Publications by authors named "Mevlana Derya Balbay"

67 Publications

Genitalia Preserving Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation in the Female: Experience in 5 Cases.

Robot Surg 2021 28;8:1-7. Epub 2021 Apr 28.

Koç University, School of Medicine, Department of Urology, Istanbul, Turkey.

We present operative, postoperative, oncologic and functional outcomes of genital tract sparing robot-assisted laparoscopic radical cystectomy, bilateral extended pelvic lymph node (LN) dissection and intracorporeal Studer pouch construction on five female patients with bladder cancer. One of the cases had concomitant nephroureterectomy performed due to a non-functioning kidney. Median patient age, mean operation time, median estimated blood loss and mean duration of hospital stay were 59 (39-78), 462 ± 25, 400 (50-970), 8.8 ± 2.5, respectively. Pathologic stages were pTis (n=1), pT1 (n=1), pT3 (n=1), pT4a (n=1) and pT4b (n=1). Mean LN yield was 32.4 ± 8.9. Positive surgical margins were detected in 2 patients with pT4 diseases. Only minor complications developed that were resolved with medical treatment. Two patients had no, 1 patient had mild, and 2 patients had moderate daytime incontinence. One patient had good, 3 patients had fair, and 1 had poor night-time incontinence. This complex robotic surgery can be performed safely with acceptable short-term surgical, oncological and functional outcomes.
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http://dx.doi.org/10.2147/RSRR.S300598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8092426PMC
April 2021

The clinical impact of Prostate Imaging-Reporting and Data System classification in patients with haemospermia undergoing multiparametric magnetic resonance imaging of the prostate.

Andrologia 2021 Jun 10;53(5):e14041. Epub 2021 Mar 10.

Department of Urology, VKF American Hospital, Istanbul, Turkey.

In this study, we evaluated the role of the Prostate Imaging-Reporting and Data System (PI-RADS) classification of multiparametric magnetic resonance imaging (mpMRI) to determine the likelihood of prostate cancer (PCa) in patients with haemospermia. Fifty-one patients presenting with haemospermia between 2018 and 2020 were included in this retrospective study. Forty-two of the patients (82.4%) were over 40 years, and the median prostate-specific antigen (PSA) level was 1.4 ng/ml. Fourteen of the patients (27.5%) had recurrent haemospermia. All patients underwent mpMRI, and assessments were classified according to PI-RADS v2. The mpMRI revealed PI-RADS one to four lesions in 10 (19.6%), 30 (58.8%), 6 (11.8%) and 5 (9.8%) patients respectively. One patient with PI-RADS 3 and five with PI-RADS 4 lesions underwent cognitive fusion prostate biopsy depending on MRI findings, and two patients with PI-RADS 4 lesions were diagnosed with PCa. Patients with haemospermia and risk factors, that is aged over 40 years, a high PSA level or familial history of PCa, need a more thorough evaluation with mpMRI.
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http://dx.doi.org/10.1111/and.14041DOI Listing
June 2021

Ga-PSMA-11 Positron Emission Tomography/Computed Tomography for Primary Lymph Node Staging Before Radical Prostatectomy: Central Review of Imaging and Comparison with Histopathology of Extended Lymphadenectomy.

Eur Urol Focus 2021 Mar 25;7(2):288-293. Epub 2021 Jan 25.

Department of Urology, Koc University Hospital, Istanbul, Turkey; Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

Background: Results from prospective trials have shown higher accuracy of prostate-specific membrane antigen (PSMA)-based positron emission tomography (PET)/computed tomography (CT) in detection of lymph node metastasis (LNM) compared to conventional imaging.

Objective: To evaluate the accuracy of Ga-PSMA-11 PET/CT for LNM detection in patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (PLND).

Design, Setting, And Participants: Between June 2014 and November 2020, 96 patients with Ga-PSMA PET/CT for primary staging underwent RP and extended PLND.

Outcome Measurements And Statistical Analysis: The results from Ga-PSMA PET/CT were compared with histologic data from primary PLND in 96 patients. All Ga-PSMA PET/CT scans were centrally reviewed.

Results And Limitations: Of 96 patients, 15.6% (n = 15) harbored LNMs. The median prostate-specific antigen at Ga-PSMA PET/CT was 8.0 ng/ml (interquartile range 5.5-11.7). The majority of patients had intermediate- (52.1%) or high-risk disease (41.7%). Biopsy grade group 4 and 5 was present in 22.9% and 15.6%, respectively. The Ga-PSMA PET/CT scans identified eight of 15 patients (53.3%) as LN-positive (true positive). The calculated per-patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of Ga-PSMA PET/CT in the detection of LNM were 53.3%, 98.8%, 88.9%, 92.0%, and 91.7%, respectively. The per-patient sensitivity and specificity in the detection of LNMs larger than 2 mm were 61.5% and 98.8%, respectively. The main limitation is the retrospective design of the study.

Conclusions: Ga-PSMA PET/CT is accurate in lymph node staging and the results support its use for primary staging of prostate cancer.

