Chih-Chieh Lin

Measurement of Testicular Volume in Smaller Testes: How Accurate Is the Conventional Orchidometer?

The aim of this study was to evaluate the accuracy of different methods, including the Seager orchidometer (SO) and ultrasonography (US), for assessing testicular volume of smaller testes (testes volume less than 18 mL). Moreover, the equations used for the calculations--the Hansen formula (length [L] x width [W](2) x 0.52, equation A), the prolate ellipsoid formula (L x W x height [H] x 0.52, equation B), and the Lambert equation (L x W x H x 0.71, equation C)--were also examined and compared with the gold standard testicular volume obtained by water displacement (Archimedes principle). In this study, 30 testes from 15 men, mean age 75.3 (+/-8.3) years, were included. They all had advanced prostate cancer and were admitted for orchiectomy. Before the procedure, all the testes were assessed using SO and US. The dimensions were then input into each equation to obtain the volume estimates. The testicular volume by water displacement was 8.1 +/- 3.5 mL. Correlation coefficients (R(2)) of the 2 different methods (SO, US) to the gold standard were 0.70 and 0.85, respectively. The calculated testicular volumes were 9.2 +/- 3.9 mL (measured by SO, equation A), 11.9 +/- 5.2 mL (measured by SO, equation C), 7.3 +/- 4.2 mL (measured by US, equation A), 6.5 +/- 3.3 mL (measured by US, equation B) and 8.9 +/- 4.5 mL (measured by US, equation C). Only the mean size measured by US and volume calculated with the Hansen equation (equation A) and the mean size measured by US and volume calculated with the Lambert equation (equation C) showed no significant differences when compared with the volumes estimated by water displacement (mean difference 0.81 mL, P = .053, and 0.81 mL, P = .056, respectively). Based on our measurements, we categorized testicular volume by different cutoff values (7.0 mL, 7.5 mL, 8.0 mL, and 8.5 mL) to calculate a new constant for use in the Hansen equation. The new constant was 0.59. We then reexamined the equations using the new 0.59 constant, and found that the equation Volume (V) = L x W(2) x 0.59 was the best for describing testicular volume among our subjects (difference between the new equation and the gold standard of water displacement = 0.19 mL, P = .726). We also found that US was more precise in measuring testicular dimensions. We propose a new formula, V = L x W(2) x 0.59, to assess the volumes of smaller testes.

XP11.2 Translocation renal cell carcinoma: Clinical experience of Taipei Veterans General Hospital

Background: Xp11.2 translocation renal cell carcinoma (RCC), a recently recognized distinct subtype of RCC, is characterized by various translocations, all involving the TFE3 transcription factor gene. These rare cancers occur predominantly in children and young adults and comprise about one‐third of pediatric RCCs. In the present study, we review the clinical course of Xp11.2 translocation renal cell carcinoma in our institution. Methods: We identified eight cases with Xp11.2 translocation RCC between 2007 and 2010 from the pathological archives of the Taipei Veterans General Hospital. We retrospectively analyzed the patients’ characteristics, clinical manifestations, and specific pathological features for definitive diagnosis, surgical and systemic treatment and clinical outcome of these rare cancers. Results: Patients were aged 20 years to 49 years (mean age 28 years) with female predominance (6 females, 2 males). One patient presented with asymptomatic renal mass detected incidentally during abdominal sonography. Four patients complained of flank or abdominal pain, and the other three complained of gross hematuria at initial presentation. The mean tumor size was 9.2 cm (range, 4 cm–17 cm). Seven patients underwent radical nephrectomy for the primary tumor, while one presented with multiple metastases. All cases were confirmed by TFE3 immunohistochemistry, a sensitive and specific marker of tumors with TFE3 gene fusion, which showed positive nuclear staining. Three patients presented initially with metastatic diseases, and another three patients progressed to lung, liver and bone metastases at eight, seven and nine months postoperatively. Conclusion: Although RT‐PCR and DNA sequencing are the final diagnoses of the molecular identity of Xp11.2 translocation RCC, experienced pathologists could confirm the histologic diagnosis based on the distinctive morphologic features with positive TFE3 immunochemical nuclear stain. Surgical resection is the only treatment. The role of systemic therapy for local recurrence and metastasis remains to be determined.

Predictive factors of lower calyceal stone clearance after extracorporeal shockwave lithotripsy (ESWL): the impact of radiological anatomy.

