Aslan Demir

Gastrointestinal Complications of Laparoscopic/Robot-Assisted Urologic Surgery and a Review of the Literature

Gastrointestinal injuries that occur during or after laparoscopic and robot-assisted surgery are serious side effects that affect patient outcome. In this review, we attempt to highlight the identification, incidence and management of gastrointestinal and visceral complications of laparoscopic and robot-assisted surgery. A search of Medline and PubMed databases was performed using the following terms: gastrointestinal complications of laparoscopy, laparoscopic, kidney and robotic surgery. A total of 1,072 papers related to the subject were analyzed. Forty-six of these papers were included in the present review. These papers reported high numbers of participants and had a high level of evidence. Gastrointestinal complications during laparoscopic and robot-assisted surgery are rare, but similar, and can occur at any time between access and closure. Despite their infrequency, these complications can result in mortality. The early recognition and management of gastrointestinal complications is very important. Unrecognized or delayed identification of gastrointestinal complications may cause sepsis and death.

Flexible Ureterorenoscopy versus Extracorporeal Shock Wave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10–20 mm: a retrospective analysis of 174 patients

To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm.A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications.87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1) was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05).F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10–20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10–20 mm and reserved for cases with failure in ESWL.

Small cell carcinoma of the prostate presenting with skin metastasis: a case report

IntroductionSmall cell carcinoma of the prostate is a very rare and aggressive type of prostatic cancer. Most cases are diagnosed at advanced stage due to early metastasis. The bones, liver, regional and distant lymph nodes are the most common sites of metastasis of small cell carcinoma of the prostate. Skin metastasis of small cell carcinoma of the prostate is a very rare entity due to the uncommon metastatic site. Here, we describe the case of a patient with small cell carcinoma of the prostate which metastasized to his skin.Case presentationA 74-year-old Caucasian man presented to another urology center for mild lower urinary tract symptoms in 2003. His prostate-specific antigen was 23ng/mL. According to the physical examination signs and prostate-specific antigen, he underwent a transrectal ultrasound-guided prostate biopsy. The pathologic examination of his prostate revealed a Gleason score: 3+4=7 adenocarcinoma of the prostate. Investigations showed stage T2N0M0 disease and he was treated with radiotherapy to his pelvic lymph nodes and prostate. Six years after the initial diagnosis, he complained of a palpable left-side 2×2cm subcutaneous solitary mass localized just behind his scapula. The results of his laboratory tests including serum acid phosphatase and prostate-specific antigen were in normal ranges. Our general surgery department performed a diagnostic biopsy of the mass and totally excised the lesion. The pathologic examination of the mass showed small cell carcinoma metastasis with chromogranin + and the pathologist advised us to examine the lung or prostate for the primary tumor. The patient undertook a transrectal ultrasound-guided prostate biopsy and the pathologic result revealed small cell carcinoma within residual adenocarcinoma. We investigated the other sites for metastasis and restaging investigations showed a 1cm metastatic lesion in his liver. Our medical oncology department decided to treat him with combination chemotherapy with etoposide and cisplatin in six cycles; however, he died due to disseminated myocardial infarction before starting the fifth combination chemotherapy cycle.ConclusionsClinicians should keep in mind that early diagnosis of this disease is very difficult due to early metastatic spread of small cell carcinoma and lack of concordant elevation of prostate-specific antigen. There is no accepted standard treatment modality for this pathology and overall prognosis is poor.

The course of metastatic prostate cancer under treatment

The first-line management of metastatic prostate cancer is hormonal therapy. However, resistance to this treatment will emerge within an average of 24 months. Our purpose was to determine the course of metastatic prostate cancer under treatment.A total of 56 patients who were diagnosed with metastatic prostate cancer were enrolled. As initial management, 3 kinds of hormonal therapy consisting of bilateral orchiectomy (BSO) alone, BSO + anti-androgene (AA) and LH-RH + AA were applied. The patients were followed until the emergence of hormone resistance. Serum PSA levels at the time of first diagnosis, post-treatment nadir PSA levels, time to nadir PSA, time to hormonal resistance and PSA levels at hormonal resistance were assessed, retrospectively. The localization and number of metastases and the survival term from the beginning of the emergence of hormone resistance until death were investigatedNo significant differences could be established between the groups. The mean time to reach hormone refractory status was 30.3 months for the whole study group. The average term of survival was 42.7 months for the whole group. Distance metastases were found in 8 patients during follow-up.There were no statistical differences between the groups in terms of treatment modalities applied for metastatic prostate cancer. Patients with androgen independent prostate cancer demonstrated progression despite chemical or surgical castration, and had poor prognosis. Initial hormonal therapy failed after an average of 2 years in metastatic prostate cancer.

