UROLOGY

ROBOTIC-ASSISTED SURGERIES
 

The primary diseases for which our physicians at Urology Clinic apply robotic-assisted surgery are as follows:

• Robotic-assisted prostate cancer surgeries
• Robotic-assisted kidney cancer surgeries
• Robotic-assisted surgeries of renal collecting system cancers
• Robotic-assisted urinary bladder cancer surgery and reconstruction of a new urinary bladder using small intestines with robotic approach (neobladder reconstruction)
• Testicle cancer surgeries during which intra-abdominal lymph nodes are extracted using robotic-assisted surgery
• Robotic-assisted surgeries for severe benign prostate hyperplasia
• Robotic-assisted renal transplant surgeries
• Robotic-assisted surgeries for tumors and diseases of adrenal gland
• Robotic-assisted surgeries for stenotic ureteropelvic junction in pediatric and adult patients
• Robotic-assisted surgeries for certain female urinary incontinence types

 
Koç University Hospital gained the “Robotic Training Center” status with the approval of European Association of Urology, Robotic Urology Section (ERUS) in 2019.
 
Prof. Erdem Canda, M.D., one of the physicians at our Urology Clinic and Prof. Derya Tilki, M.D. our guest lecturer from Martini Clinical Urology Department in Germany are also members of Administrative Board of ERUS. Professor Canda, who also provides training for other specialists abroad in international courses as an ERUS Robotic Urology trainer, was awarded 3 times in ERUS congresses due to his studies on robotic urology.
 
Multiple courses on endoscopic, laparoscopic and robotic-assisted surgery are provided by our staff at Koç University Hosptial and RMK AIMES (Rahmi M Koç Academy of Interventional Medicine, Education & Simulation) training center of our hospital.
 

Robotic-Assisted Surgery in Prostate Cancer

Cancer types that affect prostate, which is a part of male reproductive system, are observed especially after the age of 50. Diagnosis requires magnetic resonance imaging (multiparametric MRI) of prostate in addition to blood tests and examination. MRI fusion prostate biopsy, which is currently the most sensitive method of performing biopsy for cancer foci in prostate, can be applied in Koç University Hosptial. Following diagnosis of prostate cancer, body screening is performed with Computerized Tomography (CT), bone scintigraphy and PET CT (Galium-68 PSMA). All these diagnostic methods are performed in the most ideal conditions at our hospital. When surgery is decided in light of these examinations, prostate cancer surgeries are performed with robotic-assisted surgery technique.
 
Our physicians at Koç University Hospital are also able to benefit from below mentioned technological advancements to increase the success of robotic-assisted prostate cancer surgery with Da Vinci Xi surgery robot.
 

*3D Tumor Navigation with Robotic-Assisted Surgery

Locations of tumor foci are identified on Prostate MRI images, these images are reformatted in 3D form and forwarded to robotic system. Our surgeon performs the surgery by using these images as a guide along the robotic surgery. The purpose of this method is to increase the success of robotic-assisted surgery, especially in high-risk prostate cancers. This project conducted by Professor Canda was deemed worthy of the 3^rd prize in  European Association of Urology, Robotic Urology (ERUS) Congress which was organized in Portugal in 2019. Scientific article of the project was published in British Journal of International Compass in 2020.

*Extraction of Lymph Nodes under Guidance of ICG:

Cancer in the prostate may spread to nearby lymph nodes. These lymph nodes are also extracted along with the prostate during robotic-assisted surgery. An agent called ICG (indocyanine green) is injected to cancer foci in prostate during robotic-assisted prostate cancer surgery to assist identifying lymph nodes with the highest possibility of cancer spread. This agent reaches to lymph nodes with the highest possibility of cancer spread through lymph vessels. When florescent light feature of robotic 3D lens is used to visualize lymph nodes with risk, these lymph nodes appear in neon green color to the robotic surgeon and extraction can be performed more easily and securely. Experiences of our physicians on the subject were shared with the international community in the European Association of Urology, Robotic Urology (ERUS) Congress.
 

*Utilization of Martini-Klinik NeuroSAFE Frozen Pathological Examination Method:

The nerves and vessels around the prostate can be visualized with much more clarity and detail during robotic-assisted prostate cancer surgeries thanks to 3D lens of the robotic system which includes a magnifying feature. Moreover, these nerves and vessels are better preserved due to high maneuver ability of the instruments used in the surgery such as robotic scissor and robotic tissue holder, along with the experience of the robotic surgeon who performs the surgery. Especially preservation of the nerves has critical importance regarding urinary continence and conservation of male reproductive functions during postoperative period.