Background: This study was carried out to determine whether or not there is a significant relationship between the radiologic anatomy of the lower calyx, as seen on preoperative intravenous urography (IVU), and the outcome of stone clearance after extracorporeal shockwave lithotripsy (ESWL) for lower renal calyceal stones. Methods: Between June 1998 and April 2007, 112 patients with a solitary lower renal calyceal stone measuring 20 mm or less in size were enrolled in this retrospective study. Pretreatment IVU was reviewed for measuring the anatomical predictors, such as lower pole infundibular length, infundibular width (IW) and infundibulopelvic angle, while the stone location and size were determined on plain abdominal X‐ray. All patients were treated with ESWL using a Siemens Lithostar Plus lithotriptor and were followed‐up for the outcome of stone clearance 3 months after ESWL with plain abdominal X‐ray films and ultrasonography. Results: Three months after ESWL, only 49 (43.7%) patients were stone‐free. Under multivariate analysis with logistic regression, smaller stone size (10 mm or less, p = 0.005) and greater IW (4 mm or more, p = 0.029) were significant favorable predictors for better stone clearance. Conclusions: In addition to the influence of stone size, lower pole anatomy, especially IW, has a significant impact on stone clearance for lower calyceal stone after ESWL.

Are patients with the symptoms of overactive bladder and urodynamic detrusor overactivity different from those with overactive bladder but not detrusor overactivity

Background: The aim of this study is to identify the differences between patients with overactive bladder (OAB) and detrusor overactivity (DO) and those with OAB but without DO. Methods: We prospectively recruited patients with OAB symptoms between December 2008 and September 2009. All patients were required to complete a 3‐day frequency–volume chart. Symptom severity was evaluated using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS) questionnaires. All patients also underwent urodynamic studies. Demographics, symptom severity, urinary frequency and volume, and urodynamic variables of patients with and without DO were compared. Results: Of the 133 enrolled patients (76 women and 57 men), DO was diagnosed in 80 patients (60.2%). All demographic variables were similar among the OAB patients, regardless of DO status. Total IPSS and OABSS scores did not differ between the OAB and DO groups. However, the nighttime urinary frequency subscore on the OABSS differed significantly between OAB patients with DO and without DO (p = 0.048). There were no significant differences in terms of urodynamic variables, urinary frequency, or urine volume between OAB patients with and without DO. Conclusion: Patients with OAB symptoms and urodynamic DO show different clinical symptoms than OAB patients without DO. Patients with DO experience more frequent nocturnal urinary episodes.

Diagnosis of Prostate Cancer : Repeated Transrectal Prostate Biopsy or Transurethral Resection

Background: Transrectal ultrasound‐guided biopsy of the prostate is the major method by which prostate cancer is diagnosed. However, many patients might be overlooked with the initial biopsy. Not uncommonly, patients need repeated biopsies when they continue to exhibit suspicious clinical signs. This may cause psychological stress to both patients and doctors. The purpose of this study was to determine how many repeat transrectal biopsies are adequate for prostate cancer detection and when to switch to transurethral resection. Methods: We retrospectively studied a cohort of 2,996 patients who had undergone prostate biopsy. If the biopsy specimen was negative for malignancy, patients were given the choice of either being managed with observation or undergoing transurethral resection of the prostate (TURP) if indicated. If there was a high suspicion of cancer, patients were advised to undergo additional biopsies. The primary endpoint of this study was a diagnosis of cancer. Results: The cancer detection rate was 22.9% (685 of 2,996 patients) in specimens taken during the first transrectal biopsy, 8.7% in those taken during the second biopsy (32 of 336 patients), and 6.1% in those taken during the third biopsy (6 of 98 patients). The cancer detection rate of TURP after 1 negative biopsy result was 9.3% (35 of 375 patients), and that after 2 negative biopsy results was 17.1% (6 of 35 patients). TURP‐derived specimens that were pathologically diagnosed as malignant had lower Gleason grade on average, no matter how many repeat biopsies there were in patients whose previous transrectal biopsy specimens were negative for malignancy (p = 0.002 for 2 negative biopsy results and p = 0.007 for 3 negative biopsy results). Conclusion: The chance of detecting malignancy beyond a third transrectal biopsy procedure is low. TURP, therefore, might be an alternative procedure for obtaining tissue for pathologic diagnosis, especially in patients with rising prostate‐specific antigen levels and comorbid illnesses such as obstructive symptoms.

Ketamine-Induced Uropathy: A New Clinical Entity Causing Lower Urinary Tract Symptoms

Objectives: Ketamine abuse can damage the urinary tract and cause lower urinary tract symptoms (LUTS). This report presents our observations and management on urinary tract damage caused by ketamine abuse.

Microvascular Injury in Ketamine-Induced Bladder Dysfunction.

