Tolga Akman

Graft Materials in Peyronie's Disease Surgery: A Comprehensive Review

OBJECTIVE To discuss the currently used graft materials in Peyronies surgery. METHODS A MEDLINE search was conducted till the end of September 2006 on the surgical treatment of Peyronies disease, and all aspects of the graft materials used for Peyronies surgery were examined. RESULTS Currently available interposing graft materials may be classified in three categories: autologous tissues, extracellular matrix (ECM) tissues, and synthetic materials. Each grafting material in these categories has its own advantages and drawbacks in terms of tissue properties, antigenicity, availability, and cost-effectiveness. Saphenous vein grafts are the most widely used among autologous grafts, with acceptable functional outcomes in the long term. Other graft materials include tunica vaginalis, fascia lata, rectus fascia, and buccal mucosa, with variable results. Despite numerous advantages in terms of tissue compatibility, the major drawback of autologous grafts is tissue harvesting that to morbidities and longer operative durations. For this reason, the use of readily available ECM tissues as the products of tissue engineering is recommended by some authors. Among ECM grafts, cadaveric and bovine pericardia have satisfactory mid-term outcomes. However, longer follow-ups with an adequate number of patients are lacking. On the other hand, recent evidence suggests that small intestinal submucosa may be associated with high rate of operative failure and complications. Generally, synthetic materials are no longer used in grafting procedures in Peyronies surgery because of their antigenicity and inappropriate functional properties. For prosthesis surgery, pericardia as well as autologous rectus fascia grafts are probably the most suitable graft materials because of their suitable tissue characteristics that satisfy the mechanical demands of the prosthesis. CONCLUSION Saphenous vein grafting from autologous tissues and pericardium from ECM tissues have satisfactory results. However, further research and clinical studies are needed in order to determine the optimal graft material.

Comparison of percutaneous nephrolithotomy and retrograde flexible nephrolithotripsy for the management of 2–4 cm stones: a matched‐pair analysis

Study Type – Therapy (case control)

Factors Affecting Bleeding During Percutaneous Nephrolithotomy: Single Surgeon Experience

PURPOSE To investigate variables that affect bleeding during percutaneous nephrolithotomy (PCNL), focusing on the experience of a single surgeon. PATIENTS AND METHODS The records of 649 PCNL procedures that were performed by the same surgeon were reviewed retrospectively. The effect of surgical experience; patient and stone-related factors, including age, sex, hypertension, and diabetes, serum creatinine level, history of ipsilateral renal procedures, stone surface area and type, degree of hydronephrosis, preoperative hemoglobin level; operative factors, such as the calix of puncture, number of accesses, operative time; and intraoperative complications, such as pelvicaliceal system perforation on bleeding (described as decrease in hemoglobin level and need for blood transfusion), were investigated. For statistical assessment, univariate analyses and multivariate stepwise regression analyses were used. RESULTS A 92.3% success rate was achieved after one session PCNL. The overall blood transfusion rate was 10.8%. The number of accesses, stone type, diabetes, preoperative hemoglobin level, and operative time were the most important factors for blood transfusion requirement. In the receiver operating characteristic curve, the best cutoff point of operative time was 58 minutes for the blood transfusion requirement. Multivariate stepwise regression analyses showed that there was an association between diabetes, operative time, number of accesses, and stone type with the decrease in hemoglobin levels. No correlation between surgical experience and decrease in hemoglobin level as well as blood transfusion necessity was found. CONCLUSIONS Depending on the results achieved by a single surgeon, multiple access tracts, staghorn calculi, presence of diabetes, and prolonged operative time, but not surgical experience, significantly increased blood loss during PCNL.

A prospective, randomized trial of management for asymptomatic lower pole calculi.

