Haluk Ander

Urological and Surgical Complications in 362 Consecutive Living Related Donor Kidney Transplantations

Objective: The aim of this study is to review retrospectively the surgical and urological complications encountered in 362 cases of living related donor kidney transplantations (LRDTs). Material and Methods: Between 1983 and 2002, 362 consecutive LRDTs were performed at our institution. The urological and surgical complications were determined in these cases. Results: Overall, urological and surgical complications were encountered in 57 (15.7%) of the renal transplants. Of the 362 patients, urological complications were detected in 29 of them (8.01%), including 5 urinary fistula (with 1 distal ureteral necrosis), 2 ureteric stenosis, 1 renal calculi, 8 symptomatic vesicoureteral reflux and 13 lymphocele requiring intervention. Vascular complications were developed in 5 patients such as renal vein thrombus in 1 and renal arterial stenosis in 4 cases. Wound infection was detected in 6 patients. Fourteen patients underwent surgical explorations due to perinephric hematoma during the early postoperative period. Renal allograft rupture due to accelerated rejection was developed in 2 cases. A lower segmental arterial injury occurred in 1 patient during the operation. Conclusion: LRDT is an important treatment alternative for patients with end-stage renal disease. Many complications may occur after renal transplantations. Our rate of complications is within the range of the current literature. After a modification of our surgical technique, as not dissecting the external iliac artery, the number of lymphoceles has decreased dramatically and with using ureteric stents, we detected a significant decrease in urinary complication rates.

Metabolic Risk Factors in Pediatric and Adult Calcium Oxalate Urinary Stone Formers: Is There Any Difference?

Objectives: Urolithiasis in children is recognized with an increasing frequency, while exact etiological factors remain to be determined. The aim of this study is to compare the metabolic risk factors and saturation of urine in pediatric and adult calcium oxalate (Ca-Ox) stone formers. Methods: A total of 33 pediatric (mean age: 6.8 ± 3.1 years) and 120 adult patients (mean age: 39.7 ± 5.7 years), with documented Ca-Ox urinary stone disease, underwent a comprehensive metabolic evaluation at our institution. Beside a broad serum analysis, concentrations of calcium, oxalate, magnesium, uric acid and citrate were measured in 24-hour collected urine. Saturation of urine was calculated by Marshall-Robertson’s nomograms. Results: Hypocitraturia, observed in 60.6%, and hypomagnesuria, detected in 39.4%, but not hypercalciuria, were the most common metabolic risk factors in the pediatric group. In adults, hypercalciuria still represented one of the major metabolic risk factors, detected in 44.1%, although hypocitraturia, observed in 45.8%, was the most prevalent metabolic risk factor, as it was in the pediatric group. Pediatric cases had significantly (p < 0.05) higher prevalence of hypocitraturia, hypomagnesuria and supersaturated urine when compared to adults. Metabolic abnormalities could be detected in a high percentage (82%) of primary and recurrent pediatric Ca-Ox stone formers, but not in primary adult stone formers. Conclusions: Metabolic risk factors significantly differ in pediatric and adult Ca-Ox stone formers. Hypocitraturia and hypomagnesuria seem to play a major role in stone formation, and metabolic abnormalities can be detected in a significant percentage of both primary and recurrent pediatric stone formers. Thus, a comprehensive metabolic evaluation is of utmost importance for all children with Ca-Ox stones.

Urologic Complications of Extravesical Ureteroneocystostomy in Renal Transplantation from Living Related Donors

Introduction: Reconstruction of the urinary system during renal transplantation is usually performed with antirefluxive ureteroneocystostomy techniques and extravesical methods are usually preferred. Material and Methods: Between 1983 and 1997, 241 renal transplantations from living donors were performed at our institution. A variation of the Lich-Gregoir technique was used as the ureteroneocystostomy method in all cases. Results: A total of 12 (4.9%) urologic complications were observed. Urinary fistula developed in 5 (2%) cases and were explored surgically during the early postoperative period. Postoperative vesicoureteral reflux (VUR) to the transplanted kidney was identified in 7 (2.9%) cases. Either endoscopic or surgical interventions resolved VUR in 4 cases while the other 3 did not need further treatment. No ureteral stenosis was observed. There was no loss of graft due to urologic complications. Conclusions: Urologic complications after renal transplantation are reported to be about 7% and ischemia is blamed as the major contributing factor. Preparation of the native ureter during donor nephrectomy and preservation of distal periureteral fatty tissue, anastomosis technique variations in vascular anatomy, rejections and medications are the major factors determining the ischemia.

