Erdinc Unluer

Is Prophylactic Breast Radiotherapy Necessary in All Patients With Prostate Cancer and Gynecomastia and/or Breast Pain?

PURPOSE We investigated the efficacy of prophylactic radiotherapy for gynecomastia/breast pain induced by 150 mg bicalutamide in a prospective, randomized, multi-institutional trial. MATERIALS AND METHODS After definitive treatment for localized prostate cancer 125 patients were randomized to 12 Gy radiotherapy before bicalutamide as prophylactic radiotherapy (53) or bicalutamide only for nonprophylactic radiotherapy (72). The incidence of gynecomastia, breast pain and tenderness, and discomfort perceived by the patients was assessed by physical examination and direct questioning at 3, 6 and 12 months of followup. RESULTS At the end of 12 months the gynecomastia rate was 15.8% in the prophylactic group and 50.8% in the nonprophylactic group (p <0.001). On patient evaluation the breast enlargement rate was 34.4%. The severity of breast pain and tenderness was not different between the groups. The breast pain rate was 36.4% and 49.2% by 12 months in the prophylactic and nonprophylactic groups, and the rate of patients who felt discomfort from gynecomastia was 11.4% and 29.5%, respectively. CONCLUSIONS In this prospective study the incidence of gynecomastia was not as high as previously believed. Although prophylactic breast irradiation seemed to decrease the gynecomastia rate in patients on 150 mg bicalutamide, our study proves that not all patients need prophylaxis since only 52% were significantly bothered by gynecomastia. Thus, individual assessment is needed to select patients who need prophylactic radiation while on 150 mg bicalutamide.

Expression of NOS isoforms in internal spermatic veins of infertile men with varicocele

Although varicocele is a relatively common entity encountered in the evaluation of infertile men, the exact pathophysiology still remains unclear. Recently, as previously widely investigated in various parts of human circulatory system, nitric oxide synthase (NOS) and its product, nitric oxide (NO) have been thought to play a role in the development of varicocele and thus male infertility. In this study, we determined the concentration of NO metabolite and the expression of NOS isoforms in the internal spermatic (ISV) and superficial branch of inferior epigastric veins of infertile men with varicocele. The study included 60 infertile men with clinically unilateral or bilateral varicocele. Expression of inducible and endothelial NOS (iNOS and eNOS) isoforms were investigated in tissue arrays of internal spermatic and superficial branch of inferior epigastric veins with immunohistochemistry. NO metabolite (nitrite) levels were measured using the calorimetric method. A significantly higher expression of eNOS was observed in the varicose veins (mean score: 2.25 and 1.55, respectively; p = 0.0001). However, statistically, there was no significant difference for expression of iNOS between varicose and control veins (p = 0.094). The nitrite concentration and NOS expression were not found to be correlated with clinical variables (varicocele grade, maximum varicose vein diameter, and sperm concentration, motility, and morphology) (p > 0.05). As a result, the significantly higher expression of eNOS in ISV may be responsible for the development of varicocele, although this finding is not accompanied by an increase in NO concentration. Still, the pattern of the relationship between varicocele and increased eNOS expression warrants further investigation.

Prognostic factors in radical cystectomy affecting survival

Introduction The aim of the study was to evaluate the prognostic factors in radical cystectomy affecting survival. Material and methods A total of 100 hundred patients were included in the study. Incontinent diversion was applied to 73 of these, and continent diversion to 27. Prospective and retrospective data of the patients were examined. The prognostic value for survival was evaluated for of lymph node involvement, tumor grade (low grade: grade 0-II, high grade: ≥ III or epidermoid carcinoma), tumor stage (low stage: stage pT0-2, high stage: stage ≥ 3a pT3a), presence of preoperative unilateral of bilateral hydronephrosis, presence of preoperative uremia (serum urea value: ≤ 60), and age (> 70 and ≤ 70 years of age) on survival were investigated. Kaplan-Meier survival analysis and Log-Rank statistical methods were used in the study. Results Grade, stage, uremia, and lymph node involvement had significant effects on survival (p values 0.0002, 0.03, 0.01, and 0.02, respectively). Presence of preoperative hydronephrosis and age had no statistically significant effects on survival (p values 0.8 and 0.2, respectively). Conclusions Tumor grade, tumor stage, preoperative uremia, and lymph node involvement are prognostic factors affecting survival. Advanced age and presence of preoperative hydronephrosis have no prognostic value for survival. The presence of uremia in the preoperative assessment of the patients is more important than hydronephrosis.

Adriamycin absorption after Nd:YAG laser coagulation compared to electrosurgical resection of the bladder wall.

