Ural Oguz

The Impact of Pelvicaliceal Anatomy on the Success of Retrograde Intrarenal Surgery in Patients With Lower Pole Renal Stones

OBJECTIVES To evaluate the impact of pelvicaliceal anatomy on the success of retrograde intrarenal surgery (RIRS) for lower pole renal stones and determine which of these factors can be used to select patients who will benefit from RIRS. METHODS We evaluated 67 patients who underwent RIRS between 2009 and 2010 for isolated lower pole renal stones. The infundibular length (IL), infundibular width (IW), pelvicaliceal height (PCH), and infundibulopelvic angle (IPA) were measured by preoperative intravenous urogram. Success was defined as either complete clearance or clearance with insignificant residual fragments≤3 mm in size at 2-months follow-up. RESULTS Mean IL was 26.7±7.9 and 28.2±5.3 mm, mean PCH was 20.7±6.6 and 23.2±4.9 mm in stone-free and non-stone-free patients, respectively. These were slightly larger in the non-stone-free group but not statistically significant (P=.140 and P=.072, respectively). Mean IW was 5.8±3.5 and 5.6±2.2 mm in stone-free and non-stone-free patients, respectively, which had no significant impact on the stone-free rate (P=.719). There were significant differences between the groups in terms of stone length (P=.001) and IPA (P=.003). The mean IPA was 49.37±11.83 and 37.61±13.22 mm in stone-free and non-stone-free patients, respectively. CONCLUSIONS In addition to the influence of stone size, lower pole anatomy, especially IPA, has a significant impact on stone clearance for lower pole stones after RIRS.

Categorizing Intraoperative Complications of Retrograde Intrarenal Surgery

Purpose: To review our intraoperative complications of retrograde intrarenal surgery (RIRS) for kidney calculi and stratify these complications according to the modified Satava classification system (SCS). Patients and Methods: 230 patients (119 males, 111 females) who underwent RIRS because of kidney calculi were analyzed. We documented and stratified the intraoperative complications according to the modified SCS. There are four grades for this classification: grade 1 complications include events without consequences for patients; grade 2a complications include events that could be treated with endoscopic surgery intraoperatively; grade 2b complications include events which were treated with endoscopic treatment in another session, and grade 3 describes the events requiring laparoscopic or open surgery. Results: Mean age was 39.1 years (range 1-78). The stone-free rate after one session was 81%. Intraoperative complications were recorded in 30.4% of the patients. According to the modified SCS, grade 1 complications were documented in 15.9%, grade 2a complications were documented in 5.6%, and grade 2b complications were documented in 8.9% of the patients. Grade 3 complications were not detected in any of the patients. Conclusion: In our opinion, the modified SCS can facilitate patients to understand the safety of this surgery and can make it easier to compare the results of different institutes and surgeons.

In vivo Porcine Model for Practicing Retrograde Intrarenal Surgery

Objectives: To examine the feasibility of retrograde intrarenal surgery (RIRS) in a porcine model. Materials and Methods: Female pigs (n = 3) were placed in a dorsal lithotomy position under general anesthesia, and stone material was inserted into the renal pelvis of the pigs. The bladder was entered with a cystoscope, and a 0.038-inch hydrophilic guidewire was passed into the renal pelvis. Following successful placement of the guidewire, a ureteral access sheath (9.5/11.5 Fr) was placed to allow for optimal visualization. A 7.5-Fr flexible ureteroscope (Karl Storz Flex-X2) and a 200-μm laser fiber were used for lithotripsy. When basketing was deemed necessary, zero-tipped nitinol stone baskets were used. Trainees then practiced all these manipulations on the model. Results: Urologists with moderate experience in advanced endourologic surgery were trained using this model. However, there were some surgical difficulties due to the urinary system anatomy of the pig. Intravaginal location of the urethra, bladder neck location of the ureters, tight ureteric orifices, tortuous ureters, longitudinally elongated renal pelvis, narrow infundibulopelvic angle and shallow calices made the passage of the instruments and maneuverability of the flexible ureteroscope more difficult than in a human model. Conclusions: Despite some difficulties, our porcine model was very effective, because all the trainees successfully practiced the RIRS manipulations on this model.

