Kubilay Inci

Sperm retrieval and intracytoplasmic sperm injection in men with nonobstructive azoospermia, and treated and untreated varicocele.

PURPOSE We evaluated the impact of varicocelectomy on the sperm retrieval success rate using microsurgical testicular sperm extraction and intracytoplasmic sperm injection in men with clinical varicocele and nonobstructive azoospermia. MATERIALS AND METHODS The study included 96 men with complete nonobstructive azoospermia with a history of clinical unilateral or bilateral varicocele. Of the patients 66 previously underwent successful varicocelectomy and 30 had any grade of varicocele at sperm extraction. RESULTS Mean patient age was 34.8 and 32.3 years in the treated and untreated groups respectively. There were no differences in mean follicle-stimulating hormone, testicular volume, infertility duration or female partner age between the 2 groups. The proportion of female factor problems in the 2 groups was similar. The distribution of varicocele grade in the treated and untreated groups was not different. The sperm retrieval rate was significantly higher in the treated group (53% vs 30%, OR 2.63, 95% CI 1.05-6.60, p = 0.036). There was no significant difference in the normal 2PN fertilization rate (63.9% vs 53.6%). The rate of high quality embryos and mean number of transferred embryos were similar in the groups. The clinical pregnancy rate in the treated and untreated groups was 31.4% and 22.2%, respectively (p >0.05). CONCLUSIONS Our results suggest that varicocele repair significantly increased the sperm retrieval rate in patients with clinical varicocele and nonobstructive azoospermia.

Prospective long-term followup of patients with asymptomatic lower pole caliceal stones.

PURPOSE The intervention time of asymptomatic lower pole calculi remains controversial. In this prospective study we evaluated the natural history and progression rate of asymptomatic lower pole stones. MATERIALS AND METHODS Patients were followed every 6 months. Computerized tomography in even years, ultrasound scan in odd years after initial visit and abdominal plain films between these visits were evaluated. The largest diameter was measured for each calculus and the cumulative diameter was calculated for cases of multiple stones. Disease progression was defined as pain experienced during followup, stone growth or the need for intervention. RESULTS A total of 24 patients, 14 male and 10 female, were followed for a mean of 52.3 months (range 24 to 72). Of the 24 patients 3 had bilateral lower pole stones. Mean cumulative stone diameter at presentation was 8.8 mm (range 2.0 to 26.0). Progression in stone size was demonstrated in 9 of 27 renal units (33.3%) with 2 (11.1%) requiring intervention. There was no need for intervention during the first 2 years of followup. Three stones passed spontaneously without any symptoms. Pain developed in 3 patients during followup, and 2 of them passed a stone and responded to the analgesics without further treatment. None of the patients had a pyelonephritic attack during followup. CONCLUSIONS Our results showed that observation could be considered for patients with asymptomatic lower pole stones. However, patients should be counseled about the 33% disease progression and 11% intervention rates.

Tubeless Mini Percutaneous Nephrolithotomy in Infants and Preschool Children: A Preliminary Report

PURPOSE We retrospectively analyzed the outcomes of tubeless mini percutaneous nephrolithotomy in infants and preschool children, and compared them with age matched controls who underwent nephrostomy drainage. MATERIALS AND METHODS A total of 28 renal units in 26 children were operated on for stone disease using the mini percutaneous nephrolithotomy technique. Holmium laser and pneumatic lithotriptor were used for stone fragmentation. Children who underwent complete stone removal and had a clear nephrostomy tract only had a ureteral catheter placed. Those with residual stones or bleeding from the nephrostomy tract underwent nephrostomy drainage. We compared both groups with regard to patient and stone characteristics, and postoperative findings. RESULTS A total of 12 renal units had only a ureteral catheter for diversion, while 16 had nephrostomy drainage. Mean respective ages of the stentless and nephrostomy groups were 3 (range 0.58 to 6) and 3.3 years (1.5 to 6). Mean respective stone burdens were 192 (range 100 to 400) and 416 (775 to 1,380) mm2. Surgery and fluoroscopy times were shorter in the tubeless group. Complication rates were higher (6 of 14 vs 0 of 12) and duration of hospitalization was longer (4.9 [range 3 to 14] vs 3.1 days [2 to 6]) in the nephrostomy group. Stone-free rates were 91.6% in the tubeless and 78.5% in the nephrostomy groups. CONCLUSIONS Tubeless percutaneous nephrolithotomy was observed to be a safe option for selected children with stone disease. The success and safety of tubeless percutaneous nephrolithotomy depends on patient selection criteria, including low volume and infection-free stones that are removed completely without any bleeding from the access tract.

Renal Artery Pseudoaneurysm: Complication of Minimally Invasive Kidney Surgery

PURPOSE We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. MATERIALS AND METHODS In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. RESULTS In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. CONCLUSION There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

Sildenafil attenuates renal ischemia reperfusion injury by decreasing leukocyte infiltration

