Kl Ho

Androgen deprivation therapy and cardiovascular risk in chinese patients with nonmetastatic carcinoma of prostate.

Background. Androgen deprivation therapy (ADT) in nonmetastatic prostate cancer is unclear. Recent data suggests possible increase in the cardiovascular risks receiving ADT. The aim of the study was to investigate the cardiovascular outcomes in a cohort of Chinese nonmetastatic prostate cancer patients with no previously documented cardiovascular disease. Methods and Results. 745 patients with no previously documented cardiovascular disease and/or diabetes mellitus diagnosed to have nonmetastatic prostate cancer were recruited. Of these, 517 patients received ADT and the remaining 228 did not. After a mean follow-up of 5.3 years, 60 patients developed primary composite endpoint including (1) coronary artery disease, (2) congestive heart failure, and (3) ischemic stroke. Higher proportion of patients on ADT (51 patients, 9.9%) developed composite endpoint compared with those not on ADT (9 patients, 3.9%) with hazard ratio (HR) of 2.06 (95% confidence interval (CI): 1.03–3.24, P = 0.04). Furthermore, Cox regression analysis revealed that only the use of ADT (HR: 2.1, 95% CI: 1.03–4.25, P = 0.04) and hypertension (HR: 2.0, 95% CI: 1.21–3.33, P < 0.01) were independent predictors for primary composite endpoint. Conclusion. ADT in Chinese patients with nonmetastatic prostate cancer with no previously documented cardiovascular disease was associated with subsequent development of cardiovascular events.

Association of time to prostate-specific antigen nadir and logarithm of prostate-specific antigen velocity after progression in metastatic prostate cancer with prior primary androgen deprivation therapy.

We investigated the association of time to prostate-specific antigen nadir (TTPN) and logarithm of prostate-specific antigen velocity after progression Log(PSAVAP) in metastatic prostate cancer with prior primary androgen deprivation therapy (ADT). All metastatic prostate cancer patients treated with primary ADT from 2000 to 2009 were reviewed. Patients who developed disease progression were included in the subsequent analyses. Patients were categorized into three groups according to their TTPN: TTPN of <3 months, 3-17 months, and >17 months. We compared the Log(PSAVAP) between the different TTPN groups using Mann-Whitney U-test and Kruskal-Wallis test. Further multiple linear regression analyses on Log(PSAVAP) were performed to adjust for other potential confounding factors. Among 419 patients who were treated with primary ADT, 306 patients developed disease progression with a median follow-up of 28 months. Longer TTPN was associated with lower Log(PSAVAP) (P = 0.008) within all subgroup analyses (TTPN of <3 vs 3-17 months, P= 0.020; TTPN of 3-17 vs >17 months, P= 0.009; and TTPN of <3 vs >17 months, P= 0.001). Upon multiple linear regression analyses, baseline PSA (regression coefficient 0.001, P= 0.045), PSA nadir (regression coefficient 0.002, P= 0.040), and TTPN (regression coefficient −0.030, P= 0.001) were the three factors that were significantly associated with Log(PSAVAP). In conclusion, a longer TTPN was associated with lower Log(PSAVAP) in metastatic prostate cancer patients following primary ADT. TTPN cut-offs at 3 months and 17 months appeared to have prognostic significance in predicting Log(PSAVAP). TTPN may serve as a good prognostic indicator in deciding the treatment strategy in patients with disease progression.

Disease spectrum and treatment patterns in a local male infertility clinic.

OBJECTIVE To review disease spectrum and treatment patterns in a local male infertility clinic. DESIGN Case series. SETTING Male infertility clinic in a teaching hospital in Hong Kong. PATIENTS Patients who were seen as new cases in a local male infertility clinic between January 2008 and December 2012. INTERVENTION Infertility assessment and counselling on treatment options. MAIN OUTCOME MEASURES Disease spectrum and treatment patterns. RESULTS A total of 387 new patients were assessed in the male infertility clinic. The mean age of the patients and their female partners was 37.2 and 32.1 years, respectively. The median duration of infertility was 3 years. Among the patients, 36.2% had azoospermia, 8.0% had congenital absence of vas deferens, and 48.3% of patients had other abnormalities in semen parameters. The commonest causes of male infertility were unknown (idiopathic), clinically significant varicoceles, congenital absence of vas deferens, mumps after puberty, and erectile or ejaculatory dysfunction. Overall, 66.1% of patients chose assisted reproductive treatment and 12.4% of patients preferred surgical correction of reversible male infertility conditions. Altogether 36.7% of patients required either surgical sperm retrieval or correction of male infertility conditions. CONCLUSIONS The present study provided important local data on the disease spectrum and treatment patterns in a male infertility clinic. The incidences of azoospermia and congenital absence of vas deferens were much higher than those reported in the contemporary literature. A significant proportion of patients required either surgical sperm retrieval or correction of reversible male infertility conditions.

Subinguinal microsurgical varicocelectomy for male factor subfertility: a ten-year experience

OBJECTIVE To investigate the impact of subinguinal microsurgical varicocelectomy on semen parameters and pregnancy outcomes in couples with male factor subfertility. DESIGN Case series. SETTING Male Infertility Clinic in an academic institution in Hong Kong. PATIENTS The clinical records of 42 consecutive subfertile male patients who had subinguinal microsurgical varicocelectomy (from January 2000 to December 2009) were retrospectively reviewed. All the patients had a known history of subfertility and abnormalities in one or more semen parameters. Female subfertility factors were not addressed. Only grade 2 or higher clinically palpable varicoceles were operated on. MAIN OUTCOME MEASURES Preoperative and postoperative semen analyses based on the World Health Organization criteria; the outcome measures included changes in semen parameters and whether a pregnancy ensued. RESULTS The mean age of patients and their spouses were 38 and 33 years, respectively. The mean duration of infertility was 4 years; 37 patients had primary infertility and five had secondary infertility. The mean (± standard deviation) sperm concentration improved from 12 ± 19 million/mL to 23 ± 29 million/mL following varicocelectomy (P<0.001), the mean sperm motility improved from 26% ± 16% to 32% ± 18% (P<0.001), and the mean normal morphology increased from 5% ± 7% to 6% ± 6% (P<0.001). Postoperatively, 23 (55%) of the patients achieved pregnancy, 11 (26%) being