Chia-Chun Tsai

Epithelioid Angiomyolipoma of the Kidney Mimicking Renal Cell Carcinoma: A Clinicopathologic Analysis of Cases and Literature Review

Classical renal angiomyolipoma (AML) is a common tumor that, in most cases, follows a benign course and has clearly defined radiologic and histological characteristics. However, rare cases of clinically aggressive or malignant AML, the epithelioid variant of AML (EAML), have been reported. Here, we review the five cases of EAML diagnosed since 2000 at our institution to highlight the spectrum of clinical, radiological and histological characteristics. In all cases, renal lesions seen on computed tomography (CT) were considered as suspicious for renal cell carcinoma (RCC) without tumor extension or metastasis. One of the two patients with definitive tuberous sclerosis complex had a small conventional AML with fat content in the other kidney. Histologically, these tumors can resemble sarcomatoid RCC or high grade RCC. The final diagnosis is established by the presence of perivascular epithelioid cells and immunohistochemistry markers. There was no evidence of local recurrence or metastatic disease found by sonography, CT and magnetic resonance imaging during the follow‐up period. EAMLs are capable of aggressive or malignant clinical behavior. Approximately one third of the reported EAMLs show advanced disease; therefore, we recommend that it is important to treat and closely follow‐up such cases, similar to that for RCC, because of its malignant potential.

Paraganglioma of the urinary bladder first presented by bladder bloody tamponade: two case reports and review of the literatures.

Pheochromocytomas and paragangliomas (extra‐adrenal pheochromocytomas) are catecholamine‐secreting tumors. The paraganglioma of the urinary bladder is an uncommon neoplasm with a higher malignancy rate. Only about 60% of bladder paragangliomas presented with hematuria, and most of them were microscopic hematuria. Herein, we report two cases of bladder paraganglioma with bladder bloody tamponade. In Case 1, radical cystectomy and regional lymphadenectomy were performed for a huge bladder tumor and left pelvic lymph nodes metastasized. In Case 2, we chose endoscopic transurethral resection of the bladder tumor. Literatures since 1989 were also reviewed to illustrate the clinical characteristics and current treatments.

The impact of irritative lower urinary tract symptoms on erectile dysfunction in aging Taiwanese males

Objective. This study assessed the possible associations between lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in aging Taiwanese males and investigated the impact of various aspects of LUTS on ED. Methods. A free health screening for aging males (≥40 years old) was conducted in Kaohsiung Medical University Hospital. All the subjects had completed clinical data and answered questionnaires. ED and LUTS were assessed by validated symptom scales: the International Index of Erectile Function-5 (IIEF-5) and the International Prostate Symptom Score (IPSS). Results. A total of 339 eligible patients enrolled in this study with a mean age of 60.1 years old. In multiple logistic regression analysis, age and IPSS (p < 0.001 and p = 0.013, respectively) were significantly associated with ED after controlling other comorbidities. In a further age-adjusted multiple regression analysis, our results showed that irritative symptoms (p = 0.042) have a more significant association with ED than the obstructive symptoms (p = 0.101). Conclusions. Our results indicate that age and LUTS are the two most independent risk factors for ED. Aging Taiwanese males with LUTS are at increasing risk for ED, especially for those with significant irritative symptoms.

Clinical study of ammonium acid urate urolithiasis

Ammonium acid urate (AAU) urolithiasis is a rare condition; however, it is endemic in some countries, with an especially high incidence in Asia. This study was conducted to investigate the special presentation of patients with AAU urolithiasis in Taiwan. Reports of 3457 stones were retrospectively reviewed from January 2005 to January 2010 and 25 patients with urinary stones (0.7%) containing AAU crystals were identified. The clinical and biochemical presentation of all stones were compared to evaluate the specific comorbidities of AAU stones. AAU stones were observed in 11 males (44%) and 14 females (56%) with a mean age of 60.60 ± 16.81 years and mean body mass index of 25.55 ± 3.73 kg/m2. AAU stones were frequently observed in the bladder (44%) and they were significantly larger (mean size 1.90 cm) than the non‐AAU stones (mean size 1.22 cm). Other significant comorbidities of AAU stones included chronic kidney disease (CKD) (60%), urinary tract infections (UTIs) (52%), irritable bowel syndrome (IBS) (36%), and gout (28%). In addition, there were also three patients with coexisting urothelial carcinoma (12%) in the AAU‐stone group. Patients with AAU urolithiasis were predominantly female, older in age, had increased bladder presentation, larger stones and a high percentage of coexisting CKD, UTIs, IBS, gout, and even urothelial carcinoma. Therefore, it is important for clinicians to evaluate and protect renal function in patients with AAU urolithiasis.

