Jung-Tsung Shen

Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients.

OBJECTIVES To follow up the long-term prognosis of patients who underwent nephroureterectomy for primary upper urinary tract (UUT) cancer and to evaluate the predictive factors of tumour recurrence and survival. METHODS Between January 1990 and June 2005, 260 patients with primary UUT transitional cell carcinoma (TCC) underwent radical nephroureterectomy at our institution. The medical records of these patients were retrospectively reviewed. The clinical and histopathological data were analyzed to evaluate predictive factors. RESULTS The median follow-up time was 52 mo. In total, 89 patients (34.1%) developed subsequent bladder tumours. Predictive factors of bladder tumour recurrence were being male and having renal insufficiency. Local recurrence developed in 16 patients (6.2%); only the tumour stage was significantly associated with local recurrence. Metachronous contralateral UUT tumour was diagnosed in 12 patients (4.6%), with gender being the only predictive factor. Of the 260 patients, 167 (63.9%) were disease-free and alive at a median follow-up of 56.5 mo, and 45 (17.2%) died of urothelial cancer at a median period of 20 mo. Only the tumour stage was a prognostic factor to predict cancer-specific survival. CONCLUSIONS In patients with UUT-TCC after radical nephroureterectomy, tumour stage is the only prognostic factor for both local recurrence and cancer-specific survival. Male patients with renal insufficiency should be alerted to the possibility of bladder tumour recurrence. Because female patients were more likely to develop contralateral recurrences, renal ultrasonography, intravenous pyelography, or retrograde pyelography should be performed more frequently for female patients who live in the high-prevalence area.

High melamine migration in daily-use melamine-made tableware

Melamine is commonly used to manufacture tableware, and this could be one of the important exposure sources in humans. The study aims to measure melamine migrated from different material-made tableware by the most sensitive technique of liquid chromatography-tandem mass spectrometry (LC-MS/MS). The test samples were filled with pre-warmed designated-temperature (from room temperature (∼20 °C), 30 °C, 40 °C, 50 °C, 60 °C, 70 °C, 80 °C, to 90 °C) simulant (either distilled water or 3% acetic acid) up to 20 ml and immersed in a water bath at that designated temperature for 15 or 30 minutes (min). High melamine migration levels, ranging from 6.97 to 19.03 μg/ml, can be measured from all melamine-made samples containing 20 ml 3% acetic acid in water bath of 90 °C for 30 min, whereas melamine cannot be detectable in all other material-made samples in the same condition. In addition, the cheaper the melamine-made tableware samples, the higher the melamine migration levels. The migration of melamine amount is dependent on different temperatures, contact times, simulant, and prices of tableware. Since tableware is used in daily life, it is prudent to cautiously select materials that contain foodstuffs.

Management of Symptomatic Urolithiasis during Pregnancy

Urinary calculi during pregnancy present not only a diagnostic challenge but also a management dilemma. In this retrospective study, we describe our experience with diagnosis and management of symptomatic urolithiasis in pregnant women. A total of 18 pregnant women were treated for urolithiasis at the Department of Urology, Kaohsiung Municipal Hsiao‐Kang Hospital, between 1999 and 2004. The incidence of symptomatic urolithiasis during pregnancy was 0.35%. Of the 20 stones found, nine were on the right side and 11 were on the left, and two patients had bilateral urinary stones. Most urolithiasis cases during pregnancy (55.5%) occurred in the third trimester. Flank pain (94.4%) was the most common clinical presentation. Conservative management was successful in 10 patients until the end of pregnancy and then definite treatment was performed. In four patients, a double‐J stent was inserted successfully for persistent pain. In three cases with persistent pain, failure of double‐J stent placement was treated with ureteroscopic lithotripsy under epidural anesthesia. One patient received percutaneous nephrostomy for persistent renal colic and pyonephrosis. Ultrasonographic evaluation of pregnant women with suspected renal colic is a reasonable diagnostic procedure. Ureteroscopy is another choice when conservative treatment fails.