These nerves being in close contact with prostate may cause difficulty when extracting prostate without leaving residual disease in the body. Utilization of Martini-Klinik NeuroSAFE frozen method can show highly effective results as a solution of the problem. While using this method, all nerves around the prostate are preserved as a priority during the robotic-assisted surgery and the extracted prostate is examined under microscope during the surgery by our pathologists after being stained using special dyes. When it is verified after the examination that all surgical margins are clear regarding cancer, the surgery is ended, in such way that all nerves around the   prostate are preserved. If cancer is observed within surgical margins, the preserved nerves in that area are also extracted before the surgery is terminated and the robotic surgery is completed without leaving residual cancer cells in the body. Experiences of our physicians on this subject were also shared in the European Association of Urology, Robotic Urology (ERUS) Congress.
 

Robotic-Assisted Surgery in Kidney Cancers

Today, kidney cancers are generally identified incidentally before causing any complaints with ultrasound, computerized tomography or magnetic resonance imaging methods during routine controls.
 
Robotic surgery is frequently used in extraction of these tumors when identified in small sizes. The procedure consists of below-mentioned stages: 4 to 5 incisions smaller than 1 cm are made on abdominal region, arms of the robot and lens that forms 3D images are inserted to the intra-abdominal cavity. This way, the images of tumor and peripheral tissues are magnified and then the tumor and cancerous tissues in kidney can be removed easily. After the area with tumor is extracted, remaining part of the kidney can be preserved at the end of the procedure.
 
Moreover, an agent called ICD (indocyanine green) can be administered during robotic-assisted surgeries, which allows managing the feeding of the kidney cleaned from tumor during the operation.
 
It is necessary to cool the kidney with sterile ice pieces during certain tumor extraction procedures. While ice cooling the kidney is possible in open surgeries, it could not be done during closed robotic-assisted surgeries until recently. Now, the kidney can be cooled with ice during robotic-assisted surgeries with the method developed by our urologists. This very special method was presented in Robotic Urology European Association of Urology Robotic Urology(ERUS) Congress and the video and article were published in Central European Journal of Urology in 2020. Our urologists also benefit from the Argon Laser available at our hospital during robotic-assisted kidney cancer surgeries. The scientific article that describes benefits and advantages of this method was published in Journal of Robotic Surgery in 2020.
 

Robotic-Assisted Surgery in Urinary Bladder Cancers

The most important and common cause of urinary bladder cancer is smoking. In this cancer type, patients generally present to a physician with blood in urine that is not associated with pain. Tumor foci in urinary bladder can be identified in light of performed urinary tests, ultrasound, computerized tomography or magnetic resonance imaging. Then, a procedure called cystoscopy is required. This procedure is performed in operating theatre conditions and under anesthesia at our hospital. This procedure is performed as follows: Access is made through urinary canal via cystoscope and it is advanced inside the urinary bladder. The tumor foci visualized inside the urinary bladder are removed endoscopically. After diagnosis is made with pathological examination, removal of urinary bladder can be necessary for some of the urinary bladder cancer types. This procedure requires a major surgery; prostate and lymph nodes around the urinary bladder in male patients and cervix, ovaries and lymph nodes around the urinary bladder in female patients are removed along with the urinary bladder and then a new bladder is reconstructed using small intestines.
 
Our urologists are able to perform this major surgery entirely with robotic method. Our center is accepted as the most experienced center in our country on the subject, as a member of both European Association of Urology, Robotic Urology Section (ERUS) in Europe and International Robotic Cystectomy Consortium (IRCC) in the USA, which are the two largest international work groups on the subject. Many scientific articles prepared by our clinic with these work groups are published in most prestigious journals around the globe.
 
A technique for reconstructing a new urinary bladder using small intestines with robotic method developed by Prof. M Derya Balbay, M.D. was used as cover in Journal of Endourology, one of the most prestigious journals internationally, and the scientific article was published in this journal. Moreover, Prof. M. Derya Balbay, M.D. was deemed worthy of award by MD Anderson Cancer Center in Houston, USA with this method. The robotic method of reconstructing a new bladder using small intestines developed by Prof. M. Derya Balbay, M.D. provides critical advantages for the patients. As a result of this surgery, a higher urine storing and continence capacity is gained while complications of small intestines are lowered.
 
