Onur Dede

Ultra-mini-percutaneous nephrolithotomy in pediatric nephrolithiasis: Both low pressure and high efficiency

INTRODUCTION The management of urolithiasis in children differs from adults because of anatomic and metabolic abnormalities. At present, various minimally invasive and invasive treatment strategies have been recommended to treat urinary tract Stones, including shock wave lithotripsy (SWL), standard percutaneous nephrolithotomy (PNL), mini-PNL, retrograde intrarenal surgery (RIRS), micro-PNL, and a new technique termed ultra-mini PNL (UMP). UMP is a new method for the treatment of kidney stones. The main difference between UMP and standard PNL or mini-PNL lies in the small access sheath and in its design. A 9.5F pediatric compact cystoscope was used (Figure). A major advantage of UMP is that it provides similar stone-free rates when compared with standard PNL, with lower intrarenal pressure than micro-PNL. OBJECTIVE The aim of the study was to determine the applicability and safety of UMP in the treatment of pediatric kidney stones. PATIENTS AND METHODS We retrospectively reviewed the files of 39 kidney stones in children who had undergone UMP between May 2011 and October 2014. The indications for UMP included stones resistant to SWL, stones requiring repeated sessions of SWL, and stones size larger than 20 mm. RESULTS The study included 17 females and 22 males, with a mean age of 5.8 ± 4.6 years. The mean hemoglobin loss was 0.9 ± 0.6 mg/dL and none of the patients required a blood transfusion. The complication rate of the PNL procedure was 15.3% (n = 6). Complete clearance was achieved in 32 patients (82%) with UMP monotherapy, which increased to 34% (87.1%) 4 weeks after the operation. DISCUSSION Management of urolithiasis necessitates a balance between stone clearance and morbidity related to the procedure. SWL often leads to persistent residual stones. The developing RIRS can minimize the risks associated with bleeding and visceral injury, but sometimes the abnormal pelvicaliceal anatomy and poor imaging of the flexible ureteroscopy may impact its success rate and applications. It has been reported that PNL can be performed safely and effectively to achieve a higher stone-free rate; however, it has serious complications such as bleeding that requires blood transfusion in 11-14% of the cases with increased risk of kidney loss. The recent development of smaller sheaths allows tract formation with minimal damage to the renal parenchyma, thereby reducing procedure-related morbidity without diminishing its therapeutic efficacy. CONCLUSION The most important advantage of this surgical technique that has been developed is similar stone-free rates to standard PNL and lower intrarenal pressure than micro-PNL. Our experience supports that UMP is safe and effective for the management of renal stones in children.

The short-term efficacy of dilatation therapy combined with steroid after internal urethrotomy in the management of urethral stenoses.

PURPOSE To present the short-term results of hydrophilic dilatation catheter or steroid-coated hydrophilic dilatation catheter usage in the management of primary urethral stricture. PATIENTS AND METHODS Forty-five male patients with a diagnosis of primary urethral stricture shorter than 1.5 cm and no comorbities were included in this study. After application of visual internal uretrotomy interna, these patients were randomized into three groups. A steroid-coated (triamcinolone acetonide 1%) 18F hydrophilic dilatation catheter was applied to the patients in group 1 for 2 weeks and an 18F hydrophilic dilatation catheter was applied to the patients in group 2 for 2 weeks. An 18F silicone urethral catheter was applied to the patients in group 3, and catheters were removed after 3 days. Uroflowmetry was used in postoperative follow-ups. RESULTS Mean patient age and follow-ups were 33.4 (19-45) years and 16.4 (6-18) months, respectively. The postoperative maximum urinary flow rate was 15.3 +/- standard deviation (SD) 4.6, 13.8 +/- SD 4.8, and 12.4 +/- SD 4.4 for groups 1, 2, and 3, respectively (P 0.323). Failure was detected in three (20%) patients in group 1, seven (46.7%) patients in group 2, and nine (60%) patients in group 3 (P > 0.05). CONCLUSIONS As an adjuvant treatment, this method is effortless, low in complications, and hopeful. Certainly, application to larger patient populations is needed to objectively accept its efficiency.

Comparison of Retrograde Intrarenal Surgery and Micro-Percutaneous Nephrolithotomy in Moderately Sized Pediatric Kidney Stones

