Evaluating the Oncological and Functional Outcomes in 167 Patients Undergoing Laparoscopic Radical Prostatectomy: Could Laparoscopy Still be a Viable Option in Suitable Patients?

Aim: To evaluate the oncological and functional outcomes of 167 patients who underwent laparoscopic radical prostatectomy (LRP). Materials and Methods: The retrospective study included 167 patients who were treated with LRP due to clinically localized prostate cancer between January 2007 and April 2012. Most of the patients were treated with the extraperitoneal approach. Preoperative evaluations included age, serum prostate-specific antigen (PSA) level, and biopsy Gleason score. Perioperative evaluations included duration of operative time and anastomosis time, blood loss (milliliter), and complications. Postoperative evaluations included length of hospital stay and catheterization time. Continence and erectile function were evaluated both pre- and postoperatively. The patients who used no pads or no more than one pad daily and the ones who had only a few urine leakages on effort or exertion were accepted as continent. Postoperative potency was defined as the ability to achieve sexual intercourse with or without the use of PDE-5 inhibitors. Results: Mean age and mean operative time were 62.4 ± 6.0 years and 220.5 ± 45.6 minutes, respectively. Mean anastomosis time was 35.6 ± 9.8 minutes. Mean serum PSA level and mean Gleason score were 17.5 ± 9.97 ng/mL and 6.16 ± 0.42, respectively. Pelvic lymphadenectomy was performed in 94 patients and nerve-sparing procedures in 61 patients. The pathological analysis revealed positive surgical margin in 35 patients (20.9%). Bilateral and unilateral nerve-sparing LRP procedures were performed in 51 (30.5%) and 10 (6%) patients, respectively. At 12 months after surgery, 3 (1.8%) patients were using 2 or more pads per day, 19 (26.4%) patients were satisfied with erection, hardness, and duration of intercourse, and 9 (12.5%) patients had an erection with insufficient hardness and duration. Conclusion: LRP is an acceptable method in localized prostate cancer due to its perioperative and early postoperative results.

Can a single-layer of renorrhaphy be applied with hemostatic agent in robotassisted laparoscopic nephron-sparing surgery applied to complex renal tumors?

Objective: To compare outcomes of single- layer renorrhaphy suturing and hemostatic agent application with double-layer renorrhaphy among complex renal tumors. Material and Methods: 51 patients who underwent robotic partial nephrectomy due to complex renal tumors (PADUA score ≥10) between August 2017 and February 2021 were retrospectively enrolled. A double-layer renorrhaphy was applied in 36 patients (Group 1), and a single-layer renorrhaphy plus hemostatic agent FloSeal® (Baxter Medical, Fremont, CA) was applied in 15 patients (Group 2). Pre- and post-operative serum creatinine, glomerular filtration rate, hemoglobin levels, surgical and warm ischemia time, drainage, hospital stay duration, as well as complications were all evaluated. Results: Group 1 and Group 2 mean PADUA scores were 11 and 10.47, respectively. The mean preoperative, postoperative 1st day and 6th month serum creatinine were 1.02, 1.15 and 1.09 mg/dL in the Group 1 and were 0.93, 1.02 and 0.90 mg/dL in the Group 2, respectively. The mean preoperative, postoperative 1st day and 6th month glomerular filtration rates were 91.47, 77.31 and 81.90 mL/ min/1.73m2 in the Group 1 and were 92.07, 84.93 ve 90.73 mL/min/1.73m2 in the Group 2, respectively. Operation and warm ischemia time were 118min and 23min in the Group 1, and 101min and 13 min in the Group 2, respectively. There was no significant difference between groups in terms of drain removal time and hospital stay. Perioperative only Clavien I and II complications were observed with no recurrence during the follow-up. Conclusion: A single-layer of renorrhaphy plus hemostatic agent application can be safely applied in complex renal tumors with a PADUA score between 10-11 undergoing robotic partial nephrectomy. Keywords: robotic partial nephrectomy, nephron sparing surgery, renorrhaphy, complex renal tumor

Alternative Management of a Pediatric Case of Hemorrhagic Cystitis due to BK Virus: Use of Thulium Laser Coagulation

We report on a pediatric case of hemorrhagic cystitis due to BK virus in a patient with acute lymphoblastic leukemia who had undergone bone marrow transplantation. A very large hematoma that almost completely filled the bladder was aspirated using a morcellator via suprapubic percutaneous access, and a thulium laser was then used to cauterize extensive areas of diffuse uroepithelial bleeding. This combined minimally invasive procedure was successful in clearing the bladder hematoma and achieving hemostasis.

Comparison of Flexible Ureterorenoscopy and Mini Percutaneous Nephrolithotomy in the Management of Multiple Renal Calculi in 10-30 mm Size

PURPOSE

To evaluate the efficacy and safety of flexible ureterorenoscopy (f-URS) and mini percutaneous nephrolithotomy (mini-perc) in the management of 10-30 millimeter multiple renal stones.

MATERIALS AND METHODS

The charts of patients who underwent f-URS or mini-perc for multiple kidney stones between January 2011 and July 2015 were retrospectively analyzed. Patients with multiple 10-30-mm-sized renal stones were enrolled in the study. A total of 374 patients underwent mini-perc and 85 patients met the study inclusion criteria. In the same period, f-URS was performed in 562 patients, and 163 had 10-30-mm multiple renal stones. We selected 85 patients to serve as the control group from this cohort using propensity score matching with respect to the patient's age, ASA score, number, size, and location of stones to avoid potential bias between groups.

RESULTS

The mean operation time and fluoroscopy screening time (FST) was significantly longer in the mini-perc group (P = .001 and P = .001, respectively). The mean hospitalization time was 76.9±38.7 hours in the mini-perc group and 25.0±27.7 hours in the f-URS group (P = .001). Post-operative complications, according to the Clavien classification system, were significantly more frequent in the mini-perc group (P = .003). The stone-free rate was 87% in the f-URS group and 83.5% in the mini-perc group (P = .66).

CONCLUSION

Our study demonstrated that f-URS and mini-perc were effective treatment options for multiple renal stones 10-30 mm in size. However, f-URS was associated with a significantly lower complication rate, shorter operation time, shorter FST, and shorter hospitalization time.

