Chi-Rei Yang

Congenital Renal Arterio-Venous Malformation

Congenital renal arterio-venous malformation (AVM) is a rare abnormal collection of blood vessels and is usually located in the medullary region. Gross hematuria is the most common symptom. Color Doppler ultrasound is the first choice for renal AVM screening but a definitive diagnosis still requires angiography. Embolization of AVM has progressively replaced surgery for the treatment of renal AVM in recent years. Here we presented a 44 year-old woman with congenital idiopathic AVM of the kidney. She received transarterial embolization and the patient underwent an obvious symptomatic improvement.

MP-4.05: Comparison of Robotic-Assisted Versus Retropubic Radical Prostatectomy Performed by a Single Surgeon

BACKGROUND To compare perioperative outcomes between patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) and patients undergoing retropubic radical prostatectomy (RRP) performed by a single surgeon in Taiwan. PATIENTS AND METHODS This study was a retrospective review of 30 consecutive patients who underwent RRP and 30 initial patients who underwent RALP. The preoperative parameters, operation parameters (operative time, vesicourethral anastomosis time, blood loss, transfusion and complication rates) and postoperative parameters (post-operative stay, catheter duration, cystography received, continence rate, sexual function and histopathologic factors) were evaluated. RESULTS Preoperative clinical parameters were similar between groups. Vesicourethral anastomosis time was shorter in RRP group than in RALP group. RRP had higher incidence of bilateral pelvic lymph node dissection than RALP (100% vs. 73.3%), but lower incidence of neurovascular bundle preservation (6.7% vs. 53.3%). Significant differences were found in blood loss (RALP 314 mL vs. RRP 912 mL) and transfusion rates (RALP 13.3% vs. RRP 60%) between groups. A statistically significant difference was found in incidence of cystograms performed between RRP and RALP groups (93.3% vs. 43.3%) before removing urethral catheter. Positive surgical margin was 20% in RRP group vs. 50% in RALP group, demonstrating statistical significance. Shorter catheterization duration and postoperative stays were found with RALP. Three-month continence rate was higher in RALP patients than in RRP patients (76.7% vs. 36.7%, p=0.04). CONCLUSION RALP is minimally invasive with less blood loss and lower transfusion rates than RRP. RALP had greater incidence of neurovascular bundle preservation and faster convalescence than RRP.

Orthotopic Neobladder (Studer Pouch) after Radical Cystoprostatectomy：Experience in Taichung Veterans General Hospital

OBJECTIVE: We analyzed the results of our patients receiving orthotopic neobladder after radical cystoprostatectomy. MATERIAL AND METHODE: Between January 1992 and September 1998, nin patients underwent a Studer neobladder substitute after radical cystoprostatectomy for invasive bladder cancer in our hospital. Patients were followed up for a period ranging from 12 to 78 months (mean, 42 months). Blood chemistry, renal function, and upper urinary tract status were checked every 3 months during the first year. Urinary tract infection as well as tumor progression were evaluated. Urodynamic studies and continence were evaluated at 6 and 12 months postoperatively. Therefore, patients were seen at least once every 6 months. RESULTS: There was no perioperative mortality. One patient died 5 years after surgery due to non-cancer-related pneumonia; the remainder showed no evidence of metastasis in the follow-up period. The mean cystometric capacity exceeded 400 ml with pressure of less than 45 cm of water after 6 months. All patients were continent during the daytime and only 1 patient required 1 pad per night for nocturnal enuresis after 1 year. Excretory urograms revealed good upper tract function. There was no noticeable electrolyte or vitamin B12 abnormalities during follow up. CONCLUSION: The Studer neobladder is relatively simple to use with good results, and it is suitable for lower urinary tract reconstruction in selected patients whenever the urethra can be preserved.

