Orcun Celik

Laparoscopic transvesical repair of recurrent vesicovaginal fistula using with fleece-bound sealing system

BackgroundVesicovaginal fistula (VVF) is an epithelium-lined communication between the urinary bladder and vagina. Most of VVFs are repaired by conventional open surgery. Laparoscopic repair of VVFs is rare and so far no report is available about laparoscopic repair of persistent VVF using fleece-bound sealing system as a tissue barrier in the literature. Here we describe the operative technique and briefly review the literature.CaseWe present the case of a 37-year-old woman with recurring VVF in two times after abdominal and transvaginal repairs caused by a massive bleeding during caesarian-section due to placenta previa and underwent hysterectomy. During the laparoscopic repair of the fistula and excision of the vaginal cuff, fleece-bound sealing system (TachoSil®) was used as tissue barrier. Laparoscopic transperitoneal transvesical repair was successfully performed by suturing the defects and fixing two TachoSil between the bladder and vagina. The postoperative period of the patient was uneventful and after a follow up of 6 months no recurrence was found.ConclusionWe believe that laparoscopic repair of vesicovaginal fistula is a feasible and efficacious minimally invasive approach for the management of this entity. Whilst proper identification of tissue planes and good laparoscopic suturing technique are required, using fleece-bound sealing system might be convenient especially for persistent VVF.

Role of TNF-related apoptosis-inducing ligand (TRAIL) in the pathogenesis of varicocele-induced testicular dysfunction.

The higher frequency of varicocele in men with infertility has drawn attention and resulted in increased research at the molecular level towards treatments. The aim of this study was to investigate the role of tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) and its receptors in varicocele-induced testicular dysfunction in an experimental rat model. The rats were divided into three groups: control, sham and varicocele. Varicoceles in rats were induced by partial ligation of the left renal vein and left testes. The rats were analyzed 13 weeks after surgery. The degree of DNA fragmentation within cells in the testis was determined using terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling (TUNEL) assay. Tubule degeneration was evaluated using the Johnsen score. The expression of TRAIL and its receptors was detected by immunohistochemical and Western blotting techniques. The apoptotic index, Johnsen score and the expression of TRAIL and TRAIL receptors were examined. The data are presented as the mean±s.d. and were analyzed using computer software. The Kruskal-Wallis and Dunns multiple comparison tests were used in the statistical analyses. The germ cell apoptotic index was increased in rats with varicoceles when compared with the sham and control groups (P=0.0031). The Johnsen score was significantly decreased in the varicocele group when compared with the sham and control groups (P<0.0001). Immunohistochemical and Western blotting analyses showed that after varicocele induction, the expression of TRAIL-R1 and TRAIL-R4 in germ cells was increased and the expression of TRAIL-R2 was decreased. There are no significant differences among the groups in terms of TRAIL and TRAIL-R3 receptor expression. The results of this study indicate that TRAIL and its receptors may have a potential role in the pathogenesis of varicocele-induced testicular dysfunction.

Endoscopic Vesicoureteral Reflux Correction in Transplanted Kidneys: Does Injection Technique Matter?

AIM AND BACKGROUND Posttransplant vesicoureteral reflux (VUR) is a common urologic complication after renal transplantation, although its management is controversial. The treatment of choice is open surgical revision ureteral reimplantation with significant morbidity. Recently, endoscopic correction by using nonanimal dextranomer/hyaluronic acid copolymer (NA Dx/HA) injection has been reported to be effective in the treatment of VUR of transplanted kidneys. Herein, we present our 3-year endoscopic correction results in transplanted kidneys where we used two different injection techniques, subureteral and intraureteral. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent endoscopic VUR correction of posttransplant VUR by NA Dx/HA injection between July 2005 and March 2009. We excluded patients with underlying urologic abnormalities. RESULTS A total of 26 patients (14 women and 12 men) with a mean age of 32.2 years (range: 15–55) were studied. The VUR was also graded as nondilating reflux in 10 (grade I–II) and dilating reflux in 16 (grade III–IV). Seventeen ureters (5 nondilating and 12 dilating VUR) were injected NA Dx/HA intraureterally, and 9 ureters (5 nondilating and 4 dilating VUR) were injected NA Dx/HA subureterally. Overall success rate was 53.8% (14 out of 26). Intraureteral injection technique was successful in nine cases (52.9%), and subureteral injection technique was successful in five cases (55.5%). In nondilating VUR, injection corrected 90% (9 out of 10) of posttransplant patients, whereas in dilating VUR group injection corrected only 31.25% (5 out of 16). We found no statistical significance of injection technique on the success rate. CONCLUSIONS Endoscopic correction by using NA Dx/HA with any injection technique seems to be a plausible alternative to correction of refluxing posttransplant ureters, particularly in nondilating VUR.

