Tarkan Soygür

Effect of Potassium Citrate Therapy on Stone Recurrence and Residual Fragments after Shockwave Lithotripsy in Lower Caliceal Calcium Oxalate Urolithiasis: A Randomized Controlled Trial

BACKGROUND AND PURPOSE To evaluate the efficacy of potassium citrate treatment in preventing stone recurrences and residual fragments after shockwave lithotripsy (SWL) for lower pole calcium oxalate urolithiasis. PATIENTS AND METHODS One hundred ten patients who underwent SWL because of lower caliceal stones and who were stone free or who had residual stone 4 weeks later were enrolled in the study. The average patient age was 41.7 years. All patients had documented simple calcium oxalate lithiasis without urinary tract infection and with normal renal morphology and function. Four weeks after SWL, patients who were stone free (N = 56) and patients who had residual stones (N = 34) were independently randomized into two subgroups that were matched for sex, age, and urinary values of citrate, calcium, and uric acid. One group was given oral potassium citrate 60 mEq per day, and the other group served as controls. RESULTS In patients who were stone free after SWL and receiving medical treatment, the stone recurrence rate at 12 months was 0 whereas untreated patients showed a 28.5% stone recurrence rate (P < 0.05). Similarly, in the residual fragment group, the medically treated patients had a significantly greater remission rate than the untreated patients (44.5 v 12.5%; P < 0.05). CONCLUSION Potassium citrate therapy significantly alleviated calcium oxalate stone activity after SWL for lower pole stones in patients who were stone free. An important observation was the beneficial effect of medical treatment on stone activity after SWL among patients with residual calculi.

Factors Affecting Complication Rates of Ureteroscopic Lithotripsy in Children: Results of Multi-Institutional Retrospective Analysis by Pediatric Stone Disease Study Group of Turkish Pediatric Urology Society

PURPOSE We evaluated factors affecting complication rates of ureteroscopy for pediatric ureteral calculi. MATERIALS AND METHODS We retrospectively evaluated 642 children who underwent ureteroscopy at 16 Turkish centers between 2000 and 2010. Semirigid ureteroscopy was used with various calibers to treat 670 ureteral units in 660 sessions. Complications were evaluated according to the Satava and Clavien classification systems. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. RESULTS A total of 367 females and 265 males were studied. Mean±SD patient age was 90.2±51.4 months (range 4 to 204). Mean±SD stone size, operative time and postoperative hospital stay were 8.9±4.7 mm, 45.8±23.8 minutes and 1.8±2.8 days, respectively. At a mean±SD followup of 13.3±17.6 months 92.8% of patients were stone-free and efficacy quotient was 90.3%. Complications, which occurred in 8.4% of patients (54 of 642), were intraoperative in 25 (Satava grade I to II in 22), early postoperative in 25 (Clavien grade I to II in 23) and late postoperative in 4 (all grade III). While operative time, age, institutional experience, orifice dilation, stenting and stone burden were statistically significant on univariate analysis, multivariate analysis revealed that operative time was the only statistically significant parameter affecting the complication rate. CONCLUSIONS Semirigid ureteroscopy is effective, with a 90% stone-free rate and efficacy quotient. Most complications are low grade and self-limiting. Our results confirm that prolonged operative time is an independent predictor of complications, and should be considered when choosing and performing the treatment modality.

Nephrostomy Tract Dilation Using a Balloon Dilator in Percutaneous Renal Surgery: Experience with 95 Cases and Comparison with the Fascial Dilator System

Introduction: Nephrostomy tract dilation is one of the important steps of percutaneous renal surgery. In this study, we present our initial experience with the balloon dilator in 95 patients and compare our results retrospectively with a group of 30 patients in whom Amplatz dilators were used. Patients and Methods: The medical records of 95 patients who underwent percutaneous renal operations, including percutaneous nephrolithotomy and antegrade endopyelotomy, between September 1999 and September 2002 were reviewed. All procedures were performed using balloon dilators. The operative technique is the same as the other dilation procedures. Thirty consecutive patients who had previously undergone percutaneous renal surgery using the Amplatz dilators were taken as the control group and their charts were reviewed retrospectively, and the results compared with the results of patients in whom balloon dilation was used. Results: There were no major perioperative complications or deaths in both groups. The mean operative time and tract formation times for the balloon dilation group and the Amplatz dilation group were 106.8 ± 41.4 and 11.2 ± 3.0, and 116.4 ± 23.7 and 16.3 ± 2.4 min, respectively. Thirteen (13.7%) patients had significant bleeding and required blood transfusion in the balloon dilation group, whereas 5 (16.6%) patients had significant bleeding in the Amplatz dilation group. Collecting system perforation due to too far advancement of the dilator occurred in 11 (11.6%) patients but there was no major parenchymal or vascular injury medially in the balloon dilation group. On the other hand, collecting system perforation occurred during sequential Amplatz dilation in 5 (16.6%) patients. Conclusion: We believe that the balloon system allows one-step dilation and shortens the dilation procedure. It may minimize bleeding which can occur during the stepwise fascial dilation. When using fascial dilators it is sometimes possible to go out of the collecting system by changing the size of the dilators. We think that balloon dilation may prevent these intraoperative and time-consuming situations.