The toxicity of intravesical drugs used for the treatment of bladder cancer is increased by systemic absorption. Therefore, treatment is often delayed several weeks after transurethral resection until sufficient healing occurs. Since a neodymium:YAG laser causes tissue injury by thermal coagulation, we investigated differences in bladder permeability after laser treatment compared to TUR. Comparable 2.5 cm in diameter areas of tissue injury were created in the bladder of mongrel dogs either by Nd:YAG laser coagulation or transurethral electrocautery resection (TUR). Subsequently, 30 mg. of adriamycin were instilled intravesically. A control group consisted of animals receiving adriamycin alone. Blood was taken at 10, 30, 60, and 120 minutes after instillation and the serum concentration of adriamycin measured quantitatively by high performance liquid chromatography (HPLC) with fluorescence detection. The maximum serum ADM concentration during 120 minutes for the control group was 28.0 +/- 12.9 ng/ml compared to 38.9 +/- 4.8 for the laser group and 102.9 +/- 29.9 for TUR. The area under the curve was 35.1 +/- 10.2 ng x hours/ml for control, 43.5 +/- 3.9 for laser and 127.7 +/- 49.9 for TUR. Using a two-tailed Students t test, the difference between the TUR and the laser group was significant (p less than 0.01). There was no difference between laser and control. These results suggest that laser treatment has minimal effect on the absorption of drugs from the bladder. The clinical practice of delaying intravesical therapy after TUR is verified but a similar policy may not be necessary after laser treatment.

Transrectal ultrasound-guided prostate rebiopsy: How many core sampling should be applied to which patient?

Background: We investigated the correlation between the sampled number of cores in rebiopsy and the cancer detection rate (CDR). Materials and Methods: Two hundred and twelve patients with normal rectal examination who had undergone rebiopsy in the past 5 years were examined retrospectively. Moreover, 68% of them had undergone 12 cores (Group 1) while 32% had undergone 20 cores (Group 2). Both groups were compared with respect to the CDR. Results: There was no difference between groups in terms of age, total prostate-specific antigen, and prostate volume (P > 0.05). Forty-one (19%) of 212 patients were diagnosed with cancer, and the CDR was significantly higher in Group 2 (30.9% vs. 13.9%, P = 0.004). This rate increased from 6.5% to 20% (P = 0.025) and from 0% to 33.3% (P = 0.023), respectively, with 12-core and 20-core rebiopsies in patients whose initial pathology indicated benign and high-grade prostatic intraepithelial neoplasia (HGPIN). Furthermore, cancer was detected in 24 (40%) of 60 patients who were diagnosed with atypical small acinar proliferation (ASAP) in the initial biopsy. However, despite being higher in 20-core biopsy group (47.6% vs. 35.9%), this was not statistically significant (P = 0.377). Conclusions: At least 20 cores should be sampled in rebiopsy, especially in the patients diagnosed with benign and HGPIN. However, we believe that standard systematic sampling will be sufficient for the patients diagnosed with ASAP.

Relationship between Prostate Size and Positive Surgical Margin in the Open Radical Prostatectomy Surgery

Methodology: In our study, a number of 450 patients who had undergone radical prostatectomy surgery at 2 centers within the last 5 years was evaluated. Age, total PSA, number of positive cores for prostate cancer, Gleason score, transfusion amount and prostate volume were all evaluated in the study. Evaluated all these parameters, 170 consecutive patients of whom data were available were included in the study

Learning curve in laparoscopic renal surgery and influencing factors

Amaç: Son 20 yıl içerisinde edinilen deneyimler böbrek cerrahisinde laparoskopik girişimlerin, kabul edilebilir cerrahi sonuçlar, düşük komplikasyon oranları ve yüksek hasta memnuniyeti ve yaşam kalitesi ile açık cerrahi prosedürlere alternatif olduğunu göstermektedir. Ancak, laparoskopik cerrahinin, açık cerrahiye oranla daha teknik bir prosedür olması ve öğrenim sürecinin nispeten uzun olması prosedürü zorlaştırmaktadır. Bu çalışmadaki amacımız, laparoskopik böbrek ameliyatlarındaki öğrenim sürecini irdeleyerek, bunu etkileyen faktörleri ortaya koymak ve böylece laparoskopik cerrahi öğrenim sürecini doğru planlamaktır. Gereç ve Yöntem: Kliniğimizde 2004 2008 tarihleri arasında gerçekleştirilen laparoskopik böbrek cerrahisi girişimleri retrospektif olarak, komplikasyon oranları ve açık prosedüre geçilme oranları açısından değerlendirildi. Bulgular: Yıllara göre açık operasyona geçiş oranları değerlendirildiğinde sırasıyla, %15, %28, %10,2, %10,5 ve %6,3 olarak bulundu. Yapılan operasyona göre açık prosedüre geçme oranları değerlendirildiğinde, renal kistektomide %8, basit nefrektomide %11, radikal nefrektomide %23 oranları izlendi. Komplikasyon oranları yıllara göre değerlendirildiğinde sırasıyla, %20, %25, %13, %18 ve %12 olarak bulundu. Bu sonuçlarla çalışmaya katılan cerrahın 1. ve 2. yıl kazandığı tecrübe ve çalışmayı gerçekleştiren cerrahın 2. yılda katıldığı laparoskopi kursundan sonra, çalışmanın 3. ve 4. yıllarında peroperatif komplikasyonların ve açık prosedüre geçilme oranlarının azaldığı izlendi. Sonuç: Laparoskopik cerrahide klasikleşmiş cerrahi eğitim modelinde geçerli olan usta-çırak aktarımı öğrenme sürecinde tek başına yeterli olmamaktadır. Laparoskopik cerrahi eğitim sürecinde bilimsel bir planlamaya oturtulmuş, yoğunlaştırılmış eğitim programlarına katılmanın belirgin yararı vardır ve teşvik edilmelidir.