Mehmet Remzi Erdem

Micropercutaneous Nephrolithotomy in the Treatment of Moderate-Size Renal Calculi

PURPOSE We present our initial experience with microperc in patients with moderate-size renal calculi. PATIENTS AND METHODS A retrospective analysis of 30 patients (male 14, female 16) with moderate-size (1-3 cm) kidney stones who underwent microperc between August 2011 and July 2012 was performed. The demographic values, perioperative and postoperative measures including age, stone size and location, body mass index, operative and fluoroscopy time, hemoglobin decrease, success and complication rates were prospectively recorded into a patient entry system. RESULTS The average stone size was 17.9±5.0 mm (10-30 mm). The mean age of the patients was 41.5±18.2 years (range 3-69 years). The duration of the operation was calculated as 63.5±36.8 minutes (range 20-200 min). Mean fluoroscopic screening time was 150.5±90.4 seconds (range 45-360 seconds). The patients were discharged after a mean hospitalization period of 35.5±18.6 hours (range 14-96 hours). An overall success rate of 93% (including 10% of insignificant residual fragment rate) was achieved. In the follow-up, residual stone fragments were detected in two (7%) patients. Conversion to miniperc was necessitated in three (10%) patients. The mean hemoglobin drop was found to be 1.1±0.8 mg/dL (range 0-2.8 mg/dL). Complications were observed in five (13.3%) patients. CONCLUSIONS Our initial results provide that microperc is a feasible, safe, and efficacious treatment modality for moderate-size kidney stones as well as small ones with its minimally invasive nature. Technical refinements are needed to achieve better results and overcome the limitations of technique.

Is Fluoroscopic Imaging Mandatory for Endoscopic Treatment of Ureteral Stones

OBJECTIVE To present the feasibility and safety of fluoro-less endoscopic treatment of ureteral stones to diminish radiation exposure of the patient and operating team, and to determine circumstances where a fluoroscopic imaging is mandatory. METHODS Between 2010 and 2011, 93 patients with ureteral calculi who underwent ureteroscopic treatment by experienced urologists were retrospectively evaluated. Manipulations, such as guidewire, ureteral stent insertion, and balloon dilatation were performed with visual and tactile cues. Patient demographics, need for fluoroscopic imaging, operation and fluoroscopy time, and complication and success rates were investigated. RESULTS The mean age of patients was 34.03 ± 12.09 years (range, 9-63 years). The mean stone size was 10.64 ± 3.16 mm (range, 6-17 mm). The stones were localized in the proximal, middle, and distal segments in 11, 30, and 52 patients, respectively. The mean duration of the operation was 34.51 ± 7.94 minutes (range, 24-55 minutes). Stone-free status was achieved for 90 patients (96.77%). Fluoroscopic imaging was required for 7 patients with a mean fluoroscopy time of 9 ± 4.72 seconds (range, 4-16 seconds) for the following reasons: stone migration to the kidney (3 patients), double collecting system with 2 ureters (1 patient), and ureteral orifice stricture extending to the upper segment (1 patient). No major complications were observed, but minor complications were observed in 11 patients (11.8%). CONCLUSION The ureteroscopic treatment of ureteral stones can be safely and effectively performed in experienced hands, with limited or no usage of fluoroscopy except in special circumstances, such as anatomic abnormalities, upper ureteral strictures, and impacted ureteral stones leading to ureteral tortuosity, kinking, and obstruction.

Female Urethral Malignant Melanoma With Vesical Invasion: A Case Report

We report a 75‐year‐old female with a primary urethral malignant melanoma. A mass protruding from inside the urethra was detected on physical examination. Abdominopelvic magnetic resonance imaging revealed a mass extending from the urethra with dimensions of 4 × 2 cm, and periurethral heterogenous fatty planes consistent with infiltration. The histopathologic examination was consistent with HMB45(+) malignant melanoma. We performed cystourethrectomy and bilateral inguinal and pelvic lymphadenectomy in one session. The pathology report revealed primary malignant melanoma of the urethra invading the inferior bladder wall. The patient received no adjuvant therapy because of cardiopulmonary morbidities and the presence of multiple pulmonary metastases. The patient eventually died 13 months after surgery.