USE OF A HOLMIUM LASER TO TREAT A FORGOTTEN DOUBLE-J STENT WITH WHOLE STENT ENCRUSTATIONS: A CASE REPORT

Short‐term placement of double‐J (D‐J) ureteral stents after endourologic procedures and some open urological surgery is common. It is rare for a patient to forget about the indwelling D‐J ureteral stent, and the major complications associated with that include infection, stone encrustation and multifractured stent. We report a case of a forgotten D‐J ureteral stent, which had been placed 24 months previously during ureterorenoscopic lithotripsy, in a 62‐year‐old man who presented with flank soreness and recurrent urinary tract infection. Radiography of the kidney, ureter and bladder, and computed tomography demonstrated stone encrustation over the whole D‐J stent. Cystolithotripsy and ureterorenoscopic lithotripsy with a Holmium laser were performed to remove the D‐J. We believe that this is the first case of successful removal of an intact, encrusted stent in one procedure by endoscopic manipulation.

The interaction of serum testosterone levels and androgen receptor CAG repeat polymorphism on the risk of erectile dysfunction in aging Taiwanese men.

Testosterone has been found to play important roles in mens sexual function. However, the effects of testosterone can be modulated by androgen receptor (AR) CAG repeat polymorphism. It could also contribute to the risk of erectile dysfunction (ED). The aim of this study is to evaluate the interaction of serum testosterone levels and AR CAG repeat polymorphism on the risk of ED in aging Taiwanese men. This cross‐sectional data of Taiwanese men older than 40 years were collected from a free health screening held between August 2010 and August 2011 in Kaohsiung city, Taiwan. All participants completed a health questionnaires included five‐item version of the International Index of Erectile Function (IIEF‐5) and the International Prostate Symptoms Score, received a detailed physical examination and provided 20 cm3 whole blood samples for biochemical and genetic evaluation. The IIEF‐5 was used to evaluate ED. Serum albumin, total testosterone (TT), and sex hormone‐binding globulin levels were measured. Free testosterone level was calculated. AR gene CAG repeat polymorphism was determined by direct sequencing. Finally, 478 men with the mean age of 55.7 ± 4.8 years were included. When TT levels were above 330 ng/dL, the effect of testosterone level on erectile function seemed to reach a plateau and a significantly negative correlation between AR CAG repeat length and the score of IIEF‐5 was found (r = −0.119, p = 0.034). After adjusting for other covariates, the longer AR CAG repeat length was still an independent risk factor for ED in subjects with TT above 330 ng/dL (p = 0.006), but not in TT of 330 ng/dL or below. In conclusion, both serum testosterone levels and AR CAG repeat polymorphism can influence erectile function concomitantly. In subjects with normal TT concentration, those with longer AR CAG repeat lengths have a higher risk of developing ED.

Low-Intensity Extracorporeal Shockwave Therapy Can Improve Erectile Function in Patients Who Failed to Respond to Phosphodiesterase Type 5 Inhibitors:

Managing patients with erectile dysfunction (ED) who failed to respond to phosphodiesterase type 5 inhibitors (PDE5is) is a challenging task. Recently, low-intensity extracorporeal shockwave therapy (LI-ESWT) was reported to improve ED by enhancing perfusion of the penis. The current study was performed to evaluate whether combined treatment with LI-ESWT and PDE5is can restore erectile function in patients who failed to respond to PDE5is alone. This was an open-label single-arm prospective study. ED patients with an erection hardness score (EHS) ≦2 under a maximal dosage of PDE5is were enrolled. Sociodemographic information and detailed medical history were recorded. LI-ESWT treatment consisted of 3,000 shockwaves once weekly for 12 weeks. All patients continued their regular PDE5is use. The EHS and the 5-item version of the International Index of Erectile Function (IIEF-5) were used to evaluate the change in erectile function 1 and 3 months after LI-ESWT. A total of 52 patients were enrolled. After LI-ESWT treatment, 35 of the 52 patients (67.3%) could achieve an erection hard enough for intercourse (EHS ≧ 3) under PDE5is use at the 1-month follow-up. Initial severity of ED was the only significant predictor of a successful response (EHS1: 35.7% vs. EHS2: 78.9%, p = .005). Thirty-three of the 35 (94.3%) subjects who responded to LI-ESWT could still maintain their erectile function at the 3-month follow-up. LI-ESWT can serve as a salvage therapy for ED patients who failed to respond to PDE5is. Initial severity of ED was an important predictor of a successful response.