PURPOSE To compare the effectiveness and reliability of retrograde intrarenal surgery (RIRS) and micro-percutaneous nephrolithotomy (micro-perc) for the management of kidney stones in pediatric patients. MATERIALS AND METHODS A retrospective analysis was made of pediatric patients aged <18 years with kidney stones that ranged from 10 to 20 mm in size, who underwent RIRS (n = 36) or micro-perc (n = 45) in referral centers. RESULTS In the RIRS group, the mean age of patients was 8.39 ± 4.72 years and in the micro-perc group, it was 5.62 ± 4.50 years (p = 0.01). The mean stone size was 12.80 ± 3.03 mm in the RIRS group and 13.97 ± 3.46 mm in the micro-perc group (p = 0.189). The success rate was 86.2% (n = 31) in the RIRS group and 80.0% (n = 36) in the micro-perc group (p = 0.47). The mean complication rate was 16.6% and 13.3% in the RIRS and micro-perc groups, respectively (p = 0.675). Hospital stay and radiation exposure were significantly lower in the RIRS group (all p < 0.001). The mean anesthesia session was 1.94 in the RIRS group and 1.26 in the micro-perc group (p < 0.001). The mean hemoglobin drop was 0.53 ± 0.87 g/dL in the micro-perc group, and none of the cases required blood transfusion. CONCLUSION The results of this study suggested that micro-perc and RIRS were highly effective methods for the treatment of moderately sized renal stones in children, with comparable success and complication rates. Patients and their parents should be informed about the currently available treatment options, and of their efficacy and safety. However, further clinical trials are needed to support these results.

The effect of music therapy during shockwave lithotripsy on patient relaxation, anxiety, and pain perception.

Abstract Objectives: To research the effect of listening to music during shock wave lithotripsy (SWL) on the patient’s pain control, anxiety levels, and satisfaction. Patients and methods: The study comprised 400 patients from three hospitals. Half of patients listened to music during their first SWL session but not during their second session. The other half had no music for the first session but the second session was accompanied by music. During all sessions, with and without music, pulse rates, blood pressure, State-Trait Anxiety Inventory-State Anxiety scores (STAI-SA), Visual Analog Scale (VAS scores for pain), willingness to repeat procedure (0 = never to 4 happily), and patient satisfaction rates (0 = poor to 4 = excellent) were assessed. Results: There was no statistical difference between the two groups in terms of blood pressure and pulse rates. In both groups, the STAI-SA and VAS pain scores were lower in the session when music was listened to (p < 0.001). The patients requested more SWL treatment be completed while listening to music and their satisfaction was greater. Conclusion: Music lowered the anxiety and pain scores of patients during SWL and provided greater satisfaction with treatment. Completing this procedure while the patient listens to music increases patient compliance greatly and reduces analgesic requirements.

Elastography to assess the effect of varicoceles on testes: a prospective controlled study

Varicoceles are the most common and treatable cause of male infertility. The pathophysiology of varicoceles primarily includes elevated temperature, adrenal hormone reflux, gonadotoxic metabolite reflux, altered testicular blood flow, antisperm antibody formation and oxidative stress. The diagnosis of a varicocele is mainly clinical. However, a Doppler ultrasound is used to obtain clinical data and to more accurately measure testicular size. Acoustic radiation force impulse (ARFI) is an additional technique to simultaneously show different areas with different densities in a colour‐coded image and a B‐mode or greyscale image. This can be used for structural analysis of testicular tissue and has become an additional method for detecting pathologic tissue alterations. We enrolled 30 patients who had clinically diagnosed with left varicoceles and male infertility (Group 1). All patients were evaluated by history taking, physical examination, a spermiogram and an endocrine profile. Thirty control patients (Group 2) were randomly chosen from patients who had applied to an andrology clinic for infertility; their physical examinations and laboratory results showed normal findings. Mean elastography results were significantly different between the groups, and significantly lower in patients who had varicoceles. The relationship between hormonal profiles and elastography parameters was calculated as statistically significant negative correlations between FSH and elasticity. Additionally, a negative correlation was determined between varicocele grade and elasticity of testes. In conclusion, our prospective study showed that ARFI imaging may be more useful than palpation for determining early damage of testicular structure by varicoceles.

The comparison of standard and tubeless percutaneous nephrolithotomy procedures

PURPOSE To compare totally tubeless and standard percutaneous nephrolitotomy procedures on many parameters. MATERIALS AND METHODS Percutaneous nephrolitotomy was performed on 195 patients between June 2009 and May 2012. The data of those patients were evaluated retrospectively. Totally tubeless cases were enrolled to Group 1, and Group 2 consisted of non-tubeless cases (re-entry or Foley catheter). RESULTS Group 1 included 85 cases and group 2 a total of 110 patients. Paper tracing values for the kidney stones were 321.25 ± 102.4 mm(2) and 324.10 ± 169.5 mm(2) respectively. Mean fluoroscopy time was 4.9 ± 1.9 min and 5.08 ± 2.7 min, mean operation time was 78.8 ± 27.9 min and 81.9 ± 28.77 min and mean decrease in hematocrit was 2.6 ± 1.6 and 3.74 ± 1.9 respectively. All these comparisons were statistically significant. Length of hospitalization was 1.6 ± 1.1 and 3.5 ± 1.5 days for Groups 1 and 2 respectively. Mean superficial pain score was 5.8 ± 1.6 and 6.7 ± 1.2 respectively for both groups after 1 hour. At 6 hours, the scores changed to 3.87 ± 1.22 and 4.84 ± 1.3 respectively. The analgesic dose was 1.00 ± 0.7 and 1.53 ± 0.6 for the groups respectively at 6 hours. All the statistical differences were significant for these three parameters. CONCLUSIONS We believe that, because of their post operative patient comfort and decreased length of hospital stay, totally tubeless procedures should be considered as an alternative to standard percutaneous nephrolitotomy.