An up-to-date overview of minimally invasive treatment methods in ureteropelvic junction obstruction.

Introduction Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction have been developed and are bcoming more popular. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, for both the transperitoneal and retroperitoneal approaches. In this review, we aimed to analyze the current status of minimally invasive therapy of ureteropelvic junction obstruction. Material and methods A PubMed database search was conducted to examine minimally invasive treatments of ureteropelvic junction obstruction. Results A large number of cases have been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric populations. A clear advantage, in terms of hospital stay, of minimally invasive over open pyeloplasty was observed only in the adult population. Conclusions Studies have shown that minimally invasive pyeloplasty techniques are a safe, effective, and feasible in adult and pediatric populations.

Results of Intravesical Chemo-Hyperthermia in High-risk Non-muscle Invasive Bladder Cancer

PURPOSE To examine the effectiveness of mitomycin-C and chemo-hyperthermia in combination for patients with high-risk non-muscle-invasive bladder cancer. MATERIALS AND METHODS Between November 2011-September 2013, 43 patients with high-risk non-muscle-invasive bladder cancer undergoing adjuvant chemo-hyperthermia in two centers were evaluated retrospectively. Treatment consisted of 6 weekly sessions, followed by 6 sessions. Recurrence and progression rate, recurrence-free interval and side effects were examined. Analyzed factors included age, gender, smoking status, AB0 blood group, body mass index, T stage and grade, concominant CIS assets. The associations between predictors and recurrence were assessed using multivariate Cox proportional hazard analyses. RESULTS A total of 40 patients completed induction therapy. Thirteen (32.5%) were diagnosed with tumor recurrence. Median follow-up was 30 months (range 9-39). Median recurrence-free survival was 23 months (range 6-36). The Kaplan-Meier-estimated recurrence-free rates for the entire group at 12 and 24 months were 82% and 61%. There was no statistically significant difference between patient subgroups. Cox hazard analyses showed that an A blood type (OR=6.23, p=0.031) was an independent predictor of recurrence- free. Adverse effects were seen in 53% of patients and these were frequently grades 1 and 2. CONCLUSIONS Intravesical therapy with combination of mitomycin-C and chemohyperthermia seems to be appropriate in high-risk patients with non-muscle-invasive bladder cancer who cannot tolerate or have contraindications for standard BCG therapy.

Initial Pre-Scrotal Approach for Palpable Cryptorchid Testis: Results During a 3-Year Period

PURPOSE Pre-scrotal orchiopexy is emerging as an alternative approach for cryptorchid testes that can be preoperatively mobilized into the scrotum. We present our 3-year pre-scrotal orchiopexy series for all palpable cryptorchid testes regardless of their mobility into the scrotum preoperatively. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent pre-scrotal orchiopexy during a 3-year period. Data collected included preoperative and postoperative testicular position, mobility of the testis into the scrotum preoperatively or with the patient under general anesthesia, patency of processus vaginalis, operative times and complications. RESULTS A total of 88 cryptorchid testes were treated using single pre-scrotal incision orchiopexy. Mean patient age was 4.9 years. Of the testes 74 (84.1%) could be milked down to the scrotum preoperatively and 14 (15.9%) could not. Of the 14 immobile testes 8 were intracanalicular and 6 were in the superficial inguinal pouch. Pre-scrotal orchiopexy was successful in all 74 testes that were mobilized into the scrotum preoperatively. However, 6 of 14 testes (43%) that could not be moved to the scrotum were effectively managed by a single pre-scrotal incision, while 8 (57%) required an additional groin incision for successful orchiopexy. No complications were observed during a mean followup of 7.1 months. CONCLUSIONS Orchiopexy using a pre-scrotal approach is a viable alternative for palpable cryptorchid testes that can be preoperatively mobilized into the scrotum. Cryptorchid testes that are palpable but cannot be moved to the scrotum can be managed by the pre-scrotal approach alone in 40% of cases or with an additional groin incision in 60%.

The relationship between serum hormone levels (follicle-stimulating hormone, luteinizing hormone, total testosterone) and semen parameters.

