Vural Solok

THE EFFICACY OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR ISOLATED LOWER POLE CALCULI COMPARED WITH ISOLATED MIDDLE AND UPPER CALICEAL CALCULI

PURPOSE We assess the efficacy of extracorporeal shock wave lithotripsy monotherapy for isolated lower pole nephrolithiasis, and compare it to that for isolated middle and upper caliceal calculi. MATERIALS AND METHODS We treated 714 renal units in 687 patients with isolated caliceal stones using a Lithostar lithotriptor (Siemens Medical Systems, Erlangen, Germany). The stones were localized in the lower, mid and upper calices in 455, 104 and 128 patients, respectively. Stone load was recorded in cm.2. Patients were stratified into 3 groups based on stone burden. The energy and shock waves, use of anesthesia, number of treatment sessions, auxiliary measures and complications were noted. Patients were evaluated with intravenous urogram or plain film of kidneys, ureters and bladder, and ultrasonography when stone-free, or clinically significant residual fragment status, including nonobstructive and noninfectious insignificant fragments 4 mm. or less, was noted at the fluoroscopic control 2 to 4 weeks after the last session. Final clinically significant residual fragment decision was made 10 to 12 weeks after the last session. Extracorporeal shock wave lithotripsy was considered a failure if no fragmentation was noted after session 3 and continued if fragmentation was noted. Results regarding caliceal localization were compared. RESULTS Complete data were available on 591 renal units. Auxiliary procedures were used in 81 (14%) units before treatment. Anesthesia was given to 101 (17%) patients. The mean number of shock waves and energy used were 2,022 and 17.4 kV., respectively. The difference in shock wave, energy and treatment rate among 3 caliceal locations reached statistical significance only for energy delivered to the lower and upper calices. The effectiveness quotient of extracorporeal shock wave lithotripsy was 36%, 46% and 41% for lower, middle and upper pole stone disease, respectively (p = 0.4). There was a highly significant correlation between stone-free and re-treatment rates, and stone burden. The overall stone-free rate was 66%, and 63%, 73% and 71% for lower, middle and upper caliceal stones, respectively (p = 0.1). For the group with stones greater than 2 cm.2 overall stone-free rate decreased to 49%, and 53%, 60% and 23% in lower, middle and upper caliceal locations, respectively. Overall, extracorporeal shock wave lithotripsy monotherapy failed in 46 (7.7%) renal units. Steinstrasse developed in 39 (6.5%) patients who were then treated with repeat lithotripsy. CONCLUSIONS Extracorporeal shock wave lithotripsy appears to be successful for management of isolated caliceal stone disease. Treatment efficacy was not significantly different among stones localized in lower, middle and upper poles. We recommend it as the primary treatment of choice for stones less than 2.0 cm.2 in all caliceal locations. Treatment should be individualized for management of caliceal stones greater than 2.0 cm.2 until large prospective randomized trials comparing shock wave lithotripsy and percutaneous nephrolithotomy are available.

Is Periprostatic Local Anesthesia For Transrectal Ultrasound Guided Prostate Biopsy Associated With Increased Infectious Or Hemorrhagic Complications? A Prospective Randomized Trial

PURPOSE Periprostatic local anesthesia for prostate biopsy requires 2 or more extra needle punctures and injection of the local anesthetic through the highly colonized rectum. To our knowledge we report the first prospective randomized trial to assess the infectious or hemorrhagic complications associated with this method. MATERIALS AND METHODS A total of 100 consecutive patients with sterile urine cultures underwent transrectal ultrasound guided prostate biopsy. They were randomized to receive a periprostatic nerve block or no anesthesia. Patients were evaluated for the amount of rectal and urethral bleeding, and symptoms and signs of infection after biopsy. RESULTS The amount of urethral bleeding was slight and similar in the 2 groups. Rectal bleeding was significantly less in the patients who received anesthesia. High fever (greater than 37.8C) was more frequent in the nerve block group and 2 patients in this group required rehospitalization. Bacteriuria in post-biopsy urine cultures was significantly more common in the anesthesia group. CONCLUSIONS Our results suggest that periprostatic local anesthesia for prostate biopsy does not increase the risk of urethral bleeding. It is associated with a decreased incidence of rectal bleeding, presumably due to decreased patient discomfort. The incidence of bacteriuria was significantly higher in the anesthesia group. High fever and hospitalization due to infectious complications were also more common in the local anesthesia group, although not statistically significant. Prospective randomized trials seem warranted to determine the optimum antibiotic prophylaxis regimen in patients undergoing biopsy with a periprostatic nerve block.

