Giray Ergin

The role of urinary nerve growth factor for the diagnosis and assessment of the biofeedback success in children with dysfunctional voiding.

INTRODUCTION Dysfunctional voiding (DV) occurs in neurologically normal children who are not able to establish brain control on detrusor muscle contractions (DMCs). It is also reported to be the result of incorrect voiding habits during toilet training. Children contract pelvic floor muscles (PFMs) to suppress DMC and DV begins. Urinary nerve growth factor (uNGF) is necessary for the synthesis and regulation of neurotransmitters, development of dorsal root ganglia (sensory neurons), and development of sympathetic cells during embryonic and post-natal life. uNGF has also a role in the intracellular signal transduction in nerve cells towards the target organ. To our knowledge, no study has investigated the association between uNGF, biofeedback treatment and DV in children. OBJECTIVES The aim was to examine the potential effect of uNGF in the assessment of the effectiveness of biofeedback success in children with lower urinary tract disorders. STUDY DESIGN Fifty-two children with the suspicion of DV and 48 children from a primary school reporting no urinary complaints were enrolled in this study from October 2010 to April 2013 in the Urology Department. uNGF levels were compared. RESULTS The mean uNGF/creatinine (Cr) level was 0.23 ± 0.26 in the control group and 0.96 ± 0.88 in the DV group (p < 0.001). The mean uNGF/Cr levels in the DV group at baseline and at the end of biofeedback therapy at 6 and 12 months were 0.90 ± 0.78, 0.26 ± 0.32, and 0.40 ± 0.50, respectively (p < 0.001) (Figure). DISCUSSION To our knowledge this study is the first to show the correlations between uNGF levels and biofeedback therapy in children with DV. Tissue NGF in 12 patients with overactive bladder (OAB)/detrusor overactivity and 15 healthy women was previously compared and it was suggested that there was no correlation between bladder tissue NGF and OAB. uNGF levels in the bladder in patients with interstitial cystitis and idiopathic sensorial urgency were evaluated previously, and uNGF levels reported. Similar to these reports, most of the previous studies handled uNGF in patients with diseases such as interstitial cystitis, OAB, urinary tract infections, urolithiasis, spinal cord injury, and prostate cancer, and found significantly higher uNGF levels. These studies were generally in adults. A previous study about uNGF comprised 40 children with OAB, in contrast to other studies. According to this study, 40 children diagnosed with OAB were administered anti-muscarinic therapy (oxybutynin 0.3-0.5 mg/kg/day). It was reported that uNGF/Cr levels of the OAB group were higher than control group. In the current study, we evaluated the uNGF difference in DV and the effect of biofeedback treatment on uNGF levels. CONCLUSIONS uNGF levels were higher in children with DV and decreased after biofeedback therapy. uNGF levels could be used for the diagnosis and the assessment of biofeedback success in these children.

Can urinary nerve growth factor distinguish high-grade prostate cancer?

To the Editor: Sir, we read with great interest the published article by Liss et al. [1] entitled “Urinary nerve growth factor as an oncologic biomarker for prostate cancer aggressiveness.” The authors have suggested that urinary nerve growth factor (uNGF) was able to distinguish high-grade prostate cancer (PCa) before radical prostatectomy, and NGF might be a biomarker for higher-grade PCa and may provide unique information about patients with PCa pending further confirmatory studies. However, we think there are some points that should be mentioned as contributory factors. The authors have defined restricted exclusion criteria. They should also state whether the patients have one of following diseases, which could possibly affect NGF levels: neuropsychiatric diseases such as epilepsy, depression, schizophrenia, and eating disorders or cardiometabolic diseases such as atherosclerosis and metabolic syndrome [2]. Moreover, they should define whether the patients have urolithiasis, overactive bladder, interstitial cystitis, bladder outlet obstruction, or coincidental upper urinary tract malignancies, which were shown to affect uNGF levels [3,4]. Urinary biomarkers are frequently reported as a normalized ratio to urinary creatinine (Cr) concentration to control for variations in urine flow rate. The implicit assumption is that urinary Cr excretion is constant across and within individuals, such that changes in the ratio will reflect changes in biomarker excretion [5]. Therefore, NGF/Cr ratio is more reliable than log10 NGF, and the findings of the authors are not satisfactory. The authors did not find statistically significant difference between groups when they used the NGF/Cr ratio; we believe that this ratio is superior to log10 NGF value to make inferences although they found difference when they used log10 NGF.

The biofeedback treatment for non-monosymptomatic enuresis nocturna

Enuresis is a child older than 5 years wetting in discrete portions during sleep. It has two subgroups: monosymptomatic enuresis nocturna (MSEN) and non‐monosymptomatic enuresis nocturna (NMSEN). In this research, we specifically aimed to examine the effect of biofeedback in NMSEN.