Retrograde Intrarenal Surgery in Patients with Spinal Deformities

PURPOSE To present our experience with retrograde intrarenal surgery (RIRS) for managing renal stones in patients with spinal deformities. PATIENTS AND METHODS We retrospectively reviewed the records of eight patients with congenital scoliosis (n=6), ankylosing spondylitis (n=1), or spina bifida (n=1) who had undergone RIRS for renal stones. Stone-free status was determined by CT 30 days after the procedure and was defined as the absence of stones in the kidney or residual fragments ≤ 1 mm. RESULTS Mean patient age was 32.5 years (8-51 years), and mean stone size was 15.8 mm (9-20 mm). The average operative time was 46.5 minutes (25-75 min), and postoperative hospital stay was 1.12 days (1-2 days). A stone-free status was obtained in six (75%) patients, and two patients were considered to have treatment failure. A Double-J stent was placed at the end of the procedure in five (62.5%) patients. Double- J stent discomfort was reported by one (20%) patient who was treated conservatively. No severe complications, either from anesthesia or the surgical procedure, were observed, and no blood transfusion was reported. CONCLUSIONS The good clearance rate with a low incidence of complications shown by the present study has demonstrated that RIRS is a safe and effective procedure for renal stones in patients with spinal deformities.

The Efficacy of Medical Prophylaxis in Children with Calcium Oxalate Urolithiasis After Percutaneous Nephrolithotomy

OBJECTIVE To evaluate whether medical prophylaxis decreases calcium oxalate stone recurrences in children after percutaneous nephrolithotomy (PNL) or not. To our knowledge this is the first study that evaluates this topic in children after PNL. PATIENTS AND METHODS We researched analysis of 42 children with calcium oxalate stone disease. They were divided into two groups. Twenty-two children who had a follow-up with medical prophylaxis after PNL were included in group I; 20 children who did not have medical prophylaxis were included in group II. They were all stone free and they were evaluated with 24-hour urine analysis and blood samples, abdominal X-ray, and ultrasonography. The average follow-up was 25.9 (12-42) months for group I and 24.6 (14-40) months for group II. RESULTS Age, gender, follow-up time, and 24-hour urine samples were similar between groups (p>0.05). New stone formation was detected in two (9.1%) and seven (35%) patients in group I and II, respectively. New stone formation seemed to be higher in group II, but because of the less number of patients, this difference was not statistically significant (p=0.062). The number of patients with recurrence was statistically higher in group II (p=0.032). Stone formation rate (SFR) was calculated as 0.034 and 0.2 per patient per year for group I and II, respectively. This difference of SFR between groups was statistically significant (p=0.028). CONCLUSION Medical prophylaxis of children after PNL can reduce new stone formation and SFR. Although it was not statistically significant because of low patient numbers, higher recurrence rate was detected in patients who did not have medical prophylaxis.

Comparative Analysis of Pedicular Vascular Control Techniques during Laparoscopic Nephrectomy: En Bloc Stapling or Separate Ligation?

Objective: To compare the safety and efficacy of en bloc stapling and separate ligation techniques for renal vascular control during laparoscopic nephrectomy. Patients and Methods: Clinical data were collected from 60 patients who underwent laparoscopic nephrectomies using en bloc stapling (n = 27, group 1) or the separate ligation method (n = 33, group 2). Comparative analysis was carried out between the two groups, examining operative times, blood loss, intra- and postoperative complications and hospital stay. Results: Compared with the separate ligation method, the en bloc hilar control technique was associated with a shorter total operating time (98 vs. 121 min, p = 0.029). However, both groups were similar in terms of estimated blood loss, hemoglobin drop, changes in creatinine level and postoperative hospital stay. The total complication rates in group 1 and 2 were 3.7 and 15.1%, respectively, with a statistically significant difference. There were no complications related to the use of the endo-GIA stapler and no patients required conversion to open surgery in group 1. In group 2, 2 patients required conversion to open surgery, including 1 due to renal vein bleeding secondary to inaccurate vascular control and the other due to bleeding from the vena cava during dissection. In addition, 1 patient had a superficial bowel injury that was repaired laparoscopically and another had a superficial liver tear that was managed without conversion or transfusion. Conclusion: En bloc ligation of the renal hilum is an easy and reliable technique that allows safe and fast control of the renal pedicle.

Effect of percutaneous nephrolithotomy on renal functions in children: assessment by quantitative SPECT of 99mTc-DMSA uptake by the kidneys

Abstract Objective: To determine the impact of percutaneous nephrolithotomy (PNL) on global and regional renal function in children. Methods: In total, 40 children (41 renal units) undergoing PNL were included in this prospective study. All patients were evaluated using quantitative single-photon emission computed tomography (QSPECT) with technetium-99 m-dimercaptosuccinic acid (99mTc-DMSA) examinations before and 3 months after surgery. Results: The mean age was 9.5 years (range, 3–16), and the mean stone size was 3.4 cm (range, 2–6.5). Of the cases, 39 (95%) were managed as being stone-free after a single session of PNL. After additional treatment procedures, 40 (97.5%) of the cases were managed as being stone-free. Of the 41 renal units, new focal cortical defects on 99mTc-DMSA scans were seen in 4 (9.7%) patients. Total relative uptake in the treated kidneys increased from 42.3% to 44.1%. The mean creatinine level before PNL was 1.18 ± 0.45 (0.8–1.6) mg/dL compared with 1.16 (0.7–1.5) mg/dL by the end of the follow-up period (not statistically significantly different, p > 0.05). Conclusions: PNL in children is a safe and feasible method for the maximal clearance of stones. QSPECT of 99mTc-DMSA confirmed that renal function is preserved or even improved after percutaneous stone removal.