Lower SHBG level is associated with higher leptin and lower adiponectin levels as well as metabolic syndrome, independent of testosterone

In addition to testosterone (T), the emerging role of sex hormone-binding globulin (SHBG) in pathogenesis of metabolic syndrome (MetS) has been noted recently. However, reports of associations with serum adipocytokine levels are still limited. Therefore, we conducted this study to evaluate whether serum T and SHBG levels are independent predictors for the risk of MetS that are associated with adiponectin and leptin levels in 614 Taiwanese men over 40 years old collected from a free health screening. Subjects in the lowest quartile of TT and SHBG levels are exposed to a 1.58 and 3.22 times risk of developing MetS, as compared to those in the highest quartile of TT and SHBG levels. However, SHBG retains its significance independent of TT as a MetS risk predictor, but not vice versa. In addition, SHBG was significantly correlated with both adiponectin and leptin levels even after adjusting for TT levels. In conclusion, SHBG served as a major predictor for the risk of MetS and was correlated with serum adiponectin and leptin levels that are independent of T. Further studies are needed to elucidate the true role of SHBG in the pathogenesis of MetS and possible mechanisms associated with serum adiponectin and leptin levels.

Urinary Incontinence in Alzheimer’s Disease: A Population-Based Cohort Study in Taiwan

Objectives: Urinary incontinence (UI) is more prevalent in the elderly populations with dementia than without dementia, and Alzheimer’s disease (AD) is the most common cause of dementia. Urinary incontinence may complicate AD morbidity and mortality. Therefore, this study aimed to evaluate the prevalence and annual incidence and determine the risk possibility of UI, which is the main type of incontinence in patients with AD in Taiwan. Methods: A total of 933 patients with AD were included in the study cohort, and a total of 2799 patients without AD by 1:3 proportion compared to the study cohort were used as a matched cohort. All participants were selected from the National Health Insurance Research Database in 2000 sample population. We utilize Cox proportional hazard regression to evaluate the risk of UI and cumulative incidence ratio curve to analyze the cumulative incidence function. Prevalence and annual incidence rate are calculated in individual medication including rivastigmine, donepezil, galantamine, and memantine only being initiated in patients with AD. Results: The risk of UI is higher in AD cohort (hazard ratio: 1.54, 95% confidence interval: 1.13-2.09). The cumulative incidence ratio of UI event between AD cohort and matched cohort presents statistical significance (P < .001). Annual incidence and prevalence of UI in patients with AD are 6.2% and 4.2%, respectively. Conclusion: The present results suggest that the risk of UI is higher in patients with AD than in the general population.

Bladder Outlet Obstruction due to an Unusual Prostatic Midline Cyst in an Adolescent Male

Most prostatic midline cysts, i.e., Mullerian duct cysts or prostatic utricular cysts, probably result from incomplete regression of the Mullerian duct remnant. Congenital cysts may be associated with other urogenital anomalies. Related symptoms include bladder outlet obstruction, hemospermia, ejaculatory-fertility impairment, and recurrent epididymitis. We report an adolescent male who presented with difficulty urinating that lasted for 2 months. After a complete survey with a urodynamic study, ultrasonography, urethrography, urethrocystoscopy, and computed tomography, a prostatic midline cyst with bladder outlet obstruction was identified. Using transurethral cyst unroofing, urination conditions improved according to the International Prostate Symptom Score and a uroflow study. Although there are various surgical interventions for a prostatic midline cyst near the urethra, endoscopic procedures are a safe and elegant alternative compared with other procedures.