OBJECTIVE The aim of this study was to investigate the effect of serum gonadotropin and total testosterone levels on semen parameters. MATERIALS AND METHODS Three hundred and eighty-two patients that applied to a male infertility polyclinic were included in our study. Serum gonadotropin and total testosterone levels and semen parameters of the patients were analyzed during the first visit to the clinic. The reference FSH value was 1.5-12.4 mIU/mL, that of LH was 1.7-8.6 mIU/mL and the reference value for total testosterone was 249-836 ng/dL. RESULTS While there was no statistically significant difference between the patients with low gonadotropin levels and the controls regarding any of the semen parameters (p > 0.05), there was a strong statistically significant difference between the patients with high gonadotropin levels and the controls regarding sperm concentration (p = 0.000), total motility (p = 0.000), progressive motility (p = 0.000), and morphology (p = 0.000). There was a strong statistically significant difference between the patients with low testosterone levels and the controls regarding total motility (p = 0.012) and progressive motility (p = 0.010), and a weak statistically significant difference in morphology (p = 0.042). There was no statistically significant difference in semen volume or sperm concentration (p > 0.05). There was no statistically significant difference in any of the semen parameters between the patients with high testosterone levels and the controls (p > 0.05). CONCLUSIONS Our findings especially regarding LH and T levels are not in agreement with previous reports. In this regard, there is a need for larger-scale and randomized trials to resolve this discrepancy.

Recent management of urinary stone disease in a pediatric population

The incidence of stone disease has been increasing and the risk of recurrent stone formation is high in a pediatric population. It is crucial to use the most effective method with the primary goal of complete stone removal to prevent recurrence from residual fragments. While extracorporeal shock wave lithotripsy (ESWL) is still considered first line therapy in many clinics for urinary tract stones in children, endoscopic techniques are widely preferred due to miniaturization of instruments and evolution of surgical techniques. The standard procedures to treat urinary stone disease in children are the same as those used in an adult population. These include ESWL, ureterorenoscopy, percutaneous nephrolithotomy (standard PCNL or mini-perc), laparoscopic and open surgery. ESWL is currently the procedure of choice for treating most upper urinary tract calculi in a pediatric population. In recent years, endourological management of pediatric urinary stone disease is preferred in many centers with increasing experience in endourological techniques and decreasing sizes of surgical equipment. The management of pediatric stone disease has evolved with improvements in the technique and a decrease in the size of surgical instruments. Recently, endoscopic methods have been safely and effectively used in children with minor complications. In this review, we aim to summarize the recent management of urolithiasis in children.

Predictive Effect of Preoperative Anemia on Long-Term Survival Outcomes with Non-Muscle Invasive Bladder Cancer.

BACKGROUND Anemia is the most common hematologic abnormality in bladder cancer (BC) patients. We evaluated the impact of preoperative anemia on oncologic outcomes in BC undergoing transurethral resection of a bladder tumor (TURBT) for the first time diagnosis. MATERIALS AND METHODS We retrospectively evaluated the data collected from 639 patients who underwent TURBT between January 2006 and September 2014 in our department. Of these patients, 320 qualified for inclusion in the study. The primary efficacy endpoint was the effect of preoperative anemia status on cancer-specific and overall survival. Independent t-test and chi-square analyses were performed to assess the effects of anemia on oncologic outcomes. Survival was estimated by using the Kaplan-Meier test. RESULTS There were 118 (36.9%) and 202 (63.1%) patients in the anemia (Group-1) and non-anemia groups (Group-2), respectively. The median follow-up duration was 68 months. Anemia was associated with decreased overall survival (<0.001). Comparison between cancer-specific survival of two groups did not show any statistically significant difference (p=0.17). CONCLUSIONS Preoperative anemia status of BC patients according to World Health Organization classification is associated with decreased overall survival, but not with cancer-specific survival. We think that preoperative hemoglobin levels should be considered in patient counseling and decision-making for additional therapy.

Diagnosis and treatment in primary bladder small cell carcinoma: Literature review.

Small cell bladder carcinoma is a rare and frequently fatal disease. It can be distinguished from classical urothelial carcinoma microscopically and immunohistochemically. Small cell bladder carcinoma has histologically similar properties with other small cell carcinomas in other organs. It has a worse prognosis when compared to urothelial bladder cancer. Multimodal treatments are recommended although there is no widely accepted consensus regarding to the treatment algorithm because of its rarity. In this review, clinical properties and diagnosis of small cell bladder carcinoma, its histopathological and immunohistochemical properties and treatment modalities are examined.