Hakan Ozkardes

Conventional testicular sperm extraction combined with the microdissection technique in nonobstructive azoospermic patients: a prospective comparative study

OBJECTIVE To perform conventional and microdissection testicular sperm extraction (TESE) at the same session and compare their effectiveness. DESIGN Prospective comparative study. SETTING University hospital setting. PATIENT(S) The study included 335 patients with nonobstructive azoospermia. INTERVENTION(S) Microdissection TESE was performed to 77 patient with atrophic testes. An additional 258 patients underwent conventional TESE using three incisions on three quadrants of the testis (upper, middle, and lower). Microdissection TESE was performed by enlarging the middle incision vertically when no spermatozoa could be detected using the conventional technique. MAIN OUTCOME MEASURE(S) Sperm retrieval, fertilization, clinical pregnancy rate (PR), and live birth rate were evaluated. The relation between sperm retrieval rate and FSH level and testis volume was also investigated. RESULT(S) Spermatozoa was detected in 33.7% of patients using conventional TESE. The spermatozoa detected increased to 50.8% using microdissection TESE. The increase was statistically significant. In the primary microdissection TESE group, the surgical retrieval rate was 20.8%. The overall sperm retrieval rate was 43.9%. There was a significant relation between the sperm retrieval rate and testis volume, whereas there was no relation between sperm retrieval rate and FSH levels. The overall fertilization rate, clinical PR, and live birth rate were 57.1%, 50.4%, 36.4%, respectively. CONCLUSION(S) Conventional TESE combined with microdissection TESE can be used in selected patients. Sperm retrieval rate of TESE can be low in patients with atrophic testes.

Factors Affecting Fever Following Percutaneous Nephrolithotomy: A Prospective Clinical Study

AIM To evaluate the preoperative and intraoperative factors that might affect development of fever following percutaneous nephrolithotomy (PCNL) and to investigate the clinical significance of intraoperative microbiologic evaluation in managing postoperative infectious complications. PATIENTS AND METHODS Sixty-one consecutive patients who had undergone PCNL between October 2006 and June 2007 were prospectively recruited into the study. Preoperative urine cultures and intraoperative stone and pelvic urine cultures were obtained from all patients. Postoperatively, patients were closely monitored for fever and other signs of systemic inflammatory response syndrome. RESULTS Of 61 patients, 10 (16.8%) had at least one body temperature recorded at 38 degrees C (group 1), the remaining patients were afebrile (group 2). Fever was associated with a systemic inflammatory response syndrome in one patient (1.6%); in that patient, the antibiotic regimen was altered. There were statistically significantly more positive stone culture results for patients in group 1 than there were for patients in group 2 (5/10 versus 9/51, P < 0.05). There were statistically significantly more positive pelvic urine culture results for patients in group 1 than there were for patients in group 2 (3/10 versus 2/51, P < 0.05). Patients in group 1 also had longer operative times and larger stone burdens than did patients in group 2. CONCLUSIONS Intraoperative microbiologic evaluation may be important in postoperative antibiotic selection and should be routinely used.

Successful percutaneous nephrolithotomy in children: multicenter study on current status of its use, efficacy and complications using Clavien classification.

PURPOSE In this multicenter study we aimed to evaluate the efficacy and safety of percutaneous nephrolithotomy in children with respect to different features and using the Clavien classification system. MATERIALS AND METHODS Percutaneous nephrolithotomies performed in children at 3 urology departments between March 2006 and May 2010 were included in the study. Results are presented for complex/simple renal stones, tubeless/totally tubeless percutaneous nephrolithotomy, simultaneous bilateral percutaneous nephrolithotomy, instrument size and age groups. Patients were divided into 3 distinct groups, infants and toddlers (3 years or younger, group 1), preschool children (4 to 7 years, group 2) and school children (8 to 16 years, group 3). Perioperative complications are presented according to the modified Clavien classification system. RESULTS A total of 140 percutaneous nephrolithotomies were performed in 130 patients (41.5% female, mean age 10.17 years). There were 23, 25 and 92 renal units in groups 1, 2 and 3, respectively. Pediatric instruments were used in 60 renal units and adult-sized instruments in 80. General assessment of complications showed Clavien grade I complications in 17 patients, II in 4, IIIa in 11 and IIIb in 7. There were no grade IV or V complications. CONCLUSIONS Percutaneous nephrolithotomy can be applied safely in children of varying ages, even infants. Complications, as assessed with Clavien classification, are comparable to those seen in adults provided there is enough experience with the technique.

Percutaneous Nephrolithotomy: Nephrostomy or Tubeless or Totally Tubeless?

