Erol Guntekin

Varicocele-Induced Testicular Dysfunction May Be Associated with Disruption of Blood-Testis Barrier

The objective of this study was to examine E-cadherin and α-catenin expression at the junctions between adjacent Sertoli cells in testicular specimens from patients with varicocele in order to determine the presence of a possible link between blood-testis barrier and pathophysiology of varicocele. A total of 51 testicular biopsies were obtained from 28 infertile men with unilateral or bilateral varicocele. Twenty-three patients had bilateral and 5 had unilateral varicocele, Grade I varicocele was detected in 30 (59%), grade II in 15 (29%) and grade III in 6 (12%) patients. Abnormal expression of E-cadherin and α-catenin at the junctions between adjacent Sertoli cells was demonstrated in 100% and 90% of the patients with varicocele, respectively. In those with grade I-III varicocele, the mean E-cadherin and α-catenin expression were 7.6 ± 11.4 and 39 ± 36; 7.6 ± 0.0 and 49 ± 30; 8.3 ± 9.3 and 58 ± 33, respectively, but the difference was not significant. Reduced E-cadherin and α-catenin expression at the junctions between adjacent Sertoli cells may be associated with disruption of blood-testis barrier in varicocele.

Determination of the site of metabolism of total, free, and complexed prostate-specific antigen

OBJECTIVES To determine the site of metabolism of total prostate-specific antigen (tPSA), free PSA (fPSA), and complexed PSA (cPSA). METHODS A total of 20 male patients, 50 years old or older, having a clinical indication for left and right heart catheterization were enrolled in this study. Selective blood samples were obtained from the infrarenal, infrahepatic, and suprahepatic inferior vena cava, renal vein, hepatic vein, superior vena cava, pulmonary artery, and femoral artery. cPSA concentration was accepted as the difference between tPSA and fPSA concentrations. RESULTS We found that tPSA and fPSA concentrations in the infrarenal inferior vena cava were significantly higher than in the systemic artery. There was no significant difference between the systemic artery and the infrarenal inferior vena cava for cPSA concentration. Although fPSA concentration decreased significantly across the renal circulation, the decreases in cPSA and tPSA concentrations were statistically insignificant. In the hepatic circulation, we found that tPSA, fPSA, and cPSA concentrations were significantly decreased. No decrease in tPSA, fPSA, and cPSA concentrations were noted across the pulmonary circulation. CONCLUSIONS Our results indicate that fPSA and tPSA are released into serum from the prostate but the prostate may not have a significant role in complex formation of PSA. In addition, the liver has a significant role in the elimination of tPSA, fPSA, and cPSA. By contrast, the kidneys have a significant role only in the elimination of fPSA. We also found that the lungs did not have a significant role in the elimination of tPSA, fPSA, or cPSA.

Do Renal Failure and Hemodialysis Have Any Effect on the Elimination of Free and Total Prostate–Specific Antigen?

Objectives: The aim of this study was first to determine the serum levels of free prostate–specific antigen (f–PSA), total prostate–specific antigen (t–PSA) and f–PSA/t–PSA ratios in patients with renal failure, and secondary, to investigate whether a significant difference between serum f–PSA and t–PSA levels consists in patients with end–stage renal disease before and after hemodialysis.Methods: Serum concentrations of f–PSA and t–PSA were measured in 36 men with end–stage renal disease before and after hemodialysis and in 95 healthy controls. A chemiluminescent enzyme assay was used to determine the levels of f–PSA and t–PSA.Results: The mean concentrations of serum t–PSA were 1.36±0.43 ng/ml in patients on hemodialysis and 1.08±0.60 ng/ml in controls. There was no significant difference in f–PSA and t–PSA levels between patients with renal failure and controls. F–PSA and t–PSA levels in patients with renal failure also showed no statistical differences before and after hemodialysis.Conclusions: The limited kidney reserve in patients with end–stage renal disease is sufficient to maintain the levels of t–PSA and f–PSA within normal ranges and hemodialysis does not alter the serum levels of different PSA forms.

The effect of location of the ureteric orifice on the efficacy of endoscopic injection to correct vesico-ureteric reflux.

To review our 11‐year experience and identify the mechanisms responsible for the failure of endoscopic injection for vesico‐ureteric reflux (VUR) with three different injectable agents, based on the location of the ureteric orifice on endoscopy.

