Bulent Onal

Robot-Assisted Laparoscopic Excision of Symptomatic Retrovesical Cysts in Boys and Young Adults

PURPOSEnWe review our surgical experience with the management of retrovesical cystic anomalies using robot-assisted laparoscopic techniques.nnnMATERIALS AND METHODSnWe retrospectively reviewed the presentation, diagnosis and treatment of 6 patients 28 months to 22 years old with retrovesical cystic anomalies who underwent robot-assisted laparoscopic excision at our hospital between January 2006 and November 2010.nnnRESULTSnPresenting signs and symptoms included urinary retention, lower urinary tract symptoms, abdominal pain and repeated epididymitis. Associated anomalies consisted of hypospadias, vesicoureteral reflux, renal agenesis, 5alpha-reductase deficiency, premature adrenarche and cryptorchidism. Cystic anomalies ranged from 3 to 6 cm long. The final diagnoses were prostatic utricular cyst, müllerian duct cyst and seminal vesicle cyst. Ectopic insertion of vas into the cyst was found in 4 cases, requiring ligation of the affected vas in 3. Mean ± SD operative time including cystoscopy was 198 ± 23.8 minutes, and estimated blood loss ranged from 5 to 10 ml. Mean ± SD hospital stay was 1.33 ± 0.52 days. All patients had resumed their regular activities within 2 weeks postoperatively. De novo contralateral epididymitis developed 2 months postoperatively in 1 patient. Otherwise, there was no recurrence of cystic mass or presenting signs or symptoms during followup of 3 to 56 months.nnnCONCLUSIONSnIn the management of retrovesical cystic anomalies robot-assisted laparoscopic excision affords a natural extension of conventional laparoscopy with the additional advantages of 3-dimensional vision and ease of instrument control.

Comparative evaluation of the resolution of hydronephrosis in children who underwent open and robotic-assisted laparoscopic pyeloplasty.

OBJECTIVESnTo assess long-term postoperative ultrasonographic outcomes of robotic-assisted laparoscopic pyeloplasty (RALP) and of conventional open pyeloplasty (COP) in pediatric patients with ureteropelvic junction obstruction.nnnMETHODSnRetrospective review of 312 patients who underwent RALP or COP in a single institution. Preoperative and postoperative ultrasounds were used to determine the grade of hydronephrosis. Postoperative assessment included 3 ultrasounds at 0-6, 6-12 and >12 months intervals. Patients were matched by age, etiology of obstruction, grade of preoperative hydronephrosis and gender for case-matched analysis.nnnRESULTSnWe identified 212 pyeloplasties that met inclusion criteria, being 58 RALP and 154 COP. Groups were different in age, gender and etiology, but similar in severity of hydronephrosis and follow-up time. At the end of follow-up, complete resolution and success rates were 62% and 74% in RALP and 45% and 70% in COP, respectively. Matching included 105 patients. Complete resolution was higher in RALP (p = 0.004), while median time before improvement was lower (12.3 months RALP vs 29.9 months COP). There was no difference in success rate at the end of follow-up between the groups.nnnCONCLUSIONnRALP shows satisfactory long-term outcomes, comparable to COP. In our cohort, patients who underwent robotic pyeloplasty showed faster resolution of hydronephrosis on ultrasound.

Nomogram and scoring system for predicting stone‐free status after extracorporeal shock wave lithotripsy in children with urolithiasis

Extracorporeal shock wave lithotripsy is often considered to be the first‐line treatment method for the majority of urinary tract stone disease in children. The stone clearance rate in children treated with ESWL is higher than that in adults. Recently, nomograms for several diseases, e.g. for specific cancers, have been developed and validated in large patient populations. They have become very popular predictive tools that provide the most objective, evidence‐based, and individualized risk estimation. These nomograms have gained acceptance as useful guides in clinical practice for use by physicians and patients. In adults, a nomogram has been created to predict stone‐free outcome after ESWL; however, to our knowledge none has been developed for children with urolithiasis. This is the first study‐generated nomogram table and scoring system for predicting the stone‐free rate after ESWL in children. This predictive tool could be useful for clinicians in counselling the parents of children with urolithiasis and in recommending treatment.

