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Öğe Impact of body mass index on outcomes after robot assisted radical prostatectomy(Springer, 2008) Castle, Erik P.; Atug, Fatih; Woods, Michael; Thomas, Raju; Davis, RodneyIn this study we evaluated the impact of body mass index (BMI) on operative and perioperative parameters and surgical margin rates, in patients who underwent robotic assisted radical prostatectomy (RARP).We retrospectively reviewed 140 consecutive RARPs performed by the same surgical team. Patients were stratified based on BMI into two categories: Group I: non-obese (91 patients) and Group II: obese (49 patients). Intraoperative parameters evaluated were: total operative time, estimated blood loss (EBL), intraoperative complications, status of nerve sparing and pelvic lymph node dissection. Postoperative parameters evaluated included positive surgical margin rate, pathological Gleason score and pathological stage, final tumor volume, length of stay (LOS), and postoperative complications. The two groups were statistically comparable for age, PSA, Gleason scores and clinical stages. Mean operative time was greater in the obese group at 300.5 min versus 247.3 min in the non-obese group. Mean EBL in obese patients and non-obese patients were 396.2 and 292.8 ml, respectively. Positive surgical margin rate was 26.5% in obese and 13.1% in non-obese patients. Robotic assisted radical prostatectomy in obese patients is a feasible procedure with acceptable perioperative outcomes and complications. In our study, obesity significantly but negatively affected operative and postoperative outcomes. Moreover, obesity was associated with higher grade tumors and higher incidence of positive surgical margins. Consequently, caution is advised in performing RARP in the obese patient in the early part of a learning curve.Öğe IS IT NECESSARY TO PLACE URETERAL STENTING AFTER UNCOMPLICATED URETEROSCOPIC LITHOTRIPSY?(Aves, 2006) Atug, Fatih; Akay, Ferruh; Akkus, Zeki; Orgen, Sait; Alar, Salih; Sahin, HayrettinIntroduction: 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 ureteroscopic 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.Öğe Should anesthesia be performed in transrectal ultrasonography guided prostate biopsies?: Review(Ortadogu Ad Pres & Publ Co, 2007) Atug, FatihProstate cancer is a major health issue throughout the world and transrectal ultrasonography (TRUS) guided prostate biopsy is essential for its detection. Studies evaluating the tolerance of prostate biopsies demonstrated that moderate to severe pain was associated with the procedure. Large numbers of patients perceive the procedure as painful with major psychological trauma. Still, there is no universally agreed standard of analgesia. Successful pain management should be performed to make TRUS-guided prostate biopsy tolerable for patients. However, standard pain-controlling techniques are used by a small number of urologists today. In this review, the effect of pain and discomfort encountered during prostate biopsies and commonly used analgesia and anesthesia methods are discussed under the light of the literature.Öğe USE OF MIDAZOLAM DURING TRANSRECTAL ULTRASONOGRAPHY GUIDED PROSTATE BIOPSY: EFFECTS OF SEDATION AND RETROGRADE AMNESIA(Aves, 2005) Atug, Fatih; Akay, Ferruh; Akay, Hatice Ozturkmen; Eksioglu, Ali; Bircan, KamuranIntroduction: 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.Öğe USE OF STONE CONE™ DEVICE IN URETEROSCOPIC MANAGEMENT OF PROXIMAL URETER STONES(Aves, 2005) Atug, Fatih; Akay, Ali Ferruh; Alar, Salih; Yamis, Sait; Bircan, M. KamuranIntroduction: Ureteroscopy is a very common modality used to treat ureteral calculi. Retrograde stone migration during ureteroscopic lithotripsy might be seen in 40-50% of proximal ureteral stones. Stones are pushed often completely back to the kidney or stone fragments might migrate. This migration increases morbidity and the need for additional procedures. Various different equipments and techniques have been developed for preventing stone migration. Lithocatch T, Lithovac T and Parachute T are some of these devices. Nevertheless these devices are only 12 Fr in largest diameter which may be too small for dilated ureters and they fill up the most of the space of the ureteroscope working channel. The stone cone T is a device that goals to prevent proximal calculus migration and allow safe extraction of small calculi during ureteroscopy. The stone cone T catheter may be used to for these aims during ureteroscopic lithotripsy. In this study, we assessed the clinical use and efficacy of the stone cone T device in the treatment of proximal ureter stones. Materials and Methods: Between 2003 and 2004, we used the stone cone T in 22 patients with proximal ureteral calculi undergoing ureteroscopic lithotipsy. The mean age of patients was 33.6 +/- 0.6 years (19 to 59) and mean stone diameter was 9.6 +/- 1.4 mm (8-21 mm). Stones were on right side in 13 patients and on left side in 9 patients. Preoperative examinations included plain x-ray film of the kidneys, ureters and bladder, excretory urography and urine culture. All procedures were performed under general anesthesia and all patients were operated on standard lithotomy position. Ureteroscopy was performed with 8.5 Fr semirigid ureteroscope. Pneumatic lithoriptor was used for lithotripsy in all cases. Stone cone T was introduced through the cystoscope under fluoroscopic control. Stone cone T was required placement under direct ureteroscopic control in patients with impacted stones. Results: Stone cone T was placed successfully in 22 patients. In 14 patients, it was placed via cystoscopy under fluoroscopic guidance, while 8 patients with impacted stones required ureteroscopic placement. Mean operation time was 55 +/- 16 minutes (35-80 min). Intracoporeal pneumatic lithotripsy was used in all patients. All stones were fragmented successfully with pneumatic lithotriptor. Ureteral stent was placed to all patients with impacted ureteral stones. Stone fragments, which were entrapped in the ureter by the stone cone T, were extracted safely with common stone baskets. Stone migration was seen in only 1 (4.5%) patient, in which a 3 mm stone fragment migrated to the kidney. No major complication was associated with the use of stone cone T. Conclusion: In this study, stone cone T catheter was used in 22 patients with proximal ureteral stone and the efficacy plus the safety of this catheter was evaluated. In our experience, stone cone T is an effective and useful device that prevents proximal ureteral stone migration and allows safe extraction of fragments during ureteroscopic lithotripsy. We think that failure in trapping fragments smaller than 3 mm, is the main disadvantage of this device. The stone cone T appears to be a useful addition to the urological armemantarium.
