Urology Journal

Purpose: To share the experience of the authors with the urological family in the world by the review of literature on supine percutaneous nephrolithotomy (PCNL). Materials and Methods: We have searched all the available databases, including PubMed or MEDLINE and Embase Biomedical Database to find any English articles related to supine PCNL from 1998 to 2010. Of 17 studies, 11 were case series and 6 were comparative. Results: A total of 1914 patients were studied. Only the results of mean operation time were significant. Supine PCNL offers several advantages, including less operation time, less patient handling, needing only one drape, easier access to the urethra and upper calyces, facilitation of drainage of stone fragment with the Amplatz sheath, less anterior kidney displacement due to lying the kidney in its normal anatomical position, less risk of the colon injury, more tolerable for the patients with pulmonary or cardiovascular disease, and better for morbid obese patients. The overlap density of the vertebrae in the semi-supine position can be avoided. Furthermore, the fluoroscopy tube is far from the puncture site; thus, the space is open for the surgeon to work and the surgeon can perform the procedure in a more comfortable seated position. Conclusion: The study showed that PCNL in the supine position is feasible. Although supine PCNL has numerous advantages, it is not routine in many surgical centers throughout the world. The practice of supine PCNL will be popular when the academic centers be encouraged to start it.

Advocates of supine percutaneous nephrolithotomy (PCNL) consider several theoretical advantages for this procedure. Despite the potential advantages of the supine PCNL, the majority of urologists have remained reluctant to perform this technique. This reluctance may be related to successful outcomes of prone PCNL and technical difficulties associated with supine PCNL. Feasibility of supine PCNL has been shown in different series and the current evidence, although limited and not fully organized, implies the application of this technique for patients with simple stones who are at high anesthesiological risk. However, there is no convincing evidence to support performing supine PCNL in morbidly obese patients and those with complex and multiple stones. Further randomized clinical trials of large sample size and high methodological quality are required to recommend extensive application of supine PCNL as an alternative to prone PCNL.

Purpose: To evaluate major and minor complications of percutaneous nephrolithotomy (PCNL) and their management in our consecutive cases. Materials and Methods: We reviewed medical records of 671 patients who had undergone PCNL in our center from March 2000 to March 2006. The demographic data, stone parameters, PCNL complications, and stone-free rate were evaluated. Multiple parameters were evaluated for their association with PCNL complications using Chi-Square test. Results: Complications occurred in 203 (30.3%) patients; renal parenchymal injury in 103 (15.4%), peri-operative bleeding in 42 (6.3%), late bleeding in 6 (0.9%), renal collecting ducts injury in 35 (5.2%), fever in 7 (1.0%), colon perforation in 2 (0.3%), major vessels injury in 3 (0.4%), pneumothorax in 3 (0.4%), and hemothorax in 2 (0.3%) subjects. Mortality occurred in 1 patient with colon perforation (0.15%). Conclusion: Percutaneous nephrolithotomy has low complication rate in experienced hands.

Purpose: To assess percutaneous nephrolithotomy (PCNL)-induced kidney tubular damage and the associated factors. Materials and Methods: One hundred and eight patients who have undergone PCNL from May 2007 to October 2007 were recruited in this study. Urinary level of β2-microglobulin (Uβ2MG) was measured on the day before the operation as well as on the 1^st, and 7^th post PCNL days. Percutaneous nephrolithotomy was performed using standard method. Patients' demographic and peri-operative data were collected to evaluate factors influencing renal injury. Results: Median urinary levels of β2-microglobulin on pre-operative, 1^st, and 7^th postoperative days were 0.2 mg/dL (range, 0.1 to 82), 0.4 mg/dL (range, 0.2 to 97), and 0.2 mg/dL (range, 0.2 to 114), respectively. High levels of Uβ2MG (> 2.3 mg/dL) were observed in 10 (9%), 20 (19%), and 10 (9%) patients pre-operatively and on the 1^st, and 7^th postoperative days, respectively. In multivariable analysis, Uβ2MG on the 1^st postoperative day was associated with pre-operative serum creatinine level (P < .001) and diabetes mellitus (P = .05), while Uβ2MG on the 7^th day after the operation was associated with pre-operative serum creatinine level (P = .01), diabetes mellitus (P = .01), and PCNL time (P = .02). Conclusion: Percutaneous nephrolithotomy does not cause kidney tubular injury beyond one week. In patients with pre-operative high serum creatinine concentration, diabetes mellitus, and/or long operation time, the likelihood of the kidney damage is higher than others.

