Mert Ali Karadag

Gastrointestinal Complications of Laparoscopic/Robot-Assisted Urologic Surgery and a Review of the Literature

Gastrointestinal injuries that occur during or after laparoscopic and robot-assisted surgery are serious side effects that affect patient outcome. In this review, we attempt to highlight the identification, incidence and management of gastrointestinal and visceral complications of laparoscopic and robot-assisted surgery. A search of Medline and PubMed databases was performed using the following terms: gastrointestinal complications of laparoscopy, laparoscopic, kidney and robotic surgery. A total of 1,072 papers related to the subject were analyzed. Forty-six of these papers were included in the present review. These papers reported high numbers of participants and had a high level of evidence. Gastrointestinal complications during laparoscopic and robot-assisted surgery are rare, but similar, and can occur at any time between access and closure. Despite their infrequency, these complications can result in mortality. The early recognition and management of gastrointestinal complications is very important. Unrecognized or delayed identification of gastrointestinal complications may cause sepsis and death.

When is open ureterolithotomy indicated for the treatment of ureteral stones

Aim: Improvements in extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy have almost eradicated the need for open surgery in ureteral stones. The aim of this study was to assess characteristics of patients who underwent open ureterolithotomy.

Does Previous Extracorporeal Shock Wave Lithotripsy Affect the Performance and Outcome of Percutaneous Nephrolithotomy

PURPOSE ESWL and percutaneous nephrolithotomy are the primary treatment modalities for kidney stones. Furthermore, percutaneous nephrolithotomy is first line treatment when ESWL fails. We assessed how previous ESWL affects the performance and outcome of percutaneous nephrolithotomy. MATERIALS AND METHODS A total of 1,008 patients underwent percutaneous nephrolithotomy between 2002 and 2007, of whom 230 (22.8%) had a recent history of failed ESWL. Patient characteristics, operative findings, success and complication rates in patients with and without a history of ESWL were analyzed and compared. RESULTS In the post-ESWL group mean stone size was significantly lower and the mean +/- SD interval between the last ESWL session and percutaneous nephrolithotomy was 3.4 +/- 2.1 months (range 1 to 12). Mean operative time and fluoroscopic screening time were similar in the 2 groups (p >0.05). However, mean operative time per cm(2) stone and fluoroscopic screening time per cm(2) stone were significantly prolonged in the post-ESWL group (p <0.05). At a mean followup of 5.6 +/- 1.2 months (range 3 to 6) an overall success rate of 89% was achieved. Success and complication rates were comparable in the 2 groups. CONCLUSIONS Although similar success and complication rates were achieved with percutaneous nephrolithotomy after failed ESWL, percutaneous nephrolithotomy is usually more difficult with prolonged operative time and fluoroscopic screening time per cm(2) stone due to the tissue effects of ESWL and scattered stone fragments in the pelvicaliceal system.

Efficacy of extracorporeal shock wave lithotripsy for ureteric stones in children

Objectives: Management of ureteral stones in children represents a challenging problem. In this study, we retrospectively analyzed our experience with extracorporeal shock wave lithotripsy (ESWL) in 192 children with ureteric stones. Methods: Between 1990 and 2003, 192 children (≤ 14 years old) with ureteric calculi were treated with the Siemens Lithostar Plus (Siemens Medical Systems, Iselin, NJ). There were 39 stones in the proximal ureter, 19 in the mid-ureter and 134 in the distal ureter. Results: Mean patient age was 7.3±4.1 years (6 months–14 years). There were 122 boys (64.2%) and 70 girls (35.8%). All procedures were performed on an outpatient basis with intravenous sedation in 73 cases (38.1%), general anesthesia in 68 cases (35.7%) and no anesthesia in 51 cases (26.2%). A maximum of 3500 shocks and 18 kV per session were used. A 94% success rate was achieved in proximal (n: 39) and mid-ureteral stones (n: 19). Stone free rates for distal ureteral calculi were 90.6% for stones less than 1 cm in diameter (n: 94) and 91.7% for stones between 1 and 2 cm (n: 26). Overall re-treatment and efficacy quotient rates for proximal ureteral stones were 45.1% and 68.9%, 62.5% and 61.5% for mid-ureteral calculi, and 49.6% and 60.0% for distal ureteral stones. Conclusion: Our results indicate that ESWL with highly satisfactory stone free rates ranging between 90 and 100% and negligible complications can be considered as a first line treatment for ureteric stones in the pediatric age group.