Ratio of Free to Total Prostate-Specific Antigen in Patients with Prostatic Intraepithelial Neoplasia

Objective: There are many reports about the effects of prostatic intraepithelial neoplasia (PIN) on serum prostate-specific antigen (PSA) level. The aim of this study was to determine the relationship between PIN and serum free PSA/total PSA (fPSA/tPSA) ratios. Methods: We evaluated 46 patients with PIN, 15 patients with benign prostatic hyperplasia (BPH), and 16 patients with localized prostatic carcinoma (CaP) for the amount of fPSA and tPSA with the chemiluminescent enzyme assay. Results: fPSA values from BPH to high-grade PIN (PIN2 and PIN3) was increased, and then a decrease was observed from high-grade PIN to CaP. fPSA was significantly different between BPH and low-grade PIN and high-grade PIN. There was no significant difference observed between BPH and CaP. tPSA values increased from BPH to CaP. tPSA was significantly different between BPH and high-grade PIN and CaP. fPSA/tPSA ratios decreased from BPH to CaP. This ratio was significantly different between CaP and BPH and low-grade PIN. There was no significant difference between CaP and high-grade PIN. Conclusions: Our results confirm that fPSA/tPSA ratio is better at discriminating between patients with CaP and those with BPH, but not between patients with CaP and those with high-grade PIN. Due to similarities between CaP and high-grade PIN, we think that decreased fPSA/tPSA ratio obtained at the time of intial diagnosis of PIN without concurrent carcinoma could be used as predictive factors to distinguish patients in whom carcinoma will be found on subsequent biopsies from those with PIN not associated with cancer on repeat biopsy.

Midline Dorsal Plication to Repair Recurrent Chordee at Reoperation for Hypospadias Surgery Complication

PURPOSE Midline dorsal plication is an efficient and safe surgical technique to correct chordee. We investigated the efficacy of midline dorsal plication for recurrent chordee in complicated hypospadias reoperations. MATERIALS AND METHODS We retrospectively evaluated the charts of 25 boys who underwent reoperation between 1999 and 2004 due to complications of primary hypospadias repair other than meatal stenosis. A total of 15 cases were initially managed elsewhere for primary repair or complications. The etiology of recurrent chordee was defined at surgical correction. When recurrent chordee was noted a midline dorsal plication was performed. RESULTS Of 25 patients 10 had previously undergone chordee repair. Nine of these patients were observed to have recurrent chordee and 1 had de novo chordee. A total of 10 patients had recurrent or delayed onset chordee. Mean patient age at primary repair was 6.28 years (range 1 to 33). Mean age at last operation for chordee was 15.9 years (range 4 to 66). Mean interval to recurrent chordee was 6 years (range 1 to 16), excluding a 66-year-old blind patient who did not know when recurrent chordee developed. Five patients had chordee recur before puberty at a mean interval of 2.6 years. Mean reoperation rate was 2.4 for recurrent chordee cases and 2.6 for chordee-free cases. Mean followup after midline dorsal plication for recurrent chordee repair was 22 months (range 8 to 56), while mean followup in pubertal and postpubertal cases was 20 months. No recurrence of chordee or surgery related morbidity was observed after recurrent chordee repair by midline dorsal plication. CONCLUSIONS Chordee may recur during puberty following successful chordee repair. The midline dorsal plication technique is simple, efficient and safe even in patients who have undergone multiple surgeries for hypospadias and chordee repair.

Complications and Associated Factors of Pediatric Extracorporeal Shock Wave Lithotripsy

PURPOSE We determined the safety, efficacy and complications of extracorporeal shock wave lithotripsy in managing pediatric urolithiasis and analyzed possible factors affecting the complication rate. MATERIALS AND METHODS We retrospectively reviewed 128 patients younger than 16 years who had undergone extracorporeal shock wave lithotripsy with a Lithostar® lithotripter between January 2000 and December 2010. Stone clearance and complications were assessed at postoperative week 1, and months 1 and 3. Success was defined as no radiological evidence of stone, or fragments 4 mm or less. Treatment failure was analyzed to find any correlation with stone size. Complications were assessed with a specific focus on rehospitalizations during postoperative week 1. RESULTS The overall success rate was 93.5% (115 of 123 patients). Repeat treatment rate was 56.1% (69 patients). Extracorporeal shock wave lithotripsy failed in 8 children, who subsequently required ancillary procedures. Mean stone size in the treatment failure group was 17.03 mm, compared to 13.04 mm in the successfully treated group. A total of 22 patients (17.8%) had complications in postoperative week 1 but only 19 (15.4%, 12 boys and 7 girls) were rehospitalized at that time. Presence of a metabolic risk factor was the only predictive factor for complications. By comparison, we found a lower success rate and higher ancillary procedure rate in the group with complications. CONCLUSIONS Extracorporeal shock wave lithotripsy is effective for pediatric urolithiasis, with a small but substantial morbidity rate. Parents should be informed about possible rehospitalization following extracorporeal shock wave lithotripsy due to complications independent of stone size.

Initial Pre-Scrotal Approach for Palpable Cryptorchid Testis: Results During a 3-Year Period