The feasibility of robotic urologic surgery in infants and toddlers

OBJECTIVEnTo determine the feasibility and safety of performing robotic-assisted laparoscopic urological surgery (RALS) in infants and young children, highlighting technical challenges posed by the smaller body size and their potential solutions.nnnPATIENTS AND METHODSnWe retrospectively reviewed perioperative records of all patients less than 3 years of age who underwent RALS at our institution between January 2006 and October 2012. Intraoperative data included difficulties with the robotic instruments or surgical procedure. Post-operative data included length of hospital stay and any complications.nnnRESULTSnA total of 65 children less than 3 years underwent RALS. The average patient age was 1.6 yearsxa0±xa00.7, with 14 patients under 1 year of age. Median patient weight was 11.6xa0kgxa0±xa02.5xa0kg. Mean operative time was 153.3xa0±xa057xa0min. No conversions to open technique or intra-operative complications were reported. A total of 12 post-operative complications were identified after a mean follow-up of 13.6 months: 7 early complications and 5 late complications. Smaller children did not have more complications than larger children.nnnCONCLUSIONnThere are inherent challenges with performing RALS in infants and young children. However, they may be overcome with specific technical maneuvers and through understanding of the limitations of the robotic system.

Additional benefit of laparoscopy for nonpalpable testes: finding a contralateral patent processus

OBJECTIVESnTo determine the incidence of contralateral patent processus vaginalis discovered at laparoscopy in patients presenting with a unilateral nonpalpable testis.nnnMETHODSnFrom August 1997 through February 2006, 159 boys underwent laparoscopic exploration for a unilateral nonpalpable testis. The data were retrospectively reviewed to determine the incidence of contralateral patency, and the results were analyzed with respect to age at repair and side and size of the unilateral nonpalpable testis.nnnRESULTSnThe median age of the patients was 1.2 years (range 2 months to 16 years). The nonpalpable testis was on the left side in 100 patients (63%) and on the right side in 59 (37%). The testis was absent in 13 patients (8%), atrophic in 78 (49%), and of normal size in 68 (42%). The overall incidence of a contralateral patent processus vaginalis was 19% (30 of 159). A contralateral patent processus vaginalis was seen in 21% of the boys younger than 2 years old, 19% of boys 2 to 5 years old, and 12% of boys older than 5 years. The incidence of a contralateral patent processus vaginalis was no different for patients with right (20%) versus left (18%) nonpalpable testes. Patients with normal-size testes (34%) had a much greater rate of a contralateral patent processus vaginalis than did those with an atrophic/absent testis (8%) (P <0.001).nnnCONCLUSIONSnOur data suggest that the incidence of a contralateral patent processus vaginalis is considerable in patients presenting with a unilateral nonpalpable testis. This is another benefit of laparoscopy in patients with nonpalpable testes.

Novel alterations in superoxide dismutase and catalase activities in the female rabbit bladder subjected to hormonal manipulations

ObjectivesPrevious studies have demonstrated that ovariectomy induces reduced blood flow and hypoxia, resulting in free radical damage of the mucosal and smooth muscle compartments of the rabbit urinary bladder, whereas estradiol administration results in angiogenesis and recovery from hypoxia. The current study was designed to investigate the effects of ovariectomy and estradiol replacement on the superoxide dismutase (SOD) and catalase (CAT) activities of the bladder.MethodsA total of 12 mature female rabbits were divided into three groups of four rabbits each: control, ovariectomy, and ovariectomy with 17-β estradiol supplementation by subcutaneous slow-release tablet. The bladder body and base of the rabbits were examined after 2xa0weeks. The bladder body and base were separated into muscle and mucosa, and the tissues were analyzed for SOD and CAT activities.ResultsQuantitative SOD activities for the mucosa and muscle of both bladder body and base increased after ovariectomy when compared with those of controls. Estradiol replacement resulted in a significant decrease in the SOD activities in the body muscle. Ovariectomy caused a decrease in the CAT activities in the bladder tissues, whereas estradiol treatment resulted in significant increases.ConclusionsThese data indicate that ovariectomy induced generation of reactive oxygen species (ROS), as evidenced by the enhanced SOD activity, indicating oxidative stress in the lower urinary tract. Estradiol replacement reversed the effects of ovariectomy; this finding suggests an anti-oxidant effect of estradiol on the bladder.