Mnimally Invasive Surgery for Adrenalectomy：Initial Experience in Taichung Veterans General Hospital

OBJECTIVE: The aim of this study was to report the preliminary experience and to compare the results of three different modalities: gasless laparoscopic assisted adrenalectomy (GLAA), gaseous laparoscopic adrenalectomy (LA) and open adrenalectomy (OA). MATERIALS AND METHODS: From March 1995 to December 1996, total 13 consecutive patients underwent adrenalectomy at our section, 5 with traditional OA and 8 with GLAA. And from July 1999 to March 2000, we had initial experience of transperitoneal and retroperitoneal laparoscopic adrenalectomy (TLA and RLA) in total 11 patients. The characteristics of the patients and the results of the four techniques were recorded on a database. To analyze dichotomous variables, the Kruskal Wallis H test and Mann-Whitney U test were performed. RESULTS: All the patients had unilateral disease in our series. The operative time of OA is the shortest (p=0.000) and the LA group was more time-consuming, especially in the transperitoneal counterpart. Perioperative blood loss was the lowest in the GLAA group, followed by RLA, TLA, and OA group. The usage of postoperative analgesic was the least after RLA and the highest after OA (p=0.000). Postoperative hospital stay was also the shortest following RLA and TLA and the longest following OA (p=0.004). CONCLUSION: Though the best choice between one of these three minimally invasive adrenalectomies is still a debate, the better cosmetic result and quicker postoperative convaliscence suggest the laparoscopic adrenalectomy (either transperitoneal or retroperitoneal) to be the preferred modality at present.

Removal of Renal Cell Carcinoma Extending into Supradiaphragmatic Inferior Vena Cava Using Cardiopulmonary Bypass with Deep Hypothermic Circulatory Arrest - A Report of 2 Cases

Cardiopulmonary bypass with deep hypothermic circulatory arrest has been established as a useful method in the surgical management of patients with rend cell carcinoma and large infe-rior vena caval tumor thrombi. We present our experience with 2 cases of renal cell carcinoma extending into the supradiaphragmatic inferior vena cave using cardiopulmonary bypass with deep hypothermic circulatory arrest. (j Urol R.O.C., 10:173-176,1999)

Recurrence and Progression of Stage T1 superficial Bladder Cancer

From October 1982 to March 1996, a total of 86 patients with superficial transitional cell carcinoma of bladder, stage T1, were treated with transurethral resection and adjuvant in-travesical chemotherapy in our hospital. Carcinoma in situ is documented as high risk of recur-rence and progression of disease and was therefore excluded from this study. The mean age was 63.9 years (range 38-84). The mean follow-up period was 60.2 months (range 13-163). Biman-ual exams under general anesthesia were routinely performed. Fractionate resections of various depths were sent. Grading metod was judged by UICC-3 classification system. Adjuvant in-travesical chemotherapy was performed in high risk groups. 86 patients were divided into four groups according to grade and whether they would undergo intravesical instillation (IVI) che-motherapy or not: Group I T1G2 without IVI(22), group II T1G2 with IVI(16), group III T1G3 without IVI(18), and group IV T1G3 with IVI(30). The average recurrence rates were 72.7%, 75%, 83.3% and 83.3% in group I,II,III and IV respectively. The overall recurrence rate of T1 category disease was 80.2%. he overall progresson rate was 22.1%. The progression rate of T1G2 disease versus that of T1G3 disease was 2.8% versus 37.5% (p＜0.001). Intravesical che-motherapy did ot alter the progression of the disease (group III vs. group IV: 38.9%vs. 36.7% p=0.878). T1G2 and T1G3 diseases represent two different disease entities. Traditional treat-ment and close follow-up are sufficient for T1G2 disease, but more effective intravesical immu-notherapy and precise prognostic parameters are recommended for T1G3 disease. (J Urol R.O.C., 9:1-6,1998)

Ureteropelvic Junction Obstruction: Comparison of Open Pyeloplasty and Endopyelotomy in 45 Patients