The aim of the study was to investigate the effects of sildenafil citrate (SC) on renal ischemia reperfusion (I/R) injury in a rat model. Forty eight male Wistar albino rats were randomly assigned into six groups: sham, ischemia, I/R, SC+sham, SC+ischemia and SC+I/R. In the I/R groups, the right kidney was removed and the artery and vein of the left kidney were clamped for 45 min followed by reperfusion for 1 h. In the SC-treated groups, SC dissolved in saline solution was given as a single dose (1 mg/kg) 60 min before the operation. Renal histology was analyzed by scoring the tubular damage and neutrophil infiltration. Tissue myeloperoxidase activity and lipid peroxidation were analyzed. The histological damage and the neutrophil infiltration induced by I/R were significantly less in the SC+I/R group (p = 0.004 and p = 0.003, respectively). Pretreatment with SC significantly diminished the tissue myeloperoxidase activity, indicating the prevention of the neutrophil sequestration into the kidney in the SC+I/R group (p = 0.004); however, it did not result in any changes in lipid peroxidation. Our results in a rat model of ischemia-reperfusion indicate that pre-ischemic treatment with sildenafil citrate can significantly attenuate ischemia/reperfusion-induced renal injury by decreasing leukocyte infiltration.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

PURPOSE We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. MATERIALS AND METHODS We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. CONCLUSIONS Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

Preoperative Evaluation of Hilar Vessel Anatomy With 3-D Computerized Tomography in Living Kidney Donors

OBJECTIVES Digital subtract angiography is the gold standard for anatomic assessment of renal vasculature for living renal donors. However, multidetector-row computerized tomography (MDCT) is less invasive than digital subtract angiography and provides information of kidney stones and other intra-abdominal organs. In this study, preoperative MDCT angiography results were compared with the peroperative findings to evaluate the accuracy of MDCT for the evaluation of renal anatomy. METHODS From December 2002 to May 2007, all 60 consecutive living kidney donors were evaluated with MDCT angiography preoperatively. We reported the number and origin of renal arteries, presence of early branching arteries, and any intrinsic renal artery disease. Renal venous anatomy was evaluated for the presence of accessory, retroaortic, and circumaortic veins using venous phase axial images. The calyces and ureters were assessed with delayed topograms. The results of the MDCT angiography were compared with the peroperative findings. RESULTS A total of 67 renal arteries were seen peroperatively in 60 renal units. Preoperative MDCT angiography detected 64 of them. The two arteries not detected by MDCT had diameters less than 3 mm. Anatomic variations were present in nine veins, five of which were detected by CT angiography. Sensitivity of MDCT angiography for arteries and veins was 95% and 93%, respectively. Positive predictive values were 100% for both arteries and veins. CONCLUSION MDCT angiography offers a less invasive, rapid, and accurate preoperative investigation modality for vascular anatomy in living kidney donors. It also provides sufficient information about extrarenal anatomy important for donor surgery.

Prevalence and predictors of benign lesions in renal masses smaller than 7 cm presumed to be renal cell carcinoma.

UNLABELLED The present study was designed to determine the incidence and predictive factors of benign renal lesions in 450 patients who underwent surgical removal of solitary renal masses <7 cm in diameter. Of the 450 renal masses, 88 (19.9%) were benign lesions. Female sex, nephron-sparing surgery, surgery between 1990 and 1996, cystic components on imaging, and small tumors (<4 cm) were independently associated with benign pathology. PURPOSE To determine the association between preoperative parameters with final benign pathology in patients who underwent surgical removal of solitary renal masses <7 cm in diameter. MATERIALS AND METHODS A database of 450 patients without metastatic disease who underwent radical nephrectomy or nephron-sparing surgery (NSS) for removal of renal masses <7 cm between January 1990 and December 2009 was reviewed. Age, sex, symptoms, year and type of surgery, solid or cystic appearance, and tumor size were analyzed as presumed predictors of benign pathology. Multivariate analysis was performed to identify parameters associated with benign pathology. RESULTS In all, 88 (19.9%) of the tumors were benign, including 39 (8.7%) oncocytomas and 22 (4.9%) angiomyolipomas. The benign lesion rate for tumors ≤2, 2.1-4, and 4.1-7 cm was 30.3%, 27.1%, and 12.5%, respectively (2P < .001). For the periods of 1990-1996, 1997-2003, and 2004-2009, the frequency of benign tumors was 25%, 17.3%, and 18.4% (2P = .271), the incidental tumor rate was 48.1%, 60.4%, and 63.8% (2P = .027), mean tumor size was 5, 4.6, and 4.1 cm (2P < .001), and the NSS rate was 28.8%, 43.2%, and 52.7% (2P < .001), respectively. Logistic regression analysis revealed that female sex, NSS, surgery between 1990 and 1996, cystic components on imaging, and small tumors (<4 cm) based on radiologic examination were independently associated with benign pathology (odds ratio [OR] = 3.26, 2.56, 2.43, 2.41, and 1.96, respectively). CONCLUSIONS The incidence of incidental and small tumors amenable to NSS increased over time. Female sex was the strongest predictor of benign pathology.

The role of varicocele treatment in the management of non-obstructive azoospermia

The literature on male reproductive medicine is continually expanding, especially regarding the diagnosis and treatment of infertility due to non-obstructive azoospermia. The advent of in vitro fertilization with intracytoplasmic sperm injection has dramatically improved the treatment of male infertility due to non-obstructive azoospermia. Assisted reproduction using testicular spermatozoa has become a treatment of hope for men previously thought to be incapable of fathering a child due to testicular failure. In addition, numerous studies on non-obstructive azoospermia have reported that varicocelectomy not only can induce spermatogenesis but can also increase the sperm retrieval rate; however, the value of varicocelectomy in patients with non-obstructive azoospermia still remains controversial. The purpose of this review is to present an overview of the current status of varicocele repair in men with non-obstructive azoospermia.

Renal cell carcinoma with inferior vena cava thrombus: The Hacettepe experience

OBJECTIVES We evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC). METHODS Between 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival. RESULTS Twenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival. CONCLUSIONS Radical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.