Covid-19 Pandemi Dönemindeki Acil Servis Başvurularında Ürolojik Hastalıkların Sıklığı ve Aciliyet Durumuna Göre Dağılımı

Amaç Çalışmamızda pandemi dönemi ve öncesinde, ürolojik şikayetlerle acil servise başvuran hastaların sıklığı ve aciliyet durumuna göre dağılımları incelenmiştir. Gereç ve Yöntem Çalışmamıza ülkemizde COVID-19 pandemisinin başladığı ve sıkı kısıtlamaların uygulandığı 11 Mart 2020–1 Haziran 2020 tarihleri arasında acil servise ürolojik şikayetlerle başvuran erişkin hastalar (n=217) ve 2019 yılındaki aynı tarih aralığında acil servise başvuran hastalar (n=249) dahil edildi. Hastaların demografik verileri, başvuru tanıları, aynı şikayetler ile acil ve üroloji polikliniklerine başvuru sıklıkları, tedavileri ve triyaj kategorileri değerlendirildi. Bulgular Hastaların tanılarına göre dağılımları; %60,1(n=280) idrar yolu enfeksiyonu, %20(n=93) renal kolik, %13,9(n=65) üriner sistem taş hastalığı, %4,1(n=19) idrar retansiyonu, %1,1(n=5) hematüri, %0,6(n=3) orşit, %0,2(n=1) skrotal yaralanma olarak bulundu. 71(%15,2) hasta acil servis başvurusu sonrasında üroloji polikliniğine başvurdu. 24(%5,2) hastanın acil servise tekrarlayan başvurusu oldu. Hastaların aciliyet durumlarına göre dağılımlarında 2019(sarı alan n=193, yeşil alan n=56) ve pandemi dönemi(sarı alan n=156, yeşil alan n=61) arasında anlamlı fark izlenmedi(p=0,163). Acile başvuran hastalar arasında yıllara göre yaş(p=0,348) ve cinsiyet(p=0,120) açısından fark bulunmadı. Üroloji polikliniğine ve acil servise yapılan tekrarlayan başvurularda 2019 yılı ile pandemi dönemi arasında anlamlı fark izlenmedi(p=0,604 ve p=0,234). Üroloji polikliniğine başvurular 2019 ve 2020’de benzer oranda gözlendi(p=0,809). Hastaların tanılarına göre dağılımları 2019 yılı ve 2020 yılı için farklılık göstermedi(p=0,386). Hastaların yıllara göre tedavi ihtiyaçlarındaki dağılımlar incelendiğinde, 2019 yılıyla 2020 yılı arasında istatistiksel olarak anlamlı farklılık bulunmadı (p=1,000). Sonuç Acil servise ürolojik şikayetlerle başvuran hastaların büyük çoğunluğunu idrar yolu enfeksiyonu geçiren hastalar ve taş hastaları oluşturmaktadır. COVID-19 pandemisi gibi riskli ve yoğun kısıtlamaların olduğu bir dönemde bile hastaların ürolojik hastalıkları sebebiyle acil servise başvurma oranları değişmemiştir

Combined surgical treatment for missed rupture of triceps tendon associated with avulsion of the ulnar collateral ligament and flexor-pronator muscle mass

Triceps tendon ruptures are rare injuries. Coexistence of ipsilateral ulnar collateral ligament injury is even rarer. Here, we describe an unusual combination injury to elbow of a 39-year-old male construction worker consisting of triceps tendon rupture, avulsion of elbow ulnar collateral ligament and flexor pronator muscle origin ipsilaterally. A simultaneous repair and reconstruction of all damaged structures was proposed with individualized postoperative rehabilitation. Return to pre-injury level of activities obtained with this treatment protocol. High degree of suspicion and careful examination were needed to prevent missed diagnosis and prolonged instability which may be inevitable after inappropriate treatment of such injury

Two Cases of Bladder Adenocarcinoma After Augmentation Cystoplasty

To draw attention to the disregarded malignancy risk after ileocystoplasty, we present two cases of adenocarcinoma. The first case was metastatic at initial diagnosis. Despite chemotherapy, the condition progressed and the patient died at the 9th month. The second patient has received cystectomy followed by chemotherapy and radiotherapy. Although the second patient was an immunosuppressed renal transplant, she was disease-free at the 27th month. As the malignancy risk after bladder augmentation is a proven fact, until the discovery of a proper diagnostic method, we recommend doing routine annual cystoscopic biopsy starting after the 10th year of ileocystoplasty

