Erim Erdem

The Effect of Varicocele Repair on Testicular Volume in Children And Adolescents With Varicocele

PURPOSE We investigated the effect of varicocele repair on testicular volume according to age in children and adolescents and review the long-term results of varicocele surgery. MATERIALS AND METHODS The study included 39 boys 11 to 19 years old with clinical palpable varicocele who underwent varicocele surgery with at least 1 year of postoperative followup. Preoperative and postoperative testicular volumes were monitored and measured with an ellipsoid Prader orchidometer. Physical examination findings (testicular volumes and testicular consistency) in all boys, and serum hormone values and semen parameters in 16 adolescents were recorded and compared before and after surgery. RESULTS Left unilateral varicocelectomy was done in 29 boys (74%) and bilateral varicocelectomy in 10 (26%). While no postoperative hematoma, infection or testicular atrophy was observed, 1 boy (2.5%) had varicocele recurrence and 2 boys (5.1%) had minimal hydroceles that required no intervention. Significant increases were observed in postoperative sperm concentration (p = 0.01), total motile sperm count (p = 0.009), testis volume (p = 0.000) and serum testosterone level (p = 0.014). All 15 boys with preoperative soft testis had normal testicular consistency postoperatively. Of the 19 boys with preoperative testicular atrophy 10 (53%) did regain normal testicular growth, while 9 (47%) retained testicular volume loss after surgery. When comparing preoperative to postoperative increase in testicular volume according to age in all boys, the mean was statistically significantly higher in boys younger than 14 years (left testis p = 0.037, right testis p = 0.000). CONCLUSIONS Testicular consistency achieved normal firmness after varicocelectomy in all boys with preoperative soft testis. While there was catch-up growth in comparison to the contralateral testis, testicular consistency improved but testicular volumes may not increase significantly after varicocele repair at ages older than 14 years. However, in these adolescents postoperative semen parameters and serum hormone values may significantly improve regardless of testicular volume. Therefore, boys with varicocele and their families should be fully informed in light of these findings.

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.

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.

Effect of bladder ischaemia/reperfusion on superoxide dismutase activity and contraction.

To correlate the effect of bilateral in‐vivo bladder ischaemia/reperfusion on superoxide dismutase activity (SOD) and then to correlate this with contractile responses to various forms of stimulation.

Proposal for Changes in Cystoscopic Follow–Up of Patients with Low–Grade pTa Bladder Tumor

Objectives: The cystoscopic follow–up of superficial bladder cancer accounts for a considerable workload for urologists and is also an invasive procedure with high costs. There is a potential benefit both to the urologist and the patient if unnecessary cystoscopies can be avoided. Methods: The recurrence and progression rates of 120 patients with pTa G1 or G2 and small (<4 cm) transitional cell carcinoma were evaluated retrospectively. Results: The recurrence rate was 6.5% (8/120) at 3 months. The recurrence rates at 6 and ■ months were 6.7 (8/119) and 3.6% (4/112), respectively. However, when the third month (first check) was clear, the recurrence rates at 6– and 9–month cystoscopy were 4.3 (5/116) and 2.7% (3/111), respectively. The recurrence rate at 12 months was 8% (8/99). For G1 tumors, the recurrence rates at 3, 6, 9 and 12 months were 6 (5/84), 5 (5/83), 2.5 (2/80) and 7% (5/71), respectively. The same results for G2 tumors were 8 (3/36), 8 (3/36), 6 (2/32) and 10.5% (3/28), respectively. The progression rate for the first year was lower than 1%. The difference between G1 and G2 tumors according to recurrence rate within the first year was not statistically significant (p>0.05). Conclusions: This study supports the proposal that for patients with small and welldifferentiated pTa tumors at diagnosis, if the first control cystoscopy is clear, it is appropriate to perform the second check cystoscopy 1 year from initial resection and subsequent controls yearly. One should note that the study group included the most suitable patients for cystoscopic follow–up according to size and multiplicity of the tumor. This change in policy is further supported by the fact that progression occured in less than 1% in this group of patients.

Association of elimination dysfunction and body mass index.

PURPOSE The reported prevalence of mild and severe obesity among US children is 30% and 15%, respectively. Childhood obesity likely relates to alterations in diet that also may cause constipation. We investigated the relationship between obesity and various forms of elimination dysfunction. MATERIALS AND METHODS The data of 251 patients who were diagnosed as having elimination dysfunction were analyzed retrospectively. Each patients age, weight, height and diagnosis were evaluated and body mass index (BMI) was calculated. The percentile BMI was then analyzed based on diagnosis. BMI percentile> or =85% was defined as mild obesity and BMI percentile> or =95% was defined as severe obesity. The patients were divided into four groups based on diagnosis: constipation (n=70), enuresis+constipation (n=21), daytime incontinence (n=96) and nocturnal enuresis (n=64). RESULTS The mean age of the patients was 9 years (range: 4-18 years). In the group with enuresis and constipation, 8/21 (38%) were mildly and 5/21 (24%) severely obese. Of patients with daytime incontinence, 36/70 (51%) were mildly and 22 (31%) severely obese, and of those with nocturnal enuresis alone, 35 (55%) were mildly and 20/64 (31%) severely obese. CONCLUSIONS Of children with voiding dysfunction, 62-86% are also obese. This is almost double the rate in the normal population. These conditions may have a common etiology.