The pathogenesis of ketamine-induced cystitis (KC) remains unclear. In this study, bladder microvascular injury was investigated as a possible contributing mechanism. A total of 36 KC patients with exposure to ketamine for more than 6 months, and 9 control subjects, were prospectively recruited. All participants completed questionnaires, including the O’Leary–Sant interstitial cystitis symptom index (ICSI) and the interstitial cystitis problem index (ICPI). All KC patients received a urodynamic study and radiological exams. Bladder tissues were obtained from cystoscopic biopsies in the control group and after hydrodistention in the KC group. Double-immunofluorescence staining of N-methyl-d-aspartate receptor subunit 1 (NMDAR1) and the endothelial marker, cluster of differentiation 31 (CD31), was performed to reveal the existence of NMDAR1 on the endothelium. Electron microscopy (EM) was applied to assess the microvascular change in the urinary bladder and to measure the thickening of the basement membrane (BM). A proximity ligation assay (PLA) was used to quantify the co-localization of the endothelial CD31 receptor and the mesenchymal marker [fibroblast-specific protein 1 (FSP-1)]. The Mann–Whitney U test and Spearman’s correlation coefficient were used for statistical analysis. The mean ICSI [14.38 (± 4.16)] and ICPI [12.67 (± 3.54)] scores of the KC group were significantly higher than those (0 and 0, respectively) of the control group (both p < 0.001). The KC patients had decreasing cystometric bladder capacity (CBC) with a mean volume of 65.38 (± 48.67) mL. NMDAR1 was expressed on endothelial cells in both groups under immunofluorescence staining. Moreover, KC patients had significant BM duplication of microvessels in the mucosa of the urinary bladder under EM. The co-expression of the endothelial marker CD31 and mesenchymal marker FSP1 was significantly stained and calculated under PLA. In conclusion, microvascular injury and mesenchymal phenotypic alteration of endothelial cells can potentially contribute to KC-induced bladder dysfunction.

Urodynamic and molecular characteristics of detrusor underactivity in a rat cryoinjury model and effects of low energy shock wave therapy

Low energy shock wave (LESW) has been shown to facilitate tissue regeneration and reduce inflammation. We investigated the effects of LESW in an underactive (DU) model induced by cryoinjury of rat detrusor.

Patients with chronic periodontitis are more likely to develop upper urinary tract stone: a nation-wide population-based eight-year follow up study

Background The purpose of this study was to investigate the relationship between chronic periodontitis (CP) and upper urinary tract stone (UUTS) in Taiwan by using a population-based data set. Methods A total of 16,292 CP patients and 48,876 randomly-selected controls without chronic periodontitis were selected from the National research database and studied retrospectively. Subjects selected have not been diagnosed with UUTS previously. These subjects were prospectively followed for at least eight years. Cox regression models were used to explore the connection between risk factors and the development of UUTS. Results The CP patients have a greater chance of developing UUTS compared to controls (1761/16292, 10.8% vs. 4775/48876, 9.8%, p-values < 0.001). Conditioned logistic regression suggested CP increases the risk of UUTS development (HR 1.14, 95% CI [1.08–1.20], p < 0.001). After respective adjustment for age, gender, hypertension and diabetes, results showed that CP still increases the risk of developing UUTS (HR 1.14, 95% CI [1.08–1.20], p < 0.001). Conclusion By using a population-based database with a minimum eight 8 follow-up of CP in Taiwan, we discovered patients with CP are more likely to develop UUTS.

Clear cell papillary renal cell carcinoma – An indolent subtype of renal tumor

Background: Clear cell papillary renal cell carcinoma (CCPRCC) is a new but rare tumor entity as listed in the World Health Organization 2016 renal tumor classification. Around 360 cases have been reported in the English literature to date, and only one tumor with sarcomatoid change was reported to develop distant metastasis. In the present study, we aim to review the clinical course and analyze the treatment outcome of CCPRCC in our institution. Methods: We retrospectively collected patients diagnosed with CCPRCC between January 2008 and September 2016 in our institute. The clinical features, pathology slides, and clinical outcomes were reviewed. Results: Twenty‐five patients were collected during the study period, with a mean age at diagnosis of 62.8 years (range 35–85 years). Three patients developed the tumor in their native kidney following a kidney transplant, and three patients were diagnosed by needle biopsy before cryoablation therapy due to high surgical risk. The mean follow‐up time was 49.7 months (range 12–119 months). During the follow‐up period, all patients were alive without local recurrence or distant metastasis. All tumor specimens in our series expressed cytokeratin 7 (CK7) diffusely in immunohistochemistry staining. One patient was diagnosed with pT3a cN0M1, Fuhrman grade 3 CCPRCC with renal vein invasion and lung metastasis in 2010 on the basis of the histologic pattern and immunoreactivity for CK7. The clinical course was not compatible with any of the reported cases in the literature, so the kidney specimen was re‐examined using whole‐exome sequencing. The diagnosis was then revised to clear cell renal cell carcinoma. Conclusion: Our series confirmed that CCPRCC has an indolent clinical behavior. When the diagnosis is made in a high‐grade renal tumor, it should be carefully re‐confirmed using cytogenetic or genomic methods.