Jong Bo Choi

Risk Factors for Acute Prostatitis after Transrectal Biopsy of the Prostate

Purpose To investigate the incidence, clinical features, pathogenic bacteria, and risk factors associated with acute prostatitis after transrectal prostate biopsy. Materials and Methods We retrospectively reviewed the medical records of 923 transrectal ultrasound-guided needle biopsies of the prostate in 878 patients performed at our institution from June 2004 to May 2009. The indications for biopsy were generally serum prostate-specific antigen (PSA) elevation, abnormal findings on a digital rectal examination, or both. All biopsies were performed with the patient hospitalized except for 10 patients who refused to be hospitalized, and ciprofloxacin was administered as an antibiotic prophylaxis. The incidence, clinical features, pathogenic bacteria, and potential risk factors associated with acute prostatitis after prostate biopsy were evaluated. Results Acute prostatitis developed in 18 (2.0%) cases after prostate biopsy. Among them, 9 (1.0%) had bacteremia and 2 (0.2%) showed clinical features of sepsis. Of the total 50 urine or blood specimens sent for culture study, 27 (54.0%) specimens showed positive cultures, including E. coli in 25. Among the 27 culture-positive specimens, 26 (96.3%) were resistant to ciprofloxacin. Among the potential risk factors for acute prostatitis after prostate biopsy, biopsy performed as an outpatient procedure without a cleansing enema (p=0.001) and past history of cerebrovascular accident (p=0.048) were statistically significant. Conclusions Fluoroquinolone is effective as an antibiotic prophylaxis for transrectal prostate biopsy in most cases. The incidence of acute prostatitis after transrectal prostate biopsy was 2.0%, and almost all cases were caused by fluoroquinolone-resistant E. coli. A cleansing enema is recommended before transrectal prostate biopsy.

Alteration of Autonomic Function in Female Urinary Incontinence

Purpose Stress urinary incontinence (SUI) and urge urinary incontinence (UUI) have different mechanisms of action. We believe that alteration of autonomic nervous system (ANS) activity may contribute to UUI because the lower urinary tract is regulated through the sympathetic and parasympathetic nervous systems. Heart rate variability (HRV) allows measurement of autonomic nervous function, therefore we measured and compared HRV parameters in women with urinary incontinence. Methods From March 2008 to March 2010, we evaluated all patients who visited 2 university hospitals for treatment of urinary incontinence. Theywere performed 3-day voiding diary, urodynamic study, physical examination and routine laboratory examination. We excluded subjects who had diabetes, cardiovascular problems, or other condition that affect ANS. Patients with mixed urinary incontinence (MUI) were also excluded. Finally 47 women with SUI (group 1) and 29 women with UUI (group 2) were enrolled according to their symptoms and voiding diary. We compared their HRV parameters. And excluding 11 patients who had detrusor underactivity, we divided them again into group A, 53 women without detrusor overactivity (DO) and group B, 12 women with DO. We compared HRV parameters between DO and non-DO group. Results Older women had a higher incidence of UUI and DO. In HRV parameters, only the ratio of low frequency (LF) and high frequency (HF) was significantly higher in group 2 than group 1 (3.5±3.6 vs. 1.6±1.1, P<0.05). Also group A had higher mean LF/HF ratio than group B (4.3±3.8 vs. 1.9±1.9, P<0.05). Conclusions Increased LF/HF values indicate relative sympathetic hyperactivity over parasympathetic activity. Changes in ANS activity could indicate the presence of UUI and potentially DO.

Heart Rate Variability in Men with Erectile dysfunction

Purpose The objective of this study is to investigate alteration of autonomic nervous system (ANS) activity in patients suffering from erectile dysfunction (ED) by comparing parameters of heart rate variability (HRV) between men with ED and healthy subjects. Methods A retrospective review was performed on 40 ED patients (mean age, 46.0±8.49 years) without any disease and 180 healthy control people (mean age, 44.4±7.83 years) without ED in our institution from June 2008 to July 2010. And electrocardiographic signals were obtained to measure HRV parameters for both patients and controls in a resting state. Results For the time domain analysis, square root of the mean differences between successive RR intervals (RMSSD) representing parasympathetic activity was lower in patients than controls although P-value was not statistically significant (P=0.060). For the frequency domain analysis, high frequency (HF) representing parasympathetic activity was lower in patients than controls (P=0.232) and low frequency (LF) representing mainly sympathetic activity was higher in patients than controls (P=0.416). Lastly, LF/HF ratio reflecting sympathetic/parasympathetic activity ratio was statistically higher in patients than controls (P=0.027). Conclusions Patients with ED exhibited different HRV parameters compared with normal controls. This suggests that the patients with ED may have some kind of imbalance in the ANS and it may be possible that general imbalance of the ANS is one of the causes of ED. Thus, HRV analysis may give valuable diagnostic information and serve as a rapid screening tool to evaluate altered ANS activity in patients with ED.