The Impact of Late Presentation of Posterior Urethral Valves on Bladder and Renal Function

PURPOSE We retrospectively reviewed the records of patients with late presentation of PUVs, and compared bladder and renal function to that in patients with an early diagnosis of PUVs. MATERIALS AND METHODS We retrospectively reviewed the charts of 36 males (mean age at diagnosis 8.8 years, range 5 to 14) with late presentation of PUVs who were treated at our institution between 1986 and 2004. Of these patients 20 had undergone urodynamic evaluation during followup (mean age 10.65 years, range 5 to 23). We chose as controls 19 age matched children with PUVs who were diagnosed and treated before age 5 years and underwent urodynamic evaluation during followup (mean age at urodynamic evaluation 8.52 years, range 6 to 15). Urodynamic parameters were compared between the 2 patient groups. Renal function in the late presenting cases was also compared to controls. RESULTS The most common symptoms at presentation were diurnal enuresis (17 patients, 47.2%) poor stream (7, 19.4%) and urinary retention (5, 13.9%). Overall, urodynamic bladder abnormalities were detected in 17 of 20 patients (85%), detrusor overactivity in 3 (15%), significant post-void residual in 9 (45%) and bladder capacity greater than expected for age in 9 (45%). No significant difference in bladder capacity, compliance or post-void residual was demonstrated between the late presenting and control groups. Only detrusor overactivity was significantly lower in the late presenting group (p = 0.013). After a mean followup of 67.03 months age specific creatinine levels were increased in 13 of 27 patients (48.1%), including 7 (25.9%) with ESRD. Renal function was significantly impaired in the late presenting group compared to controls (48.1% vs 13.7%, p = 0.001). CONCLUSIONS We found a significantly lower rate of detrusor overactivity (15%) in patients with late presenting PUVs. Comparison of urodynamic parameters between the early and late presenting groups did not reveal any significant difference. This similar pattern of bladder dysfunction, independent of age at relief of obstruction, may indicate a common pathophysiological etiology for bladder dysfunction in all patients with PUVs. Also, renal function was significantly impaired in the late presenting group in this series.

Primary signet ring cell carcinoma of the urinary bladder. Review of the literature and report of two cases.

The signet ring cell carcinoma of the urinary bladder is a rare neoplasm; the 70 cases found in the literature pursued a fulminant and mostly fatal course; the neoplasms diffusely invaded the bladder wall without forming intraluminal growths and could not be controlled by segmental resection, radiotherapy and chemotherapy alone or in combination. We herewith present 2 cases of primary signet ring cell carcinoma of the urinary bladder--one associated with high-grade transitional cell carcinoma and in situ carcinoma--and review the literature.

Lymph nodal involvement by renal angiomyolipoma

Angiomyolipoma of the kidney is a clonal neoplasm, apparently part of a family of neoplasms derived from perivascular epithelial cells. A 40‐year‐old woman presented with right flank pain and an otherwise non‐significant medical history. An abdominal computed tomography scan revealed an 18 cm solid mass in the mid‐portion of the right kidney and multiple perihilar lymph nodes. Presumptive diagnosis was renal cell carcinoma. Right radical nephrectomy and a perihilar lymph node dissection was performed through a Chevron incision for the anticipated diagnosis of renal adenocarcinoma. The renal tumor was diagnosed as angiomyolipoma and a component was identified pathologically in a dissected lymph node. There was no evidence of tumor recurrence in the follow‐up period of eight years. The consensus from other studies suggests that this phenomenon is a manifestation of the multicentric nature of angiomyolipoma, rather than due to metastasis. Genetic studies may resolve this question in the future.

