincter Erosion

OBJECTIVES To compare the outcomes of the adjustable bulbourethral male sling and artificial urinary sphincter (AUS) in patients with recurrent postprostatectomy incontinence after previous AUS erosion. METHODS Sixteen patients with recurrent postprostatectomy incontinence who had undergone either adjustable bulbourethral male sling placement (group 1, n = 8) or AUS implantation (group 2, n = 8) were included in the study. The preoperative evaluations included history, physical examination, International Consultation on Incontinence Questionnaire-short form, pad test, cystoscopy, and urodynamic studies. The follow-up examinations were performed at 1, 3, 6, and 12 months postoperatively and annually thereafter. RESULTS The mean follow-up was 10 months (range 7-19) and 22 months (range 6-38) for groups 1 and 2, respectively (P = .009). Of the 16 patients, 6 were cured, 1 with the sling and 5 with the AUS (cure was defined as no pads daily); 3 were improved, 1 with the sling and 2 with the AUS (improvement was defined as no more than 2 pads daily), and 7 had treatment failure, 6 with the sling and 1 with the AUS. No intraoperative complication was seen in either group. Readjustment of sling tension was done in 4 patients who had persistent incontinence. No reoperation, excluding the readjustments, was required in group 1; however, 3 patients had transient perineal pain. The AUS was removed for recent erosion at 6 and 12 months postoperatively in 1 cured patient and 1 patient with treatment failure, respectively. Ultimately, 50% of the patients (25% with the sling and 75% with the AUS) were cured or improved. CONCLUSIONS The results of our study have shown that AUS implantation results in better outcomes than placement of the adjustable bulbourethral male sling as secondary therapy.

Usefulness of hounsfield unit and density in the assessment and treatment of urinary stones

Computed tomography (CT) is widely used to examine stones in the urinary system. In addition to the size and location of the stone and the overall health of the kidney, CT can also assess the density of the stone in Hounsfield units (HU). The HU, or Hounsfield density, measured by CT, is related to the density of the tissue or stone. A number of studies have assessed the use of HU in urology. HUs have been used to predict the type and opacity of stones during diagnosis, and the efficacy has been assessed using methods including extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureterorenoscopic ureterolithotripsy (URSL), and medical expulsive treatment (MET). Previous studies have focused on the success rate of HU for predicting the type of stone and of ESWL treatment. Understanding the composition of the stone plays a key role in determining the most appropriate treatment modality. The most recent reports have suggested that the HU value and its variants facilitate prediction of stone composition. However, the inclusion of data regarding urine, such as pH and presence of crystals, increases the predictive accuracy. HUs, which now form part of the clinical guidelines, allow us to predict the success of ESWL; therefore, they should be taken into account when ESWL is considered as a treatment option. However, there are currently insufficient data available regarding the value of HU for assessing the efficacy of PCNL, URSL, and MET. Studies performed to date suggest that these values would make a significant contribution to the diagnosis and treatment of urinary system stones. However, more data are required to assess this further.

Prognostic factors in metastatic prostate cancer

OBJECTIVE Aim of this study is to determine the prognostic value of age, serum alkaline phosphatase, pretreatment PSA level, Gleason score, and number of bone metastasis focuses. PATIENTS AND METHODS One hundred fifty-one patients who had been followed in our clinic between years 1989 and 2006 were investigated retrospectively. RESULTS As a result of this study, it has been detected that serum alkaline phosphatase, Gleason score, and intensity of bone metastasis are important and statistically significant prognostic factors, and affects time to progression and life time. But pretreatment PSA level, and age have been detected not to be effective in predicting time to progression and life time. CONCLUSION Metastatic prostate cancer provides a wide spectrum for risk of death from the disease, and clinicians have long sought methods to predict the outcome accurately in individual patients. In our study, we found that high serum alkaline phosphatase, high Gleason score, and intense bone metastasis (>6) has negative impact on progression and survival.

