Hong K

Independent prognostic factors for initial intravesical recurrence after laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVE To elucidate clinicopathologic independent prognostic factors for intravesical recurrence after laparoscopic nephroureterectomy for primary upper urinary tract urothelial carcinoma (UUT-UC). METHODS AND MATERIALS This study included 212 consecutive patients clinically diagnosed as localized UUT-UC and treated by retroperitoneal laparoscopic nephroureterectomy between January 2002 and October 2010, after exclusion of those with a previous or concurrent history of bladder cancer. The clinicopathologic features, risk factors, and intravesical recurrence-free survival were analyzed using the Kaplan-Meier method. Univariate and multivariate analyses by Cox proportional hazards regression model was used to identify independent risk factors for intravesical tumor recurrence. RESULTS Of the patients, 64/212 (30.2%) developed subsequent intravesical recurrence during a median follow-up period of 39 months (range 7-78 months). Among them, 56/64 (87.5%) developed recurrent bladder cancer within 2 years after the surgery for UUT-UC, and the median interval between surgery and intravesical recurrence was 14 months (range 7-51 months). Multifocal tumors, renal insufficiency, and immunosuppression were determined as risk factors for intravesical recurrence by univariate analysis. However, by multivariate analyses, multifocality (hazard ratio = 2.060, P = 0.006) and immunosuppression (hazard ratio = 1.915, P = 0.037) were identified as independent predictors for the development of recurrent bladder cancer. CONCLUSIONS The incidence of intravesical recurrence after laparoscopic nephroureterectomy for UUT-UC is high, and most subsequent bladder cancers recur within 2 years after surgery. Tumor multifocality and immunosuppression are significant independent risk factors in developing initial intravesical recurrence after laparoscopic surgery for primary UUT-UC.

Efficacy and Safety of 120-W Thulium:Yttrium-Aluminum-Garnet Vapoenucleation of Prostates Compared with Holmium Laser Enucleation of Prostates for Benign Prostatic Hyperplasia

Background: This study compared the efficacy and safety between 120-W thulium:yttrium-aluminum-garnet (Tm:YAG) vapoenucleation of prostates (ThuVEP) and holmium laser enucleation of prostates (HoLEP) for patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Methods: A retrospective analysis of 88 consecutive patients with symptomatic BPH was carried out, who underwent either 120-W ThuVEP or HoLEP nonrandomly. Patient demographics and peri-operative and 12-month follow-up data were analyzed with the International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum flow rate (Qmax), postvoid residual urine volume (PVR), and rates of peri-operative and late complications. Results: The patients in each group showed no significant difference in preoperative parameters. Compared with the HoLEP group, patients in the 120-W ThuVEP group required significantly shorter time for laser enucleation (58.3 ± 12.8 min vs. 70.5 ± 22.3 min, P = 0.003), and resulted in a significant superiority in laser efficiency (resected prostate weight/laser enucleation time) for 120-W Tm:YAG laser compared to holmium:YAG laser (0.69 ± 0.18 vs. 0.61 ± 0.19, P = 0.048). During 1, 6, and 12 months of follow-ups, the procedures did not demonstrate a significant difference in IPSS, QoL score, Qmax, or PVR (P > 0.05). Mean peri-operative decrease of hemoglobin in the HoLEP group was similar to the ThuVEP group (17.1 ± 12.0 g/L vs. 15.2 ± 10.1 g/L, P = 0.415). Early and late incidences of complications were low and did not differ significantly between the two groups of 120-W ThuVEP and HoLEP patients (P > 0.05). Conclusions: 120-W ThuVEP and HoLEP are potent, safe and efficient modalities of minimally invasive surgeries for patients with LUTS due to BPH. Compared with HoLEP, 120-W ThuVEP offers advantages of reduction of laser enucleation time and improvement of laser efficiency.

Sodium-Hydrogen-Exchanger expression in human sperm and its relationship with semen parameters

PurposeSperm-specific sodium-hydrogen exchanger (sNHE) is essential to maintain sperm normal function in mice; however, its role in human sperm has not been clarified to date. The aim of this study is to investigate the expression pattern of sNHE in human spermatozoa and its relationship with sperm functional parameters.MethodSemen samples from 68 asthenozoospermic and 61 normozoospermic men were analyzed for sperm concentration, motility, and acrosome reaction, and high motile spermatozoa were collected by swim-up method. The expression of sNHE in spermatozoa was detected by Western blot and immunofluorescence staining. The relationship between sNHE expression and sperm parameters was assessed.ResultsWe identified sNHE is mainly localized to the principal piece of the human sperm tail. The expression of sNHE was positively correlated with sperm concentration, total number, and progressive motility. Moreover, sNHE expression was upregulated in swim-up sperm and associated with most of sperm motility parameters including straight line velocity and curvilinear velocity. Our results also showed that sNHE expression is decreased in sperm from patients with asthenozoospermia compared with that from normal controls. However, no correlation was found between sNHE expression and acrosome reaction in spermatozoa.ConclusionsThe expression pattern of sNHE suggested that this protein may be involved in the regulation of sperm motility, and aberration of its expression in sperm may contribute to the pathogenesis of asthenozoospermia.