Impact of varicocele repair on semen parameters in infertile men: A systematic review and meta-analysis

Purpose: Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls. Materials and Methods: A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies). Results: A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; p<0.001; I2=97.6%), total sperm count (SMD 1.894; 95% CI 0.566 to 3.222; p<0.05; I2=97.8%), progressive sperm motility (SMD 3.301; 95% CI 2.164 to 4.437; p<0.01; I2=98.5%), total sperm motility (SMD 0.887; 95% CI 0.036 to 1.738; p=0.04; I2=97.3%) and normal sperm morphology (SMD 1.673; 95% CI 0.876 to 2.470; p<0.05; I2=98.5%). All the outcomes showed a high inter-study heterogeneity, but the sensitivity analysis showed that no study was sensitive enough to change these results. Publication bias was present only in the analysis of the sperm concentration and progressive motility. No significant difference was found for the semen volume (SMD 0.313; 95% CI -0.242 to 0.868; I2=89.7%). Conclusions: This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies’ practice recommendations favoring VR to improve conventional semen parameters in infertile men

Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis

Purpose:Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls.Materials and Methods:A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies).Results:A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; pConclusions:This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies' practice recommendations favoring VR to improve conventional semen parameters in infertile men.</p

Controversy and Consensus on Indications for Sperm DNA Fragmentation Testing in Male Infertility: A Global Survey, Current Guidelines, and Expert Recommendations

Purpose: Sperm DNA fragmentation (SDF) testing was recently added to the sixth edition of the World Health Organization laboratory manual for the examination and processing of human semen. Many conditions and risk factors have been associated with elevated SDF; therefore, it is important to identify the population of infertile men who might benefit from this test. The purpose of this study was to investigate global practices related to indications for SDF testing, compare the relevant professional society guideline recommendations, and provide expert recommendations. Materials and Methods: Clinicians managing male infertility were invited to take part in a global online survey on SDF clinical practices. This was conducted following the CHERRIES checklist criteria. The responses were compared to professional society guideline recommendations related to SDF and the appropriate available evidence. Expert recommendations on indications for SDF testing were then formulated, and the Delphi method was used to reach consensus. Results: The survey was completed by 436 experts from 55 countries. Almost 75% of respondents test for SDF in all or some men with unexplained or idiopathic infertility, 39% order it routinely in the work-up of recurrent pregnancy loss (RPL), and 62.2% investigate SDF in smokers. While 47% of reproductive urologists test SDF to support the decision for varicocele repair surgery when conventional semen parameters are normal, significantly fewer general urologists (23%; p=0.008) do the same. Nearly 70% would assess SDF before assisted reproductive technologies (ART), either always or for certain conditions. Recurrent ART failure is a common indication for SDF testing. Very few society recommendations were found regarding SDF testing. Conclusions: This article presents the largest global survey on the indications for SDF testing in infertile men, and demonstrates diverse practices. Furthermore, it highlights the paucity of professional society guideline recommendations. Expert recommendations are proposed to help guide clinicians

Controversy and consensus on the management of elevated sperm DNA fragmentation in male infertility: A global survey, current guidelines, and expert recommendations

Purpose Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. Results A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. Conclusions This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians

Çocuklarda Perkütan Nefrolitotomi Sırasında Uygulanan Lokal Anestezik İnfiltrasyonunun Ameliyat Sonrası Analjezi Üzerine Etkisi