Telomerase activity in diagnosis of bladder cancer

OBJECTIVE Telomerase is an enzyme that can reconstitute the ends of chromosomes after cell division and thus circumvent the damage that occurs in normal adult somatic cells during successive mitotic cycles. Immortal cells have short but stable chromosomes and increased telomerase activity. Transitional cell carcinoma (TCC) has only a few useful markers of diagnostic or prognostic importance. The objectives of this study were to determine whether there was a correlation between telomerase activities and the grade or stage of TCC and whether the activity of the enzyme could serve as a biochemical marker of this tumor. MATERIAL AND METHODS Telomerase activity was determined by examining, using a polymerase chain reaction-based assay designed using the telomeric repeat amplification protocol (TRAP), urine cell pellets obtained from 42 bladder cancer patients, 18 patients with primary hematuria, 19 patients with benign urologic disease, 14 patients with urologic malignancies other than TCC and 20 healthy volunteers. RESULTS Telomerase activity was found in 24/31 patients with bladder tumors (77.4% sensitivity) and in 5/77 patients without tumors (93.5% specificity). No correlation was found between telomerase activity and the grade or stage of the tumor. Although none of the urine cell pellets obtained from the 20 healthy volunteers demonstrated telomerase activity, positive telomerase activity was found in two subjects in the benign urologic disease group and in three subjects in the other urologic malignancy group. It was demonstrated that gross hematuria was the cause of false-negative results in six of the nine patients (66.7%). but washing the pellets four times and diluting them before the TRAP assay solved this problem. CONCLUSION These results indicate that telomerase activity may be a promising marker for TCC but the technical aspects of the technique must be improved before it is used in routine clinical practice as a standard method. False-negative results obtained using gross hematuric urine should be carefully reevaluated and cell pellets should be washed again and diluted before analysis.

Relationship between body mass index and pediatric urologic diagnoses

OBJECTIVE We had the clinical impression that children with certain urological diagnoses were thinner and others were heavier. We therefore reviewed body mass index (BMI) in children with a variety of urological diagnoses. MATERIALS AND METHODS The data from all pediatric patients treated as outpatients in our office between 1 Jan and 30 Sept 2004 were analyzed retrospectively. The patients were counted only once, even if they came back to the office several times. They were grouped by the principal billing diagnosis, but groups of less than nine patients were excluded. BMI percentiles were determined based on data from the Centers for Disease Control and compared to diagnosis codes. RESULTS The data from 1054 patients were analyzed: 53% were female, mean age was 8.0+/-3.7, mean BMI was 18.7+/-5.1 and mean BMI percentile was 64+/-31%. BMI varied significantly by diagnosis. Children with hernias and penile problems had the lowest BMI percentile and those with urinary infection and incontinence the highest, e.g. the mean BMI percentile was 46+/-31% for children with a hernia but 71+/-27% for those patients with nocturnal enuresis. CONCLUSIONS The rate of obesity varied considerably based on pediatric urological diagnosis. Diet and personality may be part of the etiology for some urological disorders. It is possible that lifestyle changes may benefit urological patients who are obese.

Is there a relation between irritable Bowel syndrome and urinary stone disease

Our aim was to investigate the role of renal colic, a clinical condition characterized by excruciating pain, in the etiopathogenesis of irritable bowel syndrome (IBS). Two groups of patients were enrolled in the study. Group I consisted of 59 patients (33 male and 26 female) with a median age of 41.9 (18 to 58) years. The patients in group I were admitted to our clinic with urinary stone disease and with a medical history of acute renal colic. Group II consisted of 55 patients (25 male and 30 female) with a median age of 40.1 (18 to 56) years, complaining of urologic abnormalities other than stone disease. IBS was diagnosed using Rome criteria. Metabolic analysis for stone disease was performed on patients in group I. The incidence of five metabolic abnormalities—low urine volume, hypercalciuria, hyperoxaluria, hyperuricosuria and hypocitraturia—in patients with and without irritable bowel disease was investigated. IBS was found in 16 of the 59 patients (27.1%) in group I and in 6 of the 55 patients (10.9%) in group II. The difference was statistically significant (P < 0.05). Relative risk of developing IBS was 2.48 times higher in patients with urinary stone disease than in those without stone disease. There was no statistically significant difference in the metabolic analysis of patients with and without IBS in group I.IBS causes great suffering. Urinary stone disease should be considered as an etiological factor during management of IBS patients. In the presence of gastrointestinal symptoms, a patient with a medical history of acute renal colic might be referred to a gastroenterologist.

Evaluation of functional lower urinary tract dysfunction in children: are the physicians complying with the current guidelines?

Objective. To elucidate whether the diagnostic and treatment approaches of the physicians for functional lower urinary tract dysfunction (LUTD) in children is complying with the current guidelines. Material and Methods. We have conducted an internet-based national survey for the physicians from different departments randomly sampled from the database of Turkish Paediatric Urology Society. Participants were asked to answer two-page questionnaire consisting of 4 main sections: “demography,” “working conditions,” “daily practice,” and “scientific knowledge.” Kruskal Wallis and multiple logistic regression were used for statistical analyses. Results. Of the 117 departments a total of 93 have completed the survey (n: 58 urology; n: 35 paediatric nephrology). Routine use of a questionnaire with validated symptom scoring system was found to be 13.9%. Of the participants, only 38.7% were asking all of the patients to fill the bladder diary. During treatment, only 24.7% were applying standard urotherapy for every patient. Almost half of the clinicians (45.1%) believed that they were personally insufficient during the evaluation of those children. Finally, 86% reported that children with LUTD were not adequately approached. Conclusions. Evaluation of LUTD in children is not complying with the current guidelines. General approach for those children needs to be revisited by the clinicians.