Risk Factors Survey for Extracorporeal Shockwave Lithotripsy-Induced Renal Hematoma

BACKGROUND AND PURPOSE Shockwave lithotripsy (SWL) is a widely used treatment for patients with renal and ureteral stones because of its noninvasive approach. Although minor complications occur in most patients, a relative severe complication, perirenal or subcapsular hematoma, may also occur. We evaluate the possible risk factors for perirenal hematoma after SWL. PATIENTS AND METHODS Between 2001 and 2011, a total of 10,887 SWL treatments were performed for urolithiasis. All SWL procedures were performed using a Siemens Lithostar multiline lithotripter at a frequency of 2/sec under intermittent fluoroscopic guidance. All these patients underwent outpatient treatment without general anesthesia, but pethidine was administered for pain control. Treatment episodes were retrospectively reviewed for medical history, patient age, sex, body mass index (BMI), mean arterial pressure at induction, location of stone, total number of shockwaves, and peak shockwave intensity. We also compared the hematoma group with the control group (no hematoma formation after SWL with matched age and sex) for various factors. RESULTS After 10,887 treatment episodes on a total of 6177 patients during this period, subcapsular or perirenal hematoma developed in 20 patients for a total incident rate of 0.32%. Eighteen patients had the symptom of flank pain, and 2 patients received a diagnosis accidentally without symptoms. Four patients received a blood transfusion because of low hemoglobulin concentration. All of them received conservative and supportive treatment without surgical exploration. Ten (50%) patients had a history of hypertension. Renal hematoma developed in 11 patients at the second or third SWL treatment. Hypertension, higher BMI, and larger stone size are predisposing risk factors (P=0.022, 0.026 and 0.026, respectively) for renal hematoma. CONCLUSIONS Renal hematoma is a rare (incidence rate, 0.32%) but possibly lethal complication. The most common symptoms of renal hematoma are severe flank pain and hematuria. A history of hypertension and higher BMI are important predisposing factors to perirenal hematoma.

COLON PERFORATION: A RARE COMPLICATION DURING PERCUTANEOUS NEPHROLITHOTOMY

Only a few cases of colon perforation during percutaneous nephrolithotomy (PCNL) have been reported. We present here a case of colon perforation during PCNL that was managed conservatively by stenting the urinary tract, using the percutaneous catheter as the colostomy tube, and giving broad‐spectrum antibiotics. This report also reviews the anatomic and technical access to the kidney and reminds the urologist about this rare but serious complication of PCNL.

Comparison of Percutaneous Nephrolithotomy and Ureteroscopic Lithotripsy in the Management of Impacted, Large, Proximal Ureteral Stones

The optimal treatment for large, impacted, proximal ureteral stones remains controversial. We report our experience and compare treatment outcomes in patients with single, impacted, proximal ureteral stones undergoing percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL). Between January 2005 and January 2006, a total of 53 consecutive patients with solitary, impacted, proximal ureteral stones > 15 mm in diameter who had undergone PCNL or URSL treatments were enrolled in this study. The mean age was 48.5 ± 11.8 years. PCNL and URSL were performed in 22 and 31 patients. Stone burdens in the PCNL and URSL groups were 232.8 ± 113.2 mm2 and 150.3 ± 70.3 mm2, respectively. The efficiency quotient (EQ) for the PCNL and URSL groups was 0.95 and 0.67, respectively. The stone‐free rate at the 1 month follow‐up was 95.4% in the PCNL group and 58% in the URSL group (p < 0.001). Two patients in the PCNL group had blood loss requiring transfusion. Eight patients had stones showing upward migration during the URSL procedure, and these stones were subsequently treated by extracorporeal shock wave lithotripsy and PCNL. For an impacted, proximal ureteral stone > 15 mm in diameter, PCNL had better stone‐free rates and could simultaneously treat coexisting renal stones. However, URSL had the advantages of shorter operative times, shorter postoperative hospital stays, and fewer postoperative complications.

The management strategy of renal angiomyolipoma.