OBJECTIVES To compare the feasibility and morbidity of tubeless, totally tubeless, and standard percutaneous nephrolithotomy (PNL) with nephrostomy tube in a single center with selected patient population. METHODS Between July 2006 and February 2008, PNL was performed in 176 patients in this retrospective study. Patients with no serious bleeding or perforation in the collecting system during the operation, stone-free status, or clinically insignificant residual fragments (<4 mm) at the end of the procedure and patients with no more than one access were enrolled in the study. Patients were categorized into 3 groups. In group 1 (n = 43), no nephrostomy or ureter catheters were placed after PNL (totally tubeless group); in group 2 (n = 41), no nephrostomy catheter was placed but antegrade J-stent was used (tubeless group), and in group 3 (n = 92), standard nephrostomy catheters were placed (standard group). Three groups were compared with respect to age, stone volume, postoperative hemoglobin change, transfusion rate, operation time, analgesic requirement, hospitalization time, and complication rates. RESULTS No significant differences were found in mean stone volume, operation time, transfusion rates, and hemoglobin level change between the groups. However, hospitalization time and the amount of narcotic analgesic required were significantly higher in group 3 compared with the other groups (P <.05). Complications were observed in 2 (4.6%), 3 (7.3%), and 7 (7.6%) patients in groups 1, 2, and 3, respectively (P = .738). CONCLUSIONS In patients with no major intraoperative bleeding and calyceal perforation, tubeless approach is safe with decreased analgesia requirement and hospital stay.

The Efficacy of Anti-Serotoninergic Agents in the Treatment of Erectile Dysfunction

We investigated 3 agents with antiserotoninergic activity (oral trazodone, ketanserin and mianserin) in a double-blind randomized placebo controlled design in terms of the effectiveness in erectile dysfunction. Positive response rates to 30 days of treatment were 65.2% with trazodone, 19.1% with ketanserin, 31.6% with mianserin and 13.6% with placebo. Response to trazodone treatment was significantly better than with placebo (p = 0.0004) and the other 2 agents (p = 0.03 and p = 0.002 for mianserin and ketanserin, respectively). The effectiveness of ketanserin and mianserin seemed to be greater than that of placebo but the differences did not reach statistical significance (p = 0.63 and p = 0.17, respectively).

Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia.

PURPOSE We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. PATIENTS AND METHODS A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. RESULTS The mean ages of patients in groups 1 and 2 were 45 +/- 15 and 44 +/- 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 +/- 386 mm(2) and 731 +/- 394 mm(2), respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). CONCLUSIONS We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.

Follow-Up of Testicular Microlithiasis for Subsequent Testicular Cancer Development

Introduction: To demonstrate the relationship between testicular microlithiasis and testicular tumor development. Patients and Methods: Between January 1996 and March 2004, bilateral testicular microlithiasis was found in 40 of the 5,263 patients who underwent scrotal ultrasonography yielding a prevalence of 0.76%. Of the 40 patients, 4 patients with concomitant testicular tumors were excluded from the study. The remaining 36 patients were enrolled into the study and followed by ultrasonography at 6-month intervals. Results: Patient ages ranged between 1 and 69 years (mean 31 ± 14 years). The median ultrasonography follow-up was 34 months (range, 1–96). Testicular tumor development was not observed in any of these 36 patients during the follow-up period. Conclusions: Extensive evaluation including computerized tomography, testicular tumor markers and testicular biopsyof patients with testicular microlithiasis is unnecessary and also increases patient anxiety. Yet annual ultrasonography and physical examination should be performed if ever until testicular microlithiasis is completely accepted as a nonpremalignant disease.