Failure of ureteral replacement with gore-tex tube grafts

OBJECTIVES To evaluate the role of polytetrafluoroethylene (Gore-Tex) as a ureteral substitute in dogs after resection of a 5 to 8-cm-long middle segment. METHODS Five mongrel dogs underwent resection of the middle segment of the left ureter and segmental replacement of the resected part with segments of Gore-Tex over a double-J catheter. The double-J stents were removed at 21 days and the dogs were evaluated by excretory urography and abdominal ultrasonography 12 weeks after surgery. They were then killed and the ureters and the kidneys examined both grossly and microscopically. RESULTS There was radiologic evidence of advanced hydronephrosis on the left side in all 5 dogs. Grossly, the left kidneys showed marked pelvic and proximal ureteral dilatation and atrophy of parenchyma. Severe stricture at the anastomotic sites and marked fibrous tissue around the prostheses were found. No cellular lining was found in the Gore-Tex lumen. CONCLUSIONS There is no potential for ureteral replacement by Gore-Tex tube graft.

Effectiveness of Doxazosin in Treatment of Distal Ureteral Stones in Children

PURPOSE We evaluated the effectiveness of doxazosin in children with distal ureteral stones in terms of stone expulsion rates and time to expulsion. MATERIALS AND METHODS A total of 39 patients 2 to 14 years old with lower ureteral stones smaller than 10 mm were enrolled and randomly divided into 2 groups. Group 1 consisted of 20 controls receiving ibuprofen for pain and group 2 consisted of 19 patients receiving doxazosin. Doxazosin dose was approximately 0.03 mg/kg daily. All patients were evaluated with x-ray, ultrasound or spiral computerized tomography. Stone expulsion rates and time to expulsion between the groups were compared. Mean followup was 19 days. Effects of doxazosin were also evaluated by comparing subgroups with stones smaller than 5 mm and 5 to 10 mm. Results were also evaluated with special emphasis on gender and age. RESULTS Expulsion was observed in 14 patients (70%) in group 1 and 16 (84%) in group 2 (p >0.05). Mean expulsion times for groups 1 and 2 were 6.1 and 5.9 days, respectively (p >0.05). Although fewer pain episodes were observed in the treatment group, this finding could not be evaluated objectively. None of the patients experienced any adverse effects. CONCLUSIONS Administration of 0.03 mg/kg doxazosin daily in children to treat distal ureteral stones up to 10 mm is not superior to analgesic alone. This result is not affected by gender, stone size or patient age. However, additional randomized controlled studies, especially including larger stone volumes, and different doses of doxazosin and other alpha-blockers, might highlight the usefulness of alpha-blockers for ureteral stones in children.

Effect of obesity on prostatic hyperplasia: Its relation to sex steroid levels

In 68 men with benign prostatic hyperplasia, we evaluated the association between obesity and prostatic enlargement, as well as changes in serum levels of oestradiol, testosterone, dihydroepiandrosterone and dihydroepiandrosterone sulphate. Despite the larger adenomas, no increase in the symptom score for BPH was observed with increasing obesity. Average specimen weights increased with increasing obesity and increasing host age from 46 to 80 g. We also found the serum oestradiol level significantly elevated in obese men who were 140% or over recommended weight compared to underweight men younger than 60 years (51.3 pg/ml versus 26.8 pg/ml, p<0.01). This pattern was present in all age groups.These results indicate that obesity is a risk factor for prostatic enlargement but not for obstruction. Also the degree of obesity appears to have a direct effect on oestradiol levels through transformation of androgens in adipose tissue to oestrogens. In conclusion, further studies to evaluate the pathogenesis, pathophysiology, natural history and symptomatology of BPH would be of great interest and should help to define better the associations that we have recognized.

Urological Complications in Renal Transplantation: Long-Term Follow-Up of the Woodruff Ureteroneocystostomy Procedure in 433 Patients

Purpose: The two major types of urologic problems after renal transplantation are urinary leakage and obstruction. In this study, we report the urological complications of renal transplantations performed in our hospital during a 22-year period. Patients and Methods: Between 1978 and 2000, 433 consecutive patients underwent renal transplantation. Of those transplants, 50 were cadavers and 383 were living-related donor transplantation. All ureteroneocystostomies were performed with the same technique described by Woodruff. Results: Urological complications developed in 19 (4.23%) recipients. Those complications were urinary leakage in 9 (2%), ureteral obstruction in 9 (2%) and ureteral necrosis in 1 patient (0.23%). All complications occurred during the 6-month postoperative period and after re-operation or conservative management no graft or patient was lost due to urological complications. Conclusion: The quoted overall rate of urological complications varies from 2.9 to 12.5%; our complication rate was 4.23%. This relatively low rate is probably due to the Woodruff ureteroneocystostomy technique.