Emergent Intervention Criterias for Controlling Sever Bleeding after Percutaneous Nephrolithotomy

Objectives. To determine when emergent intervention for bleeding after percutaneous nephrolithotomy (PCNL) is required. Methods. We reviewed analysis data of 850 patients who had undergone PCNL in our center. Blood transfusion was needed for 60 (7%) patients during and/or after surgery. We routinely performed followup of the urine output per hour, blood pressure, and hemoglobin levels after PCNL. Five (0.6%) of them had severe bleeding that emergent intervention was needed. Results. The mean age of the 5 patients who had emergent surgery due to severe bleeding was 42.2 (19–56) years. Mean duration of surgery was 44.75 (25–65) minutes. Mean stone size was 27 (15–38) mm. Mean decrease of hemoglobin was 4.8 (3.4–5.8) ng/dL, and unit of transfused blood was 4.4 (3–6). Mean blood pH was 7.21. There were metabolic acidosis and anuria/oliguria in all these patients. One of 5 patients suffered from cardiopulmonary arrest because of massive bleeding four hours after the PCNL, and despite cardiac resuscitation, he died. Hemorrhaging was controlled by open surgery in the other 4 patients. Two patients experienced cardiac arrest during the open surgery but they responded to cardiac resuscitation. There were no metabolic asidosis and anuria/oliguria, and bleeding was managed only with blood transfusion for the other 55 patients. Conclusion. Severe bleeding after PCNL is rare and can be mortal. If metabolic asidosis and anuria/oliguria accompanied the drop of hemoglobin, emergent surgical intervention should be performed because vascular collapse may follow, and it may be too difficult to stabilise the patient.

Factors associated with postoperative pain after retrograde intrarenal surgery for kidney stones

OBJECTIVE We aimed to investigate factors related to early postoperative pain after retrograde intrarenal surgery (RIRS). MATERIAL AND METHODS A prospective data analysis of 250 patients who underwent RIRS due to kidney stones was performed. Postoperative pain was evaluated in all patients by using visual analogue scale (VAS). Patients with severe pain (VAS score ≥7) were separated and included in Group I (n=46). While patients without pain or with insignificant pain were included in Group II (n=204). The impact of patient-related (age, gender, renal anomalies, shock wave lithotripsy history, preoperative hydronephrosis) stone-related (stone number, side, size, location and opacity) and operation-related (preoperative and postoperative ureteral J-stenting, ureteral injury, postoperative bleeding and fever, stone-free rates, size of access sheath, and sheath indwelling time) factors on early stage postoperative pain (if any) were investigated. RESULTS Female gender increased the risk for pain 3.6-fold (p<0.05). One millimeter increase in stone diameter increased the risk for postoperative pain 1.15-fold. Prolonged sheath time was another important factor which increased the risk for pain (p<0.05). Patients with high residual fragments were also prone to early postoperative pain. CONCLUSION According to our results, patient-, stone-and operation-related factors associated with postoperative pain after RIRS were female gender, stone size and sheath time.

Evaluation of the pathologic results of prostate biopsies in terms of age, Gleason score and PSA level: Our experience and review of the literature

OBJECTIVE To evaluate the pathologic and clinic results of our large series of transrectal prostate biopsies in relation to Gleason score, age and PSA level. MATERIALS AND METHODS We reviewed the pathologic results of transrectal prostate biopsies performed because of high PSA levels and abnormal digital rectal examination findings between January 2008 and February 2012. RESULTS The pathologic result of 835 prostate biopsies was benign in 82.2% and malign in 17.8%. Furthermore in 3.7% high grade PIN (Prostatic Intraepitelial Neoplasia) or ASAP (Atypical Small Acinar Proliferation) was shown. In the interval of total PSA values between 4 and 10 ng/dl, that is thw so-called grey zone, cancer detection rate was 12.4%. There was a significant relationship between cancer detection and cancer stage at all high levels of PSA also in the grey zone. The most common Gleason score observed was 3 + 3 wirh a rate of 7.4% whereas the second most commonly observed scare was 3 + 4 with a rate of 2.5%. In the patients with abnormal digital rectal examination findings but normal PSA levels according to age the cancer detection rate was 8.7%, in patients with only high PSA levels the rate was 41.2% and in the patients with both high PSA levels and abnormal digital rectal examination findings. the rate was 49.3%. CONCLUSION Our study underlines the relationship between age, PSA level and pathologic stage of prostate cancer and also the importance of digital rectal examination.