Endometriosis presenting with right side hydroureteronephrosis only: a case report

IntroductionEndometriosis can be defined as the presence of endometrial glandular and stromal tissue outside the uterus. Affected sites of endometriosis can even be the urinary tract. Here, we present the case of a 30-year-old woman with right ureteral endometriosis. This case was important due to the unusual localization and no signs of the disease except for hydroureteronephrosis.Case presentationA 30-year-old Caucasian woman with para 2 was admitted to our department for right side flank pain, dysuria and suprapubic pain. She had no complaints of vaginal discharge, bleeding or painful menstruation. Her menstrual cycles were normal and lasting for three to four days. She did not have a history of any surgical interventions. A physical examination revealed a right side costovertebral angle and suprapubic tenderness. Laboratory test results including a complete blood count, serum biochemical analysis, urine analysis and urine culture were normal. Urinary ultrasonography showed right side hydroureteronephrosis with renal cortical thinning. We suspected a right ureteral stone obstructing the ureter and a computed tomography scan was performed. The computed tomography scan revealed similar right side hydroureteronephrosis with obstruction of the ureter. No signs of stone were observed on the scan. Retrograde pyelography and diagnostic ureterorenoscopy were performed and they showed a focal stricture with a length of approximately 3cm at the distal ureteral part and secondary hydroureteronephrosis. Open partial ureterectomy and ureteroneocystostomy with Boari flap were performed. The pathologic specimen of her ureter demonstrated intrinsic endometriosis of the right ureter with endometrial glandular cells and stromal tissue.ConclusionsClinicians should suspect ureteral endometriosis in premenopausal women with unilateral or bilateral distal ureteral obstruction of uncertain cause. The main goals of the treatment should be preservation of renal function, relief of obstruction and prevention of recurrence.

Re: Flexible ureteroscopic laser lithotripsy for upper urinary tract stone disease in patients with spinal cord injury.

unclear, despite the high rate of VUR in this patient population. Also, the time gap between injury and stone disease is unclear. The other important individual factors affecting the outcome of URS in SCI patients are presence of urinary tract infection (UTI) related to neurogenic bladder dysfunction, difficulties in patient positioning and anesthetic risks due to decreased pulmonary capacity [1, 3]. Patients with SCI are prone to developing simultaneous renal and bladder calculi. The presence of vesicoureteral reflux has been shown to be closely associated with renal lithiasis in these patients [2]. Also, the clinical presentation of stone disease in patients with SCI tends to involve frequent UTIs or urosepsis and at the time of presentation, patients may need emergency renal drainage. Stone disease carries a mortality rate that may be significant, especially compared with the general population, although only a few small case series have been published. There is little information reported on metabolic management of these patients or on preventative strategies that can be used after the initial stone episode. Ureteroscopy is a common modality used in the general population to manage upper tract stone disease. Traditional limitations of this procedure in patients with SCI have likely been overcome with new flexible scopes; however, the medical literature has not specifically reported on its use among patients with SCI. In conclusion, surgical procedures like URS have a higher risk in SCI patients and surgeons should be aware of the risks of the procedure in this unique group. To overcome or minimize the complications, patients should be assessed systematically and meticulously. All measures should be taken to prevent UTI and urosepsis following the procedure. We thank the authors for this important study examining the outcomes of flexible ureteroscopic laser lithotripsy (URS) for upper urinary tract stone disease in patients with spinal cord injury (SCI) [1]. With the rising implementation of URS, assessment and outcome of SCI patients play an important role in the management of urolithiasis. Previous studies report that this patient group has an increased risk of urolithiasis compared to the general population [1–3]. Given these factors, this study was undertaken to determine whether URS is an effective treatment choice for SCI patients. In accordance with this finding, surgeons can follow this modality of intervention in this group of patients. All surgeons face many challenges such as SCI in stone patients. This population has a higher risk of stone formation and also a higher risk of mortality and morbidity. Therefore, URS must be carefully discussed with patients and their families. Additionally, this study demonstrates that SCI patients have an increased risk of complications. Despite this study’s very remarkable results, it has some limitations: it is a retrospective study and the sample size is quite limited, so it may be under-powered; it lacks a comparison group of other treatment modalities [percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL)] and operation times. It is unclear why the patients did not undergo CT scan post-operatively. The VUR rate is

Plasmakinetic vaporization versus plasmakinetic resection to treat benign prostatic hyperplasia: A prospective randomized trial with 1 year follow-up

INTRODUCTION We evaluate the efficacy and outcomes of plasma-kinetic vaporization (PKVP) and plasmakinetic resection (PKR) to treat benign prostatic hyperplasia (BPH). METHODS A total of 183 patients with BPH underwent plasma-kinetic prostatic surgery between 2008 and 2012 at Kars State Hospital and Kafkas University Faculty of Medicine, Turkey. After clinical and preoperative evaluation, the patients were randomized to PKRP or PKVP groups sequentially by using computer-generated numbers. Group 1 included 96 patients treated with PKR. Group 2 included 87 patients treated with PKVP. Patients in both groups were compared in terms of hemoglobin drop, operation time, catheter duration, reobstruction, incontinence and recatheterization. RESULTS When we compared the maximum flow rates (Qmax values) at the 12th month, there was no statistical difference between 2 groups. Group 1 had a mean Qmax value of 17.92 ± 3.819 and Group 2 had a 18.15 ± 3.832 value (p > 0.05). There was a statistical difference between the groups in terms of hemoglobin drop, catheter duration and operation time. The mean catheter duration in Group 1 was 3.74 ± 1.049 days, and in Group 2 it was 2.64 ± 0.849 days (p < 0.05). Operation time was statistically longer in Group 2 (PKVP) and hemoglobin drop was statistically higher in Group 1 (PKR). CONCLUSION PKVP for BPH is safe and effective. When compared with PKRP, it provides a significantly shorter catheter duration and less bleeding due to hemostasis control with similar IPSS and Qmax improvements after 1 year.