Incision and Venous Patch Graft in the Surgical Treatment of Penile Curvature in Peyronie’s Disease

Objectives: To assess the efficacy of incision and venous patch grafting method in the surgical treatment of the curvature in Peyronie’s disease. Methods: Fifty–eight patients with Peyronie’s disease underwent incision of the tunica albuginea with Peyronie’s plaque(s) and venous patch grafting between 1994 and 1999. Segment(s) of lower saphenous vein in 48, deep dorsal vein in 7, and upper saphenous veins were used in 3 cases as venous patch(es). Assessment of the potency status, curvature, and vascular structure were performed pre–operatively with detailed history, counselling, autophotography, and color Doppler ultrasonography. Realistic expectations from the surgery was discussed with the patients in advance. Postoperative evaluation was performed at least twice, in the 6th week and the 3rd month. The third evaluation was done in 12–36 months by telephone. Results: Fifty of the patients (86%) achieved straight erections after the surgery. Five patients (9%) had improvement in their penile curvature that enabled them to perform sexual intercourse easily. In 3 of our patient (5%) recurrence of the curvature was observed. Penile shortening of 0.5–1.5 cm was observed in 13 of the cases (22.4%). Fifty–four cases (93%) reported no change in their quality of erections. Conclusion: Incision of the tunica albuginea and venous patch grafting technique is a very satisfactory surgical method in the treatment of the curvature in Peyronie’s disease.

Outcome of Nephron-Sparing Surgery: Elective versus Imperative Indications

Introduction: The increase in the detection of renal tumors incidentally in earlier stages has enhanced the enthusiasm for nephron-sparing surgery (NSS). Patients and Methods: We performed NSS in 76 patients (53 male, 23 female) with a mean age 52.3 between December 1988 and September 2001. Patients were sub-classified into 2 groups as elective or imperative indication group. They were compared regarding surgical technique, time of surgery, pathological analysis, complications, and disease free status. Results: Elective indication group (group I) with a normal contralateral kidney consisted of 50 patients, whereas there were 26 patients in the imperative indication group (group II). Tumors were incidentally detected in 63%; 74% in group I and 42% in group II. Although the mean diameter of the tumor was slightly higher in group II (39.1 vs. 36.3 mm), this difference did not reach statistical significance (p > 0.05). The partial nephrectomy was performed more frequently compared to enucleation in group I (90 vs. 69%, p = 0.050). However, the mean operation time as well as the mean clamping time did not differ significantly between the two groups (p > 0.05). In the histological evaluation tumors were benign in 16 (21%) and malignant in 60 patients. All of the patients but one with renal cell carcinoma had stage T1-T2 disease. Major complications were observed in 14 (18%) and 12 were from group II. Complication rate was significantly higher in group II (p = 0.000). Of 60 patients with renal cell carcinoma, 2 died of unrelated causes. One patient died with multiple visceral metastases. One patient was lost to follow-up. In the remaining 56 patients with a mean follow-up of 37.1 months (1–152), local recurrence or distant metastases were not detected. Serum creatinine levels have remained almost the same compared to preoperative levels (1.2 ± 0.6 vs. 1.5 ± 0.9). Overall and cancer-specific survivals were 100 and 100% in group I, 85 and 95% in group II, and 94 and 98% for the entire patient population, respectively. Conclusion: NSS is an effective and reliable treatment in low stage renal tumors. It prevents unnecessary nephrectomy in benign lesions that could not be diagnosed preoperatively. However, the patients who underwent NSS with elective indication outcome with better results, compared to those with imperative indication.

An unusual presentation of a foreign body in the urinary bladder : A migrant intrauterine device

A 35-year-old woman, who had had an intrauterine device inserted 7 years earlier, presented with dysuria, pollakiuria, suprapubic pain and urethral irritation. The intrauterine device was found in the bladder with stone formation and was removed by endoscopy.

Urologic screening for men with Behçet’s syndrome

OBJECTIVES To establish the urologic status of men with Behcets syndrome, because studies assessing the urologic aspect of Behçets syndrome are rare. METHODS During a 2.5-year period, we evaluated 104 male patients with Behçets syndrome, 16 to 50 years old (mean 31+/-7), using a urologic questionnaire and modified Boyarsky symptom score; 44 healthy men, 20 to 46 years old (mean 29+/-7), were used as control subjects. RESULTS The frequency of epididymitis in patients with Behçets syndrome was 19.2% in this study. The mean irritative symptom score was 1.22+/-1.37 (significantly higher than the control group). The frequency of lower urinary tract symptoms (eg, dysuria, urgency, nocturia, terminal dribbling, and intermittency) was significantly higher in patients with Behcets syndrome. CONCLUSIONS In this study, the frequency of epididymitis in men with Behcets syndrome was much higher than previously reported. Because some lower urinary tract symptoms were significantly more frequent in these patients, we conclude that screening of such patients with urologic questionnaire and symptom scoring is essential to identify those who need further urologic evaluation.

