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Management of Ureteral Stones with Pneumatic Lithotripsy: Report of 500 Patients

PURPOSE To evaluate the results of pneumatic lithotripsy (PL) with ureteroscopy in the treatment of ureteral stones. PATIENTS AND METHODS We reviewed, retrospectively, the records of 500 patients (366 male, 134 female) with ureteral calculi treated by PL with the Swiss Lithoclast. Of these patients, 124 (24.8%) were treated primarily and 376 (75.2%) were treated secondarily after unsuccessful extracorporeal shockwave lithotripsy (SWL). The results were evaluated 3 months after treatment by excretory urography, ultrasonography, or both. RESULTS The over-all stone-free and fragmentation rates were 94.6% and 96.8%, respectively. These values were 97.1% and 98.5% for stones <or=10 mm and 83.7% and 89.1% for stones >10 mm, respectively. The main complications were stone migration (2.0%), urosepsis (3.0%), and ureteral perforation (1.4%). CONCLUSIONS While SWL is generally excepted as a first-line treatment option in ureteral stones because of its noninvasive nature, in situ lithotripsy, and especially PL, has higher success rates with minimal morbidity. Thus, PL seems to be a good alternative in patients in whom SWL was unsuccessful or not indicated and in patients who need early stone removal.

Direct upper kidney pole access and early ligation of renal pedicle significantly facilitates transperitoneal laparoscopic nephrectomy procedures: Tunc technique.

We modified our technique in transperitoneal laparoscopic nephrectomies and compared its results with the classical technique. Classical technique was performed in 85 cases (group 1). Modified technique (n=98) included direct kidney upper pole access and early ligation of renal pedicle (group 2). No significant differences were detected regarding mean patient age, intraoperative blood loss, and duration of hospital stay between the 2 groups (P>0.05). Mean operation time was 64.9±19.3 and 28.2±7.7 minutes, respectively in groups 1 and 2 (P=0.001). Mean operation time including right nephrectomies was 68.7±23.4 and 24.2±6.3 minutes, respectively in groups 1 and 2 (P=0.001). Mean operation time including left nephrectomies was 63.8±17.1 and 33.6±5.1 minutes, respectively in groups 1 and 2 (P=0.001). Similarly, mean operation time was significantly shorter in group 2 when analysis was performed among right and left radical and simple nephrectomies between the 2 groups (P=0.001). Direct upper kidney pole access and early ligation of renal pedicle seems to be significantly facilitating transperitoneal laparoscopic nephrectomy procedures.

The risk of arteriovenous fistula formation after en bloc stapling of the renal hilum during transperitoneal laparoscopic nephrectomies.

Our aim was to evaluate the risk of arteriovenous fistula (AVF) formation after en bloc stapling of the renal hilum during transperitoneal laparoscopic nephrectomies (LNs). A retrospective review of 35 laparoscopic simple or radical nephrectomies or LNs was carried out. Patients were clinically followed up for renal hilar AVF formation, which could lead to new onset diastolic hypertension, abdominal murmur, and congestive heart failure. In addition, abdominal computed tomography and arteriography were carried out to diagnose renal hilar AVF formation during 6 to 20 months’ follow-up. No statistically significant differences were measured between the systolic and the diastolic blood pressures between the preoperative and the postoperative periods (P>0.005). Abdominal murmur and new-onset congestive heart failure were not detected in any of the patients on physical examination. Our results suggest that en bloc stapling of the renal hilum during LN procedures is safe and effective.

Effects of clinical, laboratuary and pathological features on successful sperm retrieval in non-obstructive azoospermia.

