Urology Journal

Purpose: To determine the unfavorable factors, related to lower pole anatomical characteristics (LPACs), influencing the success of retrograde intrarenal surgery (RIRS) for lower pole renal calculi (LPC).

Materials and Methods: We reviewed the data of 36 patients who underwent RIRS for LPC between Octo­ber 2012 and October 2013. The infundibulopelvic angle (IPA), infundibular length (IL) and infundibular width (IW) were measured on preoperative intravenous urographies. On follow-up stone-free status was defined as complete clearance at the first month kidney-ureter-bladder X-ray and computed tomography if necessary.

Results: The median stone size was 10 mm (range, 5-35). The stone-free rates according to LPACs at the first month follow-up were 100% (n = 17), 57.9% (n = 11), 90% (n = 18), 62.5% (n = 10), 90.5% (n = 19) and 60% (n = 9) for patients with IPA ≥ 70°, IPA < 70º, IL < 3 cm, IL ≥ 3 cm, IW ≥ 5 mm and IW < 5 mm, respec­tively. While IPA and IW were associated with success of RIRS for LPC in multivariate analysis (P = .003 and P = .046, respectively), only IW was found to be a significant factor after applying multivariate analysis (P = .05).

Conclusion: The results of our study demonstrated that only IW had a significant effect on the success rate of RIRS for LPC.

Purpose: To compare the efficacy of sublingual piroxicam 40 mg with intramuscular diclofenac 75 mg in treatment of acute renal colic. The secondary objective was to look for factors that can affect the severity of the pain and pain relief in acute renal colic.

Materials and Methods: One hundred patients with acute renal colic were randomized into two groups. Group A (n = 50) received intramuscular diclofenac and sublingual methylcobalamin. Group B (n = 50) received sublingual piroxicam 40 mg and intramuscular distilled water. Pain severity was meas­ured using Visual Analog Scale (VAS) and verbal and facial response scales. They were followed up for 3 h. Intramuscular injection of pentazocine 30 mg with promethazine 25 mg were used as rescue drugs.

Results: Both groups were comparable for age, sex distribution, body mass index (BMI), and pain duration be­fore presentation. Significant pain relief was noticed in both groups. Sixteen percent in group A and 18% in group B had complete pain relief within 30 min (P = .75). Fifteen patients in group A and 13 patients in group B needed rescue drugs, 84% of group A and 76% of group B had complete pain relief at the end of 3 hours (P = .25). Decrease in pain by each scoring method was also comparable (P = .75). In multiple regression anal­ysis, increasing age, positively affects the severity of pain and pain relief while increasing BMI negatively affect the initial pain relief. Acute renal colic seems to affect men more commonly than women, 81% of the study pop­ulation were men. Patients with low initial pain score did not require any additional pain relief. Average pain du­ration before presenting to hospital is 260 min. Sixty percent of renal colics are due to stones below pelvic brim.

Conclusion: The results show that sublingual piroxicam is as effective as intramuscular diclofenac. It can be easily self-administered and it overcomes the morbidity and time delay in getting intramuscular diclofenac.

Purpose: The prostate cancer (PCa) treatment is multimodal. Thus multidisciplinary team management (MDTM) decision-making process appears as a tool to answer all aspects of PCa treatment. Our aim was to evaluate the repro­ducibility of therapeutic decisions made at MDTM.

Materials and Methods: We compared therapeutic decisions of PCa by presenting the same file of patient un­der a fake identity after 6 to 12 months from the first presentation. Forty-nine files of radical prostatectomy (RP) (28 pT2, 21 pT3) performed for clinical localized PCa were represented at MDTM which included urologist, on­cologist, pathologist and radiologist. Analysis of therapeutic decisions comprised criteria such as: TNM stage, Gleason score, margin status and comorbidities. The reproducibility was assessed statistically by Kappa coefficient.

Results: Study subjects included 49 patients who underwent radical prostatectomy (RP). The mean age was similar in pT2 and pT3 groups (P = .09). The mean serum PSA value was 8.32 ng/mL (range, 3.56-19.5) in pT2 group and 9.4 ng/mL (range, 3.8-22) in pT3 group. The margin status in pT2 and pT3 groups was positive in 25.0% and 47.6%, respectively. The decisions made at first and second MDTM for pT2 group were the same in 100% of cases with a per­fect kappa coefficient (k = 1). In the group of pT3 (n = 21), the decisions were different in 33% at the second MDTM in comparison to the first MDTM. Especially for pT3b only 29% were reproducible decision with a slight agree­ment (k = 0.1). Concerning pT3a, 86% of the decisions were reproducible with a substantial agreement (k = 0.74).

Conclusion: We showed a reliability and reproducibility of decision made at MDTM when guidelines are well de­fined. The therapeutic attitudes were less reproducible in locally advanced PCa but decision concerning those cases should be made in the setting of guidelines.