Concised Form for Lower Urinary Tract Dysfunction Symptom Scale in Children

INTRODUCTION Symptom Scales (SS) are questionnaires for evaluating and following up of special illnesses. SS used for the diagnosis and follow-up of Lower Urinary Tract Dysfunction (LUTD) in children is called LUTD Symptom Scale (LUTDSS). AIM Aim of the present study was to identify the questions which are more important for the diagnosis of LUTD in children and create a simpler SS. MATERIALS AND METHODS From January 2005 to March 2015, 631 children between the age 5 and 15 were enrolled in this study. Eleven children with active urinary tract infections were excluded from the study. Two hundred sixty three children from the nursery and secondary school saying that they have no urinary complaints and having LUTDSS <9 were designed as control group. Three hundred fifty seven children with LUTDSS score ≥9 were thought as having LUTD and diagnoses were verified with 3-day bladder diaries and 2-time Uroflow-EMG-PVR tests. The answered questions of LUTDSS in patient and control group were compared. RESULTS Children with daytime incontinence (first question of questionnaire) were 47.7 (4.8-510) times (p=0.01), children with enuresis (third question) were 59.53 (6.2-961) times (p=0.001), children with pause while urinating (eighth question) were 28.7 (4.4-2090) times (p=0.001), children with urgency (tenth question) were 54.7 (29.3-604) times (p=0.039) more likely to have LUTD than the children not having these complaints. The area under ROC curve created by using 1,3,8, and 10 questions was calculated 86.4%. CONCLUSION The diagnosis and control of LUTD can be made by using only 1., 3., 8. and 10. questions, and these 4 questions could form simpler SS for LUTD in children.

Predictive Significance of Preoperative Neutrophil to Lymphocyte Ratio versus Platelet to Lymphocyte Ratio for Gleason score in Prostate Cancer Patients

Objective: Inflammation plays a critical role in the development and progression of cancer. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are easily accessible basic inflammatory parameters. In this study, we aimed to analyze the association between the NLR, PLR, and the Gleason score in prostate cancer, which is main parameter used in the prostate cancer prognosis. Materials and Methods: A total of 173 patients with prostate cancer (mean age, 63±6.2 years) who underwent radical prostatectomy were included into this retrospective study. The NLR and PLR were derived from the complete blood cell count results from the preoperative period. Patients were divided into two groups, as the low grade prostate cancer (Gleason score≤7 [3+4]) and the high-grade prostate cancer (Gleason score≥7 [4+3]) group. A logistic regression analysis was performed to determine the association. Results: A univariate logistic regression analysis showed that the Ln-prostate specific antigen (PSA) (1.83, 95% confidence interval [CI] [1.01, 3.3] p=0.04), Ln-lymphocyte (0.38, 95% CI [0.15, 0.94] p=0.03), and Ln-NLR (1.9, 95% CI 1.9 [1.13, 3.38] p=0.01) levels were significantly associated with the high-grade Gleason score. However, the Ln-PLR levels revealed the association with marginal statistical significance (2.06, 95 % CI [0.95, 4.4] p=0.06). In multiple analyses, after adjusting the analysis for age, Ln-NLR (1.96, 95% CI [1.12, 3.42] p=0.01) and Ln-lymphocyte levels (0.38, 95% CI [0.15, 0.97] p=0.04) were still statistically significantly associated with high-grade prostate cancer. Conclusion: Higher NLR levels were significantly associated with high-grade prostate cancer. However, PLR levels were not a significant predictor of higher Gleason scores.

Flexible Ureterorenoscopy versus Mini-Percutaneous Nephrolithotomy for the Treatment of Renal Stones

PURPOSE To compare the pain status and stone free rates of flexible ureterorenoscopy (F-URS) versus mini-percutaneousnephrolithotomy (mini-PNL) for the treatment of 1-to 2-cm renal stones. MATERIALS AND METHODS This study was retrospectively designed with match paired method. Between January 2013 and December 2016, 387 patients underwent stone surgery for renal stones, 45 patients underwent FURS and 45 patients underwent mini-PNL. 90 patients were divided into two groups according to the surgical procedures. Group 1 patients underwent F-URS, and Group 2 patients underwent mini-PNL. During the intraoperative andpostoperative periods, pain management for all patients was standardized. Pain scores were determined using a visual analogue scale (VAS) completed at 2, 6, 12 and 24 hours postoperatively. The stone free status, hemoglobin levels, fluoroscopy time (FT), operation time (OT), hospitalization time (HT), return to work time (RWT), and complications were noted for each patient. RESULTS Of all patients, the mean age was 41.1 ± 12.1 years and the mean stone size was 13.9 ± 2.9 mm. The VAS scores were significantly higher in the mini-PNL group at 2, 6, 12 and 24 hours (P < .05). The stone-free status and complication rates were similar between the two groups (P > .05); however, the hemoglobin decreases and the fluoroscopy, operation, hospitalization and return to work times were higher in the mini-PNL group than in the F-URS group (P < .05). CONCLUSION F-URS is less painful than mini-PNL for the treatment of 1- to 2-cm renal stones. However, the stone free rate is similar between the two procedures while mini-PNL is superior in terms of fluoroscopy, operation, hospitalization and return to work duration. We think that F-URS is more comfortable and less painful than mini-PNL and achieves a similar stone free rate for the treatment of 1- to 2-cm renal stones.