Skin to calyx distance is not a predictive factor for miniaturized percutaneous nephrolithotomy outcomes

Objective

To evaluate the predictive value of the distance from skin to calyx (SCD) on the outcome and complication rates of patients undergoing mPNL.

Materials and Methods

Patient’s charts, who had undergone mPNL between June 2012 and June 2015, were analyzed retrospectively. Patients who had a preoperative computerized tomography (CT) were enrolled into the study. Two separateurologists evaluated the CT scans and calculated the SCD defined as the distance between the skin and surface/lateral edge of the calyx, which was the preferred site of entry for percutaneous access. The average value of the two measurements was included inthe final analysis to avoid bias. The mean SCD was 75mm. According to the median SCD value, patients were divided into two groups: group 1 (SCD ≤75) and group 2 (SCD >75).

Results

A total of 140 patients and 130 patients were enrolled in groups 1 and 2, respectively. The mean operation time and the mean fluoroscopy time was significantly longer in group 2 (p:0.004 vs. p:0.021). The rate of blood transfusion was significantly higher in group 1 (6 patients). None of patientsin group 2required blood transfusion (p:0.017). Stone-free status after a single session of mPNL was 67.1% in group 1 and 75.4% in group 2 (p:0.112). After additional procedures, stone-free rates increased to 84.3% and 85.4% in group 1 and group 2, respectively (p:0.802).

Conclusion

Our study demonstrated that longer SCD was not a predictive factor for stone-free rates after mPNL. However, SCD over 75mm was associated with longer operation time and fluoroscopy time with lower rates of transfusion.

Retrograde intrarenal surgery in the management of pediatric cystine stones

OBJECTIVE

To investigate the efficacy and safety of retrograde intrarenal surgery (RIRS) in the treatment of pediatric cystine stones.

STUDY DESIGN

Data of the pediatric patients who underwent RIRS for kidney stones were retrospectively evaluated. A total of 14 children with cystine stones managed with RIRS were identified. In addition to the patient demographics and stone characteristics, all retrospectively obtained operative data were evaluated and discussed in detail, with an emphasis on the success and complication rates.

RESULTS

Mean age of the 14 cases was 10.9 ± 2.2 years (range: 7-15). Mean stone size was 13.6 ± 2.4 mm (range: 10-18) (Summary table). Of these stones, four were located in the renal pelvis, three were in the lower, three were in the middle and the remaining four were located in upper calyx. Ureteral access sheath was used in 12 (85.7%) patients. The double-J ureteral stent was placed pre-operatively in one case and was inserted postoperatively in 12 cases. Mean operation time was 38.2 ± 7.2 min (range: 30-50). Complications were observed in two cases: mild ureteral laceration in the first and fever on the second postoperative day in the second patient. All of the patients were stone free on sonographic evaluation at the 4-week follow-up evaluation. Although potassium citrate treatment was initiated in 11 patients, tiopronin treatment was initiated in four patients for recurrence prophylaxis during long-term follow-up. During a mean follow-up period of 25.7 ± 5.2 months, stone recurrence was noted in one patient.

DISCUSSION

Treatment of patients with cystine stones is challenging, due to high risk of rapid recurrence in the presence of residual fragments. Besides allowing complete stone clearance in all cases in the current series, RIRS is a highly reproducible method that can be safely performed, even in recurrences. The major limitations of the current study were low number of patients and short follow-up period.

CONCLUSION

The results clearly indicated that RIRS is a safe treatment modality in the management of pediatric cystine stones.

Is There A Difference Between Presence of Single Stone And Multiple Stones in Flexible Ureterorenoscopy And Laser Lithotripsy For Renal Stone Burden < 300mm2 ?

In this study, we aim to evaluate and compare the effectiveness of flexible ureterorenoscopy (f-URS) for solitary and multiple renal stones with < 300 mm2 stone burden. Patients' charts who treated with f-URS for kidney stone between January 2010 and June 2015 were reviewed, retrospectively. Patients with solitary kidney stones (n:111) were enrolled in group 1. We selected 111 patients with multiple kidney stones to serve as the control group and the patients were matched at a 1:1 ratio with respect to the patient's age, gender, body mass index and stone burden. Additionally, patients with multiple stones were divided into two groups according to the presence or abscence of lower pole stones. Stone free status was accepted as complete stone clearence and presence of residual fragments < 2 mm. According to the study design; age, stone burden, body mass index were comparable between groups. The mean operation time was longer in group 2 (p= 0.229). However, the mean fluoroscopy screening time in group 1 and in group 2 was 2.1±1.7 and 2.6±1.5 min, respectively and significantly longer in patients with multiple renal stones (P=0.043). The stone-free status was significantly higher in patients with solitary renal stones after a single session procedure (p=0.02). After third month follow up, overall success rate was 92.7% in Group 1 and 86.4% in Group 2. Our study revealed that F-URS achieved better stone free status in solitary renal stones < 300 mm2. However, outcomes of F-URS were acceptable in patients with multiple stones.

Comparison of STONE, CROES and Guy's nephrolithometry scoring systems for predicting stone-free status and complication rates after percutaneous nephrolithotomy in obese patients

In this study, we aim to evaluate the accuracy of STONE (stone size, tract length, obstruction, number of involved calyces, and essence/stone density), Clinical Research Office of the Endourological Society (CROES), and Guy's nephrolithometry scoring systems (NSS) in obese patients. The charts of patients who underwent percutaneous nephrolithotomy (PNL) between June 2008 and June 2016 were retrospectively analyzed. Calculations of the STONE, CROES, and Guy's NSS were performed by a resident who was well informed regarding each NSS. Patients were classified under nine scores according to STONE, four grades according to CROES, and four grades according to Guy's NSS. In total, 248 obese patients were enrolled in the study. Stone size was significantly higher in patients without stone-free status (p = 0.001). In patients who were stone-free and those with residual stones, the mean STONE score was 9.71 and 9.23 (p = 0.160), CROES was 172 and 129 (p = 0.001), and Guy's NSS was 1.67 and 2.75 (p = 0.001). Multivariate regression analysis identified the CROES and Guy's NSS were independent factors for PNL success in obese patients (p = 0.01 and p = 0.01, respectively). The CROES and Guy's NSS showed good accuracy with PNL success (AUC = 0.777 and AUC = 0.844, respectively). None of the three NSS systems were statically associated with a complication rate (p = 0.23 for STONE, p = 0.14 for CROES, and p = 0.51 for Guy's NSS). Our study demonstrated that CROES and Guy's NSS were independent predictors of stone-free rate following PNL in obese patients. Our study also revealed that three of the NSSs were not useful for predicting PNL complications in obese patients.

