Ali Ihsan Tasci

Laparoendoscopic Single-Site Surgery Versus Standard Laparoscopic Simple Nephrectomy: A Prospective Randomized Study

BACKGROUND AND PURPOSE Laparoendoscopic single-site surgery (LESS), an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions, has been developed recently. Our aim was to compare LESS simple nephrectomy (LESS-SN) and conventional transperitoneal laparoscopic simple nephrectomy (CTL-SN). PATIENTS AND METHODS In this randomized study that was conducted between December 2008 and September 2009, 27 patients who needed simple nephrectomy were randomized to either LESS-SN or CTL-SN. All procedures in both groups were performed by the first author, who is experienced in laparoscopic surgery. Patient characteristics, perioperative details, and time to return to work were recorded. Postoperative evaluation of pain and use of analgesic medication were recorded. RESULTS There was no difference in median operative time (117.5 vs 114 min, P = 0.52), blood loss (50.71 vs 47.15 mL, P = 0.60), transfusion rates (0% for both), and hospitalization time (2.07 vs 2.11 days, P = 0.74) between the LESS-SN and CTL-SN groups. Time to return to normal activities was shorter in the LESS-SN group compared with the CTL-SN group (10.7 vs 13.5 days, P = 0.001). Both the visual analogue scale and the postoperative use of analgesics were significantly lower during postoperative days 1, 2, and 3 in patients who underwent LESS-SN, compared with patients who underwent CTL-SN. There were no intraoperative or postoperative complications in both groups. Compared with CTL-SN, LESS-SN was more expensive, but all patients undergoing LESS-SN were very pleased with the cosmetic outcome (no visible scars). CONCLUSION The early experience described in this study suggests that LESS-SN is a safe and effective alternative to CTL-SN that provides surgeons with a minimally invasive surgical option and the ability to hide the surgical incision within the umbilicus; however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain, recovery, or cosmesis.

120-W GreenLight Laser Photoselective Vaporization of Prostate for Benign Prostatic Hyperplasia: Midterm Outcomes

OBJECTIVES To evaluate the safety and efficacy of 120-W high-performance system (HPS) laser photoselective vaporization of the prostate (PVP) in the treatment of patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia. METHODS Two experienced surgeons performed 120-W HPS laser PVP. The baseline characteristics, perioperative data, complications, and postoperative outcomes were evaluated at 3, 6, 12, 24, and 36 months postoperatively. RESULTS A total of 550 consecutive patients, with a mean age of 67.6 years, underwent PVP with a 120-W HPS laser. The mean prostate volume was 72.93 cm3, with a mean prostate-specific antigen level of 3.57 ng/mL. The mean operative duration and the mean applied energy was 61.3 minutes and 164.06 kJ, respectively. No major complication occurred intraoperatively or postoperatively. The mean follow-up was 17.80 months. Significant improvements were observed postoperatively in the mean International Prostate Symptom Score, quality of life score, maximal urinary flow rate, and postvoid residual urine volume. The mean catheterization time was 18.5 hours. The complications included delayed hematuria in 26 (4.8%), recatheterization in 24 (4.4%), reoperation owing to residual prostatic adenoma in 46 (8.5%), urethral stricture in 19 (3.5%), and bladder neck contracture in 6 (1.1%) patients. CONCLUSIONS PVP with a 120-W HPS laser for benign prostatic hyperplasia has been proved to be a safe and effective procedure for our patients, including those treated with oral anticoagulants. The functional outcome in larger prostates was similar to that in smaller glands.

Comparison of Photoselective Vaporization of the Prostate and Transurethral Resection of the Prostate: A Prospective Nonrandomized Bicenter Trial with 2-Year Follow-Up