Primary gonadotropin releasing hormone and adjunctive human chorionic gonadotropin treatment in cryptorchidism: A clinical trial

OBJECTIVES The effect of intranasal gonadotropin-releasing hormone (GnRH) and intramuscular human chorionic gonadotropin (hCG) in the treatment of cryptorchidism was investigated in 48 prepubertal boys. METHODS Forty-eight prepubertal boys with 70 undescended testes were enrolled into a prospective study between November 1989 and November 1991. GnRH was applied as nasal spray at a dose of 1.2 mg/day for 4 weeks. The patients with partial descent were subsequently treated with 1500 IU hCG weekly for 3 weeks. RESULTS Complete descent was observed in 53% (37 of 70) of testes; 58% (15 of 26) in unilateral and 50% (22 of 44) in bilateral undescended testes. One abdominally located testicle did not respond to therapy. Of 37 testes located in the inguinal canal, seven (19%) descended. On the other hand, descensus rates were 100% for the testes located at the external inguinal ring and at a high scrotal level. Six primarily descended testes (16%) showed relapse during the follow-up. Surgery was performed in 12 patients (14 testes), revealing associated hernia in nine testes and epididymal anomalies in four. CONCLUSIONS We believe that the GnRH and hCG combination is an effective therapy for undescended testes located at and beyond the external inguinal ring and should be the first treatment choice because of its noninvasiveness. Both unilateral and bilateral undescended testes responded with similar success rate to hormonal therapy. Surgery should be considered for proximal cryptorchidism.

Residual valve and stricture after posterior urethral valve ablation: How to evaluate?

OBJECTIVE To investigate the clinical and radiological parameters of posterior urethral valve (PUV) patients with residual valve or strictures after primary valve ablation. PATIENTS AND METHODS A total of 127 PUV patients were treated in our clinic between 1986 and 2009. We retrospectively reviewed the records of 101 patients, who had at least 1 year of follow-up data, regarding the presence of valve remnants or urethral strictures after PUV ablation. RESULTS A total of 21 patients (20.8%) underwent repeat-urethroscopy and, of these, residual valve leaflets or stricture were detected in 10 patients (10/101, 9.9%). In 2 of these 10 (20%), the urethra had been found to be normal on the first voiding cystourethrogram following ablation. However, these two boys underwent re-urethroscopy due to persistent vesicoureteral reflux in one and persistent hydroureteronephrosis in the other, and valve remnants were detected. The remaining 8 cases had radiological signs consistent with persistent infravesical obstruction in the early period. Obstruction was due to urethral stricture and residual valve remnants in 2 and 6 cases, respectively. CONCLUSIONS There was clinical suspicion of residual valve in about 20% of the cases and in half of these the urethra was found to be normal on urethroscopy. The possible presence of residual valve remnants after primary valve ablation should be confirmed by careful clinical, radiological and endoscopic evaluation.

A case of ureteral triplication (type 1) associated with vesicoureteral reflux in a solitary kidney

Ureteral triplication is a rare congenital anomaly of the upper urinary tract. It is reported to be associated with an increased incidence of congenital anomalies as well as a predisposition to infection and calculus formation. We report a case of type 1 variant of ureteral triplication associated with vesicoureteral reflux into lower and mid pole ureters in a solitary kidney. To our knowledge ureteral triplication in a solitary kidney has not been described previously.

How Does the Presence of Antenatally Detected Caliectasis Predict the Risk of Postnatal Surgical Intervention

OBJECTIVE To determine the effect of antenatally detected caliectasis on the postnatal surgical intervention rate. METHODS From 2006 to 2010, 56 patients with an anteroposterior diameter (APD) of 7-20 mm on the prenatal ultrasound scan performed in the third trimester of pregnancy were included in the present study. In these 56 patients, other anomalies (vesicoureteral reflux, posterior urethral valves, duplex system, megaureter) were excluded, and the postnatal clinical and radiologic follow-up data were available. The mean follow-up was 12.82 ± 10.72 months. These 56 patients were divided into 2 groups: those with (n = 32) and without (n = 24) caliectasis. In the caliectasis group, the mean follow-up was 13.6 ± 12.09 months and was 11.7 ± 8.70 months in the group without caliectasis. The statistical correlation between the postnatal operation rates and the presence of caliectasis (APD range 7-20 mm in third trimester) was investigated using the chi-square test. RESULTS In the study group (n = 56) with an APD range of 7-20 mm in the third trimester, postnatal surgical treatment (pyeloplasty) was performed in 12 (37.5%) and 3 (12.5%) of the children with and without caliectasis, respectively (P = .037). The risk of postnatal surgical treatment increased threefold in patients with an APD of 7-20 mm and a diagnosis of caliectasis (relative risk 3.0, 95% confidence interval 1.07-8.40). CONCLUSION In our study, the presence of concomitant caliectasis within the APD range of 7-20 mm on the third trimester ultrasound scan increased the risk of surgical treatment threefold. During prenatal counseling, the presence of caliectasis requires more rigorous follow-up.