The purpose of this study is to analyze the management strategy of renal angiomyolipoma. From 1990 to 2002, a total of 62 patients with renal angiomyolipoma were treated at our medical center. Angiomyolipomas were found in 44 female patients (71.0%) and 18 male patients. Of these patients the age ranged from 18 to 87 y/o (mean: 46.9 y/o). Four of 8 patients with bilateral angiomyolipomas were associated with tuberous sclerosis (TS). Nine (14.5%) of 62 patients had got spontaneous rupture. However, 54.8 per cent of patients were asymptomatic. The mean tumor size was 4.83 cm. Tumors larger than 4 cm had a greater incidence of symptoms (60.7%) and a higher nephrectomy rate (43%). Clinical management was based on tumor size and clinical presentation. Treatment consisted of conservative observation in 30 patients (group 1, 48.4%), selective embolization therapy in 2 patients with hemorrhage (group 2, 3.2%), partial nephrectomy and other surgical procedures in 14 patients (group 3, 22.6%), and total nephrectomy in 16 patients (group 4, 25.8%). Nine of 62 patients were associated with spontaneous angiomyolipoma rupture under conservative treatment in 3, TAE in 1, partial nephrectomy in 1, total nephrectomy in 3 and laparotomy to check bleeding in 1. Neither mortality no major complication was noted. Generally the outcomes were smooth and acceptable. Beyond the total nephrectomy for patients with highly suspected malignancy, we suggest conservative treatment with observation strategy for small asymptomatic tumors, selective arterial embolization as the first choice for hemorrhage or rupture and partial nephrectomy for renal sparing strategy.

Impact of Lower Pole Anatomy on Stone Clearance After Shock Wave Lithotripsy

This study retrospectively analyzed patients treated with shock wave ithotripsy (SWL) for lower calyceal stones, to determine the influence of the lower pole anatomy and stone size in predicting the clearance of fragments. Between June 2000 and March 2002, we reviewed excretory urography (IVU) of 59 patients with isolated lower pole stones treated with SWL. A total of 44 men and 15 women, with an age ranging between 23 and 78 years (mean, 55 years), were included in the study. The patients were divided into two groups, either a stone‐free group or residual‐stone group. After SWL, overall stone rate was 57.6%, and clearance for stones less than 10 mm in diameter was 64.5%, whereas clearance was 50% for stones between 10 and 20 mm in diameter. Intrarenal anatomy on IVU, such as infundibular width and infundibulopelvi‐ureteric angle showed no significant difference between the stone‐free and residual‐stone groups. Our analysis showed that three significant variables were relevant to stone clearance: infundibular length, stone size and stone burden. We conclude that SWL is the best treatment for lower pole kidney stones 10 mm or less in diameter, showing lower complication and acceptable stone‐free rates.

Laparoscopic Bladder Diverticulectomy for Large Bladder Diverticulum: A Case Report

Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. Acquired bladder diverticula are the result of outlet obstruction, mostly benign prostate enlargement, infections, or urethral stricture. Traditionally, bladder diverticulum was excised by the open method. However, the laparoscopic technique has been widely used to treat many urologic diseases, including bladder diverticulum. Laparoscopic diverticulectomy can be performed transperitoneally or extraperitoneally. We report our initial experience with laparoscopic transperitoneal diverticulectomy for a large bladder diverticulum caused by bladder outlet obstruction. The patient had satisfactory micturition and was discharged on the eighth postoperative day.

Comparison of Hand-Assisted Laparoscopic Nephroureterectomy with Open Surgery for Upper Urinary Tract Tumor

Herein we report on our initial experience in performing nephroureterectomy by hand-assisted laparoscopic surgery, and compare the results with those performed by traditional open methods. From December 2000 to September 2001, 10 patients with upper urinary tract tumors underwent hand-assisted laparoscopic nephroureterectomy. Except for one patient who required elective conversion to open surgery due to renal vein injury, this cohort of 9 patients was compared to a group of 35 patients who had received traditional open nephroureterectomy over the last 2 years. Demographic, intraoperative and postoperative data were compared retrospectively. These two groups were similar in age, body mass index, operation time and time to postoperative oral intake. However, the hand-assisted laparoscopy group was found to have significantly less blood loss, less need for parenteral narcotic and a shorter length of time needed for postoperative hospitalization than the open group. Thus, in this report we have demonstrated hand-assisted laparoscopic nephroureterectomy to be a safe and efficacious treatment of malignant urinary collecting tumors. We believe the benefits of this minimally invasive surgery make it a viable alternative technique for management of upper urinary tract tumor.