Kemal Sarica

Pediatric urolithiasis : etiology, specific pathogenesis and medical treatment

Pediatric urolithiasis is an endemic disease in certain parts of the world, namely Turkey and the Far East. As a recurrent pathology which may reveal functional as well and morphologic changes in the urinary tract, environmental factors together with urogenital abnormalities should be evaluated thoroughly in each patient. The aims of management should be complete clearance of stones, treatment of urinary tract infections, preservation of renal function and prevention of stone recurrence. In addition to certain minimally invasive stone removal procedures, treatment of pediatric urolithiasis requires a detailed metabolic evaluation in all patients on an individual basis. Obstructive pathologies have to be corrected immediately and children with a positive family history should be followed carefully with respect to a high likelihood of stone re-growth and recurrence. Although specific management of each metabolic abnormality seems to be the key factor in the medical management of stone disease, as general advice each child should be forced to adequate fluid intake which will reveal the urine volume increase in accordance with the body mass index. Moreover, medical therapeutic agents which increase urine citrate levels should be encouraged.

Renal tubular injury induced by hyperoxaluria: evaluation of apoptotic changes.

Abstract In order to evaluate the injurious effect of hyperoxaluria on renal tubular epithelium, as judged by apoptotic changes in the renal parenchyma, we performed an experimental study in 20 rabbits. In the experimental group animals (n=10) severe hyperoxaluria was induced by continuous ethylene glycol (EG; 0.75%). Histologic alterations, including crystal formation, together with apoptotic changes were evaluated after 7 and 28u2009days. Control group animals (n=10) received normal distilled drinking water. Following 7- and 28-day periods, tissue sections obtained from kidneys were examined histopathologically under light microscopy for the presence and the degree of crystal deposition in the tubular lumen. Apoptotic changes in renal tubular cells were examined using the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP in situ nick and labeling (TUNEL) method during the same follow-up period. Crystal deposition was evident in the tubular lumen of tissue sections obtained during the 7-day examination period. During the 28-day examination period, however, these findings were found to be either limited or to have disappeared. In relation to apoptotic changes, the percentage of positive nuclei stained using the TUNEL method was from 11 to 20% in the experimental group and 5.6% in the control group. Our findings indicate that both calcium oxalate (CaOx) crystals and hyperoxaluria itself may be injurious to renal tubular cells, as indicated by apoptotic changes. These changes may be responsible for the pathologic course of urolithiasis.

Influence of Experimental Spermatic Cord Torsion on the Contralateral Testis in Rats

To evaluate the degree of ischemia formation in the contralateral testicle following unilateral testicular torsion, free oxygen radical formation after detorsion or an orchiectomy procedure in terms of superoxide dismutase (SOD) and catalase activities was detected in adult male Wistar rats. Animals were divided into 4 groups and following 2 and 6 h of unilateral torsion, the orchiectomy or detorsion procedures were performed and free radical scavenger enzyme activities (SOD, catalase) were measured in the contralateral testes after 24 h, 1 week and 1 month. Evaluation of our results revealed no meaningful ischemia formation in the contralateral testes of rats undergoing 2 h of unilateral testicular torsion. However, animals undergoing 6 h of unilateral testicular torsion demonstrated a statistically significant alteration with respect to enzyme concentrations. Alterations in the contralateral testes were more prominent in animals that had undergone the detorsion procedure following 6 h of testicular torsion. Our results indicate that preservation of twisted testes through a detorsion procedure could cause further deterioration by way of reperfusion injury, indicating the importance of removal of the damaged testicle to minimize long-term histopathologic alterations in the contralateral testes.