Is standard percutaneous nephrolithotomy still the standard treatment modality for renal stones less than three centimeters?

OBJECTIVE

The aim of study was to compare the efficiency and safety of standard percutaneous nephrolithotomy (sPNL) and miniaturized percutaneous nephrolithotomy (mPNL) in lower calyx and/or pelvic stones smaller than three centimeters.

MATERIAL AND METHODS

From October 2010 to August 2015, 108 mPNL and 176 sPNL procedures were performed for renal stones smaller than three cm and located in the lower calyx and/or renal pelvis. All patients were evaluated preoperatively with intravenous pyelography and/or computed tomography. Intraoperative parameters, post-operative results and complications were recorded. Postoperative success was defined as complete stone clearance and/or clinically insignificant residual fragments at 3^rd month.

RESULTS

Preoperative characteristics were similar between sPNL and mPNL groups except previous renal stone operation history and gender. The mean operation time was significantly shorter in the sPNL group (p<0.001). The mean hemoglobin drop was significantly less in the mPNL group (p=0.001), we found a 1.27±1.4 and 0.5±1.3 decrease in mean hemoglobin levels (mg/dL) in the sPNL and mPNL groups, respectively. Transfusion rate was 1.9% in mPNL and 5.6% in sPNL groups, and the difference was statistically significant (p=0.048). Only one patient in the sPNL group needed angiography and embolization. Postoperative JJ stent insertion rate was significantly higher in the mPNL group (p=0.03).

CONCLUSION

Both sPNL and mPNL are safe and effective surgical procedures for lower calyx and/or pelvis stones smaller than 3 cm. However, use of smaller caliber instruments was associated with a lesser hemoglobin drop and need for transfusion.

Comparison of CROES, S.T.O.N.E, and Guy's scoring systems for the prediction of stone-free status and complication rates following percutaneous nephrolithotomy in patients with chronic kidney disease

PURPOSE

To evaluate and compare the accuracy of S.T.O.N.E, Clinical Research Office of the Endourological Society (CROES), and Guy's stone score in patients with chronic kidney disease (CKD) following percutaneous nephrolithotomy (PNL).

METHODS

The charts of patients who had undergone a prone percutaneous nephrolithotomy from June 2006 to June 2016 were retrospectively analyzed. Patients accepted as stage 3 and higher according to chronic kidney disease epidemiology collaboration formula, were enrolled into the study. Calculation of the CROES, S.T.O.N.E, and Guy's scoring system (SS) was made as defined in original papers. Patients were categorized into four scores according to CROES, into nine scores according to S.T.O.N.E, and into four scores according to Guy's SS.

RESULTS

A total of 303 patients fulfilled the study inclusion criteria. The mean preoperative eGFR and creatinine levels were 47 mL/min and 1.55 mg/dL, respectively. In patients who were stone free and those with residual stones, the mean CROES SS was 179 and 137 (p < 0.001), the mean S.T.O.N.E score was 8.8 and 9.9 (p < 0.001), and the mean Guy's SS was 1.8 and 2.4 (p < 0.001), respectively. Multivariate regression analysis revealed CROES SS was the only scoring system, which had a predictive value for PNL outcome in patients with CKD (p = 0.011) and any of three SS were not useful for predicting PNL complications in patients with CKD.

CONCLUSION

Our study demonstrated the CROES SS was the only independent factor in the prediction of PNL outcome in CKD patients. Furthermore, three of the NSSs were not useful for predicting PNL complications in patients with CKD.

External Validation and Evaluation of Reliability and Validity of the Triple D Score to Predict Stone-Free Status After Extracorporeal Shockwave Lithotripsy

OBJECTIVE

The Triple D scoring system is defined as novel and simple nomogram using the main parameters (skin-to-stone distance, stone density, and volume) to indicate most appropriate patients for extracorporeal shockwave lithotripsy (SWL). We aimed to evaluate the accuracy of the Triple D scoring system in predicting SWL success rates.

PATIENTS AND METHODS

In two tertiary academic centers, charts were retrospectively analyzed of patients who had, between January 2014 and May 2016, been treated by SWL for radiopaque kidney stones. A total of 200 patients were enrolled into the study. Parameters were calculated for each of the three specified variables. Since one point was assigned for any parameter that was less than the cutoff value, Triple D scores ranged from 0 (worst) to 3 (best).

RESULTS

Stone-free status was achieved in 115 patients (57.5%), and 85 patients had one or more residual fragments (42.5%). Differences in stone characteristics, including stone location, density, and volume, were statistically significant in patients whether SWL achieved stone-free status or not (p < 0.001, p < 0.001, and p < 0.001, respectively). Triple D scores were significantly higher in patients treated with SWL compared with patients in whom SWL failed (p < 0.001). Triple D scores of 0, 1, 2, and 3 correlated with stone-free rates of 41.7%, 33.7%, 69.4%, and 97%, respectively. The multivariate analyses revealed that Triple D score and stone location were identified as independent factors affecting SWL success (p < 0.001 and p = 0.008, respectively). The mean number of SWL sessions was significantly higher in patients with SWL failure (p = 0.003).

CONCLUSION

Our study externally validates that the Triple D scoring system is associated with SWL success in the treatment of renal and ureteral stones. Further studies are warranted to assess clinical usefulness and the accuracy of this nomogram in different patient groups.

Bleeding during laparoscopic partial nephrectomy: Can a hemostatic matrix help to improve hemostasis?