Patient Summary: We compared prostate-specific membrane antigen (PSMA)-based positron emission tomography (PET)/computed tomography (CT) findings with histopathology results after extended lymph node dissection and showed that it is accurate in detecting lymph node metastases. Our results support the use of PSMA PET/CT for primary staging of prostate cancer.
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http://dx.doi.org/10.1016/j.euf.2021.01.004DOI Listing
March 2021

Outcomes and complications of radical cystectomy with ileal conduit urinary diversion: A comparison between open, semi-robotic and totally robotic surgery.

Int J Med Robot 2021 Jun 25;17(3):e2221. Epub 2021 Jan 25.

Department of Urology, Ankara City Hospital, Ankara, Turkey.

Background: It was aimed to compare open versus robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (ICIC), versus RARC with extracorporeal ileal conduit (ECIC) formation for bladder cancer.

Materials And Methods: Open, RARC-ECIC and RARC-ICIC groups were compared in terms of patient demographics, operative and postoperative parameters, pathological parameters, complications and functional outcomes.

Results: Mean operative times were lower in the RARC-ECIC group (p = 0.004). Mean estimated blood loss was significantly lower (p < 0.01) in the robotic groups. The blood transfusion was lower in RARC-ICIC groups (p < 0.001). Rates of stage pT3-4 disease were the highest in the RARC-ICIC group (p = 0.004). LOS was significantly shorter in the RARC-ICIC group (p = 0.01). Numbers of Clavien 3-5 complications were lower in the robotic groups (p = 0.012).

Conclusions: RARC and ICIC is a complex procedure involving an increased operation time but with the advantages of lower estimated blood loss, transfusion rates, complications and hospital stays compared with open surgery.
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http://dx.doi.org/10.1002/rcs.2221DOI Listing
June 2021

Robot Assisted Radical Cystectomy Outcomes in Micropapillary and Plasmacytoid Variants.

Urol J 2020 Nov 23;17(6):607-613. Epub 2020 Nov 23.

Department of Urology, School of Medicine, Koç University, Istanbul, Turkey.

Purpose: To compare the patients who underwent robot assisted radical cystectomy (RARC) and extended pelvic lymph node dissection (EPLND) and whose pathology result was reported as micropapillary variant (MV), plasmacytoid variant (PV) and pure urothelial carcinoma (PUC).

Materials And Methods: The data of 133 patients who underwent RARC and EPLND with the postoperative pathology results reported as MV, PV and PUC were analyzed. According to the postoperative pathology results, patients were divided into two groups in initial analyses as variant pathologies group (n=14) and PUC group (n=119). In secondary analyses, patients were divided into three groups as MV group (n=7), PV group (n=7) and PUC group (n=119). The operative data, oncologic outcomes and complications were compared between the groups.

Results: Median operation time and estimated blood loss were significantly increased in variant pathologies group (P <0.001 and P = .001, respectively). The postoperative pathological T stage, positive surgical margin rate and lymph node involvement were also significantly increased in variant pathologies (P = .001, P = 0.004, P <0.001, respectively). Kaplan-Meier analysis revealed significant decrease in OS and CSS times in PV group compared to PUC group (P = .048 and P = .016, respectively).

Conclusion: MV and PV are rarely seen variant pathologies with higher pathological T stages. RARC is a minimally invasive surgical technique that can be performed successfully by an experienced surgical team with low morbidity rates and similar oncological results, even in challenging cases.
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http://dx.doi.org/10.22037/uj.v16i7.6446DOI Listing
November 2020

Feasibility, safety and efficacy of argon beam coagulation in robot-assisted partial nephrectomy for solid renal masses ≤ 7 cm in size.

J Robot Surg 2020 Oct 13. Epub 2020 Oct 13.

Department of Urology, School of Medicine, Koç University, 34010, İstanbul, Turkey.

One of the most important steps of the partial nephrectomy (PN) is hemostatic control of tumor bed which also effects the warm ischemia time (WIT). Argon beam coagulation (ABC) for decades is a well-known method for surface controls during major open surgical sites. This study aimed to compare peri- and postoperative relevant parameters in patients with ABC or internal renorrhaphy (IR) during robot-assisted partial nephrectomy (RAPN). One hundred seventy patients with ≤ 7 cm tumors, who underwent RAPN at our institutions, were included in this retrospective study. Tumor bed was controlled by either IR or by ABC after closing isolated overt collecting system defects. No additional IR was performed in patients with ABC. Estimated blood loss (EBL), WIT, estimated glomerular filtration rate (eGFR) change, on- vs. off-clamp procedure as well as Clavien-Dindo > 2 complications in both groups were compared. Eighty-seven (51.1%) patients had ABC and 83 (48.9%) had IR as their tumor bed control method. Tumor size, side and RENAL nephrometry score in both groups were similar. Mean warm ischemia time (WIT) was 20.8 min in ABC group and 23.8 min in IR group (p = 0.03). In 4-7 cm tumors, WIT was 19.9 min in ABC group while 26.6 min in IR group (p = 0.026). eGFR change from baseline and EBL favored ABC in entire cohort as well as in 4-7 cm tumors with statistical significance. There were more off-clamp procedures with ABC in ≤ 4 cm tumors. No ABC specific complications were observed. Within 2 years of follow-up, no patient developed recurrences. The control of the tumor base with ABC during RAPN shortens the warm ischemia times significantly compared to IR. Besides, ABC had better EBL and GFR changes outcomes. With close monitoring of intra-abdominal pressure and frequent venting, disturbing complications of ABC could completely be avoided. ABC was found to be feasible, safe and effective during RAPN.
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http://dx.doi.org/10.1007/s11701-020-01158-4DOI Listing
October 2020

Serving as a bedside surgeon before performing robotic radical prostatectomy improves surgical outcomes.