Relationship among pediatric voiding dysfunction and vesicoureteral reflux and renal scars

OBJECTIVES To analyze the relationship among non-neurogenic voiding dysfunction, vesicoureteral reflux (VUR), and renal scarring, taking into consideration whether the reflux was unilateral or bilateral. VUR is a common problem in the pediatric age group. Although unilateral reflux is usually due to primary insufficiency of the vesicoureteral junction, bilateral reflux can also be the result of underlying voiding dysfunction. METHODS Between 1993 and 1998, 80 children, 52 girls and 28 boys, median age 5.7 years (range 3.8 to 14), were evaluated because of VUR. Eighteen patients who presented with associated anomalies and obvious neuropathic bladder dysfunction were excluded from the study. Complete urologic, neurologic, and urodynamic investigations were performed in all patients. RESULTS Of 62 patients, 25 (40.3%) had unilateral and 37 (59.6%) had bilateral reflux. Voiding dysfunction was found in 7 patients (28%) with unilateral reflux and in 27 patients (72.9%) with bilateral reflux (P <0.01 ). Two (25%) of the 8 patients with unilateral reflux and renal scarring had voiding dysfunction but no demonstrable urinary tract infection, and 10 (55.5%) of the 18 patients with bilateral reflux and renal scarring had voiding dysfunction and no demonstrable urinary tract infection (P <0.01). CONCLUSIONS If VUR is bilateral, the prevalence of existing underlying voiding dysfunction seems to be higher. The first step in management should be a detailed evaluation of bladder function to choose an appropriate treatment modality and to prevent renal deterioration.

A Prospective Randomized Study of Transurethral Resection of the Prostate and Transurethral Vaporization of the Prostate as a Therapeutic Alternative in the Management of Men with BPH

Objective: The common goals of new surgical treatment for benign prostatic hyperplasia (BPH) are to improve subjective and objective symptoms, to decrease the risk of postoperative complications and short hospitalization. Transurethral electrovaporization of the prostate (TUVP) is a new, minimally invasive and a promising alternative to standard transurethral resection of the prostate (TURP) in the treatment of BPH. The aim of this study is to compare the efficacy and safety of these two treatment alternatives. Methods: A prospective randomized trial of 60 patients with symptomatic BPH was performed. Preoperative and postoperative International Prostate Symptom Score (IPSS), maximum flow rates (Qmax) and complications were recorded in each patient. The volume of the prostate was measured preoperatively and postoperatively using transrectal ultrasound. Results: Of the 30 patients who underwent TURP, mean hospital stay was 4.5 days. The Foley catheter was removed on postoperative day 4 following surgery. IPSS decreased from 21.6 to 5.2, Qmax increased from 9.2 to 19.2 ml/s at 3 months. Mean prostatic volume at 3 months decreased from 51.7 to 26.2 g, a 49.3% reduction. Of 30 patients undergoing TUVP, mean hospital stay was 2.5 days and the catheter was removed within 2 days following surgery. Postoperative urinary retention did not occur in any patient. IPSS decreased from 19.4 to 4.1 and Qmax increased from 7.9 to 17.7 ml/s at 3 months. Mean prostatic volume decreased from 48.9 to 27.8 g, a 43.1% reduction at 3 months. In the TUVP group, none of the patients required blood transfusions or developed clinical transurethral resection syndrome. There were no major complications. Sphincteric incontinence, urethral strictures or bladder neck contractures were not recorded. At 3 months postoperatively, 13 patients in the TURP group and 7 patients in the TUVP group had retrograde ejaculation. Conclusion: Our initial experience of TUVP suggests advantages over conventional TURP through reduced blood loss and shorter hospital stay. It appears to be an effective treatment for BPH; however, long-term results should be evaluated.

LRIG2 Mutations Cause Urofacial Syndrome

Urofacial syndrome (UFS) (or Ochoa syndrome) is an autosomal-recessive disease characterized by congenital urinary bladder dysfunction, associated with a significant risk of kidney failure, and an abnormal facial expression upon smiling, laughing, and crying. We report that a subset of UFS-affected individuals have biallelic mutations in LRIG2, encoding leucine-rich repeats and immunoglobulin-like domains 2, a protein implicated in neural cell signaling and tumorigenesis. Importantly, we have demonstrated that rare variants in LRIG2 might be relevant to nonsyndromic bladder disease. We have previously shown that UFS is also caused by mutations in HPSE2, encoding heparanase-2. LRIG2 and heparanase-2 were immunodetected in nerve fascicles growing between muscle bundles within the human fetal bladder, directly implicating both molecules in neural development in the lower urinary tract.