Burak Turna

Early continence outcomes of posterior musculofascial plate reconstruction during robotic and laparoscopic prostatectomy

Associate Editor

Safety and Efficacy of Flexible Ureterorenoscopy and Holmium:YAG Lithotripsy for Intrarenal Stones in Anticoagulated Cases

PURPOSE We compared perioperative outcomes in patients undergoing ureterorenoscopy and Ho:YAG lithotripsy for renal calculi with or without anticoagulation. MATERIALS AND METHODS We reviewed the records of all patients undergoing flexible ureterorenoscopy and Ho:YAG lithotripsy for renal calculi at 2 institutions from 2001 to 2007. We identified 37 patients on anticoagulation with Coumadin, clopidogrel or aspirin in whom anticoagulation therapy was not discontinued before surgery. Data on the anticoagulation group were retrospectively compared to those on a contemporary matched cohort of 37 controls without anticoagulation who underwent a similar operative procedure. The 2 groups were compared with regard to the stone-free rate, and intraoperative and postoperative complications with specific reference to bleeding and thromboembolism. RESULTS The 2 groups were matched for stone size, stone location, number of stones, bilateral procedures and concomitant ureteral stones. Anticoagulation group patients were older (58.2 vs 50.4 years, p = 0.0209) and had a greater American Society of Anesthesiologists score (2.8 vs 1.9, p <0.0001) compared to the control group. No procedure had to be terminated in the anticoagulation group due to poor visibility from bleeding. The median postoperative hemoglobin decrease was greater in the anticoagulation group than in the control group (0.6 vs 0.2 gm/dl, p <0.0001). The stone-free rate (81.1% vs 78.4%, p = 0.7725), intraoperative complications (0% vs 3%, p = 0.3140), postoperative complications (11% vs 5%, p = 0.3943) and hemorrhagic or thromboembolic adverse events were comparable in the 2 groups. CONCLUSIONS When necessary, ureterorenoscopy and Ho:YAG lithotripsy can be performed safely and efficaciously for renal calculi in patients on anticoagulation therapy without the need for perioperative manipulation.

A nephrolithometric nomogram to predict treatment success of percutaneous nephrolithotomy.

PURPOSE Imaging is routinely done preoperatively and postoperatively to assess patients treated with percutaneous nephrolithotomy. We developed a nomogram for percutaneous nephrolithotomy success. MATERIALS AND METHODS From November 2007 to December 2009 the CROES (Clinical Research Office of the Endourological Society) collected data on consecutive patients at 96 centers globally. Patients were evaluated for stone-free status using plain x-ray of the kidneys, ureters and bladder. Treatment success was defined as no visible stones or residual fragments less than 4 mm. Multivariate regression was used to model the relationship between preoperative descriptors and the stone-free rate. Variables included case load, prior treatment, body mass index, staghorn stones, renal anomalies, and stone burden, location and count. Bootstrapping techniques were used to validate the model. Adjusted chi-square statistic values were used to rank the prognostic value of variables. A nomogram was developed using significant predictors from the model. We assessed the predictive accuracy of the nomogram using the ROC curve AUC. The nomogram was calibrated. RESULTS Stone burden was the best predictor of the stone-free rate (chi-square = 30.27, p <0.001). Other factors associated with the stone-free rate were case volume (chi-square = 35.75, p <0.001), prior stone treatment (chi-square = 14.55, p <0.012), staghorn stone (adjusted chi-square = 4.73, p <0.029), stone location (chi-square = 14.74, p <0.001) and stone count (chi-square = 4.78, p <0.004). A nephrolithometric nomogram was developed with predictive accuracy (AUC 0.76). CONCLUSIONS The percutaneous nephrolithotomy stone-free rate can be predicted using preclinical data and radiological information. We present a nephrolithometric nomogram for percutaneous nephrolithotomy.

Women with low libido: correlation of decreased androgen levels with female sexual function index