A Rare Renal Epithelial Tumor: Mucinous Cystadenocarcinoma Case Report and Review of the Literature

Primary renal mucinous cystadenocarcinoma is a very rare lesion of kidney which originates from the metaplasia of the renal pelvic uroepithelium. Only one case with primary mucinous cystadenocarcinoma has been reported in the English literature. We report second case of mucinous cystadenocarcinoma which was radiologically classified as type-IIF Bosniak cyst in peripheral localization. We aimed to present this extreme and unusual entity with its radiological, surgical, and pathologic aspects under the light of literature.

The All-Seeing Needle Instead of the Veress Needle in Pediatric Urologic Laparoscopy

PURPOSE To investigate the feasibility of the all-seeing needle for safe entry and creation of pneumoperitoneum in pediatric urologic laparoscopy. PATIENTS AND METHODS A total of 14 children underwent various transperitoneal urologic laparoscopic procedures. The all-seeing needle, which is 4.85F in diameter, was used for safe entry into the abdominal cavity at the site of the umblicus in all cases. The microoptic was integrated with the light system and connected via a zoom ocular enabling direct visualization of the layers between the skin and the peritoneal cavity. Once the intraperitoneal access was obtained, CO2 pneumoperitoneum was created from one port of the three-way connector attached to the proximal part of the needle. Then the laparoscopic trocars were placed under vision of the microoptical system. RESULTS Mean age of the children was 4.5 ± 2.9 years. In all children, the all-seeing needle was safely introduced into the abdominal cavity under direct vision. Then, CO2 pneumoperitoneum was succesfully performed. The mean time for optical puncture was calculated as 1.1 ± 0.8 minutes. No complication was encountered during the introduction of the needle, creation of the pneumoperitoneum, and placement of the trocars. CONCLUSIONS The all-seeing needle appears to be beneficial in safe entry and for creating pneumoperitoneum in laparoscopic pediatric urology cases. It eliminates the disadvantages of the Veress needle, which is blunt insertion, and may possibly prevent complications.

Reconstruction of Distal Urethral Strictures Confined to the Glans With Circular Buccal Mucosa Graft

OBJECTIVE To report our results with 1-stage reconstruction in short distal urethral strictures using circular buccal mucosa graft (cBMG). METHODS The data of 19 patients (median age 41.8 years, range 25-58) operated between 2001 and 2010 were reviewed. Patients were evaluated with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography (VCUG), and intraoperative urethroscopy. Stricture was limited to the glanular urethra (≤ 2 cm.) in all cases and 16 patients had lichen sclerosus. Strictured urethra was resected 0.5 cm proximal to the healthy urethra and a rectangular BMG with 4-cm length and 1.5- to 2.5-cm width (depending on the length of the defect) was rolled on a 24-Fr sound that calibrated the urethra. Proximal and distal edges of the cBMG were anastomosed circumferentially to the healthy mucosa and meatus, respectively. Foley catheter was removed within 10-14 days. Voiding symptoms, uroflowmetric parameters, and cosmesis were assessed at 1, 3, and 6 months, and yearly thereafter. RESULTS With a median follow-up of 38 months (range 12-96), 16 (84.2%) patients were cured. One patient developed early graft loss, and 2 patients developed stricture at proximal anastomotic site. Mean Q(max) (mL/s) increased from 7.8 ± 5.4 preoperatively to 21.8 ± 9.2 postoperatively (P = .001), and mean AUA score decreased from 26.7 ± 3.9 preoperatively to 7.3 ± 3.8 postoperatively (P < .001). CONCLUSION Our results suggest cBMG as a feasible alternative in 1-stage reconstruction of distal strictures confined to the glanular urethra because the glans penis has a good blood supply, providing an efficient circumferential graft take.

Comparison of Flexible and Rigid Cystoscopy-Assisted Ureteral Catheter Insertion Before Percutaneous Nephrolithotomy: A Prospective Randomized Trial

BACKGROUND AND PURPOSE To compare the advantages of flexible and rigid cystoscopy-assisted ureteral catheter placement before prone percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS From March to September 2012, a total of 80 patients with kidney stones underwent PCNL by the same surgical team. The patients were randomly assigned into one of the groups according to the technique used for ureteral catheter insertion: Flexible cystoscopy (group 1, n=40) or rigid cystoscopy (group 2, n=40). Patient demographics and operation-related factors were compared. The preparation period included positioning, cystoscopy-assisted stent insertion, and patient repositioning for PCNL. In addition, discomfort scores of the operating room (OR) staff were measured. RESULTS The demographic values of the groups in terms of patient sex, age, body mass index, and stone size were comparable. While the mean preparation period was calculated as 9.9±2.3 minutes in the flexible cystoscopy group, it was significantly longer (19.7±2.9 minutes) in the rigid cystoscopy group (P<0.0001). In addition, the discomfort score of the OR staff was found to be significantly higher in the rigid cystoscopy group (1.1±0.9 vs 2.05±0.68, P<0.0001). The rest of the operative and postoperative parameters were similar. CONCLUSIONS The insertion of a ureteral catheter with a flexible cystoscope before prone PCNL shortens the preparation period and minimizes the discomfort of OR staff related to patient positioning and transfer.

Tubularized incised plate urethroplasty with dorsal inlay graft prevents meatal/neourethral stenosis: a single surgeon's experience

To the Editor, We read the article by Shimotakahara et al [1] with great interest. In this article, the authors are evaluating of the effectiveness of dorsal inlay graft (DIG) urethroplasty for preventing meatal/neourethral stenosis (M/N-S) after hypospadias repair. For this purpose, they have compared the outcomes of snodgrass urethroplasty (SUP) and SUP plus DIG. Finally, they reported that using DIG during SUP is significantly decreasing the M/N-S, and therefore, they strongly recommend the routine use of this technique. However, there are some limitations of the study that need to be clarified. The main drawback of the study is the use of DIG in cases with shallow groove as indicated in the “Methods” section. Although the authors are using this technique in only select cases, it is not wise to strongly recommend the routine use of DIG during every SUP. If the indication of this technique is limited to the patients with narrow or shallow glans, unless randomized studies have been conducted in hypospadiac patients, the suggestion of the routine use of DIG should be avoided. The other technical factor when considering the routine use of DIG from the inner preputial skin is perhaps the severity of the hypospadias. The safe use of DIG in distally located primary hypospadias cases have been previously reported [2,3]. However, in the present study, the meatus of the penis is proximally located in almost half of the children preoperatively. Especially in this group of patients, the preputial skin is generally saved and is used to cover the corpora of the penis, which is exposed and lengthened after the degloving and chordectomy phases. Therefore, sometimes it might be technically difficult to sacrifice a large portion of the inner preputial skin to cover the incised urethra. In that special group of cases, we suggest that harvesting a buccal mucosa for the preparation of the inlay graft would be a better choice of treatment instead of using an inner preputial skin. We also have an experience of using DIG prepared from the inner prepuce in 15 primary distal hypospadias cases at our institution. After a mean follow-up of 9.1

Extraordinary cause of complete colonic obstruction in children: Urinary retention

Complete colonic obstruction in children may occur secondary to congenital, and acquired factors related to the gastrointestinal system. Herein, we report an extraordinary presentation of complete colonic obstruction due to extensive urinary retention in a 3‐year‐old boy. The possible underlying mechanism was detected as urinary infection in a child with horseshoe kidney. The treatment of the bladder symptoms and urinary infection relieved the obstruction of the colon. To our knowledge, especially in children, colonic obstruction due to urinary retention has not been reported in the literature.

Malignant Melanoma in Genito-Urinary Tract

It manifests itself with flank pain and usually renal involvement is detected at the time of diagnosis. Additionally, distant lymph node metastasis could also be detected. Absence of previous unilateral adrenal gland involvement, presence of pigmented lesions without any signs of endocrine disorder, and negative immunohistochemical endocrine markers are typical characteristics of primary malignant melanoma of the adrenal gland. Presence of an occult primary lesion should also be excluded by autopsy. Pluripotent neural crest cells are localized within adrenal gland medulla. They are precursors of melanocytes, neurons, glial cells of the peripheral nervous system, and adrenal chromaffin cells. Under the influence of microenvironment, and various growth factors, these multipotent cells might transform into different cell types.