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    Is it necessary to place ureteral stenting after uncomplicated ureteroscopic lithotripsy?
    (2006) Atuğ F.; Akay F.; Akkuş Z.; Örgen S.; Alar S.; Şahin H.
    Introduction: The routine placement of ureteral stents after ureteroscopic lithotripsy procedure is controversial. The main aim of placing a ureteral stent is to prevent ureteral obstruction and renal colic which may develop as a result of uretral edema. Additionally, stents are thought to assist the passage of residual fragments after lithotripsy through passive ureteral dilatation. However, the placement of a ureteral stent is associated with complications including stent migration, breakage, encrustation, stone formation, urinary tract infections and patient discomfort. Therefore numerous studies have been questioned the routine use of ureteral stents after uncomplicated uretroscopic lithotripsy. In this study we compared the results and stone free rates of patients with and without ureteral stenting after uncomplicated ureteroscopic lithotripsy. Materials and methods: In this study, 367 patients who underwent ureteroscopie lithotripsy between 1996 and 2004 were evaluated retrospectively. Patients were divided into two groups. The first group consisted of 236 stented patients and the second group consisted of 132 non-stented patients. In both groups, patients were evaluated for results and stone free rates. Only uncomplicated ureteroscopy patients were included to the study. Patients with solitary kidney, history of renal failure, transplant kidney and a significant perforation or injury to ureter, high grade hydronephrosis, urinary tract infections and patients with impacted stones were excluded from the study. Additionally, patients with retrogarde stone migration were excluded from the study. The operation was performed under general anesthesia with 8.5 F rigid ureteroscope and stones were fragmented with pneumatic lithotriptor. In stented patients a double-J stent was placed in the treated ureter under fluoroscopic monitoring. In the non-stented group the safety wire was removed from the ureter and then the procedure was terminated. In stented patients, stents were removed cystoscopically under local or general anesthesia. Results: The mean age of patients was 40.1 years (range 22 to 76) in the stented group and 37.8 (range 19 to 65) in the non-stented group. The mean stone size was 9.1 mm (range 4 to 21) and 7.8 mm (range 3 to 17) in the in the stented and nonstented patients, respectively. There was no statistical difference between stone free rates in both groups. The stone free rate was %92.4 in stented group and %90.8 in the non-stented group (p>0.05). However, there was statistically significant difference for operative times between the two groups. The mean operative time was 51.4 min (range 30 to 110) in the stented group and 40.2 min. in the non-stented group (range 25 to 70) (p<0.05). The mean operative times increased 28% in the stented group. The symptoms of urinary frequency, flank pain, urgency and dysuria were more common and severe in the stented group. Additionally, hematuria was more severe and prolonged in stented patients when compared to non-stented patients. Conclusion: Our results demonstrate that it is not necessary to place uretral stent after uncomplicated ureteroscopic pneumatic lithotripsy. There was no difference between nonstented and stented patients with respect to stone free status. Ureteral stent placement following uncomplicated lithotripsy augments the operation time, surgical cost and increases patient morbidity.
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    Use of midazolam during transrectal ultrasonography guided prostate biopsy: Effects of sedation and retrograde amnesia
    (2005) Atu? F.; Akay F.; Öztürkmen Akay H.; Ekşio?lu A.; Bircan K.
    Introduction: Urologists perform approximately 500.000 prostate biopsies per year in United States of America. Currently there is no universally agreed standard of analgesia. Several studies evaluating the tolerance of transrectal ultrasound (TRUS) guided biopsies showed that moderate to severe pain was associated with the procedure. Patients may not return for repeat biopsies due to unpleasant experience with prior biopsies. Large number of patients perceives the procedure painful with major psychological trauma. Midazolam is used for gastrointestinal endoscopies because of its sedative and amnestic effects. To this end, we evaluated the feasibility of midazolam and retrograde amnesia effect in patients undergoing transrectal prostate biopsy. Materials and methods: A total of 52 patients undergoing TRUS-guided prostate biopsy were enrolled into the study. Indications for biopsy were increased prostate specific antigen (PSA) or abnormal digital rectal examination of the prostate. Patients were given midazolam as a bolus injection (70 mcg/kg, maximum total dosage: 5 mg) before the biopsy procedure. All patients were examined in left lateral decubitus position and TRUS biopsies were performed with a 7 MHz probe. Four core biopsies were obtained from the each lobe of the prostate. After completion of biopsy, flumazenil (0.5 mg IV) was used to reverse the effects of midazolam. All patients were placed on oxygen saturation monitorization during the procedure. The degree of sedation, degree of pain, side effects and retrograde amnesia were evaluated with a validated questionnaire by the surgeon and patient. A visual analog scale (VAS) was used to asses the pain score and Ramsey sedation score was used to asses the sedation score. The Ramsey sedation scale scores between 2 and 4 were accepted as satisfactory degree of sedation. Results: After injection of midazolam, sedation was achieved in all patients in a short period of time. Ninety-six percent of patients exhibited procedural amnesia, characterized by an inability to recall neither the initial probe insertion nor the biopsy procedure. Only two patients remembered some parts of the procedure. Forty four patients (%85) were willing to undergo re-biopsy if needed. These patients stated that they will undergo a second biopsy only under the same conditions. Eight patients (%15) refused to undergo any further diagnostic test or examination. The mean pain score of patients was 1.96±0.69. The Ramsey sedation scale scores ranged between 2 and 4 in all patients. Nausea and vomiting due to midazolam were not observed in our study, and we did not see any complication related to midazolam usage. Conclusion: In this study we found high satisfaction rates, lower pain scores and lower anxiety in patients undergoing TRUS guided biopsies due to sedative and amnestic effects of midazolam. This resulted in higher acceptability of a repeat biopsy procedure, if indicated. Besides its sedative properties, midazolam can be used as an effective agent during TRUS-guided prostate biopsies due to its procedural amnesia effect, which results in minimal psychological trauma to patients.