Evaluation of a synchronous twin-pulse technique for shock wave lithotripsy: a prospective randomized study of effectiveness and safety in comparison to standard single-pulse technique

OBJECTIVE

To asses the efficacy and safety of bidirectional synchronous twin‐pulse extracorporeal shock wave lithotripsy (ESWL) compared with standard ESWL.

PATIENTS AND METHODS

Between March 2003 and December 2006, 240 patients with a radio‐opaque single renal stone of ≤25 mm were randomized to treatment either by the Twinheads (TH) lithotripter (FMD, Lorton, Virginia, USA) or the Dornier Lithotripter S (DLS, Dornier MedTech Europe GmbH, Germering, Germany). Before and after ESWL, urinary N‐acetyl‐B‐glucosaminidase (NAG) levels were assessed and patients were evaluated with dynamic MRI. The efficacy and complications were compared, with success defined as no residual fragments.

RESULTS

For stones of >10 mm the rate for the failure of disintegration was 13.3% for the DLS vs 1.4% for the TH (P = 0.009). For stones of ≤10 mm the stone‐free rate was 74.4% for the TH vs 67.7% for the DLS (P = 0.6), while for stones of >10 mm it was 78.1% and 66.7%, respectively (P = 0.14). The median (range) number of sessions in both groups was 2 (1–5). After ESWL urinary NAG levels were increased significantly in both groups; in the TH group it declined below the level before ESWL after 2 days, while in the DLS group it remained high after 7 days. In the DLS group four patients developed subcapsular or parenchymal haematoma after ESWL, vs none in the TH group. There was loss of corticomedullary differentiation after ESWL in three patients in the DLS group and only one in the TH group. In the DLS group there was a statistically significantly decrease in bilateral renal perfusion after ESWL, but no changes in the TH group.

CONCLUSIONS

Synchronous twin‐pulse ESWL has clinical advantages over standard ESWL in terms of safety and efficacy.     

The multifilament polypropylene tape erosion trouble: tape structure vs surgical technique. Which one is the cause?

This study was designed to clarify whether the structure of multifilament tape or the surgical technique is associated with vaginal erosions. Patients were randomized into two groups: in group 1, formed from the patients who were operated with the technique “setting the tape loosely leaving a scissor tip gap between the tape and the urethra,” and in group 2, formed from the patients who were operated with the technique “setting the tape actually touched the urethra and covering the tape by the adjacent pubocervicovaginal fascia with the aid of a suture.” After 4-year follow-up, it was found that the erosion rate was very high in group 1 (13.6%). We conclude that the high erosion rate seen in multifilament tapes is associated with the surgical technique that is used, not the structure of the multifilament tape.     

Use of “House” Advancement Flap in Anorectal Diseases

BACKGROUND: A retrospective review of 28 patients who had "house flap" anoplasty was carried out to evaluate the therapeutic effectiveness of the procedure. METHODS: House flap anoplasty was performed at Istanbul University Cerrahpasa Medical School, General Surgery Department, in 28 patients over 4 years. Indications were chronic anal fissure, anal stenosis, high transsphincteric fistula, low rectovaginal fistula, anal neoplasia, and obstetric third-degree perineal tear and incontinence. After rectangular excision of the anal or perianal lesion, the "walls" and "roof" of the house flap were incised to the depth of ischiorectal fat. The "base" of this house-shaped flap was then fixed to the top of the excised area. RESULTS: Median postoperative hospital stay was 4.86 (range = 2-12) days. Postoperative complications included three patients with minimal wound dehiscence and one with rectovaginal fistula recurrence. At a median follow-up of 26.4 (range = 1-46) months, excluding the patient with recurrence, all patients were satisfied with house flap anoplasty. CONCLUSION: House advancement flap anoplasty is a relatively simple procedure, combining the beneficial features of rectangular flaps and V-Y plasties. It can be used in nearly all types of anoderm deficiencies with a high rate of success and patient satisfaction.     

Use of intrathecal midazolam to improve perioperative analgesia: a meta-analysis

Intrathecal midazolam binds with gamma aminobutyric acid-A receptors in the spinal cord leading to an analgesic effect. Clinical studies suggested that intrathecal midazolam may also reduce nausea and vomiting when used as an adjunct to other spinal medications. However, the potential neurotoxic effect of intrathecal midazolam remains a concern. This meta-analysis aims to evaluate the effectiveness and side-effects of intrathecal midazolam in the perioperative and peripartum settings. Thirteen randomised controlled studies from MEDLINE (from 1966 to July 1, 2007), EMBASE and Cochrane Controlled Trials Register databases, involving a total of 672 patients, were considered. Volunteer, animal and chronic pain studies were excluded. Adding intrathecal midazolam to other spinal medications reduced the incidence of nausea and vomiting (odds ratio 0.50, 95% confidence interval [CI] 0.27 to 0.90, P=0.02; I2=4%) and delayed the time to request for rescue analgesia (weighted-mean-difference=98.7 min, 95% CI: 76.1 to 121.4, P<0.00001; I2=98.5%). Intrathecal midazolam did not affect the duration of motor blockade (weighted-mean-difference =25.1 min, 95% CI -7.6 to 57.8, P=0.13, I2=94.8%). The incidence of neurological symptoms after intrathecal midazolam was uncommon (1.8%) and did not differ from placebo (odds ratio 1.20, 95% CI 0.22 to 6.68, P=0.84). Based on the limited data available, intrathecal midazolam appears to improve perioperative analgesia and reduce nausea and vomiting during caesarean delivery. A multicentre registry or large randomised controlled study with a prolonged follow-up period would be useful to confirm the clinical safety of intrathecal midazolam.     

