İbrahim Gülmez

Retroperitoneoscopic ureterolithotomy for the treatment of ureteral calculi.

Introduction: Most upper or middle ureteral stones are treated with shock wave lithotripsy or endoscopic techniques. In rare cases the ureteral stones are treated with open surgery after failure of first-line treatments. Retroperitoneoscopy is a minimally invasive alternative to open surgery. Patients and Methods: Between May 1995 and January 2001, twenty-one patients underwent retroperitoneoscopic ureterolithotomy. The stones in upper and middle ureter were large and impacted (5 patients) or not fragmented after shock wave lithotripsy (16 patients). A balloon dissector was placed and infiltrated with 800 ml air in the retroperitoneal space. Three 10-mm trocars were used. The pressure was kept at 15 mm Hg by carbon dioxide insufflation. The stones were extracted from the ureter using a laparoscopic stylet. Results: The stones in 17 patients were successfully removed in a median operating time of 105 (min–max 45–190) min. Urine extravasation in all cases and pnomoscrotum in 2 cases were observed as postoperative complications. The median hospital stay was 6 (min–max 3–22) days with minimal analgesic requirement. Conclusion: Retroperitoneoscopic ureterolithotomy is a useful and effective alternative treatment technique to open surgery when first-line treatments have failed or are unlikely to be effective.

Big bladder stones around an intravesical migrated intrauterine device

Spontaneous migration of the intrauterinedevices into the bladder and secondary stoneformation are rare complications. A 33-year-old women in whom a copper T intrauterinedevice had been placed two years previously, presented complaining of irritative lowerurinary tract symptoms. Intravesical migrationof intrauterine device and big stones around itwere confirmed by radiography and cystoscopy.The stones were fragmented by usingelectrohydraulic lithotriptor. And then allfragments of the stones and IUD werecystoscopically removed by a grasping forcepswithout any complication.

Can Neutrophil-Lymphocyte Ratio and Lymph Node Density Be Used as Prognostic Factors in Patients Undergoing Radical Cystectomy?

Objective. To assessment the role of preoperative neutrophil-lymphocyte ratio and postoperative lymph node density in predicting prognosis in patients undergoing radical cystectomy for bladder cancer. Material and Methods. Preoperatively, neutrophil and lymphocyte counts as well as neutrophil-lymphocyte ratios were recorded in 201 patients who underwent radical cystectomy for bladder cancer. Patients with an infection were excluded. Based on the pathology reports, the number of positive lymph nodes was divided by the total number of lymph nodes to calculate lymph node density. Results. The mean follow-up duration was 37.22 ± 35.922 months in patients without lymph node involvement and 27.75 ± 31.501 months in those with lymph node involvement (P = 0.015). Median lymph node density was 17% (4–80) in patients with lymph node involvement. There was no difference according to lymph node density lower than 17% and greater than 17% (P = 0.336). There was no significant difference between patients with an NLR below or above 2.5 in terms of overall survival (P = 0.702). Pathological T stage was associated with survival (P = 0.004). Conclusion. In patients undergoing RC for bladder cancer, lymph node density and preoperative NLR were not found to be independent predictors of prognosis.

INTRAPERITONEALIZATION OF THE URETER DURING LAPAROSCOPIC URETEROLYSIS: A MODIFICATION OF THE TECHNIQUE

A 41-year-old man presented with a 3-month history of nocturia. Serum creatinine was 5.5 mg./dl. (normal 0.5 to 1.6) and blood urea nitrogen was 51 mg./dl. (normal 5 to 23). Ultrasound showed that the right kidney had moderate hydronephrosis, whereas the left kidney was atrophic. The severe and long stricture in the right middle ureter was detected on retrograde pyelography (fig. 1). A periureteral mass was demonstrated on computerized tomography. Percutaneous nephrostomy was inserted into the right kidney to relieve obstruction. After normal renal function resumed, the patient was placed in the semi-flank position, pneumoperitoneum with carbon dioxide was achieved and 3 laparoscopic ports were used. The line of Toldt was incised and the right colon was reflected medially. The thickened and widened mid ureter was completely dissected between the ureteropelvic junction and common iliac vessels. During the dissection, normal ureter was observed just below and above the involved ureteral segment. Histological analysis of the biopsies from periureteral tissue revealed chronic inflammation and fibrosis. The involved ureter was completely peeled away, and the fibrotic tissue, and right colon and cecum were passed under it, and the right colon was fixed to the abdominal wall with a 10 mm. hernia stapler. A drain was placed. There were no complications and operative time was 200 minutes. The drain was removed on postoperative day 4, and the patient was discharged from the hospital on postoperative day 5. Antegrade pyelography performed 1 month later showed decreased hydronephrosis and a normal ureteral passage. Therefore, percutaneous nephrostomy was removed. At 10-month followup excretory urography showed a moderately lateralized ureter from the spinal column with no evidence of obstruction (fig. 2).

The first case of periureteric hibernoma : Case report

Hibernoma is a rare type of soft tissue neoplasm originating from brown fat tissue. The present case is the first periureteric hibernoma concentrically surrounding the ureter with a concomitant renal pelvis stone.

Comparison of Infection and Urosepsis Rates of Ciprofloxacin and Ceftriaxone Prophylaxis before Percutaneous Nephrolithotomy: A Prospective and Randomised Study

This study aimed at determining the choice and administration duration of ideal antibiotic prophylaxis before percutaneous nephrolithotomy (PNL) operation, a treatment modality for nephrolithiasis. The study included 90 patients who had no internal problem, yet had a negative urine culture and underwent a PNL operation. We compared infection rates between ciprofloxacin and ceftriaxone groups and their subgroups. The results showed no statistical difference between ciprofloxacin and ceftriaxone groups in terms of systemic inflammatory response syndrome (SIRS) (CIPP = 0.306,  CTX P = 0.334. As a result of this study no statistical difference was observed between ciprofloxacin and ceftriaxone in terms of SIRS. It seems, however, reasonable to choose ceftriaxone, considering antibiotic sensitivity of microorganisms and detection of three cases accepted as urosepsis in the ciprofloxacin group. As there is no difference between short, and long-term prophylactic use of these antibiotics, preference of short-term prophylaxis for patients with no risk of infection will be important to avoid inappropriate antibiotic usage.

