Altug Tuncel

Determinants of Quality of Life for Patients With Kidney Stones

PURPOSE We evaluated various factors relating to quality of life in a population of patients with stones. MATERIALS AND METHODS A total of 155 patients seen at our urology clinic for stones between January and May 2007 were prospectively questioned regarding stone history and were administered the SF-36 questionnaire to assess quality of life. Age, body mass index, American Society of Anesthesiologists score, number of stone episodes, interval from the last stone episode, number of surgical procedures for stones and associated complications, missed days of work and long-term medical treatment were elicited from the patients. Individual SF-36 domains and composite scores were compared to those of the American general population. Univariate and multivariate regression analyses were performed to assess the impact of all covariates on quality of life scores. RESULTS Patients with stones scored lower than the average American population in 5 of the 8 domains of the SF-36 as well as in the physical composite score. Multivariate regression modeling showed that increasing body mass index and age were the strongest predictors of decreased physical well-being. The number of stone episodes did not influence SF-36 scores, although the number of surgical procedures impacted physical and mental components. The number of ureteroscopy procedures and stent placements primarily impacted mental well-being. Medical therapy, particularly the use of potassium citrate, was associated with more favorable quality of life. CONCLUSIONS Various factors impact quality of life in patients with urolithiasis but the most important are body mass index, age and the number of surgical procedures. Prospective longitudinal studies may further elucidate the determinants of quality of life and they might be used to optimize patient care.

Fournier's Gangrene: Overview of Prognostic Factors and Definition of New Prognostic Parameter

OBJECTIVES To identify the prognostic factors and the new parameters that might predict a worse outcome in nonsurvivors compared with survivors of Fourniers gangrene (FG) and evaluated the validity of the Fourniers Gangrene Severity Index (FGSI) in patients with FG. METHODS The medical records of 18 patients with FG who were treated and followed up in our clinic were reviewed. Data were collected in terms of medical history, symptoms, and physical examination findings. The biochemical, hematologic, and bacteriologic study (aerobic and anaeorobic wound cultures) results at admission and at the final evaluation, the physical examination findings, the timing and extent of surgical debridement, and the antibiotic therapy were also recorded. The Charlson Comorbidity Index (CCI) and FGSI were evaluated stratified by survival. RESULTS The results were evaluated for 2 groups: those who survived (n = 14) and those who did not (n = 4). The admission FGSI score was 5.00 +/- 2.91 (range 0-10) for survivors compared with 13.5 +/- 2.62 (range 9-15) for nonsurvivors (P = .001). The CCI score was 3 +/- 1.5 in survivors and 7 +/- 2.2 in nonsurvivors (P = .008). Individual laboratory parameters such as hypomagnesemia, hemoglobin, hematocrit, alkaline phosphatase, creatinine, and the heart and respiratory rates were associated with a worse prognosis. In addition, a FGSI >9, rectal involvement, colostomy diversion, and a high CCI were associated with high mortality. CONCLUSIONS Low magnesium levels might be a new parameter for a worse prognosis. High CCI and FGSI scores might be associated with a worse prognosis in patients with FG. A FGSI threshold of 9 was a predictor of mortality during the initial assessment.

Training on a Virtual Reality Laparoscopic Simulator Improves Performance of an Unfamiliar Live Laparoscopic Procedure

PURPOSE Virtual reality simulators provide a safe and efficient means of acquiring laparoscopic skills. We evaluated whether training on a virtual reality laparoscopic cholecystectomy simulator (Lap Mentor) improves the performance of a live, unrelated laparoscopic urological procedure. MATERIALS AND METHODS A total of 32 medical students with no previous laparoscopic experience were oriented to the Lap Mentor, and then performed virtual reality laparoscopic cholecystectomy which was assessed by 2 experienced laparoscopists using the previously validated Objective Structured Assessment of Technical Skills scoring. Subjects were randomized to group 1, in which participants completed 6, 30-minute virtual reality training sessions within 3 weeks, or group 2, in which participants received no training. All participants then performed live laparoscopic nephrectomy in a porcine model and performance was evaluated using Objective Structured Assessment of Technical Skills by 2 experts blinded to training status. RESULTS Mean total pretraining laparoscopic cholecystectomy Objective Structured Assessment of Technical Skills scores were comparable between the groups (16.9 +/- 4.3 for group 1 vs 15.4 +/- 6.2 for group 2, p = 0.4). After training total Objective Structured Assessment of Technical Skills scores for live porcine laparoscopic nephrectomy were significantly higher in group 1 compared to group 2 (21.0 +/- 6.8 vs 15.7 +/- 6.6, respectively, p = 0.03). Likewise, individual subcategory Objective Structured Assessment of Technical Skills scores were higher in group 1 than in group 2, although significant differences were noted only in the categories of instrument handling and knowledge of the procedure. CONCLUSIONS Surgical skills acquired as a result of training on a virtual reality laparoscopic simulator are not procedure specific but improve overall surgical skills, thereby translating into superior performance of an unrelated live laparoscopic urological procedure.