Heart Rate Variability in Assessment of Autonomic Dysfunction in Patients With Chronic Prostatitis/Chronic Pelvic Pain Syndrome

OBJECTIVE To determine and compare autonomic dysfunction in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). METHODS The subjects were 30-60 years old and had no known systemic disease. Electrocardiographic signals in the patients in the resting state were obtained from 59 patients with CP/CPPS (age 46.5 ± 7.02 years) and 94 healthy subjects (age 48.4 ± 5.96 years), and heart rate variability parameters were compared. RESULTS The standard deviation of the N-N interval (P < .001), square root of the mean squared differences of the successive N-N intervals (P = .004), total power (P = .004), very low frequency (P = .012), and high frequency (P < .001) were lower in the patients with CP/CPPS. However, no significant differences were found in the low frequency and low frequency/high frequency ratios. CONCLUSION Patients with CP/CPPS exhibited lower heart rate variability parameters compared with normal controls, with the exception of low frequency and low frequency/high frequency ratios. Possible differences in autonomic nervous system between those with CP/CPPS and normal healthy subjects could exist and autonomic dysfunction might be 1 of the causes that aggravates CP/CPPS.

Failure of carbon dioxide laser treatment in three patients with penoscrotal extramammary Paget's disease

A 64-year-old man presented with a 3-month history of a 4r6 cm eczematoid erythematous skin lesion in the penoscrotal area (Fig. 1). The lesion involved about half of the proximal penile shaft and the left scrotum; the lesion was con®rmed as extramammary Pagets disease (EPD) by skin-punch biopsy. Other studies including serum PSA, IVU, abdominal ultrasonography, gastric and colonic endoscopic examination showed no other abnormality. Using Woods ̄uorescent visualization, the EPD was identi®ed and the lesion treated with a CO2 laser (10±60 W), resurfacing with 300±500 mJ of pulse energy. The resulting charred surface was removed by lightly abrading the surface with moist saline-soaked gauze. This process was repeated layer-by-layer using the same parameters until all remaining abnormal ̄uorescent tissue had been removed. The skin was vaporized to a depth of < 2 mm and horizontally 1 cm beyond the ̄uorescent area. After 10±14 days the wound healing was almost completed; at 1 month after treatment the healing of the lesion showed good granulation and no ̄uorescence was detectable for 2 months (Fig. 2). However, after 6 months there was a diffuse ̄uorescent area at the treated site which was con®rmed as EPD by punch biopsy. The lesion was then widely excised with normal tissue for 3 cm beyond the ̄uorescent lesion; the lesion was then covered by a split-skin graft from the buttock area.

Characteristics of autonomic nervous system activity in men with lower urinary tract symptoms (LUTS): analysis of heart rate variability in men with LUTS.

OBJECTIVES To identify the difference in autonomic nervous dysfunction activity in men between voiding symptom-predominant lower urinary tract symptoms (LUTS) and storage symptom-predominant LUTS. METHODS A total of 39 men with LUTS (mean age 56.9 +/- 8.96 years) and 23 healthy men (mean age 57.0 +/- 1.76 years) were included in the present study. Seven questions numbered Q1 to Q7 in the order of appearance in International Prostate Symptom Score were divided into 2 clusters: one with Q1, Q3, Q5, and Q6 and the other with Q2, Q4, and Q7, representing voiding and storage symptoms, respectively. Patients were divided into either voiding symptom-predominant group, if mean voiding symptom score, defined as (Q1 + Q3 + Q5 + Q6)/4, is bigger than mean storage symptom score, defined as (Q2 +Q4 + Q7)/3, or storage symptom-predominant group otherwise. We measured and compared parameters of heart rate variability between men with LUTS and healthy normal subjects. We also compared heart rate variability of men between storage symptom-predominant LUTS and voiding symptom-predominant LUTS. RESULTS On frequency domain analysis, there was evidence of decreased high frequency (HF) in patients with LUTS (P <.05). In comparison of autonomic nervous dysfunction activity in LUTS patients, men with voiding symptom-predominant LUTS had relatively increased ratio of low frequency and HF than what was observed in men with storage symptom-predominant LUTS. CONCLUSIONS Patients with LUTS exhibited decreased HF indicated that they may have had some disease or imbalance in the autonomic nervous system, which may distinguish LUTS patients from healthy men. Also, patients with voiding symptom-predominant LUTS had relatively increased sympathetic activity than storage symptom-predominant LUTS patients.

Transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement: a quality and meta-analysis.

