Cheng-Keng Chuang

Xanthogranulomatous Pyelonephritis: Experience in 36 Cases

A retrospective study of 36 patients with xanthogranulomatous pyelonephritis who underwent nephrectomy at our hospital was performed. The disease occurred most frequently in middle-aged women with a history of recurrent urinary tract disorder. There were 2 cases of focal xanthogranulomatous pyelonephritis, 2 associated with emphysematous pyelonephritis, 2 that manifested as fistula formation between the colon or skin, and 1 with deep sinus formation into the hip joint that presented as septic arthritis. Flank pain and fever were the most frequent complaints. Escherichia coli (67%) and Proteus mirabilis (26%) were the most common organisms isolated from the voided urine, kidney and blood stream. Cephalothin plus gentamicin or tobramycin were the drugs of choice before surgical intervention.

The clinical outcome of hepatitis C virus antibody-positive renal allograft recipients.

In order to investigate the prevalence of antibody to hepatitis C virus (anti-HCV) in renal transplant patients, the evolution of anti-HCV status, and clinical outcome in anti-HCV-positive renal allograft recipients, we tested the sera from 120 renal transplant patients for anti-HCV. Thirty-eight patients were hepatitis B surface antigen (HBsAg)-positive. Two patients were anti-delta-positive. A total of 79 patients (65.8%) had at least one serum positive for anti-HCV. Anti-HCV positivity decreased after transplantation for more than 5 years (65.5% at transplantation versus 37.9%, 78.3 +/- 13.4 months later). Among those with positive anti-HCV, the HBsAg-positive group had significantly higher incidence of chronic hepatitis (50% vs. 25.5%, P = 0.026) and liver cirrhosis (21.4% vs. 0%, P = 0.001) than HBsAg-negative group. Among the 82 HBsAg-negative patients, the prevalence of anti-HCV was significantly higher in those with chronic hepatitis than in those without (86.7% vs. 56.7%, P = 0.027). We conclude from this study: (1) anti-HCV positivity is quite prevalent in renal transplant patients; (2) coinfection of hepatitis B virus (HBV) and hepatitis C virus (HCV) may lead to aggressive liver disease and cirrhosis; HCV infection alone has a more benign clinical outcome; and (3) HCV infection is an important cause of posttransplant chronic hepatitis in HBsAg-negative patients.

The Nutcracker Syndrome Managed by Autotransplantation

Entrapment of the left renal vein between the aorta and superior mesenteric artery can cause renal venous hypertension, resulting in renal vein and left gonadal vein varices. This condition, which is a rare cause of hematuria and left flank pain, has previously been described as the nutcracker syndrome. It is not known why compression of the vein occurs in only a few cases, although passage of the left renal vein between the aorta and superior mesenteric artery is a normal anatomical finding. The diagnosis is made according to pressure gradients of the left renal vein and inferior vena cava during investigation of left hematuria. Surgery is controversial but autotransplantation is safe and it should be considered a treatment alternative. We report a case of the nutcracker syndrome managed by autotransplantation.

Contemporary management of penile cancer including surgery and adjuvant radiotherapy: an experience in Taiwan.

This retrospective study reports on the treatment outcomes of 45 men with penile cancer and seeks to address the issue concerning the treatment of inguinal lymph nodes (LN). Of these 45 patients, five had verrucous carcinoma and the other 40 had squamous cell carcinoma. Eighteen patients had inguinal lymph nodes (LNs) metastasis and received treatments of inguinal LNs involving bilateral inguinal LN dissection or unilateral inguinal LN dissection with or without postoperative radiotherapy. The median follow-up was 37xa0months. The ultimate local and regional controls for patients with verrucous carcinoma were 100 and 100%, respectively. Among the 40 patients with squamous cell carcinoma, the overall local control rate was 90%. The 5-year overall survival (OS) and disease-free survival (DFS) rates of patients without or with pathological inguinal LN metastasis were 70 vs. 22% (p=0.01), and 55 vs. 16% (p=0.004), respectively. The regional failure rates after inguinal LN dissection for pathological inguinal LN metastasis were 11% (1/9) and 60% (3/5) in patients with and without adjuvant radiotherapy. This study demonstrates that verrucous carcinoma shows excellent treatment outcomes following surgery alone. Squamous cell carcinoma of the penis is associated with a high incidence of inguinal lymph node metastasis. Elective groin dissection is indicated for all penile cancer patients except those with verrucous carcinoma and pT1 cancer with well-differentiated tumor. For patients with pathologically positive inguinal LN metastasis, adjuvant radiotherapy can increase inguinal control in this study. It warrants further prospective trial to prove the value of adjuvant radiotherapy in patients with pathological documented inguinal LN metastasis in penile cancer.