Micro-percutaneous nephrolithotomy in the treatment of pediatric nephrolithiasis: A single-center experience

OBJECTIVE We aimed to clarify the applicability and safety of micro-PNL (microperc) in the treatment of pediatric kidney stones. MATERIAL AND METHODS A single center prospective trial was initiated, and microperc was performed in 40 children using the same two methods: the classical all-seeing needle and microsheath method. Stone fragmentation was performed using a 200-μm holmium:YAG laser fiber. RESULTS The mean age of the patients was 6.3±4.4years (range: 7months-16years). Fourteen were less than 3years old. The average calculous size was 16.5mm (range: 10-36mm). In 20 patients, access was achieved through the all-seeing needle method. In the other patients, access was achieved by the microsheath method. Conversion to mini-PNL was required in 2 patients due to intraoperative bleeding in one and a high stone burden in the other. The mean hospital stay was 3.8±1.2days (range: 1-10days), and the mean hemoglobin decrease was 0.7±0.3mg/dl (range: 0-1.7mg/dl).The duration of surgery and fluoroscopic screening was 75min and 3.7min, respectively. A DJ stent was placed in 11 patients due to a high stone burden. A ureteral stent was left for 1day in the rest of the cases. Complete clearance was achieved in the other 32 children. None of the patients required transfusion caused by renal hemorrhage. In 1 patient, extravasation of the irrigation fluid caused abdominal distention. As assessed by KUB and/or an ultrasound, the overall stone-free rate at 6weeks was 80%. There were residual fragments in 6 patients (15%). CONCLUSIONS Our results show that microperc is a safe and effective procedure for the treatment of pediatric kidney stones. Children with small renal calculi and with nonobstructed collecting systems are suitable for microperc.

Potential biomarkers for the early detection of acute kidney injury after percutaneous nephrolithotripsy.

Abstract This study aims to investigate the role of urinary biomarkers in the determination of the potential risks of renal parenchymal tubular damage in adult patients who underwent percutaneous nephrolithotomy (PNL) with the indication of renal stone. A randomized and prospective controlled study was performed between June and December 2013. We enrolled 29 consecutive patients with renal calculi > 2 cm and who underwent PNL, as well as 47 healthy control subjects. Urine samples, including 2 h before surgery, 2 and 24 h after surgery were collected from the patient group. Freshly voided urine samples were collected from the control group. Kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-glucosaminidase (NAG), and liver-type fatty acid binding protein (LFABP) levels were measured from these urine samples. The mean KIM-1/Cr value that measured 24 h after the operation was statistically significant, higher than its preoperative (preop) level (p = 0.045). A significant difference was detected between the mean preop and postoperative (postop) 24 h NAG/Cr values (p < 0.001). Also, postop 24 h NGAL/Cr levels were statistically significant, higher than its preop levels (p = 0.013). According to the comparison of preop and postop levels, an increase in LFABP/Cr values secondary to surgical intervention was observed without any statistically significant difference. Besides the LFABP/Cr levels do not change after percutaneous kidney surgery, KIM-1/Cr, NAG/Cr, and NGAL/Cr levels increase postop period, especially at 24 h. Further studies with a larger series and repeated measurements should be performed to clarify if they can be used to demonstrate renal damage after percutaneous surgery or not.

Ultrasound-guided micropercutaneous nephrolithotomy in pediatric patients with kidney stones: Micropercutaneous nephrolithototomy

To present the outcomes of ultrasound‐guided micropercutaneous nephrolithotomy for the treatment of renal stones in pediatric patients.

Effect of spermatic vein ligation on seminal total antioxidant capacity in terms of varicocele grading

We aimed to assess the effect of spermatic vein ligation on seminal total antioxidant capacity (TAC) in patients with varicocele. Twenty infertile male patients with varicocele and 20 normal fertile men (control group) were included in the study. All the male patients were diagnosed with primary infertility and varicocele. The patients with varicocele were divided into two groups as nonpalpable (GI) (eight patients) and palpable (GII–III) (12 patients) varicocele groups. All the patients underwent microsurgical spermatic vein ligation. Seminal TAC levels and sperm parameters were evaluated in all the patients. Preoperative sperm count, sperm motility, sperm morphology and seminal TAC levels with equivalent figures 3–6 months after spermatic vein ligation and the same values of the control group were compared. There was a statistically significant increase in the total seminal antioxidant capacity level after spermatic vein ligation, and there was a statistically significant increase in the sperm count, sperm motility and spermatozoa with normal morphology. However, evaluation of the patients for varicocele grade showed a statistically significant increase in the TAC level only in the GII–III varicocele group. Spermatic vein ligation can improve the total seminal antioxidant capacity levels especially in patients with middle and high grade varicocele.