Evaluation of Erectile Function in Renal Transplant Recipients

RECTILE dysfunction describes the inability to achieve and maintain penile erection sufficient for coitus. Renal insufficiency is a chronic disease during which erectile function deteriorates, however, the etiology of this condition in such patients is multifactorial, involving organic and nonorganic (psychogenic) factors. 1 The condition may result from neuroendocrine disturbance, uremia, hypoxia, and atherosclerosis. 2 Neuroendocrine disturbance is often reversed by renal transplantation, but not by dialysis. 3 Psychological factors may also cause erectile dysfunction in dialysis patients, since approximately one fourth of these individuals are depressed at any given time. 4 Patients often regain potency after transplantation but in some cases, especially second transplantations, erectile function is adversely affected by interference with arterial blood flow. In this study, we evaluated the effect of renal transplantation on erectile function. PATIENTS AND METHODS Information on erectile function was collected by means of a questionnaire given to 65 men who were renal transplant recipients. The patients ranged in age from 20 to 57 years (mean 42.5 years). A second transplantation had been performed in four cases (6%). Posttransplantation follow-up ranged from 2 to 168 months (mean 72 months). A detailed medical history was taken and complete blood count, urinalysis, and a biochemical and endocrinologic blood analysis were routinely performed for all patients. A papaverine test, penile Doppler ultrasonography, cavernosometry, cavernosography, and pudendal angiography were done where indicated. For patients who had no erectile dysfunction before or after renal transplantation, the questionnaire and routine tests completed the evaluation. This group was considered to have experienced no change in erectile function due to renal transplantation. Similarly, no further tests were performed on patients who were afflicted with erectile dysfunction prior to renal transplantation but regained sexual function following transplantation. These patients were defined as the group with improved sexual function. On the other hand, patients with deteriorated erectile function after renal transplantation were evaluated in detail. All underwent a papaverine test involving intracavernous injection of 50 mg of papaverine and observation of response after 30 minutes. The group which experienced full erection after papaverine treatment (papaverine responders) was considered to have nonorganic (psychogenic) erectile dysfunction. Patients who did not respond to papaverine were further evaluated by penile Doppler ultrasonography for vasculogenic impotence. Papaverine-stimulated penile Doppler ultrasound was performed using a 7.5-MHz linear probe. Peak systolic velocities in the cavernous arteries were measured bilaterally. A peak systolic velocity of ,25 cm/s was considered as arterial insufficiency. Patients with arterial insufficiency underwent pudendal angiography, while those with normal penile Doppler ultrasound findings underwent dynamic infusion cavernosometry and cavernosography to assess for suspected veno-occlusive dysfunction. RESULTS Thirty-two patients (49.2%) experienced no alteration in erectile function before or after renal transplantation. Twelve patients (18.4%) said they regained erectile function after renal transplantation. Twenty-one patients (32.3%) with normal erectile function prior to transplantation during the hemodialysis period reported erectile dysfunction after the transplantation, constituting the group which was evaluated further. Seven of these patients were papaverine responders (nonorganic impotence) and benefited from antiserotoninergic treatment. All seven men received 150 mg/d trazodone initially, however, two patients who reported severe side effects with this drug were switched to sertraline at a dose of 50 mg/d. All patients in this group achieved erections sufficient for coitus within 3 months. In three patients, deterioration of erectile function was associated with hyperprolactinemia accompanied by a low testosterone level. A papaverine test was not performed in these cases. Oral testosterone replacement resulted in improved sexual function. Eleven of 21 patients who reported a deterioration in erectile function after transplantation did not respond to papaverine. These individuals were considered to have vasculogenic impotence. According to penile Doppler ultrasound, nine of these men had arterial insufficiency, while two had normal peak systolic velocities in their cavernous arteries, indicating no arterial insufficiency. These two patients underwent cavernosometry and cavernosography, which confirmed veno-occlusive dysfunction. They were treated with deep dorsal vein embolization using n-butyl cyanoacrylate, and regained satisfactory erections within 3 months, at which time control cavernosometry was normal.

Balloon dilatation versus Amplatz dilatation for nephrostomy tract dilatation.

PURPOSE In this study, we present our experience using balloon and Amplatz dilatation to establish a percutaneous tract. We also discuss advantages and risk factors of both techniques. MATERIALS AND METHODS We retrospectively reviewed medical records of 229 patients who had undergone 235 percutaneous nephrolithotomy procedures. The nephrostomy tract had been dilated using a balloon (42 patients) or Amplatz (187 patients) dilator. Total operating time, preoperative and postoperative hemoglobin concentrations, number of tracts required, stone burden, blood transfusion rates, tract dilatation failures, and the cost of the dilatation system were compared between the groups. RESULTS There were no statistically significant differences in operative time (85.7+/-43.2 v 86.3+/-41.2 minutes; P=0.42), preoperative hemoglobin concentration (14.1+/-1.1 v 13.8+/-1.4 mg/dL; P= .153), postoperative hemoglobin concentration (11.6+/-1.7 v 11.2+/-1.5 mg/dL; P= .601), or blood transfusion rate (18.6% v 21.3%; P= .687) between the two groups. Also, there were no differences in failure rates between the two groups. CONCLUSIONS The Amplatz dilator is comparable with the balloon dilator with regard to efficacy, speed, and safety. The Amplatz dilator is more cost-effective than the balloon dilator. However, kidney hypermobility may be a significant problem during Amplatz dilatation.

Covered metallic ureteral stent in the management of malignant ureteral obstruction: preliminary results

OBJECTIVES To evaluate the effectiveness of ureteral Dacron-covered metallic stents in the management of malignant ureteral obstruction. METHODS Covered metallic stents were placed unilaterally using a percutaneous approach in an antegrade fashion into nine ureters of 8 patients with bilateral malignant ureteral obstruction. The contralateral kidneys were drained by percutaneous nephrostomy in 7 patients. The primary diagnoses were rectal cancer in 5 patients and cervical, bladder, and prostate cancers in the remaining cases. RESULTS Covered metallic stents could be successfully placed in all patients. Only one of nine ureters was stented with a double J-stent. In a mean follow-up of 9 months (range 1 to 14), 7 of 8 patients died because of their primary disease. During the follow-up period, none of the stents were obstructed, displaced, or infected. CONCLUSIONS Dacron-covered metallic stents appear to be successful in the treatment of patients with malignant ureteral obstruction. The preliminary outcome encourages and justifies the application of this drainage method.