OBJECTIVE The study aims to evaluate the correlation of testicular sperm extraction (TESE) and histopathology with various features of non-obstructive azoospermia (NOA) cases who consulted to our university-based infertility clinic, and the probability of prompting couples about TESE success and to investigate the cost reduction chance through cost-beneficial aspects. MATERIAL AND METHODS One hundred and twenty-five patients were enrolled in this study. Age, unprotected intercourse period, age of puberty, and concomittant diseases were noted. Testicular volumes were measured. The correlations between genetic test results and serum levels of Follicle-Stimulating Hormone (FSH), Luteinizing Hormone (LH), free testosterone, prolactine were investigated. RESULTS The incidence of NOA among infertile men was found to be 15.1%. Median age of the cases was 33.1 years. Decrease in TESE success rate was seen in the group aged >30, and those who practiced unprotected intercourse for more than 10 years. TESE success rate was 40 percent. The required negative correlation between FSH levels, and testicular volume was not observed when the patient had additional diseases and/or genitourinary surgery. FSH and LH levels were significantly different between TESE- positive and negative groups (p=0.006, and p=0.001 respectively). Success rate in bilateral TESE group was 14.2%, and 96% of TESE- negative patients had bilateral TESE. Fifteen of 118 patients had Y chromosome microdeletions. These results were similar in both TESE- positive and negative group. CONCLUSION None of the parameters investigated herein predicted succesful TESE outcomes. However, in cases with increased FSH and AZFa/AZFb deletion before application of bilateral TESE, in cases of increased FSH and AZFa/AZFb deletion, detailed information should be given to these patients about low success rates and risk of disease inheritance which may reduce procedural costs. Knowing groups with poor prognosis, may help rearrangement of the appropriation of infertility in health policies.

Detailed Surgical Anatomy of Prostate: Relationship between Urethra and Dorsal Vein Complex with Apex

Aim: To describe our surgical technique for dissecting the apex of prostate during robotic-assisted laparoscopic radical prostatectomy (RALP) and detailed surgical anatomy of prostate including relationship between urethra and dorsal vein complex with apex. Materials and Methods: In retrospective view of prospective collected data, 73 patients underwent RALP between December 2012 and September 2014. Surgical anatomy of prostate was revealed in all procedures. Quality of life (QoL) scores were assessed before, immediately after catheter removal, and 1 month after surgery. We divided urinary continence into 3 groups, as very early continence; continence at time of urethral catheter removal, early continent; and continence 1 month after surgery. The rest of the patients were accepted as continence. Results: The mean follow-up was 10.2 ± 5.4 months and mean age was 61.5 ± 6.6. Maximum protection of urethra could be provided in all. Mean catheter removal was 8.9 ± 1.7 days, and all patients were continent at the time of catheter removal. QoL scores before RALP could be protected after surgery (p = 0.2). Neither conversion to open/conventional laparoscopic surgery nor complications related with bladder neck were detected. Conclusions: Our surgical technique can be a strong candidate for being a surgical technique for preserving urethra and very early continence could be provided after surgery.

The use of polymer clips in transperitoneal laparoscopic nephropexy.

Here we report a patient with symptomatic mobile kidney (nephroptosis) who was treated successfully with transperitoneal laparoscopic nephropexy with the use of nonabsorbable polymer clips. In this procedure, clips were used on Gerotas fascia to fix the kidney to the transversus abdominis fascia and the triangular ligament. This method is easier and requires less time than previously reported techniques.

Re: Is It Just Enough to Keep Long Membranous Urethra for Providing Early Continence After Robot-Assisted Laparoscopic Radical Prostatectomy? (From: Haga N, Ogawa S, Yabe M, et al. J Endourol 2015;29:683-690).

