I-Ni Chiang

Major Complications and Associated Risk Factors of Transrectal Ultrasound Guided Prostate Needle Biopsy: A Retrospective Study of 1875 Cases in Taiwan

BACKGROUND/PURPOSE Complications from transrectal ultrasound (TRUS) guided prostate needle biopsy are occasionally encountered in the daily practice of urologists. We tried to determine the associated risk factors of patients who suffered from major complications that required hospitalization after TRUS guided prostate needle biopsies. METHODS We did a retrospective review of 1875 TRUS guided prostate biopsies performed between January 2002 and December 2005. We defined major complications as patients with complications that needed hospitalization. We analyzed the association between biopsy complications and suspected factors, including age, prostate volume, patients underlying disease, selection of prophylactic antibiotics, biopsy core numbers (6, 12, and 15 cores), and antiplatelet/anticoagulant usage. RESULTS There were 124 patients (6.6%) with major complication. These major complications were categorized as acute prostatitis (3.8%), acute urinary retention (2.1%), hematuria (1.9%), rectal bleeding (0.2%), epididymitis (0.2%), sepsis (0.05%), and vasovagal syncope (0.05%). Patients with larger prostate size were noted to have higher risk of developing transient acute prostatitis and acute urinary retention after prostate biopsy. In contrast, age, prophylactic antibiotics (levofloxacin and pipemidic acid), underlying diseases (diabetic mellitus, hypertension, hyperlipidemia, cerebrovascular accident, coronary artery disease), increased biopsy core numbers, and antiplatelet/anticoagulant usage were not associated with major complications after prostate biopsy. CONCLUSION TRUS guided prostate needle biopsy is a safe diagnostic tool in most elderly males with or without systemic underlying disease.

The effectiveness of tamsulosin in treating women with voiding difficulty

Objectives:  To prospectively evaluate the effectiveness of tamsulosin in treating women with voiding difficulty.

Age- and gender-specific nomograms for single and dual post-void residual urine in healthy children†‡

To establish the first age‐ and gender‐specific nomograms for single and two consecutive tests for post‐void residual urine (PVR).

Large voided volume suggestive of abnormal uroflow pattern and elevated post-void residual urine†‡

To report the cut‐off value for large voided volume (LVV) suggestive of abnormal uroflow pattern or elevated post‐void residual urine (PVR) in healthy kindergarteners.

Obese children at higher risk for having overactive bladder symptoms: A community‐based study

To investigate the association between obesity and lower urinary tract symptoms (LUTS) in healthy children.

Prostate Volume Did Not Affect Voiding Function Improvements in Diode Laser Enucleation of the Prostate

PURPOSE We compared safety and surgical outcomes in patients with different prostate sizes treated with diode laser enucleation of the prostate. MATERIALS AND METHODS From 2008 to 2012 consecutive patients with benign prostatic obstruction undergoing diode laser prostate enucleation at our institution were enrolled for analysis. A single surgeon performed diode laser prostate enucleation with an end firing, continuous wave diode laser (980 nm). Based on preoperative prostate volume on transrectal ultrasound, patients were stratified into 2 groups, including group 1-65 with less than 60 ml and group 2-55 with 60 ml or greater. Baseline and perioperative characteristics, and postoperative surgical outcomes were compared between the 2 groups. RESULTS A total of 120 men with a mean ± SD age of 70.2 ± 9.0 years were enrolled for analysis. Compared with group 1 patients, those in group 2 had larger mean total prostate volume (85.0 ± 24.6 vs 40.9 ± 10.8 ml), longer mean operative time (117.7 ± 48.2 vs 60.7 ± 25.0 minutes), higher mean retrieved prostate weight (37.3 ± 16.1 vs 12.5 ± 7.3 gm) and a higher mean tissue retrieval ratio (74.4% ± 22.2% vs 58.8% ± 23.2%, p <0.01). There was no significant difference in the postoperative hemoglobin decrease in the 2 groups (median 0.5 vs 0.9 mg/dl, p = 0.11). The rate of temporary postoperative urinary retention after Foley catheter removal was significantly lower in group 2 (15.4% vs 3.6%, p = 0.04). Postoperative improvements in the peak flow rate, post-void residual urine volume and International Prostate Symptom Score were comparable in the 2 groups. CONCLUSIONS Although patients with a larger prostate required significantly longer operative time and laser energy, voiding function improvements and surgical complication rates of diode laser prostate enucleation were comparable in patients with a larger vs smaller prostate.

LETTERS TO THE EDITOR: Extrication of Penile Constriction Device with Corpora Aspiration

We read the excellent review and recommendations for extrication of penile constriction device by Silberstein et al. [1]. They resolved the difficult situation with the use of electric cutting device. We would like to share our experiences in removing penile constriction device successfully with penile corpora aspiration. In Taiwan, a kind of Chinese kung fu called Nine-Nine Chi-Gung is believed to have good therapeutic effects in enhancing the sexual function in men after long-term practice in certain population. A steel ring will be placed on the penile root during practice with heavy objects of weight ranging from 500 grams to more than 10 kilograms which hang on the fishhook tied to the steel ring (Figure 1A). The case we encountered is a middle-aged man. He practiced Nine-Nine ChiGung with a steel ring tied at the penile root since 11:00 o’clock in the morning. As a result of progressive edema of the distal penis and glans, he could not remove the ring 1 hour later. He visited our emergency department immediately and we were consulted for removing the constriction device. Initially, nonelectric cutting was tried in vain because the ring was 1 cm in thickness (Figure 1A). The little space between the ring and penile skin made the electric cutting not applicable. Therefore, two 21-gauge butterfly needles were inserted into the bilateral corpora cavernosum after local anesthesia (Figure 1B). Aspiration of the dark blood from the cavernosum and irrigation with saline was performed. After gentle compression of the glans and distal corpora cavernosum, lubricants were applied on the skin to help remove the device. The ring was removed successfully with neither urethral nor skin erosion. The patient did not come back for follow-up at clinics and therefore no subsequent information of his sexual function was reported. The motivation for the placement of constriction devices is to prolong or to aid erection rigidity during intercourse [2]. However, penile constriction device would block venous return initially and lead to further arterial supply impairment, causing ischemia, possible corporal fibrosis, impotence, and even penile gangrene [3]. The process resembles ischemic priapism [4]. According to previous literatures and our experiences, we believe that the main treatment protocols in removing the device are reducing the swollen penis’ size and breaking the device. Silberstein et al. [1] have provided excellent recommendations for electric cutting devices. In our experiences, we noted that penile aspiration with saline irrigation would reduce the swollen