Int Braz J Urol 2019 Nov-Dec;45(6):1122-1128

Department of Urology, American Hospital, Koc University, Turkey.

Introduction: To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy.

Materials And Methods: The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate.

Results: Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant.

Conclusion: Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2019.0330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6909862PMC
January 2020

Intracorporeal Studer Pouch Formation with Balbay's Technique Following Robotic Radical Cystectomy for Bladder Cancer: Experience with 22 Cases with Oncologic and Functional Outcomes.

J Endourol 2020 03 3;34(3):273-280. Epub 2020 Mar 3.

Department of Urology, School of Medicine, Koç University, Istanbul, Turkey.

Robot-assisted radical cystectomy (RARC) with intracorporeal Studer pouch formation (ICSPF) is increasingly being performed. Balbay's technique of ICSPF replicates the open approach with the additional advantages of inserting internal Double-J stents. Between June 2011 and April 2019, 22 patients with muscle-invasive bladder cancer were included who underwent RARC and ICSPF with Balbay's technique. Mean follow-up was 35.7 months. Operative, postoperative, and pathological measures, complications, and oncologic and functional outcomes were evaluated. Mean operation time, estimated blood loss, mean lymph node yield, and mean duration of hospital stay were 9.2 hours, 361.4 mL, 38.6, and 10.5 days, respectively. Surgical margins were positive in 3 (9.1%) patients. Postoperative pT stages included pT0 ( = 4), pTis ( = 4), pT1 ( = 2), pT2 ( = 1), pT3a ( = 3), pT3b ( = 5), and pT4a ( = 3). Daytime continence outcomes were (patients with ≥1-year follow-up,  = 17) as follows: 10 (58.8%) fully continent, 4 (23.5%) mild, and 3 (17.7%) moderate incontinence. Two-year cancer-specific survival, overall survival, and recurrence-free survival were 68.6%, 66.0%, and 69.7%, respectively. The retrospective nature of the study was the main limitation. Complications (modified Clavien-Dindo classification,  = 32) included 23 minor and 2 major during the perioperative (0-30 days) period and 3 minor and 4 major during the postoperative (31-90 days) period. Ileus developed in 3 patients (9.3%). Readmission rates were 3 (13.6%) and 8 (36.4%) in perioperative and postoperative periods, respectively. RARC and ICSPF by Balbay's technique have acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results with additional advantages of exclusion of external stents, exact replication of the open approach, and fewer gastrointestinal complications.
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http://dx.doi.org/10.1089/end.2019.0559DOI Listing
March 2020

Distal ureteral stone formation over migrated Hem-o-lok clip after robot-assisted partial nephrectomy.

Int J Surg Case Rep 2019 30;58:201-204. Epub 2019 Mar 30.

Department of Urology, Koc University, School of Medicine, Istanbul, Turkey.

Introduction: Hem-o-lok clip migration into the ipsilateral collecting system and formation of a distal ureteral stone after robot-assited partial nephrectomy (PN) is a rare condition of stone disease.

Presentation Of Case: A 48-year-old male presented with hematuria. Physical examination was unremarkable. Urinalysis showed presence of red blood cells. Serum multiple analysis and ultrasonography were within normal limits. Contrast enhanced abdominal computerized tomography scan revealed an 8-mm right distal ureteral stone, which was not associated with ipsilateral hydronephrosis.

Discussion: With the widespread adoption of minimally invasive surgery, it is not uncommon to utilize foreign bodies as surgical facilitators which also have the potential to migrate to the urothelium-lined urinary tract and act as a stone nidus when used for endoscopic PN CONCLUSION: Clinicians should be aware of the possibility of migrated hem-o-lok clips serving as a nidus for urinary tract stone formation in patients who have undergone endoscopic PN.
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http://dx.doi.org/10.1016/j.ijscr.2019.03.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6514724PMC
March 2019

Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation for Bladder Cancer: Experience in Ninety-Eight Cases.

J Endourol 2019 05 30;33(5):375-382. Epub 2019 Mar 30.

