Aykut Baser

Optic-Guided Vaginal Repair of Vesicovaginal Fistula

BACKGROUND AND PURPOSE The transvaginal approach for the repair of vesicovaginal fistula (VVF) can sometimes be challenging, especially in fistulas located near the vaginal cuff. We describe a simple technique for the vaginal repair of VVF with the use of endoscopic optics. PATIENTS AND METHODS Three women were admitted to our department with urinary incontinence after total hysterectomy. Assessment with a clinical examination, imaging, and cystoscopy confirmed the diagnosis of VVF. All patients were operated on between December 2012 and January 2013. The operations were conducted under spinal anesthesia with the patients in the lithotomy position. Cystoscopy was performed and retrograde pyelography ruled out any ureteral damage or fistula. A 10F to 12F Foley catheter was inserted into the fistula. From this point, the operation proceeded with optic vision, mimicking laparoscopic dissection and suturing techniques using a standard 5 mm, 30-degree optic lens, a surgical monitor, and open surgical instruments. The fistula was circumferentially incised and widely mobilized from the surrounding tissues and closed without tension in two layers. A urethral Foley catheter was inserted and maintained for 14 days. RESULTS The mean operative time was 70 (range 60-80) minutes. Estimated blood loss was minimal. All patients were discharged at postoperative day 1. No complications were observed. At the postoperative first and third month follow-up visits, all patients were voiding without any urinary leakage or complaints. CONCLUSIONS The use of optics in the vaginal repair of VVF is a useful technique. Optic guidance facilitates surgical vision, dissection, and hemostasis. It is also excellent for surgeon comfort, ergonomics, and resident training.

A rare cause of ureteral injuries; simultaneous common iliac artery and ureter injury during posterior lumbar disc surgery.

Major vascular injuries during lumbar disc surgery are rare but well-recognized complications. However, vascular injuries of the branches of the aorta and ureteral injuries are very rare. Although its incidence is not known definitely, it is estimated to be 1/1000. Ureteral injuries comprise less than 1% of all genitourinary traumas. In this article, we report clinical progress of a patient who had simultaneous internal iliac artery and ureteral injury during lumbar discectomy. The patient was managed with primary ureteroureterostomy. To our knowledge, this is the first case reported with simultaneous ureter and iliac artery trauma during lumbar disc surgery.

Can feeling of incomplete bladder emptying reflect significant postvoid residual urine? Is it reliable as a symptom solely?

Purpose The main objective of this study was to reveal the relationship between lower urinary tract symptoms (LUTS) and post-void residual (PVR) urine volume. Materials and Methods Between October 2014 and February 2015, older than 40 years patients were included in this study. Volunteers filled out a questionnaire consisted of demographic characteristics, comorbidities, medications, history of surgery and LUTS. Volunteers were undergone PVR measurement with transabdominal ultrasonography. The relationship between symptoms, demographic characteristics and PVR were analyzed. Results A total of 939 patients (756 men and 183 women) were enrolled in this study. There was a positive correlation between the sensation of incomplete bladder emptying and PVR volume in all age groups of women (p=0.0001). However such a relationship was found only over the age of 60 in the subgroup analysis of men (p=0.001). PVR volume increased in men by age (0.65 mL per year of age, p=0.011). In men, voiding symptoms and urgency were associated with a high PVR volume. In women, storage and voiding symptoms (except slow stream and terminal dribble) did not correlate with PVR volume. Conclusions Our study showed that all men over the age of 60 years and all women with the complaint of feeling of incomplete emptying should undergone PVR measurement. Women with the complaint of poor stream and men mainly with voiding symptoms are other candidates in whom PVR measurement would be considered as an important tool in the clinical management and follow-up.

Human TLR gene family members are differentially expressed in patients with urothelial carcinoma of the bladder

PURPOSE Toll-like receptors (TLRs) have an important role in the activation of both innate and adaptive immunity in response to pathogens and endogenous danger signals from damaged or dying cells. The aim of this study was to determine the relationship between urothelial carcinoma (UC) and TLR expression. BASIC PROCEDURES Real-time polymerase chain reaction evaluation was made of the messenger RNA expression of TLRs 1-10 in 24 UC samples and 46 nontumoral bladder tissue samples. The levels of proinflammatory cytokines (IL-1β, IL-6, and IL-8) in the urine samples were also determined with enzyme-linked immunosorbent assay. MAIN FINDINGS TLR2-7 and TLR10 expressions were significantly higher in UC than in the control group (P<0.05 for all comparisons). No concordance was found between matched tumor tissue and urine samples in terms of TLR expression. IL-1β, IL-6, and IL-8 levels were significantly higher in urine specimens of patients with UC (P = 0.033, P = 0.001, and P = 0.008, respectively). PRINCIPAL CONCLUSIONS The results of this study demonstrated that the TLR gene expression profiles reflect the heterogeneity within UC. These results might also prompt further investigation to better understand the role of the TLR gene family expression in the tumor progression of UC.

