Ahmet Metin

THE COEXISTENCE OF INTRINSIC SPHINCTER DEFICIENCY WITH TYPE II STRESS INCONTINENCE

PURPOSE We investigate the coexistence of intrinsic sphincter deficiency and urethral hypermobility with type II stress incontinence and moderate cystocele. MATERIALS AND METHODS Abdominal leak point pressure measurements were performed during cystometric evaluation with Valsalvas maneuvers in 50 consecutive women 33 to 73 years old (mean age 48.8) diagnosed with urethral hypermobility and moderate cystocele on pelvic examination and cotton swab test. Patients with unstable detrusor contractions or urgency with detrusor hypocompliance were excluded from the study. RESULTS Of the 50 women 36 (72%) had pure urethral hypermobility, and 14 (28%) were diagnosed with intrinsic sphincteric deficiency and hypermobility (mixed incontinence group), including 6 (42.8%) who had undergone previous surgery. No predisposing factor responsible for intrinsic sphincteric deficiency was noted in 8 mixed incontinence group patients (57.2%). CONCLUSIONS The high rate of intrinsic sphincteric deficiency in patients with urethral hypermobility indicates that the incidence with stress incontinence may be greater than previously believed, and may influence the apparently higher failure rates after bladder neck suspension. We believe that leak point pressure measurements are not necessary with sling procedures which correct urethral hypermobility and intrinsic sphincter deficiency but are required if bladder neck suspension is planned.

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.

MULTIFACTORIAL EVALUATION OF DIABETIC ERECTILE DYSFUNCTION

We determined arterial venous and sinusoidal factors in 20 patients with insulin dependent diabetes mellitus and erectile dysfunction by performing dynamic infusion cavernosometry (DIC), colour flow Doppler ultrasonography, penile biothesiometry and corpus cavernosum electromyography (CCE).DIC, colour flow Doppler ultrasonography and penile biothesiometry were done in standard fashion except for CCE. Paradoxical increase in the electrical activity of corpus cavernosum after intracavernous (IC) papaverine was called a discoordination that was due to cavernous smooth muscle contraction instead of relaxatoon.Arterial and accompanying pathologies were found in 10 (50%) patients. In 3 (15%) of them pure arterial pathology, in 6 (30%) patients arterial and veno-occlusive dysfunction (VOD) and in one patient arterial pathology with abnormal biothesiometry were found.VOD and accompanying pathologies were found in 12 (60%) patients. In 6 (30%) of them VOD and arterial, in 4 (20%) patients VOD and discoordination and in 2 (10%) patients VOD and abnormal biothesiometric values were present. A higher frequency and coexistence of VOD and discoordination pattern were observed.In conclusion, patients with diabetic impotence show a wide range pathophysiology of erection and the evaluation of these patients must include multistep techniques.

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.

Is Only Perianal Anesthesia with Lidocaine-Prilocaine Cream Sufficient to Decrease the Pain during Transrectal Ultrasound-Guided Prostate Biopsy? A Prospective Randomized Study

Aims: To determine the optimal place to apply the local anesthetic agent and to investigate the efficacy of lidocaine-prilocaine cream on the perianal and intrarectal region during prostate biopsy. Methods: The study included 80 patients. Patients were randomized into four groups: group 1 served as the control group and was administered no anesthesia; group 2 received 5 ml lidocaine-prilocaine cream perianally; group 3 received 5 ml lidocaine-prilocaine cream intrarectally, and group 4 received lidocaine-prilocaine cream perianally and intrarectally. Pain scores during probe insertion, biopsy procedure, and the overall pain score were assessed. Mean pain scores in each group were compared statistically. Results: In group 1, the mean pain score was significantly higher during probe insertion than that during biopsy (p < 0.001). For the mean overall pain scores, there was no significant difference between groups 1 and 3 (p = 0.942), but the results of group 1 were statistically different from groups 2 (p = 0.001) and 4 (p < 0.001). When we compared the biopsy pain scores, there was no significant difference among the groups (p > 0.05). During probe insertion, subjects in groups 2 and 4 reported significantly lower pain scores than the control group (p = 0.002, p = 0.001, respectively). Conclusions: Perianal anesthesia with lidocaine-prilocaine cream may solely be sufficient to decrease the pain during prostate biopsy.

Electromyographic Changes of Corpus Cavernosum Due to Papaverine and Nitroprusside in Veno-Occlusive Dysfunction

PURPOSE We compared electrical activity of the corpus cavernosum after intracavernous papaverine and nitroprusside injections. Some aspects of the androgen modulator system in patients with veno-occlusive dysfunction are discussed. MATERIALS AND METHODS Electromyography of the corpus cavernosum was performed before and 1 day after intracavernous injection of 60 mg. papaverine and 400 micrograms. sodium nitroprusside in 22 patients with veno-occlusive dysfunction. Changes in duration and amplitude of electromyographic potentials were compared in groups with and without incoordination patterns. RESULTS The decreases in electrical amplitude and duration in 15 patients with a negative incoordination pattern, and increases in 7 with a positive pattern were more significant with intracavernous sodium nitroprusside than with papaverine injections. CONCLUSIONS Electromyographic changes were more prominent with nitroprusside than with papaverine, which demonstrates the use of nitroprusside when performing corpus cavernosum electromyography.