We read the article by Haga and colleagues with great interest. The early continence is recently a hot topic, specifically at the time of catheter removal in followup after robot-assisted laparoscopic radical prostatectomy (RARP). The article is interesting and contributes science with distinctive statistical findings. According to the study, if the postoperative membranous urethral length (MUL) was longer than 17 mm, early continence could be provided according to multivariate analyses. Hakimi and colleagues reported importance of stretched and long urethra for continence after RARP. Furthermore, Rocco and colleagues concluded the benefits of posterior reconstructions in bladder neck. Srougi and colleagues disagreed with benefits of preserving bladder neck after open radical prostatectomy. Haga and colleagues pointed out that early acquisition of urinary continence had not been adequately revealed from the perspective of urethral and vesical anatomical features after RARP. In view of these conflicting data, we evaluated important parts of continence after RARP at a glance. Recently, surgical techniques and anatomic details of male pelvis have been reinvestigated for continence after RARP. Magnified vision is one of the well-known benefits of laparoscopic and robot-assisted laparoscopic surgery. Thus, anatomical details can be better identified. Moreover, robot-assisted laparoscopic surgery has more advantages than the laparoscopic one with 360 -rotating wrested-end effector instruments. Besides, classical anatomic details are repeated as preprostatic urethra includes muscle fibers of external urinary sphincter. The preserved neurovascular bundle could contribute continence by stimulating muscle fibers. A long membranous urethra includes much more muscle fibers of external urethral sphincter. If the surgeon can ensure urethral stump long during RARP, this may contribute continence after RARP. In contrast, most of the positive surgical margin (PSM) belongs to apex of prostate and every patient has his unique anatomical shape of apex. Sometimes apex of prostate may extend forward on urethra. Surgeons should be careful during apical dissection of prostate in terms of not leaving PSM, providing long urethra, and preserving neurovascular bundle. Haga and colleagues concluded that the postoperative MUL was the most important factor for recovery of urinary continence in the early postoperative period after RARP. We disagree with them. In a previous study, we showed effects of preserving bladder neck in terms of keeping internal sphincter for urinary continence after RARP. We also described very early continence after RARP, at time of catheter removal. In brief, the fatty connective tissue between bladder neck and prostate was introduced, and circular muscle fibers of internal sphincter were seen and preserved, in all patients. In addition, we agree with Haga and colleagues that long urethral stump was also necessary for continence after RARP. However, it should be with preserved bladder neck (internal sphincter) for very early continence. Finally, surgeons who perform RARP should consider anatomic details of male pelvis. The main factors of continence are to preserve bladder neck (internal sphincter) and to provide long membranous urethra, after RARP. Thus, very early continence can be provided at the time of catheter removal, after RARP.

Transperitoneal Laparoskopik Nefrektomi

L nefrektomi ilk olarak 1991 yılında transperitoneal olarak gerçekleştirilmiştir (1). O tarihten beri, birçok merkez yaptığı çalışmalarda açık cerrahiyle karşılaştırıldığında laparoskopik yaklaşımın avantajlarını bildirmişlerdir (2-4). Ancak, bugüne kadar yapılmış çoğu çalışmada, transperitonal nefrektomi için kullanılan yöntem standart basit nefrektomi için kulanılan yöntem ile paralelik göstermektedir. Az sayıdaki çalışmada transperitoneal laparoskopik nefrektomi için alternatif teknikler araştırılmıştır (5,6-8). Bu makalenin amacı, transperitoneal laparoskopik nefrektomi tekniğimizi bazı önemli püf noktaları ile birlikte aktarmaktır. Kullandığımız yöntemin, açık ve standart transperitoneal laparoskopik nefrektomi tekniklerden en önemli farkı, diseksiyona böbrek üst polünden başlanması ve renal pediküle olan yaklaşımdır.

The use of titanium ligation clips in microsurgical subinguinal varicocelectomy

OBJECTIVE The aim of this study is to evaluate the use of titanium ligation clips for dilated spermatic veins in microsurgical subinguinal varicocelectomy. MATERIAL AND METHODS In this retrospective study, eighty-four men with clinical varicocele underwent microsurgical varicocele repair. The patients were divided into two groups according to the ligation materials used for the varicocelectomy (silk sutures vs. titanium clips). Group 1 included 43 patients; these patients underwent microsurgical subinguinal varicocelectomy with the titanium clips. The 41 patients included in Group 2 underwent microsurgical subinguinal varicocelectomy with silk sutures. Microsurgical subinguinal varicocelectomy was performed in all patients. The two study groups were compared in terms of intra-operative and postoperative parameters. RESULTS The mean age of the patients was 28.6±4.6 years, and the mean follow-up was 12.3±2.7 months. The two groups exhibited comparable improvements in sperm motility and/or concentration: 79.1% and 82.9% in Group 1 and Group 2, respectively (p>0.05). The operation time in Group 1 (titanium clip) was significantly shorter than in Group 2 (silk sutures). None of the patients experienced any intra-operative complications. There were no significant differences between Group 1 and Group 2 with regard to postoperative recurrences, ligated veins, postoperative complications and hydrocele formation, hospitalization time, the requirement for postoperative analgesia or the time until the patient could return to work. CONCLUSION Titanium ligation clips can be used for the ligation of dilated vessels during microsurgical subinguinal varicocelectomy, and the operation time is significantly reduced with the use of titanium ligation clips.