The other critical advantages of removing urinary bladder and constructing a new bladder from small intestines with robotic method are as follows.
 

• The surgery is performed under 3 dimensional magnified images without requiring major abdominal incisions,
• Nerves and vessels, especially ones around the bladder and prostate are better preserved,
• Less bleeding and less requirement of blood transfusion,
• Less complications, faster recovery and quicker discharge from hospital.

The purpose of preserving vessels and nerves around the urinary bladder and prostate using robotic-assisted surgery is to achieve higher urine storage and continence capacity and better preservation of male reproductive functions.
 

Testicle cancer surgeries with extraction of intra-abdominal lymph nodes using robotic-assisted surgery

Testicle tumors are mostly seen in young male patients. Our patients usually present to a physician with rough swelling in testicle which is not associated with pain. The testicle that contains the tumor can be removed with a small incision on inguinal region in light of an examination, blood tests, ultrasound scan, computerized tomography scan and -if required- magnetic resonance imaging. For a group of patients diagnosed with tumor after the pathological examination under microscope; the enlarged lymph nodes inside abdomen where tumor spread can be removed before or after chemotherapy. When robotic-assisted surgery is not utilized, a large incision is needed to remove these lymph nodes. Our urologists, on the other hand, are capable of performing this major surgery successfully without needing large incisions by opening holes smaller than 1 cm in the abdomen and inserting the arms of the robot and the lens that forms magnified 3 dimensional images to the intra-abdominal cavity. Our clinic is considered among the most experienced centers in our country. As cancerous lymph nodes are located between the major vessels in abdomen, robotic system is used to successfully extract lymph nodes between major vessels with the robotic system’s ability of providing three dimensional and magnified images of the tissues and high maneuver ability of robotic instruments. Less bleeding, less need for blood transfusion, smaller incisions, less wound site complications, faster recovery and quicker discharge are among the primary advantages of this method.
 

Robotic-Assisted Kidney Transplant

Our kidney transplant team started successfully performing robotic-assisted kidney transplant operations as of 2020. Thanks to robotic-assisted kidney transplant, the kidney can be placed inside the abdomen with a small incision around belly button. Similarly, robotic arms are advanced to intra-abdominal cavity by opening holes smaller than 1 cm. The vessels and urinary canal of the new kidney are connected to the body using 3D magnifying feature of the robotic system and high maneuver capability of robotic instruments. This way, bleeding, need for blood transfusion, complications and problems regarding wound site are decreased while faster wound healing following robotic-assisted kidney transplant is achieved, requirement for pain killers decrease and our patients are discharged from the hospital quicker than normal.
 

Robotic-assisted surgeries of renal collecting system cancers:

The complete kidney along with the ureter and the area this canal is connected to urinary bladder (bladder cuff) are removed entirely in cases of kidney collecting system (renal pelvis) cancers. We perform this operation with robotic-assisted surgery method. Thanks to robotic-assisted surgery, it is possible to perform this surgery with closed approach without performing two separate incisions over kidney and urinary bladder regions, by opening 1-cm holes on abdominal region and connecting the robot to the abdomen. At the end of the surgery, kidney, ureter and bladder cuff can be extracted from the body by making a small incision at urinary bladder area. The advantages of performing this surgery with robotic method includes less bleeding, less complications, making a single incision instead of two, faster recovery, less requirement for painkillers and quicker discharge.
 

Robotic-assisted surgeries for stenotic ureteropelvic junction in pediatric and adult patients:

The urine produced by the kidney is transferred to renal pelvis where it is sent to urinary bladder via a canal called ureter. The outlet of renal pelvis is named as ureteropelvic junction (UPJ). Stenosis may occur in this area (ureteropelvic stenosis). These stenoses may lead to enlargement of kidney, delay or impairment of kidney functions, pain and stone formation. This condition can be identified during childhood period or it can be diagnosed during adulthood. It is necessary for stenotic section of UP to be extracted and this area to be repaired surgically. We perform this operation successfully with robotic-assisted surgery method. The reason for this stenosis is a congenital vascular compression over this area for some patients. Robotic-assisted surgery allows a much clear and magnified visualization of the vascular compression with its three dimensional magnification feature and high maneuver ability it provides to the surgeon leading to increase in success rate of the surgery.
 