PURPOSE To present our 2-year data comparing photoselective vaporization of the prostate (PVP) and transurethral resection of the prostate (TURP) for patients suffering from lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). PATIENTS AND METHODS In this prospective non-randomized study, 210 patients with a prostate volume <70 mL underwent PVP (112) or TURP (98). Functional follow-up included measurement of maximum urinary flow rate (Q(max)), post-void residual urine volume (PVR), International Prostate Symptom Score (IPSS), and quality-of-life score (QoL) within a 24-month period. While anticoagulant therapy was discontinued before the operation in the TURP group, it was not discontinued in the PVP group. RESULTS Baseline characteristics of both groups were similar. Mean operative time was 55.5 +/- 21.8 minutes for PVP and 46.0 +/- 8.7 minutes for TURP (P < 0.001). No statistically significant difference was observed between postoperative serum sodium and hemoglobin values in both groups (P > 0.05). Catheter indwelling time and hospitalization time of the PVP group were shorter than those of the TURP group (P < 0.001). In both groups, an immediate and highly significant improvement of Q(max), PVR, IPSS, and QoL was evident. Within 24 months urethral stricture in 3 patients after TURP and bladder neck contracture in 2 patients after PVP were observed. CONCLUSIONS The postoperative micturition improvement was significant and lasting, and was equivalent in both groups. The rate of complications was equally low with both procedures. PVP had the advantage of shorter hospitalization and catheter indwelling times and no need for discontinuation of anticoagulant therapy compared to TURP.

A New Robot for Flexible Ureteroscopy: Development and Early Clinical Results (IDEAL Stage 1–2b)

BACKGROUND An improved armamentarium has had a significant impact on the emerging role of flexible ureteroscopy (FURS) for the management of nephrolithiasis; however, FURS still represents a challenging technique. OBJECTIVE To examine a robotic device designed for FURS for its impact on ergonomics and outcome of the procedure based on the IDEAL (idea, development, evaluation, assessment, long-term study) framework. DESIGN, SETTING, AND PARTICIPANTS Roboflex Avicenna consists of a surgeons console and a manipulator for the flexible ureterorenoscope. Following experimental evaluation of the prototype (IDEAL stage 1) and receipt of ethical approval, seven surgeons treated 81 patients (mean age: 42 yr [range: 6-68]) with renal calculi (mean volume: 1296±544 mm(3) [range: 432-3100 mm3]) in an observational study (IDEAL stage 2). SURGICAL PROCEDURE Robotic FURS was performed with the Roboflex Avicenna robotic device. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Numerical data were analysed with the Mann-Whitney test, and categorical variables were analysed using the chi-square test or Fisher exact test. P values <0.05 were considered statistically significant. RESULTS AND LIMITATIONS Mean robot docking time was 59.6±45 s. Mean operative time was 74min (range: 40-182). Mean fragmentation speed was 29.1±6.1 mm3/min. Ergonomics based on a validated questionnaire showed significant advantage for robotic FURS (total score: 5.6 vs 31.3; p<0.01). A 10/12F-access sheath was used in 72 patients. Two cases required secondary FURS, one because of malfunction of the flexible digital ureteroscope and another because of larger residual fragments. In the remaining 79 cases, complete stone disintegration was accomplished. CONCLUSIONS Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics. Future studies should evaluate its impact on the clinical outcome of FURS. PATIENT SUMMARY Robotic flexible ureteroscopy (FURS) was performed with the Roboflex Avicenna robotic device. Results showed that Roboflex Avicenna provides a suitable and safe platform for robotic FURS with significant improvement of ergonomics.

Possible association of the 5-HTTLPR serotonin transporter promoter gene polymorphism with premature ejaculation in a Turkish population

We evaluated the genotypes of the serotonin transporter gene (5-HTT) in patients with premature ejaculation (PE) to determine the role of genetic factors in the etiopathogenesis of PE and possibly to identify the patient subgroups. A total of 70 PE patients and 70 controls were included in this study. All men were heterosexual, had no other disorders and were either married or in a stable relationship. PE was defined as ejaculation that occurred within 1 min of vaginal intromission. Genomic DNA from patients and controls was analyzed using polymerase chain reaction, and allelic variations of the promoter region of the serotonin transporter gene (5-HTTLPR) were determined. The 5-HTTLPR (serotonin transporter promoter gene) genotypes in PE patients vs. controls were distributed as follows: L/L 16% vs. 17%, L/S 30% vs. 53% and S/S 54% vs. 28%. We examined the haplotype analysis for three polymorphisms of the 5-HTTLPR gene: LL, LS and SS. The appropriateness of the allele frequencies in the 5-HTTLPR gene was analyzed by the Hardy-Weinberg equilibrium using the chi2-test. The short (S) allele of the 5-HTTLPR gene was significantly more frequent in PE patients than in controls (P<0.05). We suggest that the 5-HTTLPR gene plays a role in the pathophysiology of all primary PE cases. Further studies are needed to evaluate the relationship between 5-HTTLPR gene polymorphism and patient subgroup (such as primary and secondary PE) responses to selective serotonin reuptake inhibitors as well as ethnic differences.