2 Department of Urology, School of Medicine, Koç University, Istanbul, Turkey.

To report the outcomes of robot-assisted radical cystectomy (RARC) with bilateral extended pelvic lymph node dissection (BEPLND) and intracorporeal Studer pouch formation for bladder cancer. Overall 98 patients (92 males, 6 females) were included. Patient demographics, operative and postoperative variables, pathological parameters, complications, and functional outcomes were evaluated. Mean age and American Society of Anesthesiologists score and body mass index were 60.9 years, 1.7 and 26 kg/m, respectively. Neoadjuvant chemotherapy was given to 18 patients. Mean operation time, intraoperative estimated blood loss, and mean lymph node (LN) yield were 8.22 hours, 314.6 mL, and 28.3, respectively. Mean hospitalization time was 13.6 days. There were one perioperative and one postoperative deaths, both due to cardiac arrest on postoperative 21st and 60th days. Drains were removed at a mean of 10 days. Surgical margins were positive in two patients. Postoperative pathological stages were reported as pT0 ( = 21), pTis ( = 7), pT1 ( = 7), pT2a ( = 14), pT2b ( = 14), pT3a ( = 15), pT3b ( = 11), and pT4a ( = 9). Positive LNs were found in 21 patients. Prostate cancer was incidentally detected in 23 patients. Twenty-five patients received adjuvant chemotherapy. At a mean follow-up period of 25.1 months, 13 patients died from metastatic disease and 7 from cardiac disease. According to the modified Clavien-Dindo system, 30 minor and 20 major complications were identified in the perioperative (0-30 days) period, and 6 minor and 7 major complications were detected in the postoperative (31-90 days) period. According to the available data of the 60 patients, 37 were fully continent, 14 had mild, 6 had moderate, and 4 had severe daytime incontinence. Due to our experience, RARC with BEPLND and intracorporeal Studer pouch reconstruction procedures are complex procedures with acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results.
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http://dx.doi.org/10.1089/end.2019.0036DOI Listing
May 2019

Does Type 2 Diabetes Mellitus Have an Impact on Postoperative Early, Mid-Term and Late-Term Urinary Continence After Robot-Assisted Radical Prostatectomy?

J Endourol 2019 03 13;33(3):201-206. Epub 2019 Feb 13.

2 Department of Urology, School of Medicine, Koc University, Istanbul, Turkey.

Objective: We evaluated the effect of diabetes mellitus (DM) on urinary continence after robotic radical prostatectomy (RARP).

Patients And Methods: Overall, 99 patients with DM and 213 patients without DM who underwent RARP with at least 2-year follow-up were included. The preoperative prostate biopsy Gleason scores and clinical stages of the groups were similar. The patients who were dry or used one safety pad per day were regarded as continent. Early (0-3 months), mid-term (4-12 months), and late-term (>12 months) continence rates were evaluated.

Results: In diabetic and nondiabetic groups, mean age was 63.3 ± 6.5 and 61.3 ± 6.8 years, respectively (p = 0.015). On the day of the removal of the urethral catheter, 61.6% (n = 61) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At third-month follow-up, 80.8% (n = 80) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At sixth-month follow-up, 89.9% (n = 89) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At first-year follow-up, 93.9% (n = 93) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.001). At 18th-month follow-up, 96.0% (n = 95) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.013). At second-year follow-up, 98.0% (n = 97) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.115). Multivariate analysis showed that age and body mass index had no impact on urinary continence (p > 0.05). Presence of diabetes (p = 0.008) and duration (≥5 years) of diabetes (p = 0.004) were independent factors that had a significant negative impact on urinary continence.

Conclusions: Diabetes seems to be a significant disadvantage in gaining urinary continence compared with nondiabetic patients particularly in the first 18 months after RARP. Diabetic patients should be informed about possible late recovery of postoperative urinary continence compared with nondiabetic patients after RARP.
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http://dx.doi.org/10.1089/end.2018.0822DOI Listing
March 2019

The 14 international prostate forum.

Asian J Androl 2018 Dec 7. Epub 2018 Dec 7.

Koç University, School of Medicine, Department of Urology, Istanbul 34365, Turkey.

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http://dx.doi.org/10.4103/aja.aja_108_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6337951PMC
December 2018

Does the experience of the bedside assistant effect the results of robotic surgeons in the learning curve of robot assisted radical prostatectomy?

Int Braz J Urol 2019 Jan-Feb;45(1):54-60

American Hospital, Istanbul, Turkey.

Introduction: The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP.

Materials And Methods: We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately.

Results: There were no significant differences between the groups in terms of age, co-morbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min , p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively).

Conclusion: Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442128PMC
June 2019

Minimally Invasive Management of Zinner's Syndrome with Same-Session Robot-Assisted Seminal Vesiculectomy and Ipsilateral Nephroureterectomy Using a Single Geometry of Trocars.

J Endourol Case Rep 2018 7;4(1):186-189. Epub 2018 Nov 7.

Department of Urology, Koc University, Istanbul, Turkey.

Seminal vesicle cyst is an extremely rare condition, which is frequently congenital and associated with Zinner's syndrome. This syndrome represents a constellation of seminal vesicle cyst, ipsilateral or contralateral renal agenesis or renal dysplasia, ureteral ectopia, and ejaculatory duct obstruction. We report a young symptomatic patient undergoing robot-assisted laparoscopic excision of a huge seminal vesicle cyst during which an atrophic ipsilateral kidney was discovered incidentally and managed by nephroureterectomy in the same session without changing trocar positions. A 23-year-old male patient presented with a 2-year history of lower urinary tract symptoms, perineal pain, and recurrent urinary tract infections. Ultrasonography revealed the absence of left kidney and a fluid-filled cystic lesion located behind the bladder on the left side, which was consistent with cystic dilatation of the left seminal vesicle. MRI confirmed the diagnosis of a huge cystic structure originating from the left seminal vesicle and identified the presence of a rudimentary left ureter without an associated renal unit. Cystoscopy revealed bulging of the bladder neck at 6 o'clock position and the ureteral orifices at normal positions and configurations. Based on these findings, the clinical diagnosis was established as Zinner's syndrome. The present case was performed by Da Vinci Si robotic platform using the 5-trocar technique. Robot-assisted laparoscopic excision is a safe and feasible option to treat large seminal vesicle cysts, which may be a component of Zinner's syndrome. Simultaneous upper urinary tract interventions, such as nephroureterectomy, can be employed by redocking the robot and repositioning the patient, using the same layout of robotic trocars.
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http://dx.doi.org/10.1089/cren.2018.0066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6222210PMC
November 2018

Testis-sparing surgery: Experience in 13 patients with oncological and functional outcomes.