Plaque incision and venous patch grafting for Peyronie's disease

Purpose:To evaluate the results of plaque incision and venous patch grafting to correct the dorsal curvature associated with Peyronies disease.Materials and methods:18 patients with Peyronies disease were treated surgically. All of the patients have dorsal penile curvature for more than one year causing intromission impossible or with some difficulty because of curvature. Median penile angulatio was 60° (range 45°–75°). A transverse incision about 2 cm long was made on the plaque where maximal site of curvature was identified. The saphenous vein harvested from the ankle region is opened longitudinally and its endothelial surface is placed and sutured in contact with the tunical defect.Results:Complete penile straightening was achieved in 16 (88.8%) cases and only two patients have residual curvature less than 30° permitting sexual intercourse. None of the patients returned to baseline preoperative angulation state in the follow up period. 3 patients (16.6%) reported penile shortening, but only one was concerned and showed dissatisfaction about it. 6 patients (33.3%) have transient changes in penile sensation that resolved within 4 months.Conclusions:Plaque incision and placement of saphenous vein patch graft offers a 94.4% satisfactory result in Peyronies disease causing penile dorsal curvature.

Electrical Activity of Corpus Cavernosum in Vasculogenic and Non-vasculogenic Erectile Dysfunction

We aimed to compare the electrical activity of corpus cavernosum before and after intracavernous papaverine injection and to determine the blood lipid profile in vascular and non-vascular erectile dysfunction, and also to assess whether vascular pathology and abnormal blood lipid levels impair cavernosal smooth-muscle relaxation. We determined total cholesterol (TC), triglyceride (TG) and high-density lipoprotein (HDL) levels in peripheral and cavernosal blood in 39 patients with erectile dysfunction. Electromyography of the corpus cavernosum was performed before and after an intracavernous injection with 60 mg of papaverine in all patients. Thirty-nine impotent patients have been divided into two groups: vasculogenic erectile dysfunction (VED) and non-vasculogenic erectile dysfunction (NVED), according to colour Doppler ultrasonic flowmetry, dynamic infusion cavernosometry and the pressure difference between the brachial arterial systolic pressure and cavernosal arterial systolic pressure measurements. Biochemical values and amplitude changes were compared in both groups. The TC level was higher in both peripheral and cavernosal samples of the VED group than in the NVED group (p = 0.000), with no differences between peripheral and cavernosal blood levels within the same groups (p > 0.05). There were no significant changes in TG and HDL levels in any of the groups (p > 0.05). The mean amplitude differences before and after papaverine injection (delta A) were found to be 2.05 +/- 0.78 microV in the VED group and 4.68 +/- 2.53 microV in the NVED group, showing that the relaxation response to papaverine was more significant in the NVED than in the VED group (p = 0.003). The moderate decreases in the amplitude of electrical activity of corpus cavernosum and the higher TC levels found in the VED group can be accepted as the parameters of impairment in the relaxation of corpus cavernosum, showing the role of hypercholesterolaemia and vascular pathologies in erectile dysfunction.

Is apolipoprotein-(a) an important indicator of vasculogenic erectile dysfunction?

We aimed to investigate whether high peripheral and cavernosal plasma levels of apolipoprotein-(a) [Lp (a)] is an indicator for vasculogenic erectile dysfunction. We determined Lp (a), total cholesterol (TC), triglyceride (TG) and high density lipoprotein (HDL) levels in peripheral and cavernosal blood in 39 patients with erectile dysfunction. Thirty-nine impotent patients have been divided into two groups: vasculogenic erectile dysfunction (VED) and nonvasculogenic erectile dysfunction (NVED), according to colour Doppler ultrasonic flowmetry, dynamic infusion cavernosometry, and the pressure difference between the brachial arterial systolic pressure and cavernosal arterial systolic pressure measurements. Biochemical values were compared in both groups. Lp (a) and TC levels were higher in both peripheral and cavernosal samples of VED group than in NVED group, with no differences between peripheral and cavernosal blood levels within the same groups. There were no significant changes in TG and HDL levels in either group. The detection of more than 31 mg/dl in Lp (a) level solely shows the vascular origin with a sensitivity and specificity of 95 and 82.3%, respectively. High Lp (a) levels can be considered an indicator of vasculogenic erectile dysfunction.

Does Lidocaine Ointment Addition Increase Fluoxetine Efficacy in the Same Group of Patients with Premature Ejaculation

Purpose: To evaluate the efficacy of fluoxetine alone and fluoxetine + lidocaine ointment in the same patient group with premature ejaculation (PE). Material and Methods: 78 patients with PE were given 20 mg fluoxetine by an ‘as-needed treatment’ 4 h before planned sexual activity for a period of 3 months. They were then told to add local lidocaine ointment to fluoxetine 30 min before sexual activity for an additional 3 months for most of their sexual attempts. They were asked to note their PE grades and intravaginal ejaculatory latency time (IELT) scores by stopwatch technique before and after each treatment modality; the results were compared statistically afterwards. Results: Of 46 patients who completed the study, the mean pretreatment, fluoxetine alone and fluoxetine + lidocaine ointment treatment PE grades and IELT scores were found to be 6.52 ± 1.42 and 2.58 ± 0.49, 3.21 ± 1.86 and 1.28 ± 0.71, 2.17 ± 1.56 and 1.04 ± 0.72, respectively, showing a decrease in PE grades and IELT scores in combined therapy. On an individual patient basis, the total significant and moderate improvement rate of combined therapy was found to be 86.9%. Failure was observed in 6 (13.1%) patients. Conclusion: The effective treatment with fluoxetine + lidocaine ointment offers the advantage of an ‘as-needed treatment’ in PE with minimal side effects and can be used as one of the first-line alternatives in the treatment of PE.