We analyzed 40 pediatric patients and 42 renal units who underwent percutaneous nephrolithotomy (PNL) for stone disease between February 2015 and February 2017, in order to prevent postoperative pain and discomfort due to surgery and diversion and to assess the efficacy of preemptive local anesthetics. Patients who received 2 mg/kg of prilocain (0.2%) and 2 mg/kg of bupivacain (0.5%) injection throught the access line before renal access constituted the LA group where patients received no medication constituted the control group. All patients have received the same anesthesia protocol and all of them also recieved 15 mg/kg of paracetamol infusion in every 6 hours postoperatively. Pediatric PNL was performed through 24F access sheath and 14 F nephrostomy chatheter was placed at the end of the procedure to all patients. Patients’ pain scores were evaluated at postoperative 15 minutes, 30 minutes, 1 hour, 6 hours and 24 hours. For pain scoring FLACC Scale (Face, Legs, Activity, Cry, Consolability) was assessed in every patient where FPS (FACES Pain Score-Revised) scale was just used in patients 8 years and older. Patients with pain scores 4 and up recieved additional meperidine 1 mg/kg i.m. as rescue analgesic. Pain scores over 7 were categorized as severe pain. Two groups were compared regarding their demographic data, stone size, stone number, operation lenght, hospitalization lenght, pain scores, presence of severe pain, analgesic manuplation and repetitive doses, drug related side effects, complications and analgesic satisfaction. Groups were founded to be similar according to demographic data, stone characteristics and operation related variables. Pain after PNL founded to be decreasing in time but the decrease rate in LA group was distinctive. Between LA and control groups there was no significant difference in pain scores (FLACC and FPS) except 24th hour, where the LA group found to be favorable (p=0.023 for FLACC, p=0.024 for FPS). Also severe pain presence was insignificant between groups (p=0,726). The rescue analgesic need was significantly less in LA group (p=0.040). Although the need for rescue analgesic was typically seen in first 15 minutes, there was no diffrence regarding analgesic administration in postoperative 15 minutes (p=0.061). Patients in control group received total number of 23 doses of rescue analgesic as LA group received 12 doses causing a marked difference (p=0.018). According to need for repetitive analgesic dose, the LA group was founded to be more advantageous (p=0.017), as there were no child needing 2nd dose of rescue analgesic in LA group. Two groups were founded to be similar regarding drug related side effects. The postoperative analgesic satisfaction of patients’ at 24th hour was favourable in LA group (p=0.002). In pediatric PNL preemptive use of LA infiltration reduces postoperative pain, the need for analgesics, the number analgesics used and also improves patients’ comfort and analgesic satisfaction.İÇİNDEKİLER Sayfa No: TEŞEKKÜRLER i ÖZET ii ABSTRACT iii İÇİNDEKİLER iv SİMGELER VE KISALTMALAR vi ŞEKİLLER DİZİNİ vii TABLOLAR DİZİNİ viii 1. GİRİŞ 1 1.1. AMAÇ 1 1.2. HİPOTEZ 2 2. GENEL BİLGİLER 3 2.1. TEMEL BİLGİLER 3 2.1.1. Üriner Sistem Taş Hastalığı 3 2.1.2. Böbrek Anatomisi 4 2.1.3. Ağrı Oluşum Mekanizması ve Analjezi 7 2.1.4. Lokal Anestezikler 8 2.2. KLİNİK BİLGİLER 9 2.2.1. Taş Hastalığının Medikal Tedavisi 9 2.2.2. ESWL (Extracorporeal Shock Wave Lithotripsy) Tedavisi 10 2.2.3. Üreterorenoskopi 11 2.2.4. Perkütan Nefrolitotomi 11 2.2.5. Açık ve Laparoskopik Cerrahi 16 2.2.6. Ağrının Değerlendirilmesi ve Ağrı Ölçütleri 16 3. OLGULAR VE YÖNTEM 19 3.1. YÖNTEM 19 3.2. İSTATİSTİK 21 4. BULGULAR 22 4.1. DEMOGRAFİK VERİLER 22 4.1.1. Taş Boyutu, Taş Sayısı, Ameliyat Süresi, Hospitalizasyon Süresi, ES Replasmanı Verileri 22 4.2. FLACC VE FPS SKORLARI 23 4.3. KURTARICI ANALJEZİK UYGULAMALARI 25 4.4. İLAÇLARA BAĞLI YAN ETKİLER 27 4.5. ANALJEZİ MEMNUNİYETİ 28 5. TARTIŞMA 29 5.1. GENEL 29 5.2. PNL TEKNİĞİNDEKİ GELİŞMELER VE MİNİMAL İNVAZİV YAKLAŞIM 30 5.3. TÜPSÜZ PNL 32 5.4. PREEMPTİF ANALJEZİ 35 5.5. PNL’DE LA UYGULAMALARI 37 5.6. ÇOCUK HASTALARDA LA UYGULAMASININ GÜVENİRLİLİĞİ 38 5.6.1. Çalışmanın Özgün Yönleri 39 5.6.2. Çalışmanın Kısıtlılıkları 39 6. SONUÇLAR 40 7. KAYNAKLAR 41Perkütan nefrolitotomi (PNL) uygulanan çocuk hastalarda cerrahinin ve ameliyatta konan diversiyonun neden olduğu ağrı ve rahatsızlığı önlemek ve bu alanda preemptif lokal anesteziklerin (LA) etkinliğini gözlemlemek üzere Şubat 2015 – Şubat 2017 tarihleri arasında nefrolitiyazis sebebiyle PNL uygulanan 40 çocuk hasta ve 42 renal ünite çalışmaya dahil edilmiştir. PNL’de renal giriş öncesi, çalışma kanalı boyunca 2 mg/kg dozunda %0,2’lik prilokain ve 2 mg/kg dozunda %0,5’lik bupivakain enjeksiyonu yapılanlar LA grubunu, işlem sırasında ilaç uygulanmayanlar ise kontrol grubunu oluşturmuştur. Tüm hastalara aynı anestezi protokolü uygulanmış ve tüm hastalara postoperatif 6 saatte bir 15 mg/kg dozunda parasetamol infüzyonu uygulanmıştır. Pediyatrik PNL 24F çalışma kılıfı üzerinden uygulanmış olup tüm hastalara işlem bitiminde 14 F nefrostomi kateteri konulmuştur. PNL sonrasında tüm hastaların 15. dakika, 30. dakika, 1. saat, 6. saat ve 24. saatte ağrı skorları değerlendirilmiştir. Tüm hastalara FLACC (Face, Legs, Activity, Cry, Consolability) ağrı skorlaması yapılırken 8 yaş ve üzeri hastalara ek olarak FPS (FACES Pain Score-Revised) ölçeği uygulanmış ve çocukların ağrıları değerlendirilmiştir. Ağrı skoru 4 ve üzeri olan hastalara ek kurtarıcı analjezik olarak meperidin 1mg/kg i.m. uygulanmıştır. Ağrı skoru>7 olan hastalar şiddetli derecede ağrı duymakta olarak sınıflandırılmıştır. İki grup demografik özellikleri, taş boyutu, taş sayısı, ameliyat süresi, yatış süresi, ağrı skorları, şiddetli derecede ağrı varlığı, analjezik uygulamaları ve tekrar sayısı, ilaç ilişkili yan etkiler, komplikasyonlar ve postoperatif ilk 24 saatteki analjezik memnuniyeti açısından karşılaştırılmıştır. Gruplar arasında demografik veriler, taş özellikleri ve operasyon ilişkili değişkenler açısından fark izlenmemiştir. Tüm hastalarda PNL sonrasında ağrının zamanla azaldığı fakat LA grubundaki azalma hızının daha belirgin olduğu bulunmuştur. LA ile kontrol grubu arası ağrı skorları (FLACC ve FPS değerleri) postoperatif 24. saat hariç benzer bulunmuştur. 24. saatte LA grubunun ağrı açısından belirgin avantajlı olduğu saptanmıştır (FLACC için p=0,023, FPS için p=0,024). Şiddetli derece ağrı açısından gruplar arası fark gösterilememiştir (p=0,726). LA uygulanan grupta istatistiksel olarak anlamlı ölçüde daha az kurtarıcı analjezik ihtiyacı gözlenmiştir (p=0,040). Kurtarıcı analjezik ihtiyacı en sık ilk 15. dakikada gözlense de gruplar arası analjezik uygulamaları açısından postoperatif 15. dakikada fark yoktur (p=0,061). Kontrol grubundaki hastalara toplam 23 doz, LA grubundakilere toplam 12 doz kurtarıcı analjezik uygulanmıştır ve bu fark istatistiksel olarak anlamlıdır (p=0,018). Tekrar eden analjezik dozu ihtiyacı değerlendirildiğinde LA grubu belirgin olarak avantajlı bulunmuş (p=0,017). LA uygulanan çocuklarda hiç 2. doz kurtarıcı analjezik ihtiyacı olmadığı gözlenmiştir. İki grup arası ilaç ilişkili yan etkiler açısından fark gözlenmemiştir. Postoperatif 24. saatteki analjezi memnuniyeti gruplar arası değerlendirildiğinde LA grubu belirgin avantajlıdır (p=0,002). Çocuk hastalarda PNL’de uygulanan preemptif LA uygulaması postoperatif ağrıyı, analjezik ihtiyacını ve uygulama sayısını azaltır, hasta konforu ve analjezi memnuniyetini arttırır

Subacromial tenoxicam injection in the treatment of impingement syndrome

Objectives: As subacromial bursa injection is widely used for pain relief and functional improvements in patients with periarticular shoulder disorder, we aimed to present our results of subacromial tenoxicam injection in the treatment of impingement syndrome