Rapid Communication: Photoselective Vaporization of the Prostate versus Transurethral Resection of the Prostate for the Large Prostate: A Prospective Nonrandomized Bicenter Trial with 2-Year Follow-Up

PURPOSE To present our 2-year data comparing photoselective vaporization of the prostate (PVP) and transurethral resection of the prostate (TURP) for patients suffering from lower urinary tract symptoms (LUTS) secondary to large-volume benign prostatic hyperplasia. MATERIALS AND METHODS In this prospective, nonrandomized study, 81 patients with a prostate volume of between 70 and 150 mL underwent either PVP (40) or TURP (41). All patients were preoperatively assessed by International Prostate Symptom Score (IPSS), transrectal ultrasonography (TRUS), uroflowmetry, and postvoid residual urine (PVR) measurement. We compared parameters, complications, and functional follow-up between the groups. RESULTS The baseline characteristics of the two groups were similar. Mean operative time was 126.2 +/- 17.4 minutes for PVP and 77.9 +/- 8.3 minutes for TURP (P < 0.001). Bleeding requiring blood transfusion in one patient and transurethral resection (TUR) syndrome in one patient were observed in the TURP group. Catheter indwelling times and hospitalization times of patients in the PVP group were all shorter than those of patients in the TURP group (P < 0.001). In both the groups, an immediate and highly significant improvement of maximum urinary flow rate (Q(max)), PVR, and IPSS was evident. Capsule perforation was observed in one patient undergoing TURP. Reoperation was required in three patients in the group of PVP and one patient in the TURP group. We observed urethral stricture in two patients after TURP. CONCLUSION The postoperative micturition improvement was significant and lasting, and was equivalent in both groups. The rate of late complications is equally low with both procedures. Catheterization time and hospital stay were significantly shorter with PVP.

Color Doppler Ultrasonography and Spectral Analysis of Venous Flow in Diagnosis of Varicocele

Objective: The standardization of diagnostic criteria for varicocele has not yet been established. This causes difficulty in evaluating both the incidence and clinical studies. Our aim was to establish diagnostic criteria for varicocele in Doppler procedures. Methods: The characteristics of blood flow in the internal spermatic vein were investigated with color Doppler ultrasonography (CDU) and venous flow spectral analysis in 100 infertile men without clinical varicocele (group I), 100 infertile men with clinical left varicocele (group II), and 50 fertile men without clinical varicocele served as controls (group III). Results: Three types of flow pattern were found in the spectral analysis of venous flow. If the venous flow was directed to the heart and did not change direction with an intra–abdominal pressure increase, it was classified as type I; venous flow directed to the heart, but changing direction with an intra–abdominal pressure increase, was classified as type II, and blood flow directed to the testicles and augmenting with an intra–abdominal pressure increase, was classified as type III. In group I, flow patterns were 39, 56 and 5% on the left side and 55, 42 and 3% on the right side for types I, II and III, respectively. In group II, flow patterns were 0, 35 and 65% on the left side and 61, 38 and 1% on the right side for type I, II and III patterns, respectively. In group III, the figures were 44, 54 and 2% for the left and 54, 46 and 0% for the right. Type II and III flow patterns were seen more frequently than type I in patients with clinical left varicocele (p<0.001). Whereas type I and II flow patterns were more common than type III in subjects without clinical varicocele (p<0.05). A type II flow pattern during normal breathing was seen at a lower rate in the control group than in the other groups (p<0.05). Conclusion: Spectral analysis of Doppler waves should be used in combination with CDU for the diagnosis of varicocele. Varicocele should not only be diagnosed with a type II flow pattern which occurs during valsalva. For the diagnosis of varicocele, the main criterion must be a type III pattern flow, as well as a type II pattern during normal breathing.