Multidisciplinary evaluation of occult spinal dysraphism in 47 children

Objective: To present the clinical (urologic, orthopedic and neurologic) and urodynamic findings of 47 children suffering from occult spinal dysraphism, together with the long-term follow-up results obtained with various treatment modalities. Material and Methods: Between 1997 and 2000 a total of 47 children (27 girls, 20 boys; male:female ratio 1.3) referred to the Urology and/or Pediatrics Departments with symptoms and signs of closed spina bifida were enrolled in the study program. All patients underwent routine assessment of the urinary tract, including detailed anamnesis, physical examination and radiologic evaluation (X-ray, renal bladder ultrasonography and sacral MRI). In addition to video-urodynamic evaluation of the lower urinary tract, all patients were also evaluated by the Orthopedic Department with respect to possible lower extremity deformities. Results: The age range of the children was 2 months to 16 years (mean 6.9 years). At first referral, 23 children were found to have normal urinary and fecal continence after toilet training; among the other presenting symptoms and signs, 34% of patients demonstrated recurrent urinary tract infections and 38.2% had abnormal findings on urinary tract investigations. Evaluation of urodynamic parameters before and after conservative treatment demonstrated an increase in age-related bladder capacity in 34 patients and detrussor instability had been cured in 23/30 patients (pu2005<u20050.05). Overall, bladder capacity was found to be normal in 40 children following conservative management (pu2005<u20050.05). The conservative approach proved to be effective in 40 children (85.1%), and intravesical instillation therapy with oxybutynine hydrochloride was successful in one of the remaining seven children (14.2%). Bladder augmentation was performed in six children (12.7%) in whom conservative measures were ineffective. Conclusions: In the light of our findings and the literature data it is obvious that a multidisciplinary approach together with early urologic evaluation to determine the extent of neurologic involvement of the lower urinary tract is essential to ensure a successful treatment outcome and to prevent the occurrence of serious functional and structural complications. Clinical, radiologic and video-urodynamic assessments should be performed to define the neuro-urologic pathophysiology and to provide management guidelines and a baseline for future comparison.

Evaluation and Therapeutic Regulation of Erectile Dysfunction with Visual Stimulation Test

Aim: An objective evaluation of the psychogenic cause of erectile dysfunction by performing the visual stimulation tumescence and rigidity (VSTR) test and sildenafil citrate test, together with the effectiveness of sildenafil citrate medication on impotence caused by different etiologies. Material and Methods: Between 1998 and 2000, a total of 36 men (12 patients with diabetic etiology, 5 patients with vasculogenic risk factor) were enrolled in this study. The mean age of patients was 53 (27–67) years. Following standard questionnaires, including a detailed anamnesis from an andrologic viewpoint, VST was performed in an ambulatory setting and beginning with a test dose of 50 mg. At the end of 2 h, the data was evaluated with computer assistance (Rigiscan device) and if a satisfactory erection had not occurred, an additional second dose of sildenafil citrate (50 mg) was given until there was a satisfactory erection. Results obtained from VST: results were classified as group I (fully rigidity, >10 min erection, >70% of rigidity, possible vaginal penetration), group II (unstable erection, 5 min erection, >70% of rigidity, possible vaginal penetration) and group III (tumescence without rigidity, <5 min erection, <70% of rigidity, impossible vaginal penetration). The results obtained during the first 1 h of the VSTR test were regarded as the patient’s own erectile condition and later data was accepted as the real effect of sildenafil citrate. The Fisher exact test was used for statistical evaluation including pre- and post-sildenafil effect on erectile rigidity and duration of erection. Results: The erection status of patients was sufficient in 17 (47.2%) in group I, it was insufficient but sufficient enough with an increased dose of sildenafil citrate in 10 (27.7%) in group II, and insufficient without/with full dose of sildenafil citrate in 9 (25%) in group III. Considering rigidity and total erectile period, there was a statistical significant difference between the first two groups with respect to the early and late sildenafil citrate effects on the VSTR test (p < 0.05). Again, 10 patients with known risk factors (diabetes mellitus 5 and vasculogenic 5) in the second group seemed to give a good response to repeated dosage of sildenafil citrate which has been found to be very interesting. However, the rest of the diabetic patients (n = 7) in the third group showed no erection despite the increasing and repeated doses of sildenafil citrate. Conclusion: Sildenafil citrate with the VSTR test has effective and reliable results which was regarded as very important to diagnose and determine objectively the amount of therapeutic doses in impotence. In accordance with the literature data, our results also confirm the reliability and the practical nature of the VSTR test, which is less time-consuming and cheaper than the nocturnal penile tumescence and rigidity (NPTR) test. In the VSTR test, necessary doses of medication needed for satisfactory erection were easily regulated in patients with certain kinds of impotence. Additionally, self-criticism advantage of the patients on erection and an unnecessary need for regular sexual partners may make this test preferable in the near future. However, we believe that a large group of patients with other definite parameters are certainly needed in order to obtain more reliable data.