PURPOSE Pre-scrotal orchiopexy is emerging as an alternative approach for cryptorchid testes that can be preoperatively mobilized into the scrotum. We present our 3-year pre-scrotal orchiopexy series for all palpable cryptorchid testes regardless of their mobility into the scrotum preoperatively. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent pre-scrotal orchiopexy during a 3-year period. Data collected included preoperative and postoperative testicular position, mobility of the testis into the scrotum preoperatively or with the patient under general anesthesia, patency of processus vaginalis, operative times and complications. RESULTS A total of 88 cryptorchid testes were treated using single pre-scrotal incision orchiopexy. Mean patient age was 4.9 years. Of the testes 74 (84.1%) could be milked down to the scrotum preoperatively and 14 (15.9%) could not. Of the 14 immobile testes 8 were intracanalicular and 6 were in the superficial inguinal pouch. Pre-scrotal orchiopexy was successful in all 74 testes that were mobilized into the scrotum preoperatively. However, 6 of 14 testes (43%) that could not be moved to the scrotum were effectively managed by a single pre-scrotal incision, while 8 (57%) required an additional groin incision for successful orchiopexy. No complications were observed during a mean followup of 7.1 months. CONCLUSIONS Orchiopexy using a pre-scrotal approach is a viable alternative for palpable cryptorchid testes that can be preoperatively mobilized into the scrotum. Cryptorchid testes that are palpable but cannot be moved to the scrotum can be managed by the pre-scrotal approach alone in 40% of cases or with an additional groin incision in 60%.

Anticholinergics do not improve cure rate of alarm treatment of monosymptomatic nocturnal enuresis.

OBJECTIVES To determine whether previous anticholinergic therapy or a combination of anticholinergics and alarm treatment could increase the success rates for monosymptomatic nocturnal enuresis. Alarm treatment of monosymptomatic nocturnal enuresis is the treatment of choice, with the greatest lasting success. It has been proposed that failures are related to a patients small bladder volume. METHODS During a 3-year period (July 2004 to July 2007), all bed-wetting patients presenting to our pediatric urology clinic were retrospectively evaluated. Of 221 enuretic patients, 142 were monosymptomatic and 85 of them had had no previous treatment. The children were treated conservatively, and those with treatment failure were given either alarm treatment or anticholinergics, as chosen by the parents. The patients with failure to the second-line treatment were given a combination of alarm therapy and anticholinergics. RESULTS The mean age of the 85 children was 8.2 years. Of the 85 children, 30 were first given anticholinergics and 55 alarm treatment. Anticholinergics alone resulted in a 10% success rate and alarm treatment alone, a 56.3% success rate. Previous anticholinergic medication did not increase the success rate of alarm treatment (33.3%). Similarly, adding anticholinergics after alarm treatment had failed did not result in treatment success. We observed no difference in the changes in the mean functional bladder capacities among the anticholinergic treatment arm, alarm treatment arm, or combination arm. CONCLUSIONS Switching from previous anticholinergic treatment that has failed to alarm treatment or using a combination of alarm treatment and anticholinergics did not improve the functional bladder volume or cure rate of children with monosymptomatic nocturnal enuresis.

Role of spinning top urethra in dysfunctional voiding.

Abstract Objective. The role of spinning top urethra (STU) in children with dysfunctional voiding was evaluated retrospectively. Material and methods. From 1995 to 2002, the records of 154 children with dysfunctional voiding were reviewed retrospectively. Of the children 110 (71%) were girls and 44 (29%) were boys (mean age 8 years, range 4–14). All children were neurologically normal and no exhibited physical signs of occult spinal dysraphism. Patients were divided into two groups according to their width of proximal urethra: group I had STU and the group II had normal urethral width. The groups were compared with each other for gender, voiding symptoms, urinary tract infection (UTI), vesicoureteral reflux (VUR) and urodynamic observations. Results. There were 84 children (mean age 8.3 ± 2.2 years, range 4–14) in group I and 70 (mean age 8.0 ± 2.1 years, range 4–14) in group II; no significant age difference was found between the two groups (p = 0.4674). Group I consisted of 66 (71%) girls and 18 (29%) boys and group II 44 (63%) girls and 26 (37%) boys. STU was observed more in girls than boys in group I (p = 0.0316). UTI was observed in 57 patients (68%) in group I and 34 (49%) in group II (p = 0.0154). Mean duration of symptoms was 42 ± 24 months (range 6–118) and 39 ± 23 (range 3–120) months in groups I and II, respectively (p = 0.6302). Postvoid residual urine (PVR) more than 10% of expected bladder capacity was detected in 15 patients (18%) in group I and seven (10%) in group II. No association was found between the meaningful PVR and STU (p = 0.1653). The presence of detrusor overactivity during filling was observed in 54 patients (64%) in group I and 42 (60%) in group II (p = 0.4676). Diminished bladder compliance (< 10 ml/cmH2O) was detected in 34 patients (40%) in group I and 17 (24%) in group II (p = 0.0335). The mean voiding pressure was measured as 56 ± 29 cmH2O in group I, which was significantly higher than in group II (49 ± 25 cmH2O) (p = 0.0373). The mean flow rate during the emptying phase of urodynamics was 16 ± 8 and 15 ± 6 ml/s in groups I and II, respectively (not significant, p = 0.2686). VUR was detected in 16 patients (19%) in group I and two (3%) in group II (p = 0.0018). Conclusions. STU was related to recurrent UTIs, VUR, poor bladder compliance and more serious functional urinary obstruction. Furthermore, STU may be a consequence of a neurogenic maturation defect in detrusor–sphincter coordination resembling that of urofacial syndrome, because development of this situation was found to be independent of the duration of symptoms.