Purpose Thanks to advancements in surgical techniques and instruments, many surgical modalities have been developed to replace transurethral resection of the prostate (TURP). However, TURP remains the gold standard for the surgical treatment of benign prostatic hyperplasia (BPH). We conducted a meta-analysis on the efficacy and safety of minimally invasive surgical therapies for BPH compared with TURP. Methods This meta-analysis used a Medline search assessing the period from 1997 to 2011. A total of 784 randomized controlled trials were identified in an electronic search. Among the 784 articles, 36 randomized controlled trials that provided the highest level of evidence (level 1b) were included in the meta-analysis. We also conducted a quality analysis of selected articles. Results Only 2 articles (5.56%) were assessed as having a low risk of bias by use of the Cochrane collaboration risk of bias tool. On the other hand, by use of the Jadad scale, there were 26 high-quality articles (72.22%). Furthermore, 28 articles (77.78%) were assessed as high-quality articles by use of the van Tulder scale. Holmium laser enucleation of the prostate (HoLEP) showed the highest reduction of the International Prostate Symptom Score compared with TURP (P<0.0001). Bipolar TURP, bipolar transurethral vaporization of the prostate, HoLEP, and open prostatectomy showed superior outcome in postvoid residual urine volume and maximum flow rate. The intraoperative complications of the minimally invasive surgeries had no statistically significant inferior outcomes compared with TURP. Also, there were no statistically significant differences in any of the modalities compared with TURP. Conclusions The selection of an appropriate surgical modality for BPH should be assessed by fully understanding each patients clinical conditions.

Midterm efficacy and complications of readjustable midurethral sling (Remeex system) in female stress urinary incontinence with recurrence or intrinsic sphincter deficiency.

OBJECTIVE To evaluate the efficacy, complications, and managements of the readjustable midurethral sling (Remeex system) for the treatment of recurrent stress urinary incontinence (SUI) after previous anti-incontinence surgeries or intrinsic sphincter deficiency (ISD). METHODS Between March 2008 and February 2012, 102 women, who presented with previous failed surgery or ISD, were treated with the Remeex system at 4 different institutions. We retrospectively reviewed medical history, physical examination, urodynamic study, postvoiding residual volume, and/or 1-hour pad test of the patients. Surgical outcomes were evaluated using the Severity Index for Urinary Incontinence. The degree of patient satisfaction was assessed, and all complications were classified according to the modified Clavien classification system. RESULTS After a mean follow-up of 27.6 months (range, 14-56 months), 91 patients (89.2%) were cured and 6 patients (5.9%) were improved. The patients satisfaction rate was 87.2% (89 of 102 patients). Overall, 41 patients (40.2%) experienced 53 complications; 15 patients (14.7%) presented de novo urgency, which was properly managed with anticholinergics, and 14 patients (13.7%) underwent delayed sling readjustment for recurrent SUI (n = 13) and urinary retention (n = 1) during follow-up. Among 6 patients (5.9%) with wound infection, 4 patients were successfully treated by daily dressing with antibiotics, and 2 patients underwent removal of the Remeex system owing to intractable infection. Most complications were classified as grade 1 (54.8%) or 2 (15.1%) and were successfully treated with minimal conservative measures. CONCLUSION The Remeex system is a valuable adjunct for recurrent SUI after previous anti-incontinence surgeries or ISD, considering most complications are Clavien grade I or II.

The efficacy and tolerability of tarafenacin, a new muscarinic acetylcholine receptor M3 antagonist in patients with overactive bladder; randomised, double-blind, placebo-controlled phase 2 study

To evaluate the dose–response relationship of tarafenacin, an antimuscarinic agent in development phase, for efficacy and safety, at daily doses of 0.2 and 0.4 mg for the treatment of overactive bladder (OAB)

Autonomous Nervous System Activity in Women with Detrusor Overactivity

Purpose To identify autonomic dysfunction among patients with urinary incontinence (UI) with or without detrusor overactivity (DO), we measured and compared heart rate variability (HRV) in these groups. Materials and Methods We studied HRV in 12 female UI patients with DO (mean age, 57.3±11.0 years) and 53 female UI patients without DO (mean age, 56.8±9.8 years). HRV parameters were measured by SA-3000P®. Heart rates, the time domain index, and the frequency domain index were compared. To compare time domain indexes, we used the standard deviation of the N-N interval (SDNN), the square root of the mean squared differences of successive N-N intervals (RMSSD), and the frequency domain indexes total power (TP), very low frequency (VLF), low frequency (LF), high frequency (HF), and the low-frequency/high-frequency ratio (LF/HF ratio). Results RMSSD values were lower in UI patients with DO than in those without DO, but the values of SDNN and HR showed no significant difference. Whereas the values of LF and HF were lower in UI patients with DO than in those without DO, the LF/HF ratio was higher. TP and VLF were not significantly different. Conclusions RMSSD, HF, and LF were lower in DO patients than in controls without DO, but the LF/HF ratio was higher. This suggests that both sympathetic and parasympathetic activity is attenuated in DO, but the autonomic imbalance is higher.