Association Between the T-593A and C6982T Polymorphisms of the Osteopontin Gene and Risk of Developing Nephrolithiasis

BACKGROUND AND AIMSnIncreased synthesis of several urinary proteins including osteopontin (OPN) has been shown to be associated with stone formation within the urinary tract. The objective of this study was to analyze the genotype distributions and allele frequencies for OPN gene promoter T-593A and C6982T (in exon 7) polymorphisms among patients with kidney stones.nnnMETHODSnIn this case-control study, the study group consisted of 121 patients with radiologically confirmed nephrolithiasis. Genomic DNA from patients and control cases (n = 100) was analyzed by single-strand conformation polymorphism method and nucleotide sequence analysis.nnnRESULTSnHomozygous carriers of the T-593T genotype were more frequent, but carriers of the A-593A genotype were less frequent in patients than in controls. There was also an increase in -593T allele (88% in patients vs. 79% in controls) and decrease in -593A allele frequencies (21% in control vs. 12% in patients) in the nephrolithiasis groups (p = 0.013). The carriers of C6982C genotype were less frequent, but marked increases in T6982T genotype (25.6% in patients vs. 7% in controls, p = 0.001) and 6982T allele frequency (53.3% in patients vs. 37.5% in controls, p = 0.001) were noted in patients of Turkish ancestry.nnnCONCLUSIONSnThese results are the first to demonstrate the existence of T-593A promoter polymorphism of the OPN gene and significant association with risk of developing nephrolithiasis. Our results showed marked associations between polymorphisms (C6982T and T-593A) of the OPN gene and the stone-forming phenotypes in the Turkish population.

Penile epithelioid sarcoma: MR imaging findings

Abstract. Magnetic resonance imaging findings of a 38-year-old man with epithelioid sarcoma of the penis is presented. It started as a firm, painless and slowly growing nodule at the base of his penis 6 months previously which caused pain radiating to the testis during coitus. It has been well known that sarcomas may well mimic reactive processes. Initial presentation of epithelioid sarcoma may provoke considerable diagnostic difficulty, and its differentiation from benign lesions, such as Peyronies disease and chronic inflammation, may be a clinical problem. In our present report the MR findings are compared with those of the epithelioid sarcomas of various locations reported in the literature and differential diagnosis of the entity is discussed. To our knowledge, this is the first report regarding the MR findings of the epithelioid sarcoma of penis.

Effects of Transurethral Prostate Resection and Transurethral Laser Prostatectomy on Plasma Hormone Levels

Objective: The short and long-term effects of two common transurethral procedures (TURP and TULP, transurethral prostatic resection and laser prostatectomy, respectively) on plasma hormone levels in patients with benign prostatic hyperplasia (BPH) have been evaluated. Patients and Methods: Totally 57 patients with histologically proven BPH (age range 54–81 years, mean 62.5 years) were included into the study program. Of these 57 patients, 44 underwent TURP and 13 underwent TULP for treatment of their bladder outlet obstructions. 20 patients with bladder cancer undergoing transurethral resection (n = 15) and those undergoing transurethral laser ablation (n = 5) constituted the control group. Plasma luteinizing hormone (LH), prolactin (PRL), follicle-stimulating hormone (FSH), adrenocorticotrophic hormone (ACTH), cortisol, aldosterone, dihydroepiandrosterone sulfate (DHEA-S) and testosterone levels were assessed in all patients before and after 3 weeks and 3 months following the aforementioned procedures. Comparative evaluation of the results with respect to the effect of different procedures have been made between study and control groups. Results: Preoperatively, we were not able to demonstrate any significant difference with respect to all but plasma prolactin levels (p < 0.05) between the study and control groups. Prolactin levels were found to be significantly higher in BPH patients. In BPH patients undergoing TURP, while LH levels were significantly higher during the 3 weeks’ evaluation (p < 0.001) no significant difference could be shown during the 3 months’ examination (p > 0.05). Again, prolactin levels did significantly decline (p < 0.05) in patients undergoing TURP during the 3 weeks’ follow-up evaluation, no difference was present 3 months postprocedure. On the other hand, in patients undergoing TULP, while we were not able to show any significant difference with respect to plasma prolactin levels (p > 0.05) pre- and postoperatively, plasma LH levels were significantly increased during the 3-month evaluation (p < 0.05). Conclusions: Alterations in the plasma levels of LH and prolactin following prostatectomy during follow-up evaluation, led the physicians to consider possible effects of some factors released from resected prostate gland. Behavior of prolactin and LH after TURP and laser ablation is quite different in our study. It may be related to the higher amount of residual prostate tissue after TULP. On the other hand, normalization of hormone levels 3 months following TURP, led us to think about the activation of some factors responsible for hormonal regulation which in turn institutes a new hormonal balance.