Development of quantum dot-mediated fluorescence thermometry for thermal therapies

As thermal therapies are frequently employed for management of tumors in various organs, there are growing demands for reliable and accurate intraoperative monitoring techniques of the thermal lesion. However, current monitoring techniques have limited accuracy, accessibility and are not capable of monitoring the thermal lesion in real-time during the procedure. In the present study, quantum dot-mediated fluorescence thermometry was developed and its performance was characterized to demonstrate the feasibility of spatiotemporal monitoring of thermal lesions. First, the temperature dependency of two different types of CdTe/ZnS quantum dots (QDs) were characterized in a temperature range relevant to hyperthermic therapies, and a temperature–intensity relationship was established for each QD. The spatial and temporal resolutions of the system were characterized by exposing QDs to a pre-determined spatial temperature gradient, and by monitoring the spatiotemporal temperature during gold nanoshell-mediated heating. The results demonstrated that QD-mediated thermometry is capable of measuring spatiotemporally varying temperature fields relevant for hyperthermic thermal therapies. Its implication for intraoperative image-guidance of thermal therapy was also discussed.

Evaluation of costs and morbidity associated with laparoscopic radiofrequency ablation and laparoscopic partial nephrectomy for treating small renal tumours.

To compare the costs and morbidity of laparoscopic radiofrequency ablation (LRFA) and laparoscopic partial nephrectomy (LPN) for treating small localized renal tumours.

Optical Reflectance Spectroscopy to Differentiate Benign From Malignant Renal Tumors at Surgery

OBJECTIVES Optical reflectance spectrophotometry (ORS) is part of a group of novel techniques that have demonstrated promise for the assessment and differentiation of various solid tumors. In this study, we evaluated the ability of ORS to differentiate malignant from benign kidney tumors at surgery. METHODS From January to April 2007, we completed optical spectroscopy measurements (OSM) at several standardized tumoral and normal parenchymal locations immediately after specimen removal during radical or partial nephrectomy. The depth of tissue penetration with our specific probe was 1 mm. We compared the slopes of the optical reflectance curves between 630- and 900-nm wavelengths and assessed the correlation between benign and malignant tumors. RESULTS There were 8 partial and 13 radical nephrectomies for 6 benign (oncocytomas) and 15 malignant (14 clear cell and 1 papillary) tumors. Overall, benign and malignant OSM slopes were significantly different (P = .005). In the near-infrared region, there was excellent correlation among benign (r = .99) and malignant OSM (r = .97). On the contrary, there was a poor correlation coefficient when we compared benign and malignant tumors (r = .49). CONCLUSIONS Optical reflectance spectrophotometry may be a novel real-time method to distinguish malignant from benign tumors in vivo. However, we performed these pilot study measurements immediately after specimen removal, and therefore expansion to in situ assessments is necessary.

An effective classification procedure for diagnosis of prostate cancer in near infrared spectra

The main purpose of this study is to develop an effective classification procedure that discriminates between normal spectra and cancerous spectra in near infrared (NIR) spectroscopic data in which the classes are highly imbalanced and overlapped. Our proposed procedure consists of several steps. First, to ensure the comparability between spectra, normalization was done by dividing each spectral point by the area of the total intensity of the spectrum. Second, clustering analysis was performed with these normalized spectra to separate the spectra that represent the normal pattern from a mixed group that contains both normal and tumor spectra. Third, we conducted two-stage classification, the first being an effort to construct a classification model with the labels obtained from the preceding clustering analysis and the second being a classification to focus on the mixed group classified from the first classification model. To increase the accuracy, the second classification model was constructed based on the selected features that capture important characteristics of the spectral data. Our proposed procedure was evaluated by its classification ability in testing samples using a leave-one-out cross validation technique, yielding acceptable classification accuracy.