Can Urol Assoc J 2019 Mar 30;13(3):E83-E88. Epub 2018 Aug 30.

Koc University, School of Medicine, Department of Urology, Istanbul, Turkey.

Introduction: We present oncological and functional outcomes of patients who underwent testis-sparing surgery (TSS).

Methods: Overall, 13 patients were included. Mean patient age was 29.9±12.5 years. In five patients, TSS was performed for sequential bilateral testicular tumours. One patient underwent concurrent left radical orchiectomy and right TSS. In eight patients with normal contralateral testis, seven underwent left and one underwent right TSS.

Results: Mean pathological tumour size was 14.6±12.5 mm. Intraoperative frozen section evaluation of the mass was performed in eight patients that revealed benign lesions. No intraoperative tumour bed biopsies were taken in this patient group. Regarding the remaining five patients, intraoperative tumour bed biopsies were taken and testicular intraepithelial neoplasia (TIN) was reported in two (40%) patients; no local testicular radiotherapy was given postoperatively. Tumour pathology was malignant in all but one lesion, including Leydig cell tumour (n=1), seminoma(n=2), embryonal carcinoma (n=1), and adenomatoid tumour (n=1). During 47.2±22.5 months of followup, local recurrence was detected in one patient who underwent radical orchiectomy. No additional local recurrence or systemic metastasis was identified in other patients with malignant lesions. For patients with malignant tumours, of the three patients with a normal preoperative testosterone levels, testosterone level was normal in one patient (with no erectile dysfunction [ED]) and was decreased in two patients (with ED) following TSS. No ED was reported in the nine patients with benign lesions.

Conclusions: In carefully selected cases, TSS appears to be a safe, feasible procedure with adequate cancer control that could preserve sexual function.
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http://dx.doi.org/10.5489/cuaj.5379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395103PMC
March 2019

Robot-assisted radical cystectomy: patient selection and special considerations.

Robot Surg 2017 19;4:101-106. Epub 2017 Oct 19.

Department of Urology, School of Medicine, Ankara Ataturk Training and Research Hospital, Yildirim Beyazit University, Ankara, Turkey.

Robot-assisted (RA) procedures are increasingly being performed as minimally invasive surgical approaches. Less insensible losses due to a closed abdomen, smaller incisions with less retractor strain, decreased analgesic requirements, and earlier postoperative ambulation are suggested advantages of robot-assisted radical cystectomy (RARC). Patients who undergo open radical cystectomy are also candidates for RARC procedure. However, the steep Trendelenburg position and pneumoperitoneum develop a non-physiological condition. Intra-abdominal adhesions preventing the placement of the ports and patients who cannot tolerate the pneumoperitoneum and/or steep Trendelenburg position are special contraindications of RARC. Besides, body mass index >30 kg/m, presence of extravesical disease, bulky lymphadenopathy, previous vascular surgery, previous distal colorectal surgery, previous pelvic radiation, previous pelvic trauma, and/or preexisting cardiovascular/pulmonary disease that is compromised with positioning are not certainly contraindicated but unwanted conditions in which the RARC may be performed successfully as the surgeons gain experience.
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http://dx.doi.org/10.2147/RSRR.S119858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193425PMC
October 2017

Is testis-sparing surgery safe in small testicular masses? Results of a multicentre study.

Can Urol Assoc J 2017 Mar-Apr;11(3-4):E100-E104. Epub 2017 Mar 16.

Memorial Sisli Hospital, Istanbul, Turkey.

Introduction: Our goal was to evaluate benign and malignant lesions and testicular intraepithelial neoplasia (TIN) in the neighbouring normal-appearing testis tissue in men who underwent radical orchiectomy for testicular mass with a pathologic tumour size of ≤3cm.

Methods: In this retrospective, multicentre study, data of 252 patients from 11 different institutions were included. Patients were divided into three groups based on tumour size: Group 1 (0-1 cm; n=35), Group 2 (1.1-2cm; n=99), and Group 3 (2.1-3 cm; n=118). Benign lesions and TIN were sought in the neighbouring testicular tissue and compared between groups.

Results: Mean patient age was 32.3 years. Benign lesions were reported in 54.3%, 33.3%, and 14.4% of Groups 1, 2, and 3, respectively (p<0.05 between groups). TIN was detected in 20%, 42.4%, and 41.5% of Groups 1, 2, and 3, respectively (p<0.05 for Group 1 vs. Groups 2 and 3; p>0.05 for Groups 2 vs. 3). Multifocality was detected in 8.6%, 4%, and 0% of Groups 1, 2, and 3, respectively (p<0.05 for both Group 1 vs. Group 3 and for Group 2 vs. Group 3; p>0.05 for Group 1 vs. Group 2). A tumour cutoff size of 1.5 cm was found to be significant for detecting benign tumour. TIN and multifocality rates were similar in patients with a tumour size of ≤1.5 vs. >1.5 cm (p>0.05).