Multiple factors affecting surgical outcomes and patency rates in use of single-armed two-suture microsurgical vasoepididymostomy: a single surgeon's experience with 81 patients.

Vasoepididymostomy (VE), as the most challenging procedure in microsurgeries, is often carried out with a double-armed two-suture technique. In this study, we evaluated the efficacy and safety of the single-armed two-suture VEs on humans and studied the factors that could possibly affect the patency rates. From July 2012 to July 2013, we reviewed 81 patients with consecutive primary epididymal obstruction who underwent single-armed two-suture longitudinal intussusception microsurgical VEs by a single surgeon, Kai Hong (KH). At the same time, we analyzed seven factors that possibly related to the patency rates. With the single-armed technique, a total of 81 men underwent the microsurgical VEs. Data on 62 patients were completely recorded. 19 patients were lost to follow-up. Mean age was 31 years old. Mean follow-up time was 8.8 (2-17) months. The patency rate was 66.1% (41/62). Natural pregnancy rate was 34.1% (14/41). Overall pregnancy rate was 22.6% (14/62). No severe surgical complications were noted. With logistic regression test analysis, there were two factors related to a higher patency rate: anastomosis sites (P = 0.035) and motile sperm found in the epididymal fluid (P = 0.006). Motile sperm found in the epididymal fluid were associated with a higher patency rate (OR = 11.80, 95% CI = 1.79, 77.65). The single-armed two-suture longitudinal VE technique is feasible for microsurgical practice. The patency and pregnancy rates are comparable to the doubled-armed technique. Anastomosis sites and motile sperm found in the epididymal fluid were the most two important factors related to higher patency.

Retroperitoneal laparoscopic nephroureterectomy with bladder cuff excision for native upper tract transitional cell carcinoma ipsilateral to a transplanted kidney.

OBJECTIVES We present preliminary experience of retroperitoneal laparoscopic nephroureterectomy (RPLNU) with bladder cuff excision by combining cystoscopic resection with open transperitoneal dissection for native upper urinary tract transitional cell carcinoma (UUT-TCC) ipsilateral to a transplanted kidney. METHODS Thirteen renal recipients with native UUT-TCC ipsilateral to a transplanted kidney were operated on with RPLNU between November 2005 and August 2008. Retroperitoneal laparoscopic nephrectomy was performed first and followed by cystoscopic excision of ipsilateral ureteral orifice with bladder cuff. A 6-cm midline lower abdominal incision was made. The distal ureter was dissected transperitoneally into the intramural segment, and the intact specimen was removed manually via the same incision. The cystostomy was generally not sutured. RESULTS The mean operation time was 264 minutes. The mean estimated blood loss was 256 mL. Three patients needed blood transfusion. No open conversion was required. Two patients experienced minor complications. Pathologic findings confirmed UUT-TCC in all patients with 8 of the pelvis and 7 of the ureter. Four were involved with bladder TCC. With the mean follow-up of 30 months, none of the patients developed retroperitoneal recurrence or distant metastasis, 2 of the 4 patients with bladder TCC had recurrence in the bladder, and 2 had contralateral UUT-TCC after the first unilateral nephroureterectomy. CONCLUSIONS RPLNU with bladder cuff excision by combining cystoscopic resection with open transperitoneal dissection might be a safe and feasible alternative for native UUT-TCC ipsilateral to a transplanted kidney with acceptable oncological outcomes.

Effects of maternal acrolein exposure during pregnancy on testicular testosterone production in fetal rats