Comparison of 6- and 12-Core Prostate Biopsy in Taiwanese Men: Impact of Total Prostate-Specific Antigen, Prostate-Specific Antigen Density and Prostate Volume on Prostate Cancer Detection

Introduction: We retrospectively compared 6- and 12-core prostate biopsies in Taiwanese men and evaluated the impact of prostate volume (PV), prostate-specific antigen (PSA), and PSA density (PSAD) on the prostate cancer detection rate (PCDR). Patients and Methods: 1,086 consecutive patients with a total PSA of 4.1–20.0 ng/ml and/or abnormal digital rectal examination undergoing first-time transrectal ultrasound-guided biopsy were included. Group I patients (n = 562) underwent sextant biopsy and group II patients (n = 524) underwent sextant biopsy with an extra three lateral cores on both sides. The patients were further stratified into subgroups according to PV (cut-off: 35 ml), PSA (cut-off: 10.0 ng/ml), and PSAD (cut-off: 0.2). Results: Prostate cancer was diagnosed in 228/1,086 (21.0%) patients. The PCDR was higher in group II (23.7%) than group I (18.5%). 12-Core biopsy yielded a significantly higher PCDR than 6-core biopsies in patients with PV >35 ml, PSA 4.1–10.0 ng/ml, PSAD ≤0.20, but not in patients with PV ≤35 ml, PSA 10.1–20.0 ng/ml, PSAD >0.20. Conclusions: 12-Core biopsy yielded a significantly higher PCDR in Taiwanese men with a total PSA of 4.1–20.0 ng/ml, especially in patients with PSA 4.1–10.0 ng/ml, PSAD ≤0.20, and PV >35 ml.

Malignant Ureteral Obstruction: Functional Duration of Metallic versus Polymeric Ureteral Stents

Background Ureteral obstruction caused by extrinsic compression is often associated with intra-abdominal cancers. Internal drainage with ureteral stents is typically the first-line therapy to relieve such obstructions. Novel designs of ureteral stents made of different materials have been invented to achieve better drainage. In this study, we described the functional outcomes of a Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) in patients with malignant ureteral obstruction and compare the functional duration of Resonance stents with regular polymeric stents in the same cohort. Methods Cancer patients who received polymeric stents and subsequent Resonance stents for ureteral obstruction between July 2009 and November 2012 were included in a chart review. Stent failure was detected by clinical symptoms, imaging studies, and renal function tests. The functional durations of each stent were calculated, and possible factors affecting stent patency were investigated. Results A total of 50 stents were successfully inserted into 50 ureteral units in 42 patients with malignant ureteral obstruction. There were 7 antegrade stents and 43 retrograde stents. There were no major complications. Stent-related symptoms were similar in both kinds of stents. After polymeric stents were replaced with Resonance metallic stents, hydronephrosis subsided or remained stable in 90% (45/50) of the ureteral units. Serum creatinine decreased or remained stable in 90% (38/42) of these patients. The Resonance stent exhibited a mean increase in functional duration of 4 months compared with the polymeric stents (p<0.0001), and 50% (25/50) of the Resonance stents exhibited a significant increase in functional duration (more than 3 months). Pre-operative serum creatinine < 2 was associated with a substantial increase in stent duration. Conclusions Resonance stents are effective and safe in relieving malignant ureteral obstructions after polymeric stents failure. Resonance stents can provide a longer functional duration than polymeric stents and should be offered as an option for internal drainage.

Advances in non-surgical treatments for urinary tract infections in children.

ObjectiveWith growing antibiotics failure due to emerging resistance of bacteria, non-surgical management of pediatric UTI plays a more important role because of its non-invasive characteristics and little adverse effects.MethodsWe searched the Pubmed for management of UTI in children other than surgical correction and antibiotics using terms: risk factor, prepuce/phimosis, steroid cream/steroid, behavioral therapy, urotherapy, biofeedback/pelvic floor exercise, adrenergic antagonist, anticholinergics, diet/dietary, dysfunctional voiding/dysfunctional elimination syndrome, constipation, dietary, clean intermittent catheterization, probiotics/lactobacillus, cranberry, vitamin supplement, breastfeeding, breast milk, with infant/child/children/pediatrics/pediatrics and urinary tract infection.ResultsThe proposed non-surgical management of pediatric UTI included behavioral modification (timed voiding and adequate fluids intake), topical steroid for phimosis, nutrient supplements (breast milk, cranberry, probiotics, and vitamin A), biofeedback training for dysfunctional voiding, anticholinergics for reducing intravesical pressure, alpha-blockers in dysfunctional voiding and neurogenic bladder, and intermittent catheterization for children with large PVR.ConclusionThe published reports usually included small number of patients and were lacking of randomization and controlled group. Further well-designed studies are warranted to support the concepts of non-operative management for pediatric UTI.