Optical Reflectance Spectroscopy to Differentiate Renal Tumor From Normal Parenchyma

PURPOSE Optical spectroscopy has been evaluated as an innovative technique for the ex vivo study of renal and prostate tumors. In this pilot study we assessed the ability of optical reflectance spectroscopy to reliably differentiate tumor and normal tissue in renal specimens. MATERIALS AND METHODS From January to April 2007 we completed optical reflectance spectroscopy measurements at several standardized tumor and normal parenchymal locations immediately after kidney tumor removal. The slopes of the optical reflectance spectroscopy curves were compared, and the correlation between tumor and normal parenchyma reflectance was assessed. RESULTS Reliable measurements were obtained from 13 radical and 8 partial nephrectomy specimens. Histology was malignant in 15 cases (clear cell in 14 and papillary in 1) and benign in 6 cases of oncocytoma. Overall we found a significant difference between the average optical reflectance spectroscopy slopes of tumor and normal parenchyma (p = 0.03). In individual radical nephrectomy specimens optical reflectance spectroscopy measurements at different locations in the tumor showed an excellent correlation (r = 0.968). Normal parenchymal measurements also correlated well (r = 0.88), although there was poor correlation between tumor and nontumor tissue in the specimen (r = 0.07). In the partial nephrectomy subset we also found a close correlation among measurements made on the normal parenchymal margin of the tumor (r = 0.94) except in 1 case of a positive margin (oncocytoma), in which the measurement from the positive margin site did not correlate with that of the adjacent parenchymal margin (r = 0.48). CONCLUSIONS Optical reflectance spectroscopy can help distinguish tumor from normal renal tissue in specimens immediately removed at surgery. Optical reflectance spectroscopy may allow real-time assessment of positive margins during partial nephrectomy.

The Impact of Transrectal Prostate Needle Biopsy on Sexuality In Men and Their Female Partners

OBJECTIVES To evaluate sexuality in men who have undergone transrectal prostate needle biopsy (TPNB) and their female partners. METHODS Ninety-seven men underwent TPNB because of high prostate-specific antigen level (>or=2.5 ng/mL) and/or abnormal digital rectal examination findings and their female partners were included in this study. Men were evaluated for erectile function before biopsy, and the first and sixth months after the biopsy with the 5-item version of the International Index of Erectile Function (IIEF-5). Female partners completed the Female Sexual Function Index (FSFI) in the same periods together with the men. We assessed IIEF-5 and FSFI score alterations after the biopsies. RESULTS The mean ages of men and their partners were 61.2 (40 to 81) years and 56.8 (34 to 70) years, respectively. The mean IIEF-5 scores were 19.1 +/- 5.8, 17.1 +/- 5.9, and 16.8 +/- 7.5 before the biopsy, and 1 and 6 months after the biopsy, respectively. We found significant differences among prebiopsy IIEF-5 scores and postbiopsy first- and sixth-month IIEF-5 scores (P <0.001). On the contrary, there was no significant difference between the postbiopsy first- and sixth-month IIEF-5 scores (P = 0.335). In the female partners, the mean prebiopsy, postbiopsy first- and sixth-month total FSFI scores were 18.0 +/- 6.8, 16.2 +/- 6.8, and 16.0 +/- 8.4, respectively (P <0.001). In first- and sixth-month postbiopsies, all FSFI subscores were significantly lower than the prebiopsy subscores. CONCLUSIONS TPNB seems to have negative impact on erectile function. Male sexual dysfunction after TPNB also has a negative effect on female sexual function. We believe that couples should be informed about the risk of erectile dysfuncton before TPNB.

How Physician and Patient Perceptions Differ Regarding Medical Management of Stone Disease

PURPOSE We compared patient and urologist perceptions regarding the medical management of stone disease. MATERIALS AND METHODS A total of 159 patients were prospectively interviewed. Patients were asked 3 questions concerning subjective tolerance of stone passage and surgical intervention weighed against the use of daily preventive medication. The same questions were sent to members of the Endourological Society. RESULTS Mean +/- SD patient age was 51 +/- 14 years. Recurrent stone formers comprised 72% of patients and 76% had undergone a prior surgical procedure while 43% were taking prophylactic medication. Overall 81% and 88% of patients responded that they would rather take medication than tolerate a single stone event at home or in the emergency room, respectively. Likewise 92% of patients stated that they would prefer daily medication compared to any surgical procedure. Among 61 urologists 26%, 38% and 18% responded that patients would likely tolerate 1, 2 or an unlimited number of stone passages at home, respectively, before agreeing to take medication. Of the urologists 66% estimated that patients would tolerate up to 2 acute stone events requiring an emergency room visit before starting medication. In addition 20%, 31% and 33% of urologists presumed that patients would accept the need for surgery annually, every other year or every third year rather than take medication. CONCLUSIONS Most patients with stones will consider preventive medical therapy to avoid recurrent pain or a surgical procedure. In contrast, most urologists perceive that patients prefer to avoid medication even if it means tolerating several acute stone events and/or surgical procedures.