BLADDER INVOLVEMENT IN BEHCET'S SYNDROME

PURPOSE We report our clinical experience with Behçets syndrome and bladder involvement. MATERIALS AND METHODS From April 1991 through July 1996, 7 men and 1 woman 25 to 53 years old with Behçets syndrome were evaluated for lower urinary tract symptoms (7) or hematuria (1). Of 8 patients 5 had neurological involvement. Evaluation consisted of history, physical examination, urinalysis and urine culture, excretory urography, urodynamic studies, urethrocystoscopy, bladder biopsies and histopathological examination. RESULTS Cystoscopy revealed bladder ulcer in 1 patient and an indurated, hypervascular lesion in another with bilateral hydronephrosis. The most common urodynamic finding was detrusor overactivity. Of 4 patients with poor compliance 1 had additional sphincteric deficiency. Common histopathological features were moderate and marked thickening of bladder vessel walls. Lymphocytic vascular reaction was present in 2 patients and lymphocytic vasculitis in 1. Clamshell augmentation ileocystoplasty was performed in 3 patients, including 1 who also underwent a sphincter enhancement procedure. The remaining 5 patients received various nonsurgical treatment. CONCLUSIONS Various types of voiding dysfunction relating to bladder and sphincteric components in both phases of micturition can be seen in Behçets syndrome. Voiding dysfunction can be due to either neurological or direct bladder involvement. Augmentation ileocystoplasty is a good treatment option for Behçets syndrome with severe bladder involvement.

Impact of Transition Zone Biopsies in Detection and Evaluation of Prostate Cancer

Objective: To analyze the impact of 2 systematic transition zone (TZ) biopsies in addition to systematic sextant biopsies in an effort to establish the importance of cancer detected in the transition zone. Methods: Between November 1995 and October 1996, TRUS-guided systematic sextant peripheral zone (PZ) and two additional TZ biopsies were performed on 189 consecutive men. Radical retropubic prostatectomy (RRP) was performed to 13 patients with organ-confined prostate cancer. The biopsy results of the 52 patients with cancer and the pathological specimens of the patients who underwent surgery were compared. Results: Of the 189 patients, 52 (27.5%) had prostate cancer of whom 20 (38.5%) both in the PZ and TZ, 31 (59.6%) only in the PZ, and 1 (1.9%) in the TZ only. Of the 96 patients with high serum PSA levels despite normal DRE, 14 had prostate cancer. TZ cancer only rate was 7.1% (1 in 14 patients) in this group. RRP was performed to 8 patients who had cancer only in the PZ and 5 patients in both TZ and PZ. The pathological stages of the postoperative specimens and extracapsular extension rates of those with cancer in the PZ and TZ were significantly higher (p = 0.029 and p = 0.008, respectively). Conclusions: Routine TZ biopsy does not substantially increase the prostate cancer detection rate, however it can be useful in selected patient groups. If further studies reveal the relationship of cancer in the transition zone, higher capsular extension rate (pT3 cancer) and higher pathological stage after radical surgery, then TZ biopsies may yield additional information that might influence the therapeutic approach.

Long-term results of Burch colposuspension

Background : We aimed to determine the long‐term results of Burch colposuspension.

Extracorporeal Shockwave Lithotripsy for Stones in Abnormal Urinary Tracts: Analysis of Results and Comparison with Normal Urinary Tracts

PURPOSE We reviewed our experience with SWL for stones in abnormal urinary tracts and compared the results with those in normal urinary tracts. PATIENTS AND METHODS The study group was composed of 2566 renal units (RU) treated on the Siemens Lithostar lithotripter at our SWL unit whose treatment and follow-up at 10 to 12 weeks were completed. Sixty-eight RUs (2.7%) belonged to 52 patients who had congenital upper urinary tract abnormalities. Logistic regression analysis was performed to analyze the impact of age, stone size, location, and the type of abnormality on the outcome of the SWL in the abnormal RU. The student t-, chi-square, and Fishers exact tests were used for the comparison of stone load, number of treatment sessions, catheter placement, and success rates of the patients with normal and abnormal RU. Results of long-term follow-up for available patients (38 RU; 56%) were also evaluated. RESULTS Age, stone load, stone location, and the type of abnormality did not have a statistically significant impact on the outcome of SWL for abnormal RU. The average stone load was 2.1 +/- 2.8 cm2 in the abnormal and 1.4 +/- 1.3 cm2 in the normal RU. Thus, the stone load was significantly higher in the abnormal RU (P < 0.05). In the abnormal group, 56% of the RU became stone free, 37% had nonobstructive and noninfectious clinically insignificant residual fragments < or = 4 mm (CIRF), and SWL failed in 7%. In the normal group, 78% of the RU became stone-free, 18.5% had CIRF, and SWL failed in 4%. There was no significant difference in the success rates in the groups if success was defined as stone free and CIRF together (P > 0.05). However, there was significant a difference when stone-free, CIRF, and failure rates were evaluated separately (P < 0.05). Recurrence, regrowth, and retreatment rates in abnormal RU were 50%, 37%, and 34%, respectively. CONCLUSIONS Although the fragmentation rates were similar, clearance of the fragments was hampered in abnormal urinary tracts. Thus, especially for large stones, other endourologic treatment options should be considered. High recurrence and regrowth rates warrant careful monitoring and consideration for medical treatment during follow-up.