Cenk Yucel Bilen

Percutaneous nephrolithotomy in patients aged 60 years or older.

PURPOSE To assess the safety and efficacy of percutaneous nephrolithotomy in patients more than 60 years old. PATIENTS AND METHODS We retrospectively evaluated and compared the data of 28 percutaneous nephrolithotomies (PCNL) performed on 27 patients aged 60 years and older (mean 65.8) with the data of the remaining 178 PCNL procedures on 166 patients performed in our clinic between December 1997 and December 1999. RESULTS Although staghorn stones seemed to be more common in the elderly group (25% v 22%), no statistical significance was demonstrated (P = 0.715), and the stone burden was similar for the two groups (P = 0.112). The only interesting finding in terms of patient characteristics was a significantly higher incidence of solitary kidney in patients aged 60 years or older (29% v 7%; P = 0.003). The success rates (stone-free patients and patients with residual stones <4 mm) were similar, being 89% for the elderly group and 92% for the younger patients (P = 0.718). Transfusion rates were also similar (21.4% in the elderly v 18% in the younger group; P = 0.662). No significant complication was observed in this elderly group, and no renal deterioration has been detected even in the follow-up of patients with a solitary kidney. CONCLUSIONS Despite the somewhat higher stone burden in the elderly patients (1077.92 mm2 v 920.85 mm2), the stone-free rate was similar to that obtained in the younger patients, without any higher rates of complications or blood transfusions or longer hospital stay. Percutaneous nephrolithotomy is a safe and effective method of stone treatment in the elderly, even if they have a solitary kidney or complex calculi.

Tubeless Mini Percutaneous Nephrolithotomy in Infants and Preschool Children: A Preliminary Report

PURPOSE We retrospectively analyzed the outcomes of tubeless mini percutaneous nephrolithotomy in infants and preschool children, and compared them with age matched controls who underwent nephrostomy drainage. MATERIALS AND METHODS A total of 28 renal units in 26 children were operated on for stone disease using the mini percutaneous nephrolithotomy technique. Holmium laser and pneumatic lithotriptor were used for stone fragmentation. Children who underwent complete stone removal and had a clear nephrostomy tract only had a ureteral catheter placed. Those with residual stones or bleeding from the nephrostomy tract underwent nephrostomy drainage. We compared both groups with regard to patient and stone characteristics, and postoperative findings. RESULTS A total of 12 renal units had only a ureteral catheter for diversion, while 16 had nephrostomy drainage. Mean respective ages of the stentless and nephrostomy groups were 3 (range 0.58 to 6) and 3.3 years (1.5 to 6). Mean respective stone burdens were 192 (range 100 to 400) and 416 (775 to 1,380) mm2. Surgery and fluoroscopy times were shorter in the tubeless group. Complication rates were higher (6 of 14 vs 0 of 12) and duration of hospitalization was longer (4.9 [range 3 to 14] vs 3.1 days [2 to 6]) in the nephrostomy group. Stone-free rates were 91.6% in the tubeless and 78.5% in the nephrostomy groups. CONCLUSIONS Tubeless percutaneous nephrolithotomy was observed to be a safe option for selected children with stone disease. The success and safety of tubeless percutaneous nephrolithotomy depends on patient selection criteria, including low volume and infection-free stones that are removed completely without any bleeding from the access tract.

Renal Artery Pseudoaneurysm: Complication of Minimally Invasive Kidney Surgery

PURPOSE We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. MATERIALS AND METHODS In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. RESULTS In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. CONCLUSION There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

PURPOSE We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Spinal-Epidural Anesthesia Versus General Anesthesia in the Management of Percutaneous Nephrolithotripsy

OBJECTIVE To compare the efficacy between combined spinal-epidural block and general anesthesia in patients undergoing percutaneous nephrolithotripsy (PNL). METHODS A total of 180 patients undergoing PNL were randomly allocated to receive spinal-epidural anesthesia plus intravenous patient-controlled anesthesia with tramadol or general anesthesia (propofol induction, maintenance with sevoflurane) plus intravenous patient-controlled anesthesia with tramadol (G group). Hemodynamic changes, postanesthesia care unit (PACU) discharge times, times to home readiness, side effects, patient and endoscopist satisfaction, postoperative pain (scored from 0 to 10 on a visual analog scale), and analgesic medication were recorded. RESULTS Rates of hypotension (p = 0.06) and bradycardia (p = 0.14) did not differ between the groups. Compared with the G group, duration of PACU and the time to home readiness (p = 0.001 for each) were shorter in the spinal-epidural group. The incidence of nausea was higher in the G group (p = 0.001); vomiting and pruritus rates were similar between groups. No patient had respiratory depression. The spinal-epidural group had better patient satisfaction (p = 0.001) and lower pain scores (p = 0.001). The G group required more diclofenac during the first 48 h (p = 0.001). CONCLUSIONS In patients undergoing PNL, spinal-epidural anesthesia and analgesia gave greater patient satisfaction, shorter times for PACU and home readiness, and less postoperative pain. Spinal-epidural anesthesia is an attractive alternative to general anesthesia in these patients.