OBJECTIVES

To evaluate the possible role of an hemostatic matrix on hemostasis, perioperative outcomes and complications in patients who underwent laparoscopic partial nephrectomy (LPN).

MATERIALS AND METHODS

Patients charts were analyzed retrospectively and their demographic characteristics, operative parameters and follow-up results were recorded. Patients were divided into two groups, according to those who used an hemostatic matrix as Group 1 (n = 41) and those who did not used as Group 2 (n = 44). Demographic characteristics of patients, tumor features, operation time, clamping of the renal vessels, ischemia time, suturing of the collecting system, perioperative hemorrhage and complications were evaluated. Histopathological results, surgical margin status, creatinine level and recurrence at the 3rd month of follow up were analyzed. Statistical analyses were performed with SPSS 17.0 and significance was set at p value of < 0.05.

RESULTS

The mean RENAL nephrometry score was 5.9 ± 2.0 and the mean tumor size was 35 ± 12 mm. All patients had a single tumor and 44 of them had a tumor in the right kidney. The renal artery was clamped in 79 cases and the mean ischemia time was 20.1 ± 7 minutes. The mean tumor size and the mean RENAL nephrometry score was statistically higher in Group 1 (p: 0.016 and p < 0.001, respectively). Pelvicaliceal repair was more common in Group 1 due to deeper extension of tumors in this group (p: 0.038). In Group 1, less hemorrhage and blood transfusion requirement, with shorter ischemia and operation time was detected.

CONCLUSION

The outcomes of the recent study showed that adjunctive use of an hemostatic matrix improves hemostasis and decreases hemorrhagic complications during LPN. Further prospective studies are required to assess the potential role of an hemostatic matrix in LPN.

External Comparison of Recent Predictive Nomograms for Stone-Free Rate Using Retrograde Flexible Ureteroscopy with Laser Lithotripsy

OBJECTIVE

To assess and compare the applicability of the Resorlu-Unsal Stone Score (RUSS) and the Modified Seoul National University Renal Stone Complexity (S-ReSC) score for flexible ureterorenoscopy (f-URS).

PATIENTS AND METHODS

We retrospectively analyzed the hospital files of 719 patients who had been treated with f-URS for kidney stone at two referral centers between July 2012 and December 2015. The RUSS and Modified S-ReSC scores were calculated by the same surgeon for each patient by using imaging methods and were compared as to their predictive capability for postoperative success.

RESULTS

A total of 339 patients (168 men and 171 women) with a mean age of 46.5 ± 16.1 (range:1-86) years and a mean body mass index of 27.1 ± 4.1 (range: 12.8-38.5) were included in the study. The mean stone size was 14.4 ± 5.4 (4-40) mm, and the mean stone surface area was 145.3 ± 76.8 (20-658) mm². The overall stone-free rate was 70.1%. The mean scores were 0.5 ± 0.7 and 1.8 ± 1.1 for the RUSS and Modified S-ReSC, respectively. In the logistic regression analysis, musculoskeletal deformity, stone size, and the RUSS were identified as independent predictive factors affecting stone-free status (p: 0, p: 0.014, p: 0.048, respectively). Among these parameters, the RUSS had the highest predictive capability (area under curve value 0.65, [95% confidence interval 589, 721]).

CONCLUSIONS

Stone size, presence of musculoskeletal abnormalities, and the RUSS score are important factors affecting SF status after f-URS. Despite the RUSS being an independent predictive factor for SF status, more comprehensive systems with higher predictive capability are needed for clinical usage and academic reporting.

Efficacy and safety of mini percutaneous nephrolithotomy in obese patients

Purpose

We aimed to evaluate the effect of obesity on surgical outcomes of mini percutaneous nephrolithotomy (Mini-PNL).

Methods

Hundred and eighty two Mini-PNL procedures were performed between May 2013 and January 2015 and their results were evaluated retrospectively. Patients were classified as non-obese (BMI, 18.5–30 kg/m²) and obese (≥30 kg/m²) groups. Obese and non-obese patients were compared according to pre-operative demographic values, intra-operative surgery techniques and post-operative results.

Results

BMI values of 133 patients were lower than 30 kg/m² while 49 patient’s BMI values were higher than 30 kg/m². There were no significant difference between operation time, fluoroscopy time, number of access and access sites when two groups were compared. No significant difference was found in total length of hospital stay, hemoglobin drop, and complication rates. Stone-free rates were 70.7 % in the non-obese and 71.4 % in the obese group (p = 0.9).

Conclusions

Mini-PNL procedure is a safe and effective treatment modality, which should be strongly considered for obese patients with appropriate sized stones.

The effects of previous open renal stone surgery types on PNL outcomes

INTRODUCTION

Our aim was to demonstrate the effect of insicion of renal parenchyma during open renal stone surgery (ORSS) on percutaneous nephrolithotomy (PNL) outcomes.

METHODS

Patients with history of ORSS who underwent PNL operation between June 2005 and June 2015 were analyzed retrospectively. Patients were divided into two groups according to their type of previous ORSS. Patients who had a history of ORSS with parenchymal insicion, such as radial nephrotomies, anatrophic nephrolithotomy, lower pole resection, and partial nephrectomy, were included in Group 1. Other patients with a history of open pyelolithotomy were enrolled in Group 2. Preoperative characteristics, perioperative data, stone-free status, and complications were compared between the groups. Stone-free status was defined as complete clearance of stone(s) or presence of residual fragments smaller than 4 mm. The retrospective nature of our study, different experience level of surgeons, and lack of the evaluation of anesthetic agents and cost of procedures were limitations of our study.

RESULTS

123 and 111 patients were enrolled in Groups 1 and 2, respectively. Preoperative characteristics were similar between groups. In Group 1, the mean operative time was statistically longer than in Group 2 (p=0.013). Stone-free status was significantly higher in Group 2 than in Group 1 (p=0.027). Complication rates were similar between groups. Hemorrhage requiring blood transfusion was the most common complication in both groups (10.5% vs. 9.9%).

CONCLUSIONS

Our study demonstrated that a history of previous ORSS with parenchymal insicion significantly reduces the success rates of PNL procedure.