Purpose: To present a 'latex glove' laparoscopic pyeloplasty (LPP) training model and determine its construct validity for its effective use in resident training. Materials and Methods: The 'latex glove' model was used to perform LPP by five operators with variable level of experience, ranging from an experienced (> 20 independent LPPs) to minimal operative experience (year 5 medical student). The palm of the glove was considered the renal pelvis with finger of the glove as the proximal ureter. A knot at the junction of the two was considered as ureteropelvic junction obstruction. A basic lap trainer was used to simulate the LPP. Operation time was noted in minutes and quality of continuous suturing was determined for each operator, using a previously described nonvalidated scoring system by a blinded reviewer. Results: The operation time varied from 47 to 160 minutes for the most to the least experienced operator, and the difference was statistically significant (P = .043), while the quality of suturing score ranged from 1 to 6 for the most to the least experienced operator, respectively (P = .038). The operation time and quality of suturing were negatively correlated with the level of experience (-0.962 and -0.987, respectively), which were statistically significant (P = .009 and P = .002, respectively). Conclusion: This novel training model has proven its validity, as a cost-effective and readily available option for LPP training.

Purpose: To define timing and methods for a balanced follow-up of testicular microlithiasis (TM) in pediatric age.

Materials and Methods: We retrospectively reviewed medical records of 21 pediatric asymptomatic patients (42 testicular units) diagnosed with TM and without associated risk factors. Microliths were found bilaterally on ultrasonography in all the patients. Distribution of microliths (focal or diffuse) inside the parenchyma was evaluated as well as its eventual variation over time. Every six months, each patient underwent clinical and ultrasonography evaluation, as well as serum chemistry markers (α-fetoprotein and β-human chorionic gonadotropin) measurement to detect potential malignancy. In the interval between the follow-ups, parents and/or patients themselves were asked to control eventual enlargement of the gonads or scrotal swelling. Testicular biopsy was not performed in any of our subjects. Results: Of 21 patients, 6 had unilateral undescended testis, 4 varicocele, and 1 patent processus vaginalis with scrotal swelling while 10 patients did not show associated anomalies. The distribution pattern of microliths on ultrasonography remained unchanged in all follow-ups in every patient, showing a predominance of diffuse pattern in the undescended testis series. Tumor markers remained within normal limits. In no subject, we observed a shift toward a malignant condition. Conclusion: In the pediatric population with an incidentally diagnosed TM and without any associated risk factor, a slight follow-up is suggested, consisting of clinical evaluation every 6 months, without any justifiable recommendation to perform a testis biopsy and a measurement of serum tumor markers.

Purpose: To investigate the correlation between pre and post surgical staging in patients undergoing radical cystectomy (RC), and study the possibility of predicting their disconcordance. Materials and Methods: We reviewed medical records of 186 patients diagnosed with transitional cell carcinoma of the bladder, who had undergone RC between the years 2007 and 2010. We determined the correlation between pre and post surgical stages and then studied the association between stage disconcordance and age, gender, smoking, history of previous transurethral resection of bladder tumor (TURBT) and intravesical treatments, re-TURBT in high-risk superficial bladder tumors, and the treatment delay between diagnosis and RC. Analysis was performed using Chi-Square and Fisher's Exact tests. Results: Post surgical up-staging occurred in 86 (46.24%) patients and even more (69.35%) if lymph node involvement was also considered as up-staging. Smokers and those with pre surgical stages of ≤ T1 and T2 with no history of re-TURBT had a significantly increased risk of disconcordance. The risk of up-staging was almost halved by an early re-TURBT in high-risk patients. Conclusion: Disconcordance between pre and post surgical stages in patients undergoing RC is common. Until better ways of staging are developed, decision making in patients with bladder tumor should be done by extra attention to patients who have risk factors associated with increased risk of up-staging, including smokers and those with nonmuscle-invasive bladder tumors or T2 tumors. An early re-TURBT will decrease the up-staging rate.

Purpose: To compare the results of microsurgical and naked eye varicocelectomy in patients with grade 3 varicocele.

Materials and Methods: This study was conducted on 84 patients with grade 3 varicocele, between 2007 and 2009. Patients were randomized into two groups, equal in number. Thereafter, microsurgical varicocelectomy was performed in the first group, while the other group underwent naked eye varicocelectomy. Groups were compared in terms of operation duration, number of ligated internal and external spermatic veins, early and late postoperative complications, and postoperative color Doppler ultrasonography findings. Parametric and nonparametric values were compared using Student's t test and Chi-Square test, respectively. Results: The mean duration of surgery was 19 ± 2.3 minutes (range, 12 to 25 minutes) in the naked eye surgery group and 43 ± 3.9 minutes (range, 25 to 75 minutes) in the microsurgery group (P = .008). The number of ligated internal and external spermatic veins, the incidence of early and late postoperative complications, and color Doppler ultrasonography findings were not significantly different between the two groups (P = .12, P = .09, P = .17, and P = .22, respectively). Conclusion: In patients with grade 3 varicocele, microsurgery and naked eye surgical methods proved similar results in terms of success and complications. Because the operation time of the classical varicocelectomy is significantly shorter, it may be preferred in this subset of patients.