Purpose

To examine the effect of routine sampling anterior apical cores in the initial prostate biopsy among patients that 14-cores of prostate biopsy planned.

Methods

Five-hundred twenty-eight patients with increased prostate-specific antigen levels and/or abnormal digital rectal examination underwent transrectal ultrasound and initial prostate biopsy between November 2012 and October 2013. We performed routinely 12-cores extended prostate biopsy plus 2 anterior apex samples that were taken from the junction of urethra and apex. Site-specific and unique cancer detection rate, tumor characteristics and biopsy related pain were evaluated.

Results

Prostate cancer was detected in 147 of 451 patients (32.6%). Lateral base of the prostate had the highest importance for cancer detection with 128 of 451 patients (28.3%) and unique cancer detection with 17 of 40 patients (43.5%). Anterior apex (n=6) was in third place after the lateral apex (n=8). The patients diagnosed by anterior apex cores were all clinically insignificant prostate cancer. The cancer diagnosis rate would be 31% if 12-cores biopsy was used, but that rate found 32.6% in 14-cores biopsy (p=0. 016). Average biopsy pain, right anterior apex biopsy pain and left anterior apex biopsy pain were found 0.61, 1.06 and 1.08, respectively. When right and left anterior apex biopsy pain is compared to average biopsy pain, the pain level was found that statistically significant higher in the biopsies of right and left anterior apex (p=0.040 and p=0.042).

Conclusions

According to our results, although more prostate cancer diagnosis would be done with 14-cores prostate biopsy, it should not be forgotten that those patients might have clinically insignificant prostate cancer.

Purpose: To present our results of laparoscopic upper pole heminephrectomy in adult patients with duplex kidney.

Materials and Methods: A total of 10 patients with an age range of 27 to 54 years old underwent laparoscopic upper pole heminephrectomy for complete duplication of the renal collecting system. The key point of the tech­nique included the placement of a catheter in the normal ureter at the beginning of the procedure. The patient was positioned in a 45-90 degrees lateral decubitus position and a 4-port transperitoneal or 3-port retroperitoneal tech­nique was applied followed by the mobilization of the upper pole ureter away from the renal hilum. Afterwards, the vasculature supplying the upper pole was precisely identified and ligated. Followed by transection of the ureter and its transposition cephalad to the hilum, the upper pole moiety was fully transected using the harmonic scalpel.

Results: Eight patients were operated on using the transperitoneal approach and 2 using the retro­peritoneal technique. One patient required preoperative percutaneous drainage due to pyonephro­sis. The operation time ranged between 150 to 350 min with minimal blood loss (0-200 mL). Hemosta­sis was achieved with an Argon laser in one patient. The lower pole calyceal system was perforated in one patient and repaired intracorporally. No major intraoperative complications occurred. All of the patients except two had their drains removed in 72 h after the operation and were generally discharged on postoperative day 3.

Conclusion: Laparoscopic upper pole heminephrectomy for an ectopic ureter is safe and reproducible and offers ben­efits of laparoscopic surgery even in patients with complicated urinary tract infection.

Purpose: To compare the complications and success rates of hand-made sling with commercial sling used in transob­turator tape (TOT) surgery.

Materials and Methods: From 2008 to 2010, hand-made slings were used in TOT surgery, whereas commercial slings were used from 2010 to 2013 in our clinic. Overall 102 patients were included in the study. Patients were cat­egorized into 2 groups: group 1 had hand-made (polypropylene monofilament) slings, while group 2 had commercial slings (polypropylene monofilament). We retrospectively reviewed 1-year follow-up results of the whole cohort. Ages, body mass indexes, menopausal status, operation time, cost of sling, success of operation and complications were recorded. All these data were compared between the 2 groups.

Results: There were 41 patients (54.29 ± 9.88 years) in group 1 and 61 patients (52.82 ± 9.85 years) in group 2. Men­opausal status and body mass index (28.1 vs. 29.2 kg/m² respectively) were similar for both groups. Previous history of incontinence or pelvic organ prolapse surgery (P = .046), mean duration of the procedure (P = .001), and vaginal extrusion rate (P = .016) were significantly lower in group 2. The cost of the sling was higher in group 2 than in group 1. There was no significant difference in success of operation between the groups (P = .319).

Conclusion: According to our results, hand-made mesh is a viable option in TOT surgery with similar efficacy, but surgeons should be careful in terms of vaginal extrusion.

Purpose: To determine the effect of Ramadan intermittent fasting on erectile function (EF), sexual desire and serum hormone levels.

Materials and Methods: Eligible male participants completed the two domains of International Index of Erectile Function (IIEF) questionnaire for EF and sexual desire. They also provided information on any known disease, treat­ment taking, smoking habits and frequency of sexual intercourse. Frequency of sexual intercourse, two domains of IIEF questionnaire, serum hormone levels, body weight before and four-weeks after the end of month of Ramadan were also recorded.