Effect of Obesity on Prone Percutaneous Nephrolithotomy Outcomes: A Systemic Review

PURPOSE

With decreased physical activity, growing sedentary lifestyle, and high fat diet, obesity has become a pandemic disease all over the world. In this review, we aim to assess the effect of obesity on prone percutaneous nephrolithotomy.(PNL) outcomes.

MATERIALS AND METHODS

We performed a comprehensive review of the published articles in PubMed®, Medline, Scopus, Cochrane database from January 1, 2004 through June 31, 2015, using the key words; body mass index, obesity, morbid obesity, super obese, urolithiasis, nephrolithiasis, percutaneous nephrolithotomy and percutaneous lithotripsy. Original research articles published in English language with accessibility to the full text article were analyzed for our review.

RESULTS

At the end of the evaluation, we found 12 articles in English language, analyzing the effect of obesity on prone PNL outcomes. Except one study, eleven studies were evaluated in this review had a retrospective nature without randomization. Stone free status of patients was in a wide range between 49%-90% in obese patients and 41%-90% in morbid obese patients.

CONCLUSION

PNL is a safe and effective treatment modality for renal stone(s) in obese and morbid obese patients. However, effect of body mass index on PNL outcomes including operation time, fluoroscopy screening time, hospitalization time, complications and stone free status are still debatable.

Laparoscopic Partial Nephrectomy for Renal-Cell Carcinoma During Pregnancy

BACKGROUND

The incidence of renal-cell carcinoma (RCC) is low during pregnancy. There are different approaches for timing of surgery and treatment modalities for RCC in pregnant women in the literature. To our knowledge, this is the first laparoscopic partial nephrectomy case in a pregnant woman.

CASE PRESENTATION

Herein, we present a 34-year-old woman with a renal mass at her 14th gestational week. She was admitted to our clinic after a right renal mass was incidentally diagnosed during routine antenatal ultrasonography. MRI revealed a completely endophytic tumor of 6 × 6.5 × 6.5 cm, located in the upper half of the right kidney. We performed laparoscopic partial nephrectomy in our patient and the postoperative course was uneventful.

CONCLUSION

This is the first presented laparoscopic partial nephrectomy case in a pregnant patient. Nephron-sparing surgeries can be performed laparoscopically in appropriate sized renal tumors in suitable pregnant patients.

Comparison of miniaturized percutaneous nephrolithotomy and flexible ureterorenoscopy for the management of 10-20 mm renal stones in obese patients

PURPOSE

To evaluate and compare effectivity and safety of flexible ureteroscopy (F-URS) and mini-percutaneous nephrolithotomy (mPNL) for 10-20 mm renal stones in obese patients.

METHODS

Between 2012 and 2015, charts of patients who were treated with F-URS or mPNL for 10-20 mm kidney stone(s) were analyzed. Patients with BMI > 30 kg/m(2) were enrolled into the study. Total of 315 patients were treated with mPNL, and 56 patients were matched our inclusion criteria. In the same period, F-URS was performed in 669 patients, and 157 of them had 10-20 mm kidney stones, and their BMI values were >30 kg/m(2). The patients were retrospectively matched at a 1:1 ratio to index F-URS-mPNL cases with respect to the patient age, gender, ASA score, BMI and size, number, and location of stone.

RESULTS

Gender, age, BMI, stone size, stone number, location of stone(s), and ASA scores were similar between groups. The mean operation time was significantly longer in mPNL group (p: 0.021). However, the mean fluoroscopy time was similar (p: 0.270). Hemoglobin drop requiring blood transfusion and angioembolization was performed in two and one patients after mPNL, respectively. Overall complication rate was significantly higher in mPNL group than F-URS group (30.3 vs. 5.3 %, p: 0.001).

CONCLUSION

Our results demonstrated that both F-URS and mPNL achieve acceptable stone-free rates in obese patients with 10-20 mm renal stones. However, complication rates were significantly lower in F-URS group.

Percutaneous nephrolithotomy for isolated calyceal stones: How important is the stone location?

OBJECTIVE

To evaluate the effect of percutaneous access site on the success and complication rates of isolated calyceal stones.

MATERIAL AND METHODS

We retrospectively evaluated 2700 patients who underwent percutaneous nephrolithotomy (PNL) in our clinic between October 2002 and August 2014. We selected only the patients with isolated lower, middle or upper calyceal stones and we grouped the patients according to the location of their stones. Successful operation was defined as complete stone clearence or retention of stone fragments smaller than 4 mm which do not lead to infection, obstruction or pain requiring treatment. Intraoperative and postoperative complications were also recorded.

RESULTS

Totally 360 patients underwent PNL for their isolated upper, middle and lower calyceal stones. Access sites for those patients were selected based on stone location. The stones were localized in the lower (n=304), middle (n=14), and upper (n=42) calices. There was no statistically significant difference between the groups with respect to operation and scopy times. Hemoglobin drop was seen more frequently in the upper calyceal access group, without any significant intergroup difference. Thoracic complications including hemothorax, pneumothorax and pleural effusion were more common in the upper calyceal access group (11.9%; p<0.001). Complete stone clerance was accomplished in 81.9%, 92.9% and 78.6% of the patients with lower, middle and upper calyceal stones respectively without any significant intergroup difference (p=0.537).

CONCLUSION

PNL is an effective and safe treatment modality for isolated calyceal kidney stones and upper calyceal access causes thoracic complications more than other access sites.

Giant kidney stone: multi-session percutaneous nephrolithotomy with 12 accesses

We report a case of a 37-year-old man with a body mass index of 28 kg/m(2) who presented to our outpatient clinic with intermittent left flank pain. Non-contrast abdominopelvic computed tomography revealed a giant coralliform calculus in the left kidney. This giant kidney stone was successfully treated with 3 sessions of percutaneous nephrolithotomy (PNL) with a total 12 accesses. There was no significant reduction in the split function of the kidney after PNL.

Previous shock-wave lithotripsy treatment does not impact the outcomes of flexible ureterorenoscopy

OBJECTIVE

Shock-wave lithotripsy (SWL) is the first-line treatment for the active removal of small and medium-sized kidney stones. Flexible ureterorenoscopy (fURS) is recommended after failed SWL treatment. The aim of this retrospective analysis is to evaluate whether prior unsuccessful SWL treatments affect the outcomes of fURS.