Our experiences with robot- assisted laparoscopic surgery in pediatric patients: the first case series from Turkey

OBJECTIVE Robotic surgery is a leading treatment option for minimally invasive surgery and has an increasing popularity in pediatric population, as well. In this article, we reported our case series of robot-assisted laparoscopic surgery in pediatric population. MATERIAL AND METHODS We retrospectively reviewed 29 consecutive pediatric patients who underwent robot- assisted procedures between May 2014 and October 2016. Patient demographics, hospitalization time, estimated blood loss, robotic time and total operative and peri-, and post-operative complications were evaluated. RESULTS A total of 24 ureter units (18 patients) with grade 1-5 vesicoureteral reflux in 13 female and 5 male, 1 male patient with vesicoureteral stenosis were underwent robot- assisted laparoscopic ureteral reimplantation (RALUR). All patients had complete resolution after surgery. Robot-assisted laparoscopic pyeloplasty (RALP) was performed in 6 patients with ureteropelvic junction obstruction. All patients had complete resolution after surgery. Completely intracorporeal robotic assisted laparoscopic augmentation ileocystoplasty (RLAIC) was applied to two patients with neurogenic bladder. The symptoms and preoperative hydronephrosis were regressed on the first month of follow-up. Robot-assisted laparoscopic reduction cystoplasty (RALRC) was performed in 14-year-old boy with a bladder diverticula and recurrent urinary tract infection. The last case was eleven- year-old female patient with non-functioning kidney. She had recurrent urinary tract infections and was treated with robotic assisted laparoscopic nephrectomy (RALN). CONCLUSION Robot-assisted laparoscopic surgery is safe and efficient in pediatric population. Although open surgery is still the gold standard for many pediatric diseases, inherent reconstructive advantages of robotic assisted laparoscopy have a chance to change this view.

Effect of Voided Volume on Voiding Patterns and Reliability of Uroflowmetry‐Electromyography Results in Children with Lower Urinary Tract Dysfunction

To examine whether voided volume (VV) could change the uroflow patterns and result in children with lower urinary tract dysfunction (LUTD).

Surgical management of urinary stones with abnormal kidney anatomy

In spite of the fact that urologic surgical techniques used by urologists are becoming more and more minimally invasive and easier because of developing technologies, surgical approaches for the urinary stones in kidneys with abnormal anatomy are still confusing. The objective of this article is to determine the treatment options in these kidneys. For this purpose, between 2005 and 2015, we retrospectively evaluated patients operated for urolithiasis with various congenital renal anomalies in five referral urology clinics in our country. Of the 178 patients (110 male, 60 female), 96 had horseshoe kidneys, 42 had pelvic ectopic kidneys (PEKs), and 40 had isolated rotation anomalies (IRAs) of the kidney. We evaluated the patients for stone‐free rate (SFR), mean operation time, mean hospitalization time, and complication rate. In horseshoe kidney, SFRs for retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) groups were 72.2% and 90%, respectively. In PEKs, these rates were 83.6% and 100% for RIRS and laparoscopic pyelolithotomy, respectively. SFRs in kidneys with IRA were 75% for RIRS and 83.3% for PNL. The mean operation time for RIRS and PNL groups in horseshoe kidney was 40.5 ± 11.2 minutes and 74.5 ± 19.3 minutes, respectively. In PEKs, these times were 52.1 ± 19.3 minutes and 53.1 ± 24.3 minutes for RIRS and laparoscopic pyelolithotomy, respectively. Mean operation time in kidneys with IRA was 48.7 ± 14.4 minutes for RIRS and 53.2 ± 11.3 minutes for PNL. Mean hospitalization times for RIRS and PNL groups in horseshoe kidneys were 1.4 ± 0.7 days and 2.2 ± 1.4 days, respectively. In PEKs, these times were 2.7 ± 1.8 days and 1.9 ± 0.4 days for RIRS and laparoscopic pyelolithotomy, respectively. Mean operation time in kidneys with IRA was 1.5 ± 0.9 days for RIRS and 1.8 ± 0.6 days for PNL. The results of our study showed that RIRS could be used in all of types of abnormal kidneys with small‐ and medium‐sized renal calculi safely and satisfactorily.

Isolated relapse of a lymphoblastic leukemia T cell precursor in the epididymis.

A 41-year-old man who had otherwise asymptomatic right scrotal swelling presented to our urology clinic. He had been diagnosed with T cell precursor lymphoblastic leukemia/lymphoma 2 years previously. On examination, his right epididymis was enlarged. A regular, homogeneous, slightly hypoechoic solid mass was observed at the right caput epididymis. This testicular mass measured approximately 7×11×12 mm. Leukemia and lymphoma appear in a variety of locations throughout the body, but an isolated relapse involving the epididymis is rare. Epididymectomy was performed which naturally removed the patients right-sided sperm duct system. Especially in the younger age group epididymal masses can lead to fertility problems.