Robotic-assisted surgeries for severe benign prostate hyperplasia (BHP)

Benign prostate hyperplasia (BHP) requires open prostate surgery when it reaches to extreme volumes. Performing this surgery with robotic method allows less bleeding, less need for blood transfusion, less complication, faster recovery, better visualization and preservation of urinary continence mechanism with three dimensional and magnified imaging of the surgery site.
 

Robotic-assisted surgeries for some female urinary incontinence types:

Urinary incontinence is an important problem in female patients and it is possible to employ robotic-assisted surgery for some urinary incontinence types. These robotic-assisted surgeries include performing small incisions on abdomen. When required, recurrence of urinary incontinence can also be prevented by placement of mesh (patch) material.
 

Robotic-assisted surgeries for tumors and diseases of adrenal gland:

Adrenal glands are organs over both kidneys which secrete some critical hormones for our body. Removal of diseased gland is necessary for some benign and malign tumors of adrenal glands (such as Cushing, Feochromacytoma and cancers). Robotic method is utilized effectively while performing these surgeries. Small incisions are made on abdomen area and three dimensional and magnified images are achieved. In some cases it is possible to extract only the diseased section of adrenal gland and preserve the healthy section. The high maneuver capability provided by robotic-assisted surgery is effective in these operations.  
 

LAPAROSCOPIC SURGICAL PROCEDURES

 
The primary diseases for which our physicians at Urology Clinic apply laparoscopic surgery are as follows:

• Laparoscopic prostate cancer surgeries
• Laparoscopic kidney cancer surgeries
• Laparoscopic surgeries of renal collecting system cancers
• Laparoscopic bladder cancer surgeries
• Testicle cancer surgeries with extraction of intra-abdominal lymph nodes using laparoscopic surgery
• Laparoscopic surgeries for severe benign prostate hyperplasia
• Laparoscopic surgeries for tumors and diseases of adrenal gland
• Laparoscopic surgeries for stenotic ureteropelvic junction in pediatric and adult patients
• Laparoscopic surgeries for some female urinary incontinence types<0}

 

Numerous courses on endoscopic laparoscopic and robotic surgery are provided by our staff at Koç University Hosptial and RMK AIMES (Rahmi M Koç Academy of Interventional Medicine, Education & Simulation) training center of our hospital.
 

Laparoscopic Surgery in Prostate Cancer

Cancer types that affect prostate, which is a part of male reproductive system, are observed especially after the age of 50. Diagnosis requires magnetic resonance imaging (multiparametric MRI) of prostate in addition to blood tests and examination. MRI fusion prostate biopsy, which is currently the most sensitive method of performing biopsy for cancer foci in prostate, can be applied in Koç University Hosptial. Following diagnosis of prostate cancer, body screening is performed with Computerized Tomography (CT), bone scintigraphy and PET CT (Galium-68 PSMA). All these diagnostic methods are performed in the most ideal conditions at our hospital. When surgery is decided in light of these examinations, prostate cancer surgeries are performed with laparoscopic surgery, which is a minimally invasive approach.
 

Laparoscopic Surgery in Kidney Cancers

Today, kidney cancers are generally identified incidentally before causing any complaints with ultrasound, computerized tomography or magnetic resonance imaging methods during routine controls.

Laparoscopic surgery is frequently used in extraction of these tumors when identified in small sizes. The procedure consists of below-mentioned stages: 4-5 incisions smaller than 1 cm are performed to abdominal region, entrance canals called “trocar" which allow entry of laparoscopic tools and camera lens are inserted to the intra-abdominal cavity. Intra-abdominal cavity is distended using carbon dioxide gas. This makes the tumor and surrounding tissues clearly visible and allows interventions. Therefore, kidney can be cleared from tumor and cancerous tissues. After the area with tumor is extracted, remaining part of the kidney can be preserved at the end of the procedure.
 
It is necessary to stop blood circulation of the kidney while extracting tumors from the kidney. This procedure is possible by temporarily clamping the common vessels of kidney or cooling the kidney with ice. These methods which have been developed for open surgical method can easily be applied with laparoscopic methods in our hospital. Our clinic is also able to utilize Argon laser, which provides remarkably high advantages in managing bleeding for specific patients, to control bleeding in residual kidney tissues after extraction of the mass lesion in the kidney.
 