Protective Effect of a Potent Antioxidant, Pomegranate Juice, in the Kidney of Rats with Nephrolithiasis Induced by Ethylene Glycol

PURPOSE We aimed to study the protective effects of pomegranate juice (PJ) on ethylene glycol (EG)-induced crystal deposition in renal tubules, renal toxicity, and inducible nitric oxide synthase (iNOS) and nuclear factor-kappaB activities in rat kidneys. MATERIALS AND METHODS Fifty-six rats were divided into four equal groups: Control, EG, EG + 50 microL PJ/d (PJ50), and EG + 100 microL PJ/d (PJ100). Rats were sacrified on days 10 and 45. Tissue sections were evaluated under light and polarized microscopy for the presence and degree of crystal deposition and toxicity in the kidneys. Crude extracts of the cortex were used to determine reduced gluthatione (GSH), nitric oxide (NO), and malondialdehyde (MDA) levels. RESULTS In the EG group, crystal depositions were more evident and mild crystalization was observed in proximal tubules on day 10; severe crystalization and granulovacuolar epithelial cell degeneration were observed on day 45. There was limited or no crystal formation in the EG + PJ-given groups. There were completely normal renal and tubular structures in the control group. There was no significant difference between the four groups in serum levels of sodium, potassium, blood urea nitrogen, and creatinine in any sampling time. Hyperoxaluria, a marked increase in MDA and NO levels, and decrease of GSH were observed in the EG-given groups compared with the others. There were marked iNOS and p65 expressions in only the EG-given rats compared with control and PJ groups, immunohistochemically. CONCLUSION This experiment shows the protective effect of PJ in the EG-induced crystal depositions in renal tubules.

Transurethral Resection of the Prostate With Monopolar Resectoscope: Single-surgeon Experience and Long-term Results of After 3589 Procedures

OBJECTIVE To present our clinical outcomes and to assess the impact of technological improvements that have occurred recently in transurethral resection of the prostate (TURP) on its morbidity. METHODS The data from the 3589 patients who underwent conventional monopolar TURP for BPH from March 2000 to December 2008 were evaluated retrospectively. Data were analyzed to obtain perioperative and postoperative complications, operative time, weight of prostate chips resected, time to catheter removal, and hospitalization time. Patients were followed at 3 months and then yearly. The follow-up included the International Prostate Symptom Score (IPSS), quality of life score (QoL), maximum urinary flow rate (Q(max.)), and prostate-specific antigen. The significant improvements in mean the IPSS, QoL score, and Q(max.) were observed in postoperative visits. RESULTS Intraoperative perforation of prostatic capsule or bladder neck was observed in 27 (0.75%) patients. In the early postoperative period, clot retention with secondary bleeding was observed in 81 (2.3%) patients. Recatheterization was required in 195 (5.4%) patients. Mild to moderate dysuria was observed in 819 (23%) patients. Urinary tract infection occurred in 234 (6.5%) cases. Severe dysuria, urgency, and urge incontinence was observed in 93 (2.6%) patients in the first week after surgery. During the follow-up period, urethral stricture and bladder neck contracture occurred in 117 (3.2%) and 39 (1.08%) patients, respectively. There was no the iatrogenic incontinence. Re-operation as a result of rest prostatic adenoma was required in 158 (4.4%) patients. CONCLUSION These data demonstrate that a technical improvement in TURP provides a lower complication rate. Conventional monopolar TURP can now be performed with excellent long-term efficacy combined with reduced complications.

Percutaneous versus Transurethral Cystolithotripsy

PURPOSE To compare transurethral cystolithotripsy (TUCL) and percutaneous cystolithotripsy (PCCL) modalities performed during simultaneous transurethral resection of the prostate (TURP) in patients with prostate hyperplasia and large bladder stones. PATIENTS AND METHODS Sixty-three patients with prostate volume >40 cc and aggregate stone size >2.5 cm were enrolled in the study between August 2003 and February 2007. TUCL (n = 38) or PCCL (n = 25) procedures were performed during simultaneous TURP. In the TUCL group, the stones were removed after fragmentation through a 23F cystolithotripter with pneumatic lithotripsy. This was followed by TURP, performed with a 26F continuous-flow resectoscope. In the PCCL group, the stones were removed through a suprapubic 30F Amplatz sheath after fragmentation. TURP was then performed with the suprapubic sheath providing continuous drainage. RESULTS Mean age and prostate volumes of the groups were similar. Mean aggregate stone sizes were significantly larger in the PCCL group. The operative time for stone removal was significantly less in the PCCL group while time needed for TURP was statistically similar in the two groups. In the TUCL group, three patients had residual stones necessitating repeated TUCL and urethral stricture developed in three patients. CONCLUSION The smaller caliber of the working channel during TUCL, compared with PCCL, necessitates disintegration of the stones into smaller fragments. This elongates the duration of the intervention and results in increased urethral and bladder trauma. Combined TURP and PCCL is a safer, more effective, and much faster alternative to combined TURP and TUCL in patients with large bladder stones and prostate hyperplasia.