Genome gender diversity in affected sib-pairs with familial vesico-ureteric reflux identified by single nucleotide polymorphism linkage analysis.

Study Type – Aetiology (case series)

The effect of maturation and age on oestrogen-induced functional hypertrophy of the female rabbit bladder

To evaluate the effect of maturation and ageing on oestrogen‐induced functional hypertrophy of the female rabbit bladder.

Does ureteral stenting matter for stone size? A retrospectıve analyses of 1361 extracorporeal shock wave lithotripsy patients.

Introduction The aim of our study was to determine the efficacy of ureteral stents for extracorporeal shock wave lithotripsy (SWL) treatment of pelvis renalis stones and to compare the results and complications in stented and non-stented patients. Material and methods Between 1995 and 2011, 1361 patients with pelvis renalis stones were treated with SWL. Patients were subdivided into three groups according to stone burden: ≤1 cm2 (group 1; n = 514), 1.1 to 2 cm2 (group 2; n = 530) and >2 cm2 (group 3; n = 317). Each group was divided into subgroups of patients who did and did not undergo ureteral stent implantation before SWL treatment. The efficacy of treatment was evaluated by determining the effectiveness quotient (EQ). Statistical analysis was performed by chi-square, Fishers exact and Mann-Whitney U tests. Results Of the 514, 530 and 317 patients in groups 1, 2 and 3 respectively, 30 (6%), 44 (8%) and 104 (33%) patients underwent auxiliary stent implantation. Steinstrasse rates did not differ significantly between stented and non-stented patients in each group. The EQ was calculated as 62%, 33% and 70% respectively in non-stented, stented and totally for group 1. This ratio calculated as 58%, 25% and 63% for group 2 and 62%, 26% and 47% for group 3. Stone-free rates were significantly higher for non-stented than for stented patients in groups 2 and 3. Conclusions Stone free rates are significantly higher in non-stented than in stented patients with pelvis renalis stones >1 cm2, whereas steinstrasse rates are not affected.

Protective Locus Against Renal Scarring on Chromosome 11 in Affected Sib Pairs with Familial Vesicoureteral Reflux Identified by Single Nucleotide Polymorphism Linkage Analysis

PURPOSEnWe identified the loci associated with renal scarring risk and protection in affected sib pairs with familial vesicoureteral reflux.nnnMATERIALS AND METHODSnA genome-wide analysis of vesicoureteral reflux with high density single nucleotide polymorphisms was conducted in 43 families with 2 or more affected children. A total of 43 probands and 58 affected siblings were included in the analysis. Genomic DNA was extracted from blood or saliva from all patients. All nuclear families had complete parental genotypes and all were Caucasian. Renal scarring was present in 23 of the 43 probands as detected by dimercapto-succinic acid imaging. easyLINKAGE software was used for the genome-wide linkage analysis. A LOD (logarithm [base 10] of odds) score of 3.3 or greater was considered significant evidence of linkage and a LOD score of 2.4 or greater but less than 3.3 was considered suggestive evidence of linkage.nnnRESULTSnUsing the affected sib pair method of analysis, a statistically significant linkage peak with a multipoint LOD score of 3.66 for patients without renal scarring was identified on chromosome 11 at 47.97 cM. For the scarring group a peak with a multipoint LOD score of 2.69 was identified on chromosome 17, which provides suggestive evidence of linkage.nnnCONCLUSIONSnOur results suggest that a locus on chromosome 11 is associated with protection against renal scarring in patients with vesicoureteral reflux. In addition, a new locus on chromosome 17 may be linked to renal scarring. Our results suggest that multiple genes contribute to the formation of the vesicoureteral reflux phenotype, with patients having a unique susceptibility to renal injury/damage.