Hsiao-Wen Chen

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.

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.

Long-Term Outcome of Surgical Repair for Penile Fracture

Penile fracture is an unusual injury which occurs following blunt trauma to the rigid penis during intercourse, masturbation, or accidents. Thirteen cases (mean age 39 yr, range 11-64 yr) of penile fracture occurring between 1987 and 1998 were retrospectively reviewed, and their current status was evaluated. Nine cases of penile fracture were secondary to mishaps during intercourse, while others were associated with masturbation or accidents. All patients were managed by surgical repair. The surgical delay ranged from 3 h to 3 d. Associated urethral injury were seen in 3 cases, and all of them recovered with normal voiding function. Follow-up time ranged from 13 to 137 mo (mean, 49.8 mo). Early recovery of erectile function was found in 12 patients. Slight penile curvature during erection were observed in 3 patients, but this did not impede coitus. Implantation of penile prosthesis was performed in I case because of persistent erectile dysfunction after penile fracture. Favorable results suggest that penile fracture should be repaired as early as possible.

Should Patients Older Than 55 Years of Age Receive Renal Transplantation

In the period from 1981 to 1997, a total of 14 patients older than 55 years received a renal transplantation at our hospital. Therapy of end-stage renal disease (ESRD) in the elderly is characterized by tremendous challenges because of the progressive increase in the proportion of elderly requiring ESRD therapy worldwide and the shortage of donor organ. Mortality occurred in 6 of our series with functioning grafts (42.9%). One patient was lost due to heart failure and another from asthma attack. Hepatocellular carcinoma was the main cause of death in 4 (66.7%), two of them combined with bladder tumor or sepsis each. On the other hand, another two grafts loss without death were attributed by acute and chronic rejection each. Patient survival at 1, 2, 3, and 5 years was 100%, 81.8%, 70.1%, and 46.7% and the graft survival 92.9%, 76.0%, 65.1%, and 43.4%, respectively. Two patients developed CMV infection (CMV pneumonitis and CMV chorioido-retinitis) with no death or graft loss. Two patients complicated with urinary tract infection and one with ureter tumor. Death with functioning grafts was the main cause of transplantation failure. Malignancy was the most prominent cause of death in our series. Our study demonstrates that cadaver renal transplantation can be performed successfully and safely in selected patients who are older than 55 years but regular follow-up for malignancy screening is necessary especially in hepatitis B and/or C carriers.

The Experience of Second Generation Lithotriptor for Treatment of Upper Urinary Tract Calculi in Children

Between June 1995 and Feb. 1997, a total of 10 children 5 to 18 yrs old with renal and ureteral calculi underwent lithotripsy at the Chang Gung Memorial Hospital. Each patient re-ceived an average of 3160 shocks with generator energy set at 15.1 kV. General anesthesia was required for lithotripsy in only 1 child, while others received intravenous sedation with me-peridine hydrochloride. Majorities of pediatric lithotripsy treatments were performed on an out-patient basis, while that of 1 patient was done on an inpatient basis. Stone fragmentation was achieved in all patients (100%), and the overall stone-free rate at 6 mo was 90%. There was a continuous decrease in the stone-free rate with increasing stone size. Early minor complications, such as fever, pain,and obstruction were observed in 1 patient during treatment. We conclude that the second generation lithotripter can be used safely and efficiently to treat upper urinary tract calculi in children. (J Urol R.O.C., 9:191-195,1998)

The Complications of Renal Transplant Biopsy and Review of Articles

In many transplant centers, there is a reluctance to perform renal transplant biopsy for fear of complications which may jeopardize the graft. For 304 renal transplants, safety of the renal allograft biopsy was evaluated by retrospectively studying 59 biopsy specimens in 57 patients between July 1981 and December 1993. Microscopic hematuria was found in 15 cases (88.2%) of open renal transplant biopsy and in 31 cases (73.8%) of echo-guided biopsy. Macroscopic hematuria was found in two cases (4.8%) of echo-guided biopsy. No macroscopic hematuria was found in open biopsy. All the cases of microscopic or macroscopic hematurid resolved spontaneously. Also, subcapsular hematoma was found in one case (5.9%) of open biopsy. The hematoma was removed by surgical intervention with stable condition of the graft. No graft loss or deterioration occurred because of renal transplant biopsy. The study demonstrated that renal transplant biopsy is a relatively safe procedure, but not without risk. Actually, any invasive procedure will potentially jeopardize a renal graft to a greater or lesser degree. Reported here are the experience and results of a study of morbidity as related to open and echo-guided biopsy of the transplanted kidney.

Clinical Experience of Pheochromocytoma

Pheocromocytomas, especially extra-adrenal lesions, can potentially cause lethal complications if they are not recognized. Because of possible unusual locations and lack of classical symptoms or signs, extra-adrenal pheochromocytomas may be easily neglected. A retrospective review of 58 cases of pheochromocytomas showed that 45 cases were adrenal lesions (Group A) and 13 cases were extra-adrenal lesions (Group B). Clinical parameters, e.g., age, sex, symptoms or signs, biochemical data, incidence of malignancy, DNA flow cytometric studies, localization methods were compared. In Group A, the male sex seemed to be more dominant than in Group B. Other clinical parameters were quite compatible in both groups. There was no difference in the incidence of malignancy or results of DNA flow cytometric studies between the groups. Radioactive iodine-labeled metaiodobenzyl-guanidine scan and computed tomography scan seemed to be the best localization methods. With improvement in diagnostic modalities, hagh index of suspicion is still the key in diagnosing extra-adrenal pheochromocytomas. As in their adrenal counterparts, malignanc is possible. Long-term follow-up for these extra-adrenal lesions is essential.