Acrolein has been reported to have diverse toxic effects on various organs, including the reproductive system. However, little is known regarding the effects of maternal acrolein exposure on testicular steroidogenesis in male offspring. The present study investigated the effects of acrolein on fetal testosterone production and associated genes. Pregnant Sprague-Dawley rats were intraperitoneally injected with vehicle (normal saline) or 1, 2 or 5 mg/kg acrolein from gestational day (GD) 14–20, and fetal testes were examined on GD 21. Fetal body and testicular weights were markedly reduced in pups following exposure to high doses of acrolein (5 mg/kg) in late pregnancy. Notably, in utero exposure of 5 mg/kg acrolein significantly decreased the testicular testosterone level and downregulated the expression levels of steroidogenic acute regulatory protein (StAR) and 3β-hydroxysteroid dehydrogenase (3β-HSD), whereas the levels of other steroidogenic enzymes, including scavenger receptor class B, cholesterol side-chain cleavage enzyme and steroid 17 alpha-hydroxylase/17,20 lyase, were unaffected. Furthermore, the 3β-HSD immunoreactive area in the interstitial region of the fetal testes was reduced at a 5 mg/kg dose, whereas the protein expression levels of 4-hydroxynonenalwere dose-dependently increased following maternal exposure to acrolein. mRNA expression levels of insulin-like factor 3, a critical gene involved in testicular descent, were unaltered following maternal acrolein exposure. Taken together, the results of the present study suggested that maternal exposure to high doses of acrolein inhibited fetal testosterone synthesis, and abnormal expression of StAR and 3β-HSD may be associated with impairment of the steroidogenic capacity.

Association Between Dosage Frequency and the Treatment Outcomes of Sildenafil in Young and Middle-aged Men With Erectile Dysfunction: A Chinese, Multicenter, Observational Study.

OBJECTIVE To evaluate the correlation between the dosage frequency of sildenafil and its treatment outcomes in men with erectile dysfunction (ED). METHODS Data were from a 4-week, multicenter, observational study of men (1699), between 18 and 60 years of age, with a clinical diagnosis of ED defined as the Sexual Health Inventory for Men (SHIM) score ≤21. The erectile function and quality of sexual life were evaluated at the baseline and the endpoint of sildenafil treatment (after 4 weeks) by using SHIM, Self-Esteem and Relationship Questionnaire, 36-Item Short Form Health Survey, Erection Hardness Score, and the global efficacy question. RESULTS Nine hundred thirty-five patients were enrolled in the ≤1 weekly, 573 in the 2-3 weekly, and 158 in the 4-7 weekly dosage frequency cohorts. After 4 weeks of treatment, a higher dosage frequency of sildenafil was associated with a better SHIM, Self-Esteem and Relationship Questionnaire, and 36-Item Short Form Health Survey score improvement (all P <.0001). Hyperlipidemia is a poor prognostic factor (odds ratio, 3.59; P = .04), whereas hypertension (odds ratio, 0.25; P <.01) and coronary heart disease (odds ratio, 0.56; P = .05) are sensitive to sildenafil treatment. CONCLUSION Higher dosage frequency of sildenafil is associated with a better improvement of sexual function and quality of life of men with ED, and the concomitant treatment of hyperlipidemia is recommended.

A clinical trial on the consistency of bilateral testicular tissue histopathology and Johnsen score: single side or bilateral side biopsy?

To evaluate and compare left and right testicular tissue histopathology and Johnsen score, and to investigate the necessity for bilateral testicular biopsy. We recruited180 patients with non-obstructiveazoospermia (NOA) on testicular biopsy who had undergonetesticular sperm aspiration (TESA). Pathological sections of testicular tissue were diagnosed by specially-assigned doctors, who evaluated pathological findings, determined the Johnsen score and confirmed for the presence or absence of sperm. Sperm positive rates for left and right testicular histopathology were 55.0% and 51.7% respectively, and the proportion of Johnsen scores≥8 for left and right testes were 53.3% and 50.0%, respectively. Cohen kappa values revealed that the identification of sperm in bilateral testicular samples was not consistent and was related to random effects; Optimized cut-off value for bilateral testicular volume was 11ml (Johnsen score ≥8), and optimized cut-off values of E2 on left and right testes were 144.5pmol/L and 133.5 pmol/L (Johnsen score≤7). However, age, serum prolactin (PRL), follicle stimulating hormone (FSH), luteinizing hormone (LH) and total testosterone (TT) levels were not accurate predictors for the existence of testicular sperm. There was nostatistical significance between left and right testicular histopathology in terms of sperm positive rates or Johnsen score; the Johnsen score were caused entirely by random effects and a score from one side could not represent the other side. Therefore, we recommend that both testes need to undergo surgery when NOA patients undergo testicular biopsy or sperm retrieval.

Ran-binding protein M is associated with human spermatogenesis and oogenesis

The aim of the present study was to explore the underlying mechanism and diagnostic potential of Ran-binding protein M (RanBPM) in human spermatogenesis and oogenesis. RanBPM expression in human testis and ovaries was analysed using polymerase chain reaction (PCR) and western blotting, and immunofluorescence was performed on testis and ovary tissue sections during different developmental stages of spermatogenesis and oogenesis using RanBPM antibodies. Interactions with a variety of functional proteins were also investigated. RanBPM mRNA and protein expression levels were determined by PCR and western blotting in the tissue sections. Results revealed that the mRNA expression levels were highest in the testis followed by the ovary. The RanBPM protein was predominantly localized in the nucleus of germ cells, and the expression levels were highest in pachytene spermatocytes and cells surrounding spermatids in testis tissue. In ovary cells, RanBPM was localized in the nucleus and cytoplasm. In conclusion, the results suggested that RanBPM may have multiple roles in the regulation of germ cell proliferation during human spermatogenesis and oogenesis. This research may provide a novel insight into the underlying molecular mechanism of RanBPM and may have implications for the clinical diagnosis and treatment of human infertility.