PURPOSE We determined the natural course and compared the deleterious effects in kidneys of shock wave lithotripsy, percutaneous nephrolithotomy and observation for asymptomatic lower caliceal stones. MATERIALS AND METHODS Between April 2007 and August 2008 patients with asymptomatic lower caliceal calculi were enrolled in the study. To assess stone status noncontrast abdominal helical computerized tomography was done 3 and 12 months after intervention. All patients were evaluated by dimercapto-succinic acid renal scintigraphy 6 weeks and 12 months after intervention. RESULTS A total of 94 patients were prospectively randomized to percutaneous nephrolithotomy (31), shock wave lithotripsy (31) and observation (32). Mean +/- SD followup was 19.3 +/- 5 months (range 12 to 29). In the percutaneous nephrolithotomy group all patients were stone-free at month 12. Scintigraphy revealed a scar in 1 patient (3.2%) on month 3 followup imaging. In the shock wave lithotripsy group the stone-free rate was 54.8%. Scintigraphy revealed scarring in 5 patients (16.1%). In the observation group 7 patients (18.7%) required intervention during followup. Median time to intervention was 22.5 +/- 3.7 months (range 18 to 26). One patient (3.1%) had spontaneous stone passage. Scintigraphy did not reveal scarring in any patient. CONCLUSIONS Stone related events were noted in more than 20% of patients with asymptomatic lower caliceal stones observed expectantly. To manage lower caliceal stones percutaneous nephrolithotomy has a significantly higher stone-free rate with less renal scarring than shock wave lithotripsy. Thus, patients with asymptomatic lower caliceal stones must be informed in detail about all management options, especially focusing on percutaneous nephrolithotomy with its outstanding outcome.

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 There a Difference in Outcomes Between Digital and Fiberoptic Flexible Ureterorenoscopy Procedures

PURPOSE We aimed to compare the outcomes of patients who were treated using digital and fiberoptic flexible ureterorenoscopy (urs) for kidney stones. PATIENTS AND METHODS Between September 2008 and December 2009, a total of 76 patients who were treated with either a conventional fiberoptic flexible ureterorenoscope (FFU) (n = 34) or digital flexible ureterorenoscope (DFU) (n = 42) were compared. All procedures were performed by the same surgeon. Preoperative, operative, and postoperative data were retrospectively analyzed. RESULTS The mean stone size was 95.2 ± 61.3 mm(2) in the FFU group while it was 93.5 ± 57.1 mm(2) in DFU group (P > 0.05). The initial assessment of the entire pyelocaliceal system was possible in 33 of 34 (97%) cases in the FFU group and in 38 of 42 cases (90.4%) in the DFU group (P > 0.05). The mean operative time was significantly longer in the FFU group (54.4 ± 14.8 minutes vs 44.8 ± 17.9 minutes, P = 0.001). Flexible URS time was 46.5 ± 13.4 minutes in the FFU group while it was 38.3 ± 17.4 minutes in the DFU group (P = 0.001). Mean fragmented stone size per minute was 2.43 ± 0.81 mm(2)/min in the DFU group and 1.96 ± 0.80 mm(2)/min in the FFU group; this was statistically significant (P = 0.01). The overall stone-free rate 1 month after the procedure was 88.2% in the FFU group and 85.7% in the DFU group (P > 0.05). The average number of uses for FFU and DFU before repair necessity was 17 and 21, respectively. CONCLUSION Although the DFU have more limited maneuverability, comparable success rates can be achieved with both conventional and digital instruments. On the other hand, the DFU significantly reduced the operative time compared with the conventional one.

Comparison of Outcomes After Percutaneous Nephrolithotomy of Staghorn Calculi in Those with Single and Multiple Accesses

PURPOSE To analyze the early outcome after single tract vs multiple tracts percutaneous nephrolithotomy (PCNL) in the management of staghorn calculi. PATIENTS AND METHODS The records of 413 patients with staghorn calculi (223 [54%] had complete and 190 [46%] had partial) who underwent PCNL were reviewed retrospectively. A total of 244 (59%) patients were managed by single access (group 1); meanwhile, multiple accesses were necessary in 169 (41%) patients (group 2). Both groups were compared in terms of perioperative findings and postoperative outcomes. Patients and stone-related factors affecting the number of accesses performed were analyzed. RESULTS The mean number of percutaneous accesses was 2.42 +/- 0.74 (range 2-6) in group 2. Mean durations of fluoroscopy screening time and operative time were significantly longer in group 2 (P = 0.002, P < 0.0001, respectively). Supracostal access was necessary in 30.7% in group 2 and in 6.9% in group 1 (P = 0.001). Success was achieved in 70.1% in group 1 and in 81.1% for group 2 after one session of PCNL (P = 0.012). The most common complication was bleeding for both groups, and it was higher in group 2 (P < 0.0001). The mean preoperative and postoperative creatinine concentrations were 1.03 mg/dL and 1.08 mg/dL in group 1, and 0.9 mg/dL and 1.03 mg/dL in group 2, respectively. The mean changes in creatinine values were not statistically significant between the groups (P = 0.16). CONCLUSIONS The impact of PCNL using either single or multiple access tracts on renal function is similar and of a temporary nature. PCNL with multiple accesses is a highly successful alternative with considerable complication rates in the management of staghorn calculi.