Purpose: To compare the outcome of corporeal plication using absorbable versus nonabsorbable sutures for the treatment of congenital penile curvature. Materials and Methods: Thirty-eight men older than 15 years old with congenital penile curvature were enrolled in the study. Patients were randomly divided into two equal groups based on the suture material (Nylon versus Vicryl) used in corporeal plication. Patients were followed up for a mean period of 8.1 ± 1.4 months (range, 6 to 9.1 months). A standardized questionnaire was used to evaluate long-term outcome and patient's satisfaction. Results: Thirty-five patients (17 in Vicryl group and 18 in Nylon group) completed the study. Mean age of the patients and degree of penile curvature were not significantly different between the two groups (P = .74). Postoperatively, 15 (88.2%) and 16 (88.9%) patients in Vicryl and Nylon groups had 75% or greater correction in penile curvature, respectively (P = .61). Patient's satisfaction rate differed between two groups (82% in Vicryl group versus 66% in Nylon group), which did not reach statistical significance (P = .44). Palpable sutures were reported by 7 (39%) patients in Nylon group and only 1 (6%) in Vicryl group (P = .04). Shortening of penile length was reported by 3 (16.7%) patients in Nylon group and 4 (23.5%) in Vicryl group (P = .69). Conclusion: Corporeal plication technique using absorbable suture provides reasonable success rate with less frequent palpable suture knots.

Purpose: To report the surgical details and results of one-stage transperineal urethroplasty using dorsal buccal mucosal graft (BMG) in treatment of panurethral stricture. Materials and Methods: This cohort study was carried out on 17 men with pan-urethral stricture who underwent one-stage transperineal BMG urethroplasty. Failure was defined as a need to any intervention during the follow-up period. Results: The etiology of stricture was trauma in 4 (23.5%), sexually transmitted diseases in 4 (23.5%), lichen sclerosus in 2 (11.8%), and idiopathic in 7 (41.1%) patients. The mean follow-up period was 8.5 months (range, 3 to 18 months). Six (35.3%) patients developed complications; namely wound infection in 2 (11.8%), meatal stenosis in 1 (5.9%), and re-stenosis in 3 (17.6%) subjects. Complication rate in patients ≤ 43 and > 43 years old was 25% (2/8) and 44% (4/9), respectively, which did not reach statistically significant difference (P = .6). The final success rate was 88.2%. None of the patients needed open redo-urethroplasty during the follow-up period. Conclusion: Reconstruction of pan-urethral strictures may be safely and effectively performed at a simple single operative procedure using a transperineal approach with combinations of dorsal BMG.

Purpose: To investigate the protective effect of zofenopril on torsion detorsion-induced biochemical and histopathological changes in experimental testicular ischemia or reperfusion injury in rats. Materials and Methods: A total of 35 prepubertal male Wistar-Albino rats were divided into five groups, including 7 rats in each group: Group I (sham, S), sham operation; group II (torsion/detorsion-early orchiectomy, T/D-E), 2 hours ischemia and 4 hours reperfusion; group III (torsion/detorsion-late orchiectomy), T/D-L), 2 hours ischemia and 5 days reperfusion; group IV (zofenopril-early orchiectomy, Z-E), 2 hours ischemia, 4 hours reperfusion, and a single dose of zofenopril; and group V (zofenopril-late orchiectomy, Z-L), 2 hours ischemia, 5 days reperfusion, and 5 doses of zofenopril. We determined the tissue levels of malondialdehyde, nitric oxide, glutathione peroxidase, and superoxide dismutase enzyme activities. Histopathologically, mean seminiferous tubule diameter measurements were used. Results: Malondialdehyde (3.490 ± 0.89 versus 1.729 ± 0.25 in early period; 3.837 ± 1.694 versus 1.694 ± 0.47 in late period) and nitric oxide levels (3.507 ± 0.44 versus 2.853 ± 0.54 in early period; 4.010 ± 0.72 versus 2.446 ± 0.29 in late period) significantly reduced and glutathione peroxidase (0.012 ± 0.001 versus 0.017 ± 0.001 in early period; 0.013 ± 0.002 versus 0.018 ± 0.001 in late period) and superoxide dismutase enzyme activities (58.030 ± 5.97 versus 70.773 ± 3.85 in early period; 57.421 ± 7.81 versus 76.329 ± 4.09 in late period) significantly increased in the testis tissue in zofenopril pretreated groups compared to group T/D both in early and late period (P < .05). The mean seminiferous tubule diameter was significantly better in pretreated group (210.33 ± 17.32) than group T/D (185.02 ± 22.45) only in late period (P < .05), but not in early period (209.38 ± 30.40 versus 208.21 ± 13.57; P > .05). Conclusion: Treatment with zofenopril decreased damage in ipsilateral testis caused by ischemia/reperfusion, and clinical application of zofenopril might be a new approach for the treatment of testicular torsion in addition to conventional detorsion.