The laparoscopic stylet

A new instrument, laparoscopic stylet, developed for the laparoscopic extraction of the ureteral and renal pelvis calculi is described. The laparoscopic stylet is made of chromium nickel as a modification of the classical stylet. Until now, this instrument has been used in 11 retroperitoneoscopic ureterolithotomy operation and found to be quite useful for the mobilisation and extraction of the calculi from the ureters,suggesting its probable use also in the laparoscopic pyelolithotomy procedures.

Comparison of extraperitoneoscopic and transperitoneoscopic techniques for the treatment of bilateral varicocele

BACKGROUND AND PURPOSE Laparoscopic varicocelectomy has been performed in patients with bilateral varicocele. This procedure could be performed either transperitoneally or extraperitoneally. The purpose of this study was to compare the effectiveness and morbidity of the two approaches. PATIENTS AND METHODS Twenty-one patients underwent transperitoneal repair. Twelve of them had complaints of infertility, and nine of them had pain. Eighteen patient underwent extraperitoneal repair. Twelve of them had complaints of infertility, and six of them had pain. All the patients with pain had clinical varicoceles. In each group, three patients with infertility had unilateral subclinical varicoceles. RESULTS No significant difference was found in the duration of surgery, artery-vein discrimination, or morbidity between the extraperitoneal and transperitoneal techniques. In both approaches, the previously infertile patients who have been followed more than 6 months had significant improvement in sperm counts and motilities (P < 0.05). There were no significant differences in the improvement in the extraperitoneal and transperitoneal groups. CONCLUSION There was no significant difference between the transperitoneal and extraperitoneal techniques in terms of effectiveness and morbidity. The difficulty in identifying the internal spermatic vein and the additional cost of the balloon dissector for the extraperitoneal technique makes us prefer transperitoneal repair.

Management of undeflatable foley catheter balloons in women

The inability to deflate a self-retaining balloon catheter is a rare problem but may be encountered by physicians. Many techniques have been described to solve the problem, some of which may be dangerous. The technique must not disturb the patient or create any additional morbidity. Those methods commonly used are the instillation of ether, liquid paraffin, chloroform or mineral oil through the inflation channel; the use of a fine wire to burst the balloon or to recanalize the obstructed inflation channel; bursting or deflating the balloon through suprapubic, transvaginal or urethral routes: and the overinflation technique. The techniques which might be most appropriate for women are explained in a stepwise manner. First the catheter is cut in the proximal segment of the valve. If this is not successful, a ureteric catheter stylet is advanced through the inflation channel until it touches the balloon. If this is still unsuccessful, the balloon is deflated through the drainage channel using the technique proposed by Davies and Thomas. As a second choice, an intravenous cannula with its inner needle drawn back is advanced through the urethra next to the catheter, towards the balloon which, is then punctured with the inner needle. If these steps are followed, the patient will have no additional discomfort and no trauma to the surrounding tissues, and there will be no need for cystoscopy or any other expensive intervention.

Rektum adenokarsinomunun invazyonu sonucunda perineal cilt ve posterior mesane duvarı harabiyeti: Olgu sunumu

Brucellosis, is an endemic disease in our country, may lead to bacteremia and cause different clinic manifestations. A 44-year-old male patient admitted to our policlinic with high fever, shivering, chilling, pollacuria, and left costovertebral pain, and interned with diagnosis of acute pyelonephritis. Subsequently, acute pyelonephritis due to acute brucellosis was detected in the clinical and laboratory examination. Antibiotic treatment for brucellosis was given to patient for eight week and after treatment full recovery was seen. Patients with brucellosis may refer with symptoms of acute pyelonephritis in endemic areas for brucellosis. By using brucellos serologies to patients who have the symptoms of acute pyelonephritis may available in the diagnosis of this rare complication in areas where brucellosis is endemic.Objectives: Internal splinting is defined as early tendon transfer performed during or just after nerve repair followsing nerve injury and is a controversial issue. The objecstives of internal splinting are avoiding the use of long term external splinting, avoiding permanent hand deformities until the injured nerve is reinnervated and supporting sensorial recovery. In this paper we present our clinical cases of internal splinting and discuss the results in terms of indications, timing, advantages, and disadvantages of internal splinting. Materials and Methods: We applied internal splinting in 11 patients, 3 patients with radial nerve injury and 8 patients with ulnar nerve injury. Internal splinting was performed contemporarily with the nerve repair in 5 pastients, in 2 weeks following nerve repair in 1 patient and in 4 weeks following nerve repair in 5 patients. Pronator teres was transferred to extensor carpi radialis brevis and flexor carpi radialis was transferred to extensor digitorum communis in radial nerve injuries. Omer\s superficial Y technique and its modification were used for ulnar nerve injuries. Results: Patients were followed up for at least 1 year with physical examination and electroneuromyelography and recovery of sensorial and motor functions were achieved in all of them. Conclusion: We concluded that internal splinting is usesful for avoiding external splint usage and preventing the establishment of hand deformity until recovery of the nerve. The contribution of internal splinting to sensorial recovery was noteworthy as stated in the literature but the lack of control group and the small number of our cases was limited to come to a definite conclusion. We did not experience any disadvantage of internal splinting.