Results: Overall, 45 men, with a mean age of 37 ± 7.2 years, participated in the study. Frequency of sexual intercourse (P = .046), sexual desire (P = .002), body weight (P = .009) and serum follicle stimulating hormone (FSH) level (P = .016) decreased significantly at the end of month of Ramadan compared to baseline. No statistically significant differ­ences were found on EF (P = .714), serum testosterone (P = .847), luteinizing hormone (P = .876), estradiol (P = .098) and dehydroepiandrosterone sulfate levels (P = .290).

Conclusion: Ramadan intermittent fasting might be associated with decrease in sexual desire, frequency of sexual intercourse and serum FSH level.

Purpose: To determine the effectiveness of intralesional administration of onabotulinumtoxinA in patients with Pey­ronie's disease (PD).

Materials and Methods: A prospective therapeutic cohort study was undertaken in patients aged ≥ 18 years with stable PD. Intervention included one-time intralesional application of 100 U of onabotulinumtoxinA. We included 22 patients who attended the urology clinic from October 1, 2011 to June 30, 2012. Primary outcome measure was degree of curvature. Secondary outcome measures were thickness of the fibrous plaque, improvement in erectile function and pain. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5) questionnaire. The Visual Analog Scale (VAS) was used to measure pain during an erection. Statistical analyses were performed by Pearson's chi-squared test for categorical variables and student's t-test for quantitative variables. Any P value < .05 was considered statistically significant.

Results: The size of the fibrous plaque was reduced from 0.34 ± 0.20 to 0.27 ± 0.13 cm after treatment (P = .014). The curvature initially averaged 32.95 ± 9.21°, and improved to 25 ± 9.38° (P = .025). According to the Kelami classifica­tion, the curvature was < 30° in 14 cases (63.6%) and was 30°-60° in eight cases (36.4%). At 16 weeks, the curvature was < 30° in 19 cases (86.4%) and 30°-60° in three cases (13.6%). The IIEF-5 score was 16.18 ± 4.46 before treatment and 18.22 ± 4.55 after treatment (P = .002). Pain was reduced from 3.36 ± 3.48 before treatment to 1.14 ± 1.58 after treatment (P = .001).

Conclusion: The administration of onabotulinumtoxinA may improve the clinical manifestations of PD resulting from fibrosis, thus improving sexual function in patients.

Purpose: Penile Mondor's disease (superficial thrombophlebitis of the dorsal vein of the penis) is a rare clinical di­agnosis. It is an easily diagnosed and treated disease. Nevertheless, when reviewing the literature, we considered that unnecessary tests are carried out for diagnosis. In this study, we aimed to indicate the redundancy of Doppler ultra­sonography for diagnosis of penile Mondor's disease.

Materials and Methods: Seven patients with the clinical presentation of penile Mondor's disease were included in the study. In the first two patients, penile Doppler ultrasonography was performed for diagnostic purposes by applying a vasoactive intracavernosal agent. This diagnostic procedure was not implemented in the next five patients.

Results: Physical examinations revealed cord-like thickening lesions on dorsal and dorsolateral penis. In the first two patients, who penile Doppler ultrasonography with an intracavernosal vasoactive agent was used for diagnostic pur­poses, was developed priapism. We did not use penile Doppler for more patients as this would be unethical according to us.

Conclusion: Recovery from penile Mondor's disease is usually spontaneous and smooth. A simple physical examina­tion is sufficient for diagnosis, and palliative treatment is effective. For the diagnosis of this disease, unnecessary tests should be avoided so that patients are not harmed.

Purpose: There are many recent observational studies on testicular microlithiasis (TM) and risk of testicular cancer. Whether TM increases the risk of testicular cancer is still inconclusive. The objective of this updated meta-analysis was to synthesize evidence from clinical observational studies that evaluated the association between TM and testic­ular cancer.

Materials and Methods: We identified eligible studies by searching the PubMed, Embase and Cochrane Library before March 2014. Adjusted relative risks (RR) with 95% confidence interval (CI) were calculated using random-or fixed-model.

Results: A total of 14 studies involving 35578 participants were included in the meta-analysis. On the basis of the Newcastle Ottawa Scale systematic review, eleven studies were identified as relatively high-quality. TM was strong association with an increased incidence of testicular cancer (RR = 12.70, 95% CI: 8.18-19.71, P < .001), with sig­nificant evidence of heterogeneity among these studies (P for heterogeneity < .001, I2 = 82.1%). The subgroup and sensitivity analysis confirmed the stability of the results and no publication bias was detected.

Conclusion: The present meta-analysis suggests that TM is significantly associated with risk of testicular cancer. More researches are warranted to clarify an understanding of the association between TM and risk of testicular cancer.