The aim of the present study was to investigate a possible correlation between decreased androgen levels and female sexual function index (FSFI) in women with low libido and compare these findings with normal age-matched subjects. In total, 20 premenopausal women with low libido (mean age 36.7; range 24–51 y) and 20 postmenopausal women with low libido (mean age 54; 45–70 y), and 20 premenopausal healthy women (mean age 32.2; range 21–51 y) and 20 postmenopausal healthy women (mean age 53.5; range 48–60 y) as controls were enrolled in the current study. Women with low libido had symptoms for at least 6 months and were in stable relationships. All premenopausal patients had regular menstrual cycles and all postmenopausal patients and controls were on estrogen replacement therapy. None of the patients were taking birth control pills, corticosteroids or had a history of chronic medical illnesses. All completed the FSFI and Becks Depression Inventory (BDI) questionnaires. Hormones measured included: cortisol; T3, T4 and TSH; estradiol; total and free testosterone; dehydroepiandrosterone sulfate (DHEA-S); sex hormone binding globulin (SHBG). We performed statistical analysis by parametric and nonparametric comparisons and correlations, as appropriate. We found significant differences between the women with low libido and the controls in total testosterone, free testosterone and DHEA-S levels and full-scale FSFI score for both pre- and postmenopausal women (P<0.05). In addition, decreased total testosterone, free testosterone and DHEA-S levels positively correlated with full-scale FSFI score and FSFI-desire, FSFI-arousal, FSFI-lubrication and FSFI-orgasm scores (P<0.05). Our data suggest that women with low libido have lower androgen levels compared to age-matched normal control groups and their decreased androgen levels correlate positively with female sexual function index domains.

Minimally Invasive Nephron Sparing Management for Renal Tumors in Solitary Kidneys

PURPOSE We present a large series of minimally invasive nephron sparing surgery outcomes in solitary kidneys with a focus on treatment selection criteria, and oncological and functional outcomes. MATERIALS AND METHODS Of 1,019 patients who underwent minimally invasive nephron sparing surgery since September 1997 at our institution 36, 36 and 29 underwent laparoscopic partial nephrectomy, cryoablation and radio frequency ablation, respectively, for tumors in a solitary kidney. Data, including patient and tumor characteristics, surgery details, complications, and postoperative renal function and intermediate term oncological outcomes in each patient, were obtained by telephone contact or from charts. The 3 groups were compared for perioperative, functional and oncological outcomes. RESULTS On multivariate analysis tumor size, aspect and remnant kidney status were independent predictors of treatment selection. Cancer specific and overall survival at 2 years was 100% and 91.2% for laparoscopic partial nephrectomy, 88.5% and 88.5% for cryoablation, and 83.9% and 83.9% for radio frequency ablation, respectively. Disease-free survival was significantly better for laparoscopic partial nephrectomy than for cryoablation and radio frequency ablation (100% vs 69.6% and 33.2%, respectively, p <0.0001). The mean estimated glomerular filtration rate change for laparoscopic partial nephrectomy, cryoablation and radio frequency ablation of 17, 3 and 7 ml per minute per 1.73 m(2) reflected a 26%, 6% and 13% decrease from baseline, respectively, which was statistically significant (p = 0.0016). CONCLUSIONS Laparoscopic partial nephrectomy and probe ablative procedures can be safely and efficiently done for renal tumor in patients with a solitary kidney. Intermediate term oncological outcomes are superior for laparoscopic partial nephrectomy despite somewhat poorer renal function outcomes than those of cryoablation and radio frequency ablation.

Risk factor analysis of postoperative complications in laparoscopic partial nephrectomy.

PURPOSE We evaluate our experience with laparoscopic partial nephrectomy to determine risk factors for postoperative complications. MATERIALS AND METHODS A prospectively maintained database of 507 laparoscopic partial nephrectomy procedures since September 1999 was retrospectively analyzed with emphasis on postoperative complications. Severity of complications was graded using a 5-tiered scale based on National Cancer Institute Common Toxicity Criteria Version 2.0 reporting criteria. Complication rates were compared between 1999 to 2002 and 2003 to 2006. Multivariate analysis of baseline and perioperative variables was performed to identify risk factors associated with postoperative complications for the 2 eras. RESULTS After 507 laparoscopic partial nephrectomy procedures 93 patients (19.7%) had 107 complications, including 49 urological (9.7%) and 58 nonurological (11.4%). Of the complications, 20.6% were grade I, 45% were grade II, 30% were grade III, 4.7% were grade IV and none were grade V. On multivariate analysis, presence of a solitary kidney (1999 to 2002 p = 0.0115, 2003 to 2006 p = 0.0045), increased warm ischemia time (1999 to 2002 p = 0.0399, 2003 to 2006 p = 0.0066) and increased estimated blood loss (1999 to 2002 p = 0.0224, 2003 to 2006 p = 0.0293) were significant predictors of overall postoperative complications for the 2 eras. Compared to the 1999 to 2002 era, the 2003 to 2006 era witnessed a dramatic increase in number of total laparoscopic partial nephrectomy procedures (100% increase) and complex tumors (132% increase), yet overall (p = 0.001), urological (p = 0.03) and nonurological (p = 0.02) complications decreased significantly. CONCLUSIONS Prolonged warm ischemia, increased intraoperative blood loss and solitary kidney status increase the likelihood of postoperative complications after laparoscopic partial nephrectomy. With experience the incidence of complications has decreased significantly despite a significant increase in tumor and procedural complexity.