Conclusions: Benign lesions and TIN in the neighbouring testis were significantly decreased and multifocality was increased in patients with a tumour mass size of ≤1 cm. Testis-sparing surgery should be performed with caution and a safety rim of normal tissue should also be excised.
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http://dx.doi.org/10.5489/cuaj.4016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5365384PMC
March 2017

Authors's reply to "Preventing atelectasia at robotic surgery".

Braz J Anesthesiol 2017 Mar - Apr;67(2):225. Epub 2016 Jul 16.

Ankara Ataturk Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey.

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http://dx.doi.org/10.1016/j.bjane.2016.06.002DOI Listing
July 2016

Removing the specimen with traction during robotic radical prostatectomy does not cause a positive surgical margin.

Turk J Med Sci 2016 Dec 20;46(6):1655-1657. Epub 2016 Dec 20.

Department of Urology, Memorial Şişli Hospital, İstanbul, Turkey.

Background/aim: The aim of this study was to gauge whether removal of a specimen with traction during robot-assisted laparoscopic radical prostatectomy causes a positive surgical margin or not.

Materials And Methods: One hundred and sixty-nine patients with localized prostate cancer who underwent robot-assisted laparoscopic radical prostatectomy from 2009 to 2011 were included in the study. After dividing the patients into two groups, we recorded their characteristics and pre-op/post-op evaluations.

Results: There were 111 and 58 patients in groups 1 (with traction) and 2 (without traction), respectively. We evaluated the patients' ages, follow-up time, body mass index (BMI), prostate-specific antigen (PSA) values, pre-op and post-op Gleason score values, pathological stage, positive surgical margin rates, and biochemical PSA recurrence rates. There was no statistically significant difference between the groups for age, pre-op PSA values, BMI, pre-op and post-op Gleason scores, positive surgical margin rates and biochemical recurrence rates. There was a significant difference between prostate weight, tumor volume, and clinical stage.

Conclusion: Removing the specimen with traction during robot-assisted laparoscopic radical prostatectomy does not cause a positive surgical margin. The incision should be as small as possible for cosmetic appearance.
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http://dx.doi.org/10.3906/sag-1503-21DOI Listing
December 2016

[Authors's reply to "Preventing atelectasia at robotic surgery"].

Rev Bras Anestesiol 2017 Mar - Apr;67(2):225. Epub 2016 Dec 28.

Ankara Ataturk Training and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turquia.

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http://dx.doi.org/10.1016/j.bjan.2016.06.004DOI Listing
October 2018

Impact of robotic partial nephrectomy with and without ischemia on renal functions: experience in 34 cases.

Turk J Urol 2016 Dec;42(4):272-277

Department of Urology, Memorial Şişli Hospital, İstanbul, Turkey.

Objective: In this study we aimed to compare renal functions in patients who underwent robotic partial nephrectomy (RPN) with on-clamp and zero- ischemia techniques.

Material And Methods: Between 2009 and 2015, 12 off-clamp and 22 on-clamp RPN procedures were performed on a total of 34 patients in two centers. The main outcome parameters examined were serum creatinine, and estimated glomerular filtration rate (eGFR) during preoperative, immediate postoperative periods, and at postoperative 3 months.

Results: There were no statistically significant differences between on-clamp and zero- ischemia groups regarding age, ASA score, BMI, PADUA and R.E.N.A.L. nephrometry scores, operation time and tumor size (p>0.05). Significant differences were found in the duration of hospital stay (3.8±0.9 days vs. 3.0±0.9 days) and amount of blood loss (85.9±49.6 mL vs. 183.3±176.2 mL) between the on-clamp and zero-ischemia groups (p<0.05). Statistically significant differences were found between preoperative and immediate post-operative periods, in terms of eGFR and serum creatinine levels in both groups. Moreover, statistically significant differences were found between preoperative and postoperative 3 month periods, in the on-clamp group in terms of eGFR and serum creatinine levels. In the zero-ischemia group, the decrease in eGFR and serum creatinine levels at postoperative 3 month relative to the preoperative period was not statistically significant.

Conclusion: Off-clamp RPN technique is superior, in short-term outcomes involving renal functions, compared to on clamp approach. However, long- term data regarding the renal functions should be evaluated to arrive at a definitive decision.
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http://dx.doi.org/10.5152/tud.2016.67790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125742PMC
December 2016

Does steep Trendelenburg positioning effect the ocular hemodynamics and intraocular pressure in patients undergoing robotic cystectomy and robotic prostatectomy?

Int Urol Nephrol 2017 Jan 1;49(1):55-60. Epub 2016 Nov 1.

Department of Urology, Ankara Ataturk Education and Research Hospital, Ankara, Turkey.

Purpose: To examine the effect of steep Trendelenburg position (ST) on intraocular pressure (IOP), resistive index of the central retinal artery, and venous impedance index of the central retinal vein during robotic prostatectomy and cystectomy.

Methods: A total of fifty-three male patients were included into the study (prostatectomy: 43, cystectomy: 10). During robotic surgery, the effect of the ST on IOP, resistive index of the central retinal artery (CRA-RI), and venous impedance index of the central retinal vein (CRV-VI) was prospectively examined. The measurement times of IOP are as follows: T1: before anesthesia while supine and awake; T2: anesthetized and supine; T3: anesthetized and ST; T4: anesthetized, ST, and intraperitoneal insufflation; T5: anesthetized in ST at the end of the procedure with CO; T6: anesthetized in ST after desufflation; and T7: anesthetized supine before awakening.