MATERIAL AND METHODS

Data from 206 patients who underwent fURS for the treatment of renal stones between September 2009 and January 2011 were collected, and the patients were divided into two groups according to their previous SWL treatment. The patient demographics, stone characteristics, operation and fluoroscopy times, stone-free rates and complications were compared.

RESULTS

Of the patients, 114 (55.3%) did not undergo SWL prior to fURS (Group 1), whereas 92 (44.6%) completed a minimum of 3 sessions of SWL and waited at least 2 weeks before the fURS operation (Group 2). Although the mean stone number was higher in Group 2, this difference was not significant (p=0.06). The mean operation (p=0.12) and fluoroscopy times (p=0.69) were similar between the groups. The mean operation time per mm(2) stone and fluoroscopy time per mm(2) stone were not significantly different (p=0.64 and p=0.76, respectively). The length of the hospitalization and the overall complication rates were similar. After the third postoperative month, the stone-free rates were not different between the groups (82.5% and 86.9%, respectively, p=0.38).

CONCLUSION

The stone-free and complication rates of fURS were not affected by previous SWL therapy.

[Isolated giant hydatid in kidney]

Cyst hydatid of the kidney is parasitic condition caused by Echinococcus granulosus and identified in many countries, especially associated with sheep farming. Echinococcal larvae enter the bloodstream using the digestive system and invade any organs in the human body. The urinary system is the third most common area affected by parasitic infection after liver and lungs, but isolated renal involvement is a very rare situation, even in endemic areas. İn our case, we aimed to report a 57-year-old female patient with an 18-centimeter isolated renal cyst hydatid treated by retroperitoneal nephrectomy. The diagnosis was based on imaging findings and confirmed by histopathologically.

Laparoscopic transperitoneal adrenalectomy: Our initial results

OBJECTIVE

To present the first 24 laparoscopic adrenalectomies performed in our clinic because of an adrenal mass.

MATERIAL AND METHODS

The medical files of 24 patients who underwent laparoscopic adrenalectomy between December 2008 and March 2013 at Haseki Teaching and Research Hospital were analyzed retrospectively. The demographic characteristics of the patients were recorded. Lateral transperitoneal laparoscopic adrenalectomy was performed in all patients. The operation time was defined as the interval between the first incision of the skin and closure of the skin. Intraoperative complications, estimated blood loss and hospital stays of the patients were evaluated. Final pathologies were recorded.

RESULTS

The mean age of the patients was 44.2±8.58 years (range: 29-66 years). Nine patients were female and 15 were male. A total of 24 masses were identified in the right (n=11), and left (n=13) adrenal glands masses were identified., Eighteen patients (75%) had no symptoms, and the masses were identified incidentally. The mean operation time was 144±46.1 minutes (range: 90-320 minutes), and the mean blood loss was 74±12.3 mL (range: 50-130 mL). None of the patients required a blood transfusion. In one patient, liver injury was identified intraoperatively due to traction. The mean duration of hospitalization was 2.9±1.1 days (range: 2-5 days). Adrenocortical adenoma and pheochromocytoma were the most common pathologies.

CONCLUSION

Laparoscopic adrenalectomy is a safe and effective method for the treatment of adrenal masses with low complication rates.

Does body mass index effect the success of percutaneous nephrolithotomy?

OBJECTIVE

In obese patients, the management of renal calculi presents a number of challenges for urologists. In this study, we aimed to evaluate the efficacy and safety of percutaneous nephrolithotomy (PNL) procedure in obese and morbidly obese patients.

MATERIAL AND METHODS

We retrospectively reviewed the medical files of 2360 patients treated with PNL between March 2002 and April 2013. The patients were stratified into four groups according to the World Health Organization (WHO) classification of body mass index (BMI): <25 kg/m(2) (average), 25-29.9 kg/m(2) (overweight), 30-39.9 kg/m(2) (obese), and >40 kg/m(2) (morbidly obese). Patients under 18 years of age and those with a body mass index under 18 kg/m(2) were excluded from the study. Intra-, and postoperative outcomes of PNL were compared between groups.

RESULTS

A total of 2102 patients with a mean age of 43±13.62 years were enrolled in the study. The mean stone size, mean number of stones, staghorn stone rate and history of previous shock wave lithotripsy were similar in all groups. The overall stone-free rate was 82 percent. The mean operation time was longer in the morbidly obese group but it was not significantly different from that in the other groups. No differences were observed in hospital stay, complication or stone-free rate among four study groups.

CONCLUSION

Percutaneous nephrolithotomy is a safe and effective treatment for renal stone disease. Body mass index does not affect the success or complication rate in PNL.

Effect of the body mass index on outcomes of flexible ureterorenoscopy

The aim of the study to compare outcomes of flexible ureterorenoscopy in patients with different body mass index (BMI) scores and to explore whether the BMI has an effect on outcomes of RIRS. Five hundred and two patients who underwent flexible URS in 3 centers between 2008 and 2012 for the management of single upper urinary tract calculi were retrospectively reviewed. Patients were categorized as normal weight BMI 18.5 to 24.99 kg/m(2), overweight 25 to 29.99 kg/m(2), obese 30 to 39.99 kg/m(2) and morbid obese >40 kg/m(2).The groups were assessed in terms of demographic parameters including age, gender, stone size, intraoperative and postoperative variables. The mean patient age was 41.3 ± 15.51 (18-81) years and with an average BMI 26.68 ± 5.2 kg/m(2) (16.64-55.15 kg/m²). Of the patients, 43.2 % had normal weight (NW), 32.2 % were overweight (OW), 21.9 % were obese (O) and 2.5 % were morbidly obese (MO). Stone-free rates after single procedure in NW, OW, O, MO groups were 60.8, 61.7, 73.6, 61.5 %, respectively (p = 0.079). Overall targeted stone-free rates were also similar in four groups (88.9, 90.1, 93.6, 90.4 %, p = 0.586). There were no statistically significant differences in the frequency of complications and mean hospitalization time among the groups (p > 0.05). In conclusion, this study demonstrated that flexible URS is a valuable option for the treatment of kidney stone in both obese and non-obese patients. BMI did not influence the postoperative outcomes.