Tubeless Procedure is Most Important Factor in Reducing Length of Hospitalization After Percutaneous Nephrolithotomy: Results of Univariable and Multivariable Models

OBJECTIVES To evaluate the effects of kidney stones and patient-related parameters on the length of hospitalization (LOH), which is one important factor affecting the cost effectiveness of percutaneous nephrolithotomy (PCNL). Recently, increases in healthcare costs have highlighted the importance of evaluating the cost effectiveness of a treatment as much as its efficacy. MATERIAL AND METHOD During an 8-year period, the records of 1669 patients with renal calculi who underwent PCNL were reviewed retrospectively. Eleven patients with urosepsis were excluded from the present study. A total of 1658 patients were categorized into 2 groups (group 1 = ≤2 days; group 2 = >2 days) according to the median LOH (median = 2 days). Multivariate binary logistic regression analysis was used to detect the effects of independent variables, including the patient age, gender, body mass index, history of extracorporeal shock wave lithotripsy or open surgery, stone size and opacity, presence of hydronephrosis, and localization and number of accesses, on the LOH after PNL. RESULTS Overall success was achieved in 86.2% of cases after one session of PCNL. The mean length of hospitalization was 2.89 ± 1.66 days (range, 1-21). According to the outcome of the multivariate analysis, diabetes (P = .0001, OR = 1.67), impaired kidney function (P = .03, OR = 1.64), stone size (P = .031, OR = 1.31), number of accesses (P = .001, OR = 1.59), intercostal access (P = .001, OR = 1.79), and tubeless procedure (P = .0001, OR = 0.23) were variables influencing LOH. CONCLUSIONS The presence of diabetes, a large stone burden, intercostals access, multiple accesses, and impaired kidney function prolong the LOH after PCNL. The use of the tubeless procedure was able to diminish the LOH.

Effects of bipolar and monopolar transurethral resection of the prostate on urinary and erectile function: a prospective randomized comparative study.

Standard monopolar transurethral resection of prostate (TURP) remains the gold standard surgical treatment of benign prostatic hyperplasia‐related lower urinary tract symptoms. Bipolar salin TURP offers rapid tissue removal and haemostasis during resection with better vision under saline irrigation while eliminating risk of TUR syndrome. Few prospective randomized studies have investigated the effect of bipolar and monopolar TURP on erectile function. The study found that bipolar saline TURP is a safe and effective procedure that is associated with a significantly shorter operating time, a smaller reduction in serum sodium levels and similar efficacy compared with conventional monopolar TURP.

Outcomes of percutaneous nephrolithotomy in patients with solitary kidneys: a single-center experience.

OBJECTIVES To evaluate the outcomes, complications, and early and late postoperative kidney function of percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys. METHODS Between 2002 and 2009, 47 patients with a solitary kidney (congenital in 10 patients, 21.3%; contralateral nephrectomy in 22 patients, 46.8%; and nonfunctional kidney in 15 patients, 31.9%) underwent PCNL. Serum creatinine was measured preoperatively, on postoperative day 1, and at each follow-up visit at regular intervals. The 4-variable modification of diet in renal disease equation was used to calculate the estimated glomerular filtration rate (eGFR). The 5-stage classification of chronic kidney disease (CKD) was used according to the National Kidney Foundation published guidelines. Of 47 patients, 44 were followed least 6 months, whereas 3 patients were lost to follow-up. RESULTS Success was achieved in 84.5% (40/47) of patients after 1 session of PCNL. Complex stones were detected in 32 (68.1%) patients. Among all patients, 23.4% (n = 11) of them required multiple accesses. Complications developed in 5 (10.6%) patients. At a mean follow-up time of 18.7 ± 11.8 (6-60) months, the overall success rate improved to 97.7% after auxiliary treatments. eGFR was 76.4 ± 27.1, 73.4 ± 26.1, and 83.5 ± 29.4 per 1.73 m(2) during preoperative period, immediate postoperative period, and at the last follow-up visit (>6 months), respectively (P < .001). According to CKD classification, kidney function was stable, improved and worse in 63.6% (n = 28), 29.5% (n = 13), and 6.8% (n = 3) of patients, respectively, compared with preoperative levels. CONCLUSIONS PCNL is safe and has an acceptably low complication rate in patients with solitary kidneys. At long-term follow-up, renal function had stabilized or improved in more than 90% of patients with a solitary kidney after PCNL.