Results: There was no difference between the IOP values of the right and left eyes in both groups. The highest IOP values were reached at T4 and T5. CRA-RI values were different, while CRV-VI values were similar at T1 and T4.

Conclusions: Despite staying in the ST for a long time provided that the ophthalmologic examination was normal, ocular complication risk is low in robotic prostatectomy and cystectomy.
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http://dx.doi.org/10.1007/s11255-016-1449-yDOI Listing
January 2017

The first recurrent intravascular papillary endothelial hyperplasia (Masson's tumor) of the kidney.

Turk J Urol 2016 Sep;42(3):202-5

Clinic of Urology, Memorial Şişli Hospital, İstanbul, Turkey.

Intravascular papillary endothelial hyperplasia (IPEH, Masson's Tumor) of the kidney is an unusual, benign vascular lesion. A rare case of recurrent IPEH in the kidney was presented in this article. A 50-year-old male with a diagnosis of a suspicious mass in the left kidney was referred to our center for robotic partial nephrectomy. Robotic zero ischemia partial nephrectomy was performed due to the suspicion of a renal malignancy. On the basis of the histopathological results, the patient was diagnosed as IPEH. A urinary ultrasound was performed on the 3(rd) postoperative month and a hyper echoic solid lesion, which was in the same localization, was detected. Due to the previous atypical pathological result, computed tomography (CT) guided fine-needle aspiration biopsy from the left renal mass was performed but malignant cytology was not confirmed with this biopsy. On follow-up CT done 6 months later, a persistent suspicious left renal mass, measuring 40 × 30 cm in size was detected with no change in its dimensions and appearance. Additionally, magnetic resonance imaging (MRI) scan revealed a bone lesion of 15 × 10 mm in the left hip, which was not present on previous MRI/CT scans. In view of the solid masses in the left kidney, and left hip on CT and MRI scan suspicious for a probably metastatic renal neoplasm, left radical nephrectomy via a left subcostal transperitoneal incision was performed. The ultimate pathological report of the patient was also supported the diagnosis of Masson's tumor and any renal malignancy was not encountered The patient was discharged on the 4(th) postoperative day and has been followed up for 4 months without any problems. In this case, we discuss the clinical features, histopathological characteristics, and the management of Masson's tumor of the kidney in the light of the current literature.
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http://dx.doi.org/10.5152/tud.2016.43789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012449PMC
September 2016

Robotic genitalia sparing female cystectomy.

Cent European J Urol 2016 6;69(2):233-4. Epub 2016 Apr 6.

Memorial Şişli Hospital, Department of Urology, Istanbul, Turkey.

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http://dx.doi.org/10.5173/ceju.2016.682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4986291PMC
August 2016

Does anterior prostatic fat tissue removed during robotic radical prostatectomy contain any lymph nodes?

Cent European J Urol 2015 21;68(4):410-4. Epub 2015 Dec 21.

Memorial Sisli Hospital, Department of Urology, Istanbul, Turkey.

Introduction: We investigated whether anterior periprostatic fat (APPF) tissue removed during robotic radical prostatectomy (RARP) contains any lymph nodes (LNs).

Material And Methods: APPF tissues removed during RARP in 129 patients were evaluated histopathologically. Correlation with postoperative pathologic stage was made. Patients with a history of previous prostate or bladder surgery and radiation therapy were excluded.

Results: Mean patient age, serum prostate specific antigen (PSA), prostate weight and body mass index (BMI) were 62.2 ±5.5 (range 45-74), 9.3 ±6.3 ng/dl (range 0.26-30.3), 60.3 ±27.2 grams (range 11.0-180) and 26.6 ±1.9 kg/m(2) (range 20.0-30.3), respectively. Overall, LNs in APPF tissues were detected in 14 (10.9%) patients with a mean LN yield of 1.1 ±0.7 LNs (range, 1-3). Among those found, no metastatic LN was detected. Of the patients with pT2a (n = 22), pT2b (n = 15), pT2c (n = 62) and pT3a (n = 21) disease, LNs in APPF tissues were detected in 1 (4.6%), 1 (6.7%), 11 (17.7%) and 1 (4.8%) patient in each group, respectively. Among the patients, LNs in APPF tissues were detected in 0 (0%), 5 (35.7%), 8 (57.1%) and 1 (7.1%) patients of underweight, optimal weight, overweight and obese patients due to body mass index, respectively.

Conclusions: In our series, LNs were detected in around 10% of the patients. Therefore, this fat should, not be pushed back during RARP but should be removed and sent for pathologic evaluation. Although no metastatic LN was detected in our series, the presence of metastatic LNs might have an impact on the oncologic outcomes of the patients and warrants further research.
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http://dx.doi.org/10.5173/ceju.2015.650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4742442PMC
February 2016

Robotic partial nephrectomy for clinical stage T1 tumors: Experience in 42 cases.

Kaohsiung J Med Sci 2016 Jan 31;32(1):16-21. Epub 2015 Oct 31.