Parenchymal thickness: does it have an impact on outcomes of percutaneous nephrolithotomy?

OBJECTIVE

To evaluate whether renal parenchymal thickness (RPT) has an effect on the outcomes of percutaneous nephrolithotomy (PNL).

METHODS

We performed a retrospective analysis of 144 patients with lower pole and/or renal pelvic stones who underwent PNL. The relationship between RPT and peri- and postoperative measures was evaluated.

RESULTS

The average age was 45.94 ± 14.47 (15-76) years. The mean BMI was calculated as 27.47 ± 4.73 (16.9-44.9) kg/m(2). The mean stone burden was 293 ± 126 (150-800 mm(2)). The mean RPT was measured as 17.33 ± 5.32 (6-35) mm. No correlation was detected between the RPT and the operation or fluoroscopy times or the duration of hospitalization (p = 0.63, 0.52, 0.08, respectively). The mean drop in hemoglobin level was 1.45 ± 1.25 (0-9) g/dl. A negative correlation was detected between hemoglobin drop and RPT (p = 0.01, r = -0.23). However, the RPT was similar in patients who did or did not require a blood transfusion (p = 0.09). The RPT was found to have no impact on success rate (p = 0.4).

CONCLUSION

The postoperative hemoglobin drop increases in parallel with the increase in RPT. However, no relationship was detected between the RPT and blood transfusion, overall success rate or any other perioperative parameters.

The impact of metabolic syndrome on long-term outcomes of percutaneous nephrolithotomy (PCNL)

Study Type--Prognosis (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? The presence of metabolic syndrome is associated with development of kidney stones and an increase in the stone-recurrence rate. However, studies reporting long-term results of percutaneous nephrolithotomy (PCNL) in metabolic syndrome are lacking. The present study showed that metabolic syndrome was associated with worsening renal function at long-term follow-up and the stone-recurrence rate recurrence after PCNL in patients with metabolic syndrome was 3.2-fold higher compared with the control group.

OBJECTIVE

• To investigate the impact of metabolic syndrome on long-term kidney function and stone recurrence rates after percutaneous nephrolithotomy (PCNL).

PATIENTS AND METHODS

• In all, 73 patients with metabolic syndrome who underwent stone analysis and had a minimum follow-up of 12 months after PCNL were reviewed. • In addition, 73 patients without any metabolic syndrome components who had undergone PCNL and were followed-up for at least 12 months were included in the study as the control group. • These control group patients were selected from 226 patients who were matched with the patients with metabolic syndrome using a 1 : 1 ratio. The matching parameters were age, gender and stone size.

RESULTS

• Stone analyses showed that calcium oxalate monohydrate (52.0%) and uric acid (21.9%) were most common among patients with metabolic syndrome, whereas calcium oxalate monohydrate (76.7%) was the most common stone type in the control group. • Stone recurrences occurred with a mean (sd, range) of 36.1 (21.3, 12-109) months follow-up in 26 patients (41.9%) and 12 patients (18.9%) in the metabolic syndrome and control groups, respectively (P = 0.003). • While estimated glomerular filtration rate was decreased from 87.8 to 66.6 mL/min/1.73 m(2) in the metabolic syndrome group, it changed from 96.4 to 91.2 mL/min/1.73 m(2) in control group at long-term follow-up.

CONCLUSIONS

• The most frequent stone type was calcium oxalate monohydrate in patients with or without metabolic syndrome. • In patients with metabolic syndrome who underwent PCNL, the stone recurrence rate was >40%. • Metabolic syndrome is associated with worsening renal function at long-term follow-up.

Perioperative prophylaxis for percutaneous nephrolithotomy: randomized study concerning the drug and dosage

PURPOSE

To compare sulbactam-ampicillin and cefuroxime antibiotics for prophylaxis of percutaneous nephrolithotomy (PCNL) and to find out the optimal regimen for antibiotic maintenance to prevent systemic inflammatory response syndrome (SIRS).

PATIENTS AND METHODS

Between February 2010 and March 2011, a total of 198 patients in whom PCNL was performed were prospectively randomized into two main groups regarding the type of prophylactic antibiotic (group1: sulbactam-ampicillin, group 2: cefuroxime). Each group was further randomized according to duration of antibiotic maintenance (a: single dose prophylaxis, b: additional dose 12 hours after prophylaxis, c: beginning with prophylactic dose until the nephrostomy tube removal). Seven patients in whom purulent urine was obtained through the access needle were excluded from the study. Groups were compared in terms of stone- and operation-related factors as well as preoperative urine cultures, access cultures, stone cultures, postoperative urine cultures, and presence of SIRS.

RESULTS

A total of 191 patients (group 1: 95, group 2: 96) were evaluated. Mean patient age, body mass index, stone size, and perioperative outcomes were similar. Positive culture rates did not differ between groups. SIRS was observed in 13 (43.3%) patients in group 1 and 17 patients (56.7%) in group 2 (P=0.44). The relation between duration of antibiotic maintenance and SIRS development was not different in each group (P=0.95 for group 1, P: 0.39 for group 2). Urosepsis was observed in two patients, and one patient died because of septic shock.

CONCLUSIONS

Sulbactam-ampicillin and cefuroxime antibiotics can be used safely for prophylaxis of PCNL. Single dose administration is sufficient.

Is there a difference in percutaneous nephrolithotomy outcomes among various types of pelvicaliceal system?

PURPOSE

During PNL procedures, stone clearance can be achieved by single access or multiple accesses for same stone size and configuration. At this point, we believed that pelvicaliceal system type may play a significant role on stone clearance. In our study, we aimed to investigate the effect of pelvicaliceal system type on PNL outcomes.

METHODS

A total of 498 patients who had preoperative intravenous urography were enrolled in our study. PCSs of the patients were classified as A1, A2, B1, and B2 according to Sampaio system after evaluation of IVU images. The exclusion criteria were unclassified pelvicaliceal system due to the presence of exaggerated renal hydronephrosis, IVUs with poor quality, radiolucent renal stones, and absence of CT or IVU in postoperative period.