Laparoscopic Surgery in Urinary Bladder Cancers

The most important and common cause of urinary bladder cancer is smoking. In this cancer type, patients generally present to a physician with blood in urine that is not associated with pain. Tumor foci in urinary bladder can be identified in light of performed urinary tests, ultrasound, computerized tomography or magnetic resonance imaging. Next, cystoscopy procedure, which is an endoscopic visualization method for internal cavity of urinary bladder, is performed. This procedure is performed in operating theatre conditions and under anesthesia at our hospital. This procedure is performed as follows: Urinary bladder is accessed from ureter with cystoscopy. The tumor foci visualized inside the urinary bladder are removed endoscopically. The bleeding is managed endoscopically using cutting-edge energy systems. After diagnosis is made with pathological examination, removal of urinary bladder can be necessary for some of the urinary bladder cancer types. This procedure requires a major surgery; prostate and lymph nodes around the urinary bladder in male patients and cervix, ovaries and lymph nodes around the urinary bladder in female patients are removed along with the urinary bladder and then a new bladder is reconstructed using small intestines.

Bladder removal surgery is performed with laparoscopy, which is a minimally invasive method, at our hospital.
 
Similar to other minimally invasive methods, advantages of laparoscopic urinary bladder removal include achieving cosmetically more successful results with performing smaller incisions in comparison to open surgery, better preservation of nerves around the prostate and urinary bladder, less bleeding and less need for blood transfusion during surgery, less complications, faster recovery and quicker discharge from hospital.
 
The purpose of preserving vessels and nerves around the urinary bladder and prostate using laparoscopic surgery is to achieve higher urine storage and continence capacity and better preservation of male reproductive functions.
 

Testicle cancer surgeries with extraction of intra-abdominal lymph nodes using laparoscopic surgery

Testicle tumors are mostly seen in young male patients. Our patients usually present to a physician with rough swelling in testicle which is not associated with pain. The testicle that contains the tumor can be removed with a small incision on inguinal region in light of an examination, blood tests, ultrasound scan, computerized tomography scan and -if required- magnetic resonance imaging. For a group of patients diagnosed with tumor after the pathological examination under microscope; the enlarged lymph nodes inside abdomen where tumor spread can be removed before or after chemotherapy. When minimally invasive surgery is not utilized, a large incision is needed to remove these lymph nodes. Our hospital is one of the rare centers which are able to perform this surgery with laparoscopy, a minimally invasive method. Even the lymph nodes located in vital places can be removed with ease due to the wide visual acuity and maneuver capability provided to the surgeon by laparoscopy. Less bleeding, less need for blood transfusion, smaller incisions, less wound site complications, faster recovery and quicker discharge are among the primary advantages of this method.
 

OTHER PROCEDURES

 

Functional Urology

Functional urology is a sub-unit of urology which aims to treat problems of urine storage or voiding with medical or surgical approaches.
 
Sexual dysfunctions are also included in the field of functional urology.
 

Diseases included in the field of Functional Urology

For Women-Urinary incontinence
-Sagging in pelvic organs (urinary bladder, cervix)
-Hyperactive urinary bladder
-Urinary voiding problems
- Urination problems secondary to neurogenic reasons
-Urinary bladder pain syndrome
-Sexual dysfunctions
 
For Men
-Urination problems secondary to benign prostate diseases
-Urinary incontinence
-Urinary voiding problems
- Urination problems secondary to neurogenic reasons
-Sexual dysfunctions
 
There are multiple types of urinary incontinence. The patients who present to our clinic with urinary incontinence are listened in detail as the first step and preliminary information regarding which urinary incontinence type is likely are obtained. Then, detailed urologic examination is performed in addition to general physical examinations for male and female patients. Treatments in accordance with patient’s complaints are planned in light of these findings. While treatments that can be administered orally are present, surgical intervention may be necessary in some cases.