Concurrent cisplatin, 5-fluorouracil, leucovorin, and radiotherapy for invasive bladder cancer

PURPOSEnTo investigate the tolerance and efficacy of a modified concurrent chemoradiation (CCRT) protocol for patients with invasive bladder cancer unfit for radical cystectomy.nnnMETHODS AND MATERIALSnTwenty-three muscle-invasive bladder cancer patients who were unfit for or unwilling to receive radical cystectomy were enrolled in this study. All patients had transitional cell carcinoma of bladder, and distribution of stage was 14 (61%), 1 (4%), and 8 (35%) for T3a, T3b, and T4, respectively. This study included a relatively old-age population, with the median age being 75 and 70% of patients over 70 years old. Patients were treated with maximal transurethral resection of the bladder tumor followed by curative CCRT. The chemotherapy (C/T) regimen was comprised of cisplatin, 50 mg/m(2) intravenously (i.v.) on Day 1; 5-fluorouracil (5-FU), 500 mg/m(2)/day by continuous i.v. infusion on Days 1-3; and leucovorin, 50 mg/day by continuous i.v. infusion on Days 1-3. Chemotherapy course was repeated at 21-day intervals. The radiation dose was 44-45 Gy to whole pelvis and 60-61.2 Gy to bladder, with a daily fraction of 1.8-2 Gy. The completeness of the CCRT protocol was defined as patients receiving at least 55 Gy of radiotherapy to the whole bladder and at least three courses C/T.nnnRESULTSnSeventy-four percent of patients (17/23) completed the CCRT protocol. Radiation Therapy Oncology Group (RTOG) Grade 3 acute toxicities were observed in 4 patients, which included leucopenia, vomiting, genitourinary (GU) tract infection, and diarrhea. No treatment-related deaths occurred during the CCRT period. RTOG Grade 3 or more late complications were observed in 3 patients; one of them died of radiation cystitis superimposed with GU infection. Of the 18 patients whose response to CCRT was evaluated, a complete tumor response was documented in 16 patients (89%). With a median follow-up of 3 years, the 3-year overall survival (OS) and disease-free survival (DFS) for all patients was 69% and 65% respectively. Meanwhile, the 3-year overall and DFS rates for patients who completed CCRT vs. those who did not complete CCRT were 82% vs. 33% and 75% vs. 33%, respectively (p = 0.18 for OS and p = 0.04 for DFS).nnnCONCLUSIONSnConcurrent cisplatin, 5-FU, leucovorin, and radiotherapy for treatment of invasive bladder cancer is a feasible and promising treatment even for relatively old patients. Our results are comparable to those in recent studies by using combined modality treatment or neoadjuvant chemotherapy plus radical cystectomy. Consequently, this novel protocol warrants a prospective clinical trial and may be a safe, effective alternative to radical cystectomy.

Minimally invasive extravesical ureteral reimplantation for vesicoureteral reflux.

PURPOSEnWe designed a new extravesical ureteral reimplantation technique with a minimally invasive approach from skin to ureterovesical junction with less perivesical tissue manipulation to avoid extensive bladder denervation.nnnMATERIALS AND METHODSnBetween July 1996 and December 2000, 37 boys and 52 girls 1.2 to 10.8 years old (mean age plus or minus standard deviation 3.8 +/- 2.5) (113 ureters) were treated with minimally invasive extravesical ureteral reimplantation. Vesicoureteral reflux was graded I to V in 8, 12, 43, 29 and 21 cases, respectively. The technique involves an approximately 10 to 15 mm. incision passing through the small triangular gap of the aponeurosis of the external abdominal oblique muscle and transversalis fascia to the point of the ureterovesical junction. The surgical field was exposed with mini-retractors and fine dissecting instruments were used to avoid unnecessary tissue manipulation.nnnRESULTSnAt postoperative followup 1 patient had persistent grade II reflux and 2 had moderate hydronephrosis and hydroureter, which resolved after 18 months. No patient returned due to voiding inefficiency or for pain control after discharge from the outpatient setting.nnnCONCLUSIONSnThis new technique can be easily used for vesicoureteral reflux with the advantages of simple intervention for surgeons, especially those with inguinal herniorrhaphy and antireflux surgery experience, and less wound discomfort for patients. The whole procedure can be performed on an outpatient basis. However, the decision to use this technique should be based on individual consideration.

Total HLA class I loss in a sarcomatoid renal carcinoma cell line caused by the coexistence of distinct mutations in the two encoding β2-microglobulin genes