Ureteropelvic junction (UPJ) obstruction has traditionally been repaired surgically by open pyeloplasty with high success rate, but endopyelotomy has been recently accepted as a primary procedure for the management of UPJ obstruction. Since endopyelotomy was first performed in our hospital in 1988, a total of 45 patients with 47 UPJ obstructions had been encountered until 1996. The majority (39/47) of UPJ obstructions were primary and the rest (8/47) had a history of previous open surgery. The results were compared between 19 obstructions with endopyelotomy (15 by percutaneous procedure, 4 by ureteroscopic manipulation) and 28 obstructions with open pyeloplasty. The patients after endopyelotomy recovered more quickly with shortened hospital days than the patients of open pyeloplasty (7.1 days, 3 days and 10.3 days). The success rate appeared comparable in two groups with 89.47% of enodpyelotomy and 89.28% of open pyeloplasty. We suggest that the endopyelotomy be the first choice for the management of UPJ obstruction.

Melanoma in Urology: Experience and Review of Literature

Primary melanoma of the genitourinary tract is uncommon. Rare cases have been described in most organs of genitourinary tract. The majority of reports show that penis and urethra are frequently involved. Unfortunately, early diagnosis is not the rule and current therapeutic modalities most often fail. Secondary involvement of genitourinary tract with malignant melanoma is a common autopsy finding, but rarely evident clinically. We report three primary cases and one secondary case involving kidney and psoas muscle between 1983 and 1996. The average age of the patients was 66 years (range, 61-73 years). All the four victims were male and died due to multiple metastases. All the available managements including conservative treatment, radical surgery, chemotherapy (dacarbazine) and immunotherapy (interferon, Bacillus Calette-Guerin) were tried. But it confirms the consensus of available reports that, irrespective of what type of therapy being used, the prognosis usually is unsatisfactory. More developed immunotherapy and biological therapy as adjuvant treatment is expectant. We also briefly review the literature of current treatments.

Eoperiences of Graft Nepgrectomy

From Oct. 1982 to Oct. 1996, totally 415 cases of kidney transplantation, including 211 cases done in our hospital and 204 in other hospitals, were followed regularly in our hospital, and 15 of them finally received graft nephrectomy. The indications for graft nephrectomy were rejection in 12 patients, graft infection in 1, arterio-venous malformation (AVM) with graft kidney rupture in 1 and arterial anastomosis leakage after kidney transplantation in 1. The causes of rejection were chronic in 8 and acute in 4. The removal was done in extraperitoneal (extracapsular n=5, subcapsular n=7) or transperitoneal approach (n=3). The overall complication rate was 26.7% (4/15). The only complication in extracapsular group was minor and the 3 cases of complication in subcapsular group were more serious. No complication occurred in transperitoneal group. One patient died of surgical complication and two died unrelated to nephrectomy. The overall mortality was 20%. The operative morbidity and mortality were not negligible because of underlying uremia and immunosuppressive status. We suggest to perform graft nephrectomy in extracapsular or transperitoneal approach when it is feasible because the subcapsular approach is difficult to achieve a low complication rate.

Pregnancy Following Renal Transplantation

A total of 211 kidney transplantations were performed at our hospital from Oct. 1982 to Oct. 1996. Of these available for this study, 96 were female and 47 were child-bearing age. A total of 7 patients with 7 successful pregnancies resulted in the birth of 8 infants (1 pair of twins). All the patients were maintained on low dose oral steroids throughout the pregnancy, 5 were on cy-closporine A, 1 on azathioprine and 1 on triple treatment All births were completed with normal vaginal delivery. Premature birth occurred in 4 re-cipients (5 infants). All the babies were below the 50 percentile of the normogram of birth weight to gestational age. None had congenital abnormalities. Premature ruptures of membrane (PROM) occurred in 2 cases and pre-eclampsia occurred in 3 patients. One patient developed graft hydronephrosis in the 2 and trimester that needed PCN for renal function preservation . All of our patients had stable renal function during the course of pregnancy. We conclude that preg-nancy and delivery may not impose a significant threat to recipients and their graft kidneys if re-cipients are followed up regularly and carefully. (J Urol R.O.C., 8:131-134, 1997)