Comparison of radical prostatectomy techniques: open, laparoscopic and robotic assisted

INTRODUCTION To review the current status of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RALP) in relation to radical retropubic prostatectomy (RRP) in the management of localized prostate cancer. MATERIALS AND METHODS Between 1982 and 2007 published literature was reviewed using the National Library of Medicine database and the following key words: retropubic, laparoscopic, robotic, robot-assisted, and radical prostatectomy. Special emphasis was given to the technical and cost considerations as well as operative, functional and oncologic outcomes. In particular, reports with pioneering work that have contributed to the evolution of the technique, presenting comparative outcomes and with large series encompassing intermediate/long term follow-up, were taken into account. RESULTS After intermediate term follow-up, LRP and RALP achieved similar oncologic and functional results compared to RRP. However, LRP and RALP were associated with decreased blood loss, faster convalescence and better cosmetics when compared to RRP. The RALP technique is undoubtedly more expensive. CONCLUSIONS The oncologic and functional outcomes for LRP and RALP are similar to RRP after intermediate term follow-up. Long term follow-up and adequately designed studies will determine the inherent advantages and disadvantages of the individual techniques in the management of localized prostate cancer.

Factors Affecting Complication Rates of Ureteroscopic Lithotripsy in Children: Results of Multi-Institutional Retrospective Analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSE We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate. CONCLUSIONS Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Laparoscopic Assisted Ileal Ureter: Technique, Outcomes and Comparison to the Open Procedure

PURPOSE Ureteral replacement with interposition of a bowel segment has traditionally required a large incision with substantial associated morbidity and prolonged time to convalescence. During the last 7 years a technique for laparoscopic assisted ileal interposition has evolved that mimics our open approach. We present a comparative analysis of functional and perioperative outcomes between patients undergoing laparoscopic or open ileal ureter replacement at our institution. MATERIALS AND METHODS A search of all procedures from 1980 to the present revealed 7 patients undergoing laparoscopic and 7 undergoing open ileal interposition. Functional and perioperative data from these patients are compared, and a detailed description of technique for the laparoscopic procedure is presented. RESULTS Narcotic analgesic use in morphine equivalents (median 38.9 vs 322.2 mg, p = 0.035) and time to convalescence (median 4 vs 5.5 weeks, p = 0.03) were significantly less in the laparoscopic group. A trend toward shorter hospital stay (median 5 vs 8 days, p = 0.101) was also noted in patients in the laparoscopic group. There was no evidence of anastomotic stricture for patients in either group at last followup. CONCLUSIONS Despite the small number of subjects involved a significant advantage was noted for postoperative recovery after laparoscopic compared to open ileal interposition. A detailed understanding of this complicated procedure can help prevent inherent pitfalls.

Laparoscopic Partial Nephrectomy versus Laparoscopic Cryoablation for Multiple Ipsilateral Renal Tumors

BACKGROUND Management of multiple ipsilateral renal tumors is a dilemma in clinical practice. The effects of minimally invasive nephron-sparing procedures in this group of patients have not been assessed. OBJECTIVE To evaluate the technical feasibility and outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) for multiple ipsilateral renal tumors. DESIGN, SETTING, AND PARTICIPANTS Between September 1999 and December 2006, 27 patients were treated with minimally invasive nephron sparing surgery (LPN or LCA) for synchronous multiple ipsilateral renal tumors in a single operating session at our institution. Fourteen patients with 28 tumors underwent LPN, and 13 patients with 31 tumors underwent LCA as the sole treatment modality. INTERVENTION Medical records were retrospectively reviewed and data were collected. MEASUREMENTS Demographic, intraoperative, postoperative, and intermediate-term follow-up data were compared between the two groups. RESULTS AND LIMITATIONS Patients in the LPN group had fewer tumors (2 vs. 2.4, p=0.04) and larger dominant tumor size (3.6 vs. 2.5 cm, p=0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4 mg/dl, p=0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125 ml, p=0.02) and longer hospital stays (90 vs. 52.3h, p=0.02). There were no open conversions, and no kidneys were lost. Complication rate, renal functional outcomes, and intermediate-term cancer-specific survival rates were similar between the two groups. CONCLUSIONS Both LPN and LCA are viable options for patients with multiple ipsilateral renal tumors in select patients. Renal functional outcomes, complication rates, and intermediate-term survival rates are comparable between the two groups in this small series.