Hidden female urinary incontinence in urology and obstetrics and gynecology outpatient clinics in Turkey: what are the determinants of bothersome urinary incontinence and help-seeking behavior?

The purpose of this study was to assess the prevalence of female urinary incontinence (UI) and risk factors of bothersomeness and help-seeking behavior of hidden female UI in urology and obstetrics and gynecology outpatient clinics. This multicentric and cross-sectional study was conducted as a part of the Turkish Overactive Bladder Study. Female patients (n = 5,565) who were referred with complaints other than UI and overactive bladder symptoms were surveyed using the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) with supplementation of five more questions. The crude prevalence of UI was found to be 35.7%. The prevalence of frequent and severe incontinence was 8.2 and 6.8%, respectively. The mean age of incontinent patients was significantly higher (p < 0.001). The prevalence of stress, urge, and mixed UI was 39.8, 24.8, and 28.9%, respectively. More than half (53%) of incontinent patients were not bothered by UI, and only 12% of incontinent patients had previously sought medical help for their problem. Frequency, severity, and type of UI were independent factors for predicting bothersome UI, while only bothersomeness increased help-seeking behavior. The ICIQ-SF score of 8 has been found to be the best cutoff value to delineate the bothersome UI. Although the crude prevalence of female UI was found to be high, bothersome UI was not so common. The majority of incontinent female patients did not seek medical help. Frequency, severity, and mixed type of UI were found to be the determinants of bothersome UI for which the ICIQ-SF cutoff score of 8 was obtained.     

Is it worth using daclizumab induction therapy with mycophenolate mofetil-based immunosuppressive regimens in live related donor kidney transplantation? A long-term follow up

Background/Aims The aim of this work is to determine the long-term therapeutic benefit(s) of daclizumab induction therapy with triple immunosuppressive protocols including prednisolone, cyclosporine microemulsion (CsA), and mycophenolate mofetil (MMF) in the living related donor kidney transplantation. Methods Twenty-one adult recipients of their first kidney allograft were allocated to receive daclizumab with triple immunosuppressive therapy (steroids, CsA, and MMF). They were compared to 50 recipients of their first grafts who received a maintenance triple immunosuppressive therapy (steroids, CsA, and azathioprine). The patients were followed up for 5 years. Results Daclizumab group significantly experienced a marked reduction of acute rejection (7/21) when compared to the control group (31/50) with subsequent significant reduction of cumulative steroids doses at the end of 5 years. The overall incidence of post-transplant complications was comparable among the two treatment groups. There was no significant difference in patients and graft survival; 5-year patient and graft survival were 95.3%, 85.7% for daclizumab and 96%, 88% for control group, respectively. Conclusions Although prophylactic daclizumab with triple immunosuppressive protocol including MMF have drastically reduced the incidence of acute rejections, the graft and patient survival are unchanged in this long-term follow up.     

Effects of Chronic Bacterial Prostatitis on Prostate Specific Antigen Levels Total and Free in Patients with Benign Prostatic Hyperplasia and Prostate Cancer

Background: Prostatic-specific antigen (PSA), a tumor marker helpful in the diagnosis and follow-up of prostate cancer, may rise due to causes such as prostatitis, chronic benign prostatic hyperplasia (BHP), etc. The aim of this study was to investigate the relationship between prostatitis and the level of total and free prostate-specific antigen in patients with no clinical evidence of prostate cancer. Methods: A comprehensive urological examination was performed on 156 patients aged 35–61 years old. All patients have symptoms of prostatitis. Prostate fluid culture was preformed. All patients underwent a course of antibacterial treatment after which the levels of total prostate specific antigen (TPSA) and free prostate specific antigen (FPSA) were evaluated. Results: An increase in TPSA (>4 ng/ml) was observed in 14/24 (58.3%) patients with acute prostatitis and in 7/45 (15.5%) and 4/44 (9.1%) in patients with chronic bacterial prostatitis (CBP) and a bacterial prostatitis, respectively. Low blood concentration of TPSA and FPSA were observed after effective antibacterial and anti-inflammatory treatment therapy in most cases. Conclusion: These data suggested that prostatitis must be considered when interpretation of TPSA and FPSA values as tumor marker.     

Delayed Diagnosis of Tuberculous Arthritis

Monoarticular tuberculosis （TB） affecting the knee is rare in all forms of TB （0.1-0.3%）. We present the case of a patient with tuberculous arthritis in whom the diagnosis was belated due to a lack of familiarity with the disease; here, we emphasize the difficulties associated with the diagnosing joint TB. A 20-year-old man was referred to our department due to swelling of the right knee and the presence of persistent, mild pain for 4 years. The lack of systemic evidence of this disease, the indolent course of disease, and the presence of non- specific symptoms renders early recognition of this disease difficult. Furthermore, in cases in which a diagnosis cannot be reached simply by culturing the synovial fluid, synovial biopsy cultures should be considered m the diagnostic process, due to the high rate of positivity of such cultures. The diagnosis and treatment of articular TB are both urgent matters; surgical debridement and strict adherence to antituberculous chemotherapy tend to yield a satisfactory functional outcome.