The comparison of laparoscopy, shock wave lithotripsy and retrograde intrarenal surgery for large proximal ureteral stones

INTRODUCTION In this study we compare the success rates and complication rates of shock wave lithotripsy (SWL), laparoscopic, and ureteroscopic approaches for large (between 1 and 2 cm) proximal ureteral stones. METHODS In total, 151 patients with ureteral stones between 1 and 2 cm in diameter were randomized into 3 groups (52 SWL, 51 laparoscopy and 48 retrograde intrarenal surgery [RIRS]). The groups were compared for stone size, success rates, and complication rates using the modified Clavien grading system. RESULTS Stone burden of the groups were similar (p = 0.36). The success rates were 96%, 81% and 79%, respectively in the laparoscopy, SWL, and ureteroscopy groups. The success rate in laparoscopy group was significantly higher (p < 0.05). When these groups were compared for complication rates, RIRS seemed to be the group with the lowest complication rates (4.11%) (p < 0.05). SWL and laparoscopy seem to have similar rates of complication (7.06% and 7.86%, respectively, p = 0.12). INTERPRETATION To our knowledge, this is the first study to compare the results of laparoscopy, SWL and RIRS in ureteral stones. Our results showed that in management of patients with upper ureteral stones between 1 and 2 cm, laparoscopy is the most successful method based on its stone-free rates and acceptable complication rates. However, the limitations of our study are lack of hospital stay and cost-effectiveness data. Also, studies conducted on larger populations should support our findings. When a less invasive method is the only choice, SWL and flexible ureterorenoscopy methods have similar success rates. RIRS, however, has a lower complication rate than the other approaches.

Routine Flexible Nephroscopy for Percutaneous Nephrolithotomy for Renal Stones with Low Density: A Prospective, Randomized Study

PURPOSE We evaluated the usefulness of routine flexible nephroscopy during percutaneous nephrolithotomy. MATERIALS AND METHODS Patients diagnosed with kidney stones who were scheduled to undergo percutaneous nephrolithotomy between March 2011 and July 2012 were randomized into 2 groups. Group 1 underwent standard percutaneous nephrolithotomy using rigid nephroscopy. Group 2 underwent flexible nephroscopy, in addition to standard percutaneous nephrolithotomy and laser lithotripsy or basket catheter stone extraction, as needed. Surgery was performed subcostally and with minimal percutaneous access in group 2 to use the advantages of flexible nephroscopy. We compared the 2 groups in terms of preoperative stone characteristics and postoperative success criteria, including the stone-free rate, bleeding, number of access sites, etc. RESULTS The study included 61 males (76.3%) and 19 females (23.8%) with a mean ± SD age of 43.75 ± 12.4 years (range 19 to 74). There was no significant difference in stone size, HU density or stone location between the 2 groups. Comparison of perioperative and postoperative parameters revealed a higher stone-free rate (92.5% vs 70%), fewer access sites and a lower hematocrit decrease in group 2. The stone-free rate was higher in patients with stones with a density of less than 677.5 HU (100% in group 2 vs 64.7% in group 1). CONCLUSIONS Routine flexible nephroscopy during percutaneous nephrolithotomy was associated with a higher stone-free rate, fewer interventions and less bleeding, especially in patients with low HU density stones.

The short-term efficacy of dilatation therapy combined with steroid after internal urethrotomy in the management of urethral stenoses.

PURPOSE To present the short-term results of hydrophilic dilatation catheter or steroid-coated hydrophilic dilatation catheter usage in the management of primary urethral stricture. PATIENTS AND METHODS Forty-five male patients with a diagnosis of primary urethral stricture shorter than 1.5 cm and no comorbities were included in this study. After application of visual internal uretrotomy interna, these patients were randomized into three groups. A steroid-coated (triamcinolone acetonide 1%) 18F hydrophilic dilatation catheter was applied to the patients in group 1 for 2 weeks and an 18F hydrophilic dilatation catheter was applied to the patients in group 2 for 2 weeks. An 18F silicone urethral catheter was applied to the patients in group 3, and catheters were removed after 3 days. Uroflowmetry was used in postoperative follow-ups. RESULTS Mean patient age and follow-ups were 33.4 (19-45) years and 16.4 (6-18) months, respectively. The postoperative maximum urinary flow rate was 15.3 +/- standard deviation (SD) 4.6, 13.8 +/- SD 4.8, and 12.4 +/- SD 4.4 for groups 1, 2, and 3, respectively (P 0.323). Failure was detected in three (20%) patients in group 1, seven (46.7%) patients in group 2, and nine (60%) patients in group 3 (P > 0.05). CONCLUSIONS As an adjuvant treatment, this method is effortless, low in complications, and hopeful. Certainly, application to larger patient populations is needed to objectively accept its efficiency.