Department of Urology, Memorial Sisli Hospital, Istanbul, Turkey.

The aim of this study was to evaluate outcomes of robotic partial nephrectomy (RAPN) procedures. At two centers, 42 patients underwent RAPN. Radius, Exo/Endophytic, Nearness, Anterior/Posterior, Location (R.E.N.A.L.) nephrometry and PADUA scores of patients were calculated by computed tomography (CT) or magnetic resonance imaging (MRI). Intra- and perioperative (0-30 days) complications were evaluated using modified Clavien classification. A four-arm da Vinci-S robotic surgical system was used and outcomes were evaluated retrospectively. Mean age of the patients was 52.3 ± 6.5 years. Mean tumor size was 3.1 ± 1.0 (1.4-6.6) cm. R.E.N.A.L. nephrometry and PADUA scores were 6.0 ± 1.5 and 7.5 ± 0.9, respectively. Mean surgical time was 127.7 ± 18.7 minutes and estimated blood loss was 100 ± 18.1 cc. Mean warm ischemia time was 16.0 ± 8.9 (0-30) minutes. Intraoperative complications did not develop in any patient. Median hospital stay was 3.0 (2-6) days. Except for 17 patients, hilar clamping was performed in 25 patients. Histopathology results included 34 renal cell carcinoma (22 clear cell, 7 chromophobe cell, 4 papillary cell, and 1 clear papillary cell). Oncocytoma (n = 4), adenoma (n = 1), fibroadipose tissue (n = 1), papillary epithelial hyperplasia (n = 1), and chronic pyelonephritis (n = 1) were present. Surgical margins were negative in all patients. During a median follow-up period of 15.5 ± 10.9 (3-46) months, neither local recurrence nor distant metastasis was detected. In conclusion, RAPN is a safe, minimally invasive surgical approach, with excellent surgical and oncological outcomes in T1 kidney tumors. Zero ischemia off-clamp RAPN is also safe in selected masses with the advantage of avoiding complete renal ischemia.
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http://dx.doi.org/10.1016/j.kjms.2015.09.008DOI Listing
January 2016

Flexible Ureteroscopy Can Be More Efficacious in the Treatment of Proximal Ureteral Stones in Select Patients.

Adv Urol 2015 4;2015:416031. Epub 2015 Nov 4.

Department of Urology, Memorial Şişli Hospital, Şişli, Istanbul, Turkey.

Purpose. We aimed to compare and evaluate the outcomes and complications of two endoscopic treatment procedures, semirigid ureteroscopy (SR-URS) and flexible ureteroscopy (F-URS), in the treatment of proximal ureteral stones (PUS). Methods. SR-URS (group 1) was done on 68 patients whereas 64 patients underwent F-URS (group 2) for the treatment of PUS. Success rate was defined as the absence of stone fragments or presence of asymptomatic insignificant residual fragments < 2 mm. Outcomes and complications were recorded. Results. The differences were statistically not significant in age, gender, body mass index (BMI), and stone characteristics between groups. Mean ureteral stone size was 9.1 ± 0.4 mm and 8.9 ± 0.5 mm for groups 1 and 2. Mean operative time was 34.1 ± 1.5 min and 49.4 ± 2.3 min for groups 1 and 2 (p = 0.001). SFRs were 76.5% and 87.5% for groups 1 and 2 (p = 0.078). Two major complications (ureteral avulsion and ureteral rupture) occurred in group 1. Conclusion. F-URS is safer and less invasive than SR-URS in patients with PUS. There is no statistically significant difference in the efficacy of either technique. Nonetheless we recommend F-URS in the management of PUS as a first-line treatment option in select cases of proximal ureteral calculi.
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http://dx.doi.org/10.1155/2015/416031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4649071PMC
November 2015

Retrograde Intrarenal Surgery in Patients Who Previously Underwent Open Renal Stone Surgery.

Minim Invasive Surg 2015 18;2015:198765. Epub 2015 Aug 18.

Department of Urology, Memorial Sisli Hospital, Okmeydani, Sisli, 34385 Istanbul, Turkey.

Purpose. To ascertain whether retrograde intrarenal surgery (RIRS) is as effective in patients treated previously with open renal stone surgery (ORSS) on the same kidney as in patients with no previous ORSS. Methods. There were 32 patients with renal stones who had previous ORSS and were treated with RIRS in the study group (Group 1). A total of 38 patients with renal stones who had no previous ORSS and were treated with RIRS were selected as the control group (Group 2). Recorded data regarding preoperative characteristics of the patients, stone properties, surgical parameters, outcomes, SFRs (no fragments or small fragments <4 mm), and complications between groups were compared. Results. Mean age, mean BMI, mean hospital stay, and mean operative time were not statistically different between groups. Mean stone size (10.1 ± 5.6 versus 10.3 ± 4.2; p = 0.551) and mean stone burden (25.4 ± 14.7 versus 23.5 ± 9.9; p = 0.504) were also similar between groups. After the second procedures, SFRs were 100% and 95% in groups 1 and 2, respectively (p = 0.496). No major perioperative complications were seen. Conclusion. RIRS can be safely and effectively performed with acceptable complication rates in patients treated previously with ORSS as in patients with no previous ORSS.
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http://dx.doi.org/10.1155/2015/198765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556324PMC
September 2015