In cases which require “urodynamic study”, this examination can be performed at the outpatient clinic, under sterile conditions and local anesthesia. Urodynamic study is based on the principle of duplicating the sensation of urinary urgency artificially by placing a catheter in both urinary canal and anus under local anesthesia and administering sterile fluid to urinary bladder. The pressure and electrical activity changes which occur inside urinary bladder and intra-abdominal cavity of the patient during this urgency period are monitored by our physicians who are experienced in the field. After the urgency stage is completed, patients are asked to urinate as the second stage. This way, an abnormal pressure or change in electric activity during urination can be observed.
 
The treatment for our patients is decided after obtaining the history, examination, urodynamic study -when required -and laboratory assessment. Patients, who require medical treatment, are assessed in outpatient clinic visits, which are performed monthly at the beginning.
 
If voiding problem in urinary bladder is identified in light of assessments, patients are provided with training to use special catheters which allow them to empty their bladders on their own (clean intermittent catheterization-CIC).

There are multiple surgical options for patients who require surgery for urinary incontinence depending on the type of incontinence. Botox (botulinum toxin injection) to urinary bladder is recommended for the patients with urinary incontinence secondary to hyperactive urinary bladder, when no improvement is observed after necessary treatment states are completed. Botox application to urinary bladder is performed by accessing urinary canal with endoscopic approach in operating theatre conditions and under general anesthesia and performing botulinum toxin injection to certain locations of urinary bladder at specified doses. Hospitalization is not required following the procedure.
 
Surgery is recommended as the primary option for patients who experience urinary incontinence following coughing, sneezing or lifting heavy objects, when this is verified during examination. The most frequently used surgery method in these cases is the bladder suspension surgery. These surgeries are performed at our clinic.
 
There are multiple surgical options focused on the sagging for patients with urinary incontinence associating with pelvic organ sagging or patients with severe pelvic organ sagging. The surgeries for sagging of pelvic organs can be performed with open, laparoscopic and robotic approaches at our clinic.
 
Basic assessment for male patients with complaints secondary to benign prostate hyperplasia is performed at our outpatient clinic. There are various surgical options for patients who do not benefit from medical treatment after need for surgery is identified with additional tests. The endoscopic resection of prostate (TUR) is performed with utilization of cutting edge technological devices. Our patients are hospitalized for 2 to 3 days and monitored following TUR procedure.

Additionally, removal of the prostate using laser prostatectomy method can be performed with different laser technologies (greenlight, HOLEP) at our clinic. Our patients are hospitalized and monitored for 1 to 2 days after this procedure.
 
Different treatment options are presented as these methods are not deemed appropriate for treatment in cases with severe enlargement of prostate. Prostate gland can be extracted with a small abdominal incision using open prostatectomy, the versions of this technique which are adapted to laparoscopy and robotic-assisted surgery are used frequently at our clinic. Laparoscopy is the surgical method where 1-2 cm incisions are performed to the abdomen, 3-4 sticks called trocar are inserted to the abdominal-cavity from these incisions, then abdominal cavity is distended by administering gas to the stomach and surgery is performed by the surgeon who utilizes technological devices designed in accordance with this ergonomy. Robotic-assisted surgery utilizes specially designed sticks which are inserted to abdominal cavity with similar methods and connected to the robot. The surgeon carries out the operation from a control mechanism named consol. The laparoscopic and robotic techniques, which are also known as minimally invasive techniques, have advantages that include better visualization of the surgical site, easier managing of bleeding, less pain and smaller incision scars due to smaller incisions. While hospitalization period of 4 to 5 days is required after open surgeries, this period shortens in cases of laparoscopic or robotic-assisted surgery applications.
 
Administration of agents causing erection and prosthesis placement to the penis are the treatment stages which are recommended internationally for the male patients with erectile dysfunction who did not benefit from the medical treatment provided following assessment of their complaints. Patients for whom an agent that causes erection will be injected to penis are provided with training for this procedure.
 
Placement of prosthesis with cutting edge technology can be performed at our clinic for patients who are deemed suitable for placement of penis prosthesis. This procedure is performed at the operating theatre by placement of the preferred prosthesis to the penis, scrotum (bag that covers testicles) and abdomen depending on the type under general anesthesia. Our patients stay at the hospital for one day after this surgery.
 
In addition, it is known that multiple diseases followed up by Neurology cause complaints regarding urinary system. Detailed urologic follow up and treatment for patients who experience urinary difficulties following diseases such as multiple sclerosis, spina bifida, cerebral hemorrhage are performed at our hospital in cooperation with Neurology Clinic.