Is Routine Radiological Surveillance Mandatory After Uncomplicated Ureteroscopic Stone Removal

PURPOSE Stricture formation and obstruction are rare but significant complications after ureteroscopy (URS), and there are controversial studies regarding follow-up. Our study sought to determine the appropriate follow-up for patients without complications. PATIENTS AND METHODS A total of 323 patients were treated with URS for removal of ureteric stones, and their charts were retrospectively reviewed. A semirigid ureteroscope was used in all patients, and stone disintegration was accomplished with a pneumatic lithotriptor. Postoperative evaluation included plain abdominal radiograph of the kidneys, ureters, and bladder (KUB) on day 1, intravenous urography (IVU) and/or ultrasonography at postoperative month 3 and annually thereafter in all patients. A KUB radiograph was also obtained on postoperative day (POD) 10 in patients with residual fragments. RESULTS Complete records of 268 patients were available. The overall success rate was 95.5%. The KUB radiograph on POD 1 revealed complete stone removal in 217 (80.9%) patients, while residual fragments were seen in 40 (14.9%) patients, who were reevaluated on POD 10. Evaluation on POD 10 showed residual fragments in 15 patients, and URS was again performed in eight patients. Perioperative minor complications were observed in 18 (6.7%) patients. IVU performed in the third postoperative month showed stricture formation in two (0.7%) patients and silent obstruction in one (0.3%). No stricture formation was observed in asymptomatic patients after uncomplicated complete stone removal. After a mean follow-up of 27.4 +/- 13.7 (range 12-58) months, annual radiologic studies did not show any additional complications. CONCLUSIONS Our results indicate that radiologic surveillance for stricture formation and obstruction is not mandatory after complete stone removal with uncomplicated URS.

Effects of testicular histopathology on sperm retrieval rates and ICSI results in non-obstructive azoospermia.

Non-obstructive azoospermia (NOA) is characterised by absence of sperm in the ejaculate. Significant relationship between the pattern of the testis histopathology of NOA and successful sperm retrieval rate is well known. In this study, we assess efficacy of testicular histopathology on sperm retrieval rates and intracytoplasmic sperm injection results after microdissection testicular sperm extraction in cases of non-obstructive azoospermia. It is a retrospective analysis of 111 NOA patients who have histopathological confirmation. According to histopathological findings, the patients were divided into three groups: Sertoli-cell-only syndrome (SCOS), maturation arrest (MA) and hypospermatogenesis. Sperm retrieval rate was significantly higher in hypospermatogenesis group compared with that in SCOS and MA groups. In terms of fertilisation and clinical pregnancy rates, there was no significant difference between the groups. As a result, compared with MA and SCOS, hypospermatogenesis has higher sperm retrieval rates. Our study revealed that once successful sperm retrieval is achieved, fertilisation and clinical pregnancy rates are similar in NOA patients.

Flexible Ureterorenoscopy versus Extracorporeal Shock Wave Lithotripsy for the treatment of upper/middle calyx kidney stones of 10–20 mm: a retrospective analysis of 174 patients

To compare the outcomes of flexible ureterorenoscopy (F-URS) with extracorporeal shock wave lithotripsy (ESWL) for the treatment of upper or mid calyx kidney stones of 10 to 20 mm.A total of 174 patients with radioopaque solitary upper or mid calyx stones who underwent ESWL or F-URS with holmium:YAG laser were enrolled in this study. Each group treated with ESWL and F-URS for upper or mid calyx kidney stones were retrospectively compared in terms of retreatment and stone free rates, and complications.87% (n = 94) of patients who underwent ESWL therapy was stone free at the end of 3rd month. This rate was 92% (n = 61) for patients of F-URS group (p = 0.270 p > 0.05). Retreatment was required in 12.9% of patients (n = 14) who underwent ESWL and these patients were referred to F-URS procedure after 3rd month radiologic investigations. The retreatment rate of cases who were operated with F-URS was 7.5% (n = 5) (p = 0.270 p > 0.05). Ureteral perforation (Clavien grade 3B) was occured in 3 patients (4.5%) who underwent F-URS. Fever (Clavien grade 1) was noted in 7 and 5 patients from ESWL and F-URS group, respectively (6.4% vs 7.5%) (p = 0.78 p > 0.05).F-URS and ESWL have similar outcomes for the treatment of upper or mid calyx renal stones of 10–20 mm. ESWL has the superiority of minimal invasiveness and avoiding of general anethesia. F-URS should be kept as the second teratment alternative for patients with upper or mid caliceal stones of 10–20 mm and reserved for cases with failure in ESWL.