Fertility achieved through in vitro fertilization in a male patient with 48,XXYY syndrome

microalbumin, and 24 h urinary protein (urinary protein: 555.0 mg l−1; urinary total protein/creatinine: 286.5; urinary albumin/creatinine: 186.9; microalbumin: 362.5 mg l−1; and 24 h urinary protein: 522 mg per 24 h). Thus, we diagnosed the patient with proteinuria resulting from some unknown reason. Biological data revealed that cholesterol and triglycerides were much higher than normal, suggesting the presence of hyperlipidemia (cholesterol: 6.87 mmol l−1; triglycerides: 5.74 mmol l−1). Hormonal data showed a low testosterone level accompanied by elevated basal gonadotropin levels (Table 1), and these data were suggestive of a sex chromosome aneuploidy. We performed karyotype analysis twice for this patient using lymphocytes from peripheral blood; 30 metaphases were counted in the first analysis (320–400 G‐banding) and 100 metaphases were counted in the second analysis (550 G‐banding). Results from the two analyses showed the presence of the 48,XXYY aneuploidy in all the cells that were analyzed (Figure 1). The result of Y chromosome microdeletion detection showed no deletion of the six sequence tagged sites (sY84, sY86, sY127, sY134, sY254, sY255) and SRY gene, suggesting that the AZF regions are complete. Although the patient suffers from azoospermia, his family had a strong fertility requirement. Microdissection testicular sperm extraction was successfully performed; surprisingly, normally shaped sperm were found under a microscope after tearing of the seminiferous tubules. Blood from the patient’s wife was examined, and the results were consistent with the experimental requirements. Under intravenous anesthesia, ovarian puncture ovulation was carried out with the guidance of vaginal ultrasound imaging. Nine eggs were successfully removed, six were mature, and four were fertilized by intracytoplasmic sperm injection. Then two embryos developed into blastula stage and were frozen, followed by in vitro fertilization with preimplantation genetic diagnosis. All the procedures were approved by the Ethics Committee of our hospital, and the informed consent was obtained from the patient and his spouse. The patient’s spouse is currently successfully pregnant, and the embryo is normal. In this report, the patient had been married for three years and had conceived no children even without contraception. Infertility Dear Editor, The 48,XXYY syndrome is a rare sex chromosome aneuploidy with an incidence of 1:18 000–1:40 000 male births1 and is associated with hypergonadotropic hypogonadism as an endocrine disorder.2,3 Most men with this syndrome are never diagnosed in China. Due to sex chromosome aneuploidies and limited effective communication, these patients suffer from infertility.4 With a rare incidence rate, 48,XXYY syndrome is characterized by tall stature, abdominal adiposity, and small testicles; it often appears after puberty.5 These patients often present with azoospermia and have difficulty with fertility. However, the literature provides little information about the fertility issues resulting from this syndrome. Advances in assisted reproductive techniques have, in rare cases, allowed for the production of offspring by patients with certain diagnoses thought to be associated with universal infertility.6,7 Here, we report the case of a 30‐year‐old male patient with 48,XXYY syndrome who was referred to our hospital in April 2016 for fertility treatment. In his family history, he was the only child of healthy nonconsanguineous parent. His mother’s pregnancy and delivery were normal. The patient was born at term with normal measurements. We noted that the patient had greater difficulties in understanding and developing social relationships. He married three years before presentation but did not have children at that time. However, there were no available data regarding his parent. The patient had a height of 185 cm, a weight of 80 kg, a body mass index of 23.4 kg m−2, and a blood pressure of 125/75 mmHg. The secondary sexual characteristics of the patient are poorly developed, and he has some feminine characteristics, such as no beard, less hair, and breast development. In addition, he presents orbital hypertelorism, eunuchoid skeleton, reduced muscle mass, elongated arms and legs, and small testicles and penis. Laboratory investigations showed a normal blood cell count, normal thyroid‐stimulating hormone (TSH), iron and calcium levels, and abnormal hepatic, renal, and gonadal functions. Most biological data from urine were within normal limits, with the exception of urinary protein, urinary total protein/creatinine, urinary albumin/creatinine, LETTER TO THE EDITOR