In renal cell carcinoma (RCC), HLA class I downregulation has been found in about 40% of the lesions examined. Since only scanty information is available about the molecular basis of these defects, we have investigated the mechanism(s) underlying HLA class I antigen downregulation or loss in six RCC cell lines. Five of them express HLA class I antigens although at various levels; on the other hand, HLA class I antigens are not detectable on the remaining cell line, the RCC52 cell line, belonging to a sarcomatoid subtype, even following incubation with IFN-γ. β2-microglobulin (β2m) was not detected in RCC52 cells. Surprisingly, RCC52 cells harbor two mutations in the β2m genes in exon 1: a single G deletion (delG) in codon 6, which introduces a premature stop at codon 7, and a CT dinucleotide deletion (delCT), which leads to a premature stop at codon 55. Analysis of eight clonal sublines isolated from the RCC52 cell line showed that the two β2m gene mutations are carried separately by RCC52 cell subpopulations. The delG/delCT double mutations were detected in two sublines with a fibroblast-like morphology, while the delCT mutation was detected in the remaining six sublines with an epithelial cell morphology. Furthermore, loss of heterozygosity (LOH) of the β2m gene at STR D15S-209 was found only in the epithelioid subpopulation, indicating loss of one copy of chromosome 15. Immunostaining results of the tumor lesion from which the cell line RCC52 was originated were consistent with the phenotyping/molecular findings of the cultured cells. This is the first example of the coexistence of distinct β2m defects in two different tumor subpopulations of a RCC, where loss of one copy of chromosome 15 occurs in one of the subpopulations with total HLA class I antigen loss.

Optic Internal Urethrotomy Under Transrectal Ultrasonographic Guide And Suprapubic Fiberoscopic Aid

Optic internal urethrotomy is the initial treatment of choice for most urethral strictures because of the relatively low morbidity and ease of accomplishment. However, the procedure is difficult and frustrating if a severe stricture or complete disruption of the urethra is encountered. Transrectal ultrasonography of the urethra offers good anatomical visualization, and defines the exact length and extent of bulbous and posterior urethral strictures, which could ensure a more accurate and aggressive incision of the stricture. Eleven patients (8 with posttraumatic and 3 with iatrogenic strictures) with complete obliteration of the bulbous and posterior urethra were successfully treated by optic internal urethrotomy with the aid of transrectal ultrasonography and a suprapubic fiberscope. After 1 year of followup, 5 of the 8 posttraumatic urethral strictures required further management, while the remaining patients had satisfactory results. Although the recurrence rate is high in the posttraumatic patients, transrectal ultrasound and the suprapubic fiberoscope afford a reliable and satisfactory aid during optic internal urethrotomy.

Deoxyribonucleic acid flow cytometricstudy in pheochromocytomas and its correlation with clinical parameters

OBJECTIVESnTo study deoxyribonucleic acid flow cytometry (DNA-FC) in pheochromocytomas and its correlation with clinical parameters.nnnMETHODSnFifty cases of pheochromocytomas of a total of 58 cases were studied for DNA-FC from archival paraffin-embedded tissue blocks and were correlated with clinical parameters (ie, size of tumor, benign or malignant pathologic type, vanillymandelic acid [VMA] level in 24 hour urine, age, sex, duration of symptoms, symptom scores).nnnRESULTSnA total of 19 cases were diploid while 31 cases (62%) showed DNA aneuploidy with 21 cases tetraploid. Four cases were malignant. All of them were tetraploid. However, among the 46 benign cases, 10 were aneuploid and 17 were tetraploid. All 19 cases with DNA diploidy were benign. The DNA-FC did not correlate with other clinical parameters in our study.nnnCONCLUSIONSnWe confirmed a high incidence of DNA aneuploidy in pheochromocytomas. All malignant pheochromocytomas were tetraploid and all cases with DNA diploidy were benign. Long-term follow-up of all cases, especially those with DNA aneuploidy (including tetraploidy), is mandatory.

Waist circumference is an independent risk factor for prostatic hyperplasia in Taiwanese males

PURPOSEnBenign prostatic hyperplasia is a common disease affecting older males. As obesity becomes an increasing problem worldwide, its role in prostatic hypertrophy has been discussed recently. The purpose of this study is to evaluate the relationship between waist circumferences and prostatic hyperplasia in Taiwan.nnnMETHODSnThere were 539 men enrolled in the study who had health examinations at the Healthcare Center of Chang Gung Memorial Hospital; 53 were excluded because of history of conditions affecting prostatic volume. Their anthropometry was measured and serum prostate-specific antigen (PSA) levels as well as lipid profiles were analyzed. Prostate volume was measured by transrectal ultrasonography performed by experienced urologists.nnnRESULTSnThe mean prostate volume was 26.43 mL, whereas mean body mass index (BMI) was 25.27 kg/m(2) and mean waist circumference (WC) was 90.81 cm. By age-adjusted logistic regression, PSA > 4 ng/mL, WC ≥ 90 cm, and BMI > 24 kg/m(2) are associated with increased risk of developing prostatic hyperplasia; only WC ≥ 90 cm can be validated by multiple logistic regression. Further analysis of obesity patterns showed that abdominal overweight/obesity places patients at increased risk independently rather than high WC or high BMI alone.nnnCONCLUSIONSnStudy results showed that waist circumference ≥ 90 cm is an independent risk factor of prostatic hyperplasia in Taiwan. Men with abdominal overweight/obesity (WC ≥ 90 cm and BMI > 24 kg/m(2)) have a twofold risk of developing prostatic hyperplasia.