The effect of systemic isotretinoin on male fertility

Abstract Background/objective: Acne vulgaris is one of the most common diseases of the youth. Systemic isotretinoin is the only drug which acts on all of the etiopathogenic mechanisms of acne. Isotretinoin has some well-known side effects. Besides these, there is a suspicion whether it causes infertility or not. In this study, we aimed to evaluate the effects of systemic isotretinoin on male fertility. Methods: Eighty one male patients, who were older than 18 years of age, and had severe or refractory acne vulgaris were included in the study. They were given a total dose of 120 mg/kg of systemic isotretinoin over a period of six months. Before and after the study, the spermiogram parameters of the patients were evaluated to show any possible effect on male fertility. The patients’ total testosterone, follicle stimulating hormone and luteinizing hormone levels were also evaluated. Results: All of the spermiogram parameters changed positively (p < 0.05). There was no significant change in the hormone levels. Conclusion: Systemic isotretinoin has a positive effect on male fertility. Since the hormone levels did not change significantly, this positive effect of isotretinoin is not via the hypothalamic–pituitary–gonadal axis but can be due to its regenerative and proliferative effects on the testes.

Pain control using pethidine in combination with diazepam compared to diclofenac in combination with hyoscine-n-butyl bromide: in patients undergoing extracorporeal shock wave lithotripsy.

Introduction Extracorporeal Shock Wave Lithotripsy (ESWL) remains the preferred least invasive treatment for urinary tract stones. The main purpose of this study was to compare two treatment modalities for pain control during the ESWL procedure. Material and methods From 2013 to 2014, 220 patients received ESWL for kidney stones. Before the procedure, the weight and height were measured to determine the body mass index (BMI); in addition, oxygen saturation and the pulse of the patients, as well as pain level were determined. The pain control provided included two different methods: diclofenac sodium plus hyoscine-N-butyl bromide in the first group and pethidine plus diazepam in the second group. The pain level of the patients was determined using two different scales: the Wong-Baker and the Visual Analogue scales (VAS). At the end of three sessions, all patients were evaluated for the stone fragmentation rate by plain abdominal X-ray, and the findings were recorded and analyzed. Results A total of 220 patients were enrolled in this study. There were 91 patients in the first group (diclofenac sodium + hyoscine-N-butyl bromide) (male/female: 63/28) and 129 (male/female: 83/46) patients in the second group (pethidine HCL +diazepam). The mean age with SD according to each group was 42.03 (±16.43) and 42.56 (±14.23), respectively (p = 0.8). With regard to pain scores (using the Wong-Baker and VAS scales), the responses were significantly lower in the second group (p <0.001). Conclusions Pethidine in combination with diazepam was superior to diclofenac and Hyoscine-N-butyl bromide for pain in patients undergoing ESWL.

Small cell carcinoma of the prostate presenting with skin metastasis: a case report

IntroductionSmall cell carcinoma of the prostate is a very rare and aggressive type of prostatic cancer. Most cases are diagnosed at advanced stage due to early metastasis. The bones, liver, regional and distant lymph nodes are the most common sites of metastasis of small cell carcinoma of the prostate. Skin metastasis of small cell carcinoma of the prostate is a very rare entity due to the uncommon metastatic site. Here, we describe the case of a patient with small cell carcinoma of the prostate which metastasized to his skin.Case presentationA 74-year-old Caucasian man presented to another urology center for mild lower urinary tract symptoms in 2003. His prostate-specific antigen was 23ng/mL. According to the physical examination signs and prostate-specific antigen, he underwent a transrectal ultrasound-guided prostate biopsy. The pathologic examination of his prostate revealed a Gleason score: 3+4=7 adenocarcinoma of the prostate. Investigations showed stage T2N0M0 disease and he was treated with radiotherapy to his pelvic lymph nodes and prostate. Six years after the initial diagnosis, he complained of a palpable left-side 2×2cm subcutaneous solitary mass localized just behind his scapula. The results of his laboratory tests including serum acid phosphatase and prostate-specific antigen were in normal ranges. Our general surgery department performed a diagnostic biopsy of the mass and totally excised the lesion. The pathologic examination of the mass showed small cell carcinoma metastasis with chromogranin + and the pathologist advised us to examine the lung or prostate for the primary tumor. The patient undertook a transrectal ultrasound-guided prostate biopsy and the pathologic result revealed small cell carcinoma within residual adenocarcinoma. We investigated the other sites for metastasis and restaging investigations showed a 1cm metastatic lesion in his liver. Our medical oncology department decided to treat him with combination chemotherapy with etoposide and cisplatin in six cycles; however, he died due to disseminated myocardial infarction before starting the fifth combination chemotherapy cycle.ConclusionsClinicians should keep in mind that early diagnosis of this disease is very difficult due to early metastatic spread of small cell carcinoma and lack of concordant elevation of prostate-specific antigen. There is no accepted standard treatment modality for this pathology and overall prognosis is poor.