Intratesticular varicocele treated with percutaneous embolization

Intratesticular varicocele is an extremely rare and a relatively new clinical entity. A 22-year-old man was admitted to our hospital with left testicular pain. On physical examination, a grade III varicocele was noted on the left side, and the testis was soft as well. Gray-scale ultrasound and color Doppler ultrasound examinations revealed intratesticular and extratesticular varicocele. Testicular venography failed to demonstrate the testicular vein. Percutaneous embolization was performed through direct puncture to the dilated veins. Percutaneous embolization under local anesthesia is an alternative treatment to other techniques.

Testicular teratoma and anti-N-methyl-D-aspartate receptor-associated encephalitis

We report a patient with a testicular teratoma and seminoma, who developed treatment-responsive encephalitis associated with antibodies to NMDA receptor, but not antibodies to Ma2 protein. A 30-year-old male was admitted to hospital with a 1-week history of personality changes, confusion, agitation and recurrent generalised tonic-clonic seizures. His past medical history was unremarkable, except for the presence of generalised fatigue and sore throat a few days before symptom onset. On physical examination, the only pathological finding was bilateral testicular enlargement. He was agitated and disoriented to time, place and person; his speech was incoherent, and he had persecutory and erotic delusions. The rest of the neurological examination was normal. The initial laboratory studies, including complete blood count, biochemistry, EEG and brain MRI, were normal. The CSF examination was significant for an elevated protein concentration (113 mg/dl) with normal glucose content and mild leukocytosis (25 cells/μl); bacterial and viral studies, including PCR for herpes simplex virus, were negative. Testicular ultrasound revealed the presence of a left testicular mass and right testicular torsion. Computerised tomography of the chest, abdomen and pelvis demonstrated the presence of a retroperitoneal lesion, which was suggestive of metastasis. These findings led us to consider the diagnosis of paraneoplastic encephalitis. Accordingly, CSF …

Horseshoe kidney: does it really have any negative impact on surgical outcomes of percutaneous nephrolithotomy?

OBJECTIVES To compare the stone-free rate and complications between horseshoe and normal kidneys. METHODS Between December 1997 and June 2008, a total of 2401 patients with 2618 renal units underwent percutaneous nephrolithotomy (PCNL). During this period, we retrospectively reviewed the data of 46 patients with 50 (1.9%) renal units with horseshoe kidneys treated by PCNL. We compared the success and complication rate in horseshoe kidney and normal kidney. RESULTS Fifty PCNL were performed in the above-mentioned 46 patients with a mean age of 41.6 years. The average stone burden ranged from 100 to 4900 mm(2) (mean, 644 +/- 135 mm(2)). The stones were located in the renal pelvis in 13 (26%), calices in 17 (34%), and in both in 11 kidneys (22%). A single tract was used in 42 kidneys (84%), and 2 tracts were created in the remaining 8 (16%). Major complications were seen in 8 PCNL procedures (16%). A detailed comparison between horseshoe and normal kidneys showed that stone burden, operation time, stone-free rates, and auxiliary procedure rates were similar. The only statistically significant difference was detected in the number of access, which is more in normal kidneys. Logistic regression analysis did not reveal that horseshoe kidney did not have any negative effect on success after PCNL. CONCLUSIONS Despite the anatomic abnormalities, PCNL is a safe and effective treatment option for calculi both in the horseshoe kidney and the normal kidney with the similar success and complications rates.

Human papillomavirus associated with bladder carcinoma? Analysis by polymerase chain reaction

Background: The aim of the present study was to assess the possible etiologic role of human papillomaviruses (HPV) in bladder tumors.

Clinical experience with BCG alone versus BCG plus epirubicin

Background : Bacillus Calmette–Guérin (BCG) and epirubicin have both been shown to be effective in the treatment of superficial bladder cancer. We studied whether the alternating combination of these agents could improve the efficacy with tolerable side‐effects in the treatment of high‐risk superficial bladder tumors.