Effects of shock wave lithotripsy on plasma and urinary levels of nitrite and adrenomedullin

Purpose: In this prospective clinical study, we aimed to determine whether shockwave lithotripsy (SWL) has any specific effect on plasma as well as urinary nitrite, a stabile metabolite of nitric oxide (NO) and adrenomedullin (AM) concentrations, and to investigate whether these variables can be used as a marker for detecting shockwave-induced impairment of renal tubular and glomerular cells. Material and Methods: A total of 20 patients with renal pelvic or caliceal stones ≤2xa0cm undergoing anesthesia-free SWL without auxiliary measures and a control group of ten patients without any urological symptoms were included in this study. The plasma and urinary concentrations of nitrite and AM were measured before, 24xa0h, and 7xa0days after SWL. Nitrite levels were measured by Griess reaction. Reverse-phase high-performance liquid chromatography (HPLC) was used to determine AM levels. Results: Application of high-energy shock waves (HESW) in our study caused a statistically significant increase in plasma levels of both NO and AM, which reflected an organized response of the kidney to this type of trauma in an attempt to maintain normal renal hemodynamics. Mean plasma nitrite concentration before SWL application was 29.9±7.6xa0μmol/l and this value was found to be 39.02±8.45xa0μmol/l at 24-h follow-up. Comparative evaluation of the plasma concentrations of AM revealed a significant increase at the 24-h examination: 20.51±3.0xa0pmol/ml and 32.54±4.3xa0pmol/l, respectively. On the other hand, comparative evaluation of urinary levels of both nitrite and AM levels before as well as 24xa0h after SWL application revealed a statistically significant increase related to markers. Conclusion: This first clinical study on plasma-urinary nitrite and AM levels in patients undergoing the SWL procedure indicated that plasma and urine levels of both peptides were increased. Our findings in turn suggested that SWL application to kidneycan stimulate the NO-cGMP signalling pathway to increase NO production in the kidney. Our findings also indicated that the increased levels of NO and AM secretion during renal parenchymal ischemia may be protective enough for renal pathological alterations resulting from SWL-induced renal trauma. We suggest that this increase may be a compensatory response to SWL induced injury.

THORACIC KIDNEY ASSOCIATED WITH SUPERIOR ECTOPIC SPLEEN

Intrathoracic ectopia of the kidney(s) denoting partial or complete renal protrusion above the level of the diaphragm into the posterior mediastinum is a rare developmental abnormality. This type of ectopia is identified at 1/13,000 to 1/15,000 autopsies and less than 5% of all patients with ectopia have an intrathoracic kidney.1 Since 1840 at least 92 cases have been collected in the literature, including 4 involving bilateral kidneys.2 When associated with superior ectopia of the kidney(s), the predominance is 1.5:1 and the sex ratio favors males at a ratio of 3:1. This entity has been detected in all age groups. The majority of individuals with this anomaly remain asymptomatic. Most cases are discovered on routine chest x-ray or at thoracotomy for a suspected mediastinal tumor. Although associated abnormalities are rare, cases have been reported with an accompanying ectopic adrenal gland.3 No consistent anomalies have been described in other organ systems. In our case, in addition to thoracic ectopia of the left kidney, the spleen was in an intrathoracic position.