Spontaneous Vesicouterine Fistula: A Case Report

The classic triad of VUF has been defined as urinary incontinence, amenorrhea, and cyclic hematuria. In the literature, spontaneous VUF without a history of previous surgery or radiotherapy has not been reported before. In this report, we present a female patient who presented with continuous urinary incontinence and was diagnosed with VUF. The patient was managed with cystectomy and hysterectomy and ileal conduit diversion. To our knowledge, this is the only reported case of spontaneous VUF.

Percutaneous Nephrolithotomy in Rare Bleeding Disorders: A Case Report and Review of the Literature

Abstract Surgery in patients with congenital or acquired coagulation defects has always been challenging and requires special care with a multidisciplinary approach. Percutaneous nephrolithotomy (PCNL) is a standard procedure performed in patients with kidney stones. Although prone to bleeding more than most of the widely performed surgical procedures, there are not much data regarding PCNL in patients with bleeding disorders or coagulation defects. There are only case reports or series with a small number of patients for the patients with common coagulation defects, including hemophilias. Moreover, there are no reports about PCNL in rare bleeding disorders. In this study, we reported a case referred for kidney stone treatment and diagnosed as Factor VII deficiency during preoperative evaluation. Because it is one of the rare bleeding disorders, we also reviewed the literature in this field.

Spontaneous ureteral rupture in a patient with polyarteritis nodosa.

extravasation was seen 1 cm distal to ureteropelvic junction (UPJ) on the left side (Fig. 1a, b). The patient was managed by minimally invasive procedures. Ureteroscopy was performed, and a double J stent was placed into the left ureter under fluoroscopy (Fig. 1c). After removing her Foley catheter the next day, she was discharged without any complication by prescribing the corticosteroid and cyclophosphamide. Two months later after the operation, double J stent was removed. On the 6 months postoperatively, intravenous pyelography revealed normal functioning kidneys and normal calibrated ureter without any extravasation (Fig. 1d). Ureteral involvement in connective tissue diseases is a rare condition. In previous case reports, systemic lupus erythematosus, rheumatoid arthritis, dermatomyositis, and sarcoidosis related with SUR were reported [3, 4]. Ureteral involvements associated with PAN in the literature are occasionally strictured and obstructed [5]. Vasculitisrelated myopathy or neuropathy of ureter was the most likely cause of this situation. Regarding ureteral perforation in connective tissue diseases, no plausible explanation has yet been published in the literature. It is proposed that periureteral vasculitis may cause ureteral obstruction or perforation [3]. The mechanism of vasculitis in PAN may be secondary to immune complex deposition along the walls of smallto mediumsized arteries. This process promotes infiltration with polymorphic leukocytes and liberation of necrotizing enzymes, which leads to thrombosis, tissue ischemia, fibrosis, and ultimately tissue scarring [5]. SUR often produces symptoms such as sudden onset abdominal and flank pain, nausea, and vomiting. Ultrasound may detect fluid collections in retroperitoneal space, and CECT shows contrast extravasation. RGP is also a useful tool for visualizing the urinary tract. Management of the Editor

Urogenital and Rectal Multisystem Organ Injury After Detonation of an Explosive Substance in the Rectum of a Schizophrenic Man

Penetrating injuries are caused by the injury of perineal area with gun or stab wounds, which may cause complex injuries or multiple organ injuries. Infections, bleeding, necrotizing fasciitis, ureterocutaneous fistulas, diverticulum, abscesses, narrowing, and incontinence may arise after urethral injuries. Although there are several case reports of urogenital system traumas in the literature, this case reports a schizophrenic patient who had a multisystem genitourinary and rectal trauma after self-detonation of an explosive in the rectum and managed with reconstructive surgery without any postoperative complications. Lower urinary tract anatomy was preserved and full continence was achieved after the surgical procedure.