RESULTS

There was no clinically significant difference for patient gender, history of open surgery, and history of previous SWL. Success rates of PNL were 79.5, 82.0, 74.3, and 80.3 % in Sampaio type A1, A2, B1, and B2 PCS, respectively (p 0.61). Multiple accesses were required for 35 (18.8 %), 14 (17.9 %), 55 (30.1 %), and 6 (11.8 %) patients according to Sampaio classification type A1, A2, B1, and B2, respectively (p 0.008). There was no clinically significant difference for stone size, stone configuration (simple or complex), and complications.

CONCLUSION

Sampaio type B1 PCSs require increased number of access for achieving stone clearance. Therefore, surgeons should be aware and also inform patients that treatment of patients with Sampaio type B1 PCS may need high number of access during PNL procedure.

Factors affecting kidney function and stone recurrence rate after percutaneous nephrolithotomy for staghorn calculi: outcomes of a long-term followup

PURPOSE

There are few studies of the long-term outcome of percutaneous nephrolithotomy for staghorn calculi. We report the long-term outcome of percutaneous nephrolithotomy in patients with staghorn calculi.

MATERIAL AND METHODS

A total of 265 study patients (272 renal units) were followed in the long term for greater than 12 months. The estimated glomerular filtration rate was calculated using the 4-variable modification of diet in renal disease equation. Cases were staged for chronic kidney disease by National Kidney Foundation guidelines. The impact of patient and procedure related factors on renal function as well as stone recurrence was analyzed retrospectively.

RESULTS

At a mean ± SD followup of 37.3 ± 25.4 months the chronic kidney disease stage classification was maintained in 177 patients (66.8%) while the classification of 34 (12.8%) and 54 (20.4%) had improved and deteriorated, respectively. Multivariate analysis revealed that an immediate postoperative change in the estimated glomerular filtration rate was the only factor predicting a change in renal function in the long term. Stones recurred in 73 of the 234 kidneys (31.2%) that were stone free 3 months after percutaneous nephrolithotomy. Stone size increased in 24 of the 38 kidneys (63.2%) with residual stones after intervention. Recurrent urinary infections during followup and diabetes were associated with stone recurrence and residual stone enlargement.

CONCLUSIONS

In almost 80% of patients with staghorn stones renal function was improved or maintained after percutaneous nephrolithotomy, as documented during long-term followup. Stones recurred in a third of the patients with staghorn calculi.

Outcomes of retrograde intrarenal surgery compared with percutaneous nephrolithotomy in elderly patients with moderate-size kidney stones: a matched-pair analysis

PURPOSE

The aim of our study was to evaluate the outcomes of retrograde intrarenal surgery (RIRS) in elderly patients with stones of moderate size.

PATIENTS AND METHODS

Between September 2008 and June 2011, a total of 28 patients over 65 years of age with single renal stones that measured 1.5 to 3 cm were treated with RIRS. The outcomes of these patients were compared with those of the patients who underwent percutaneous nephrolithotomy (PCNL) using matched-pair analysis (1:1 scenario). The matching parameters were the size and location of the stone as well as age, sex, body mass index, degree of hydronephrosis, presence of previous shockwave lithotripsy, and open surgery. SPSS version 16 was used for statistical analysis.

RESULTS

Stone-free rates after a single procedure were achieved in 82.1% of patients for the RIRS and 92.8% of patients for the PCNL group. The second flexible ureterorenoscopy procedure was performed for five patients in the RIRS group. Finally, stone-free rates during the third month of the follow-up period were 92.8% in the RIRS group and 96.4% in the PCNL group. The mean operative time per patient was 64.5 ± 20.9 minutes in the RIRS group after a total of 33 procedures, while it was 40.7 ± 10.7 minutes in the PCNL groups (P<0.0001). The overall complication rates for the RIRS and PCNL groups were 7.1% and 10.7%, respectively. Blood transfusions were needed in two patients in the PCNL group. Hospitalization time was significantly shorter in the RIRS group (26.5 ± 10.6 h per patient vs 60.0 ± 28.8 h; P<0.0001). In both groups, stones were most frequently composed of calcium oxalate (68.4% in the RIRS group and 77.7% in the PCNL group).

CONCLUSION

RIRS has a low complication rate and represents a safe and effective treatment alternative in selected geriatric patients with kidney stones of moderate size.

Updated epidemiologic study of urolithiasis in Turkey II: role of metabolic syndrome components on urolithiasis

The components of metabolic syndrome, such as obesity, hypertension, and diabetes, are thought to be associated with urolithiasis. However, there are few large-scale studies that have examined the association between metabolic syndrome and urolithiasis, which prompted us to study and evaluate the relationship between metabolic syndrome components and urolithiasis in a nationwide survey, using the cross-sectional study conducted by a professional investigation company, with 2,468 enrolled participants, aged between 18 and 70 years, from 33 provinces in Turkey. Participants were interviewed face-to-face by medical faculty students. Participants with a history of urolithiasis (Group 1) were compared with participants without a history of urolithiasis (Group 2) in terms of hypertension, diabetes, body-mass index (BMI), waist size, and trouser size using Chi-square and odds ratio tests. Of the 2,468 participants, 274 (11.1%) reported a history of urinary stone disease diagnosed by a physician. The percentage of participants with hypertension along with urolithiasis was significantly higher than that in participants without urolithiasis (16.9 and 34.3%, p 0.000, OR 3.0). The percentage of participants with diabetes in groups 1 and 2 was 14.2 and 9%, respectively (p 0.001, OR 1.83). The mean BMI was 27.2 and 25.2, respectively (p 0.01). Participants with a BMI >30 had a 2.2-fold increased risk of having urolithiasis. The mean waist size was significantly greater in participants with urolithiasis (p 0.000). Those with a waist size >100 cm had a 1.87-fold increased risk of having urolithiasis. The mean trouser size was also significantly larger in those participants who were stone formers (p 0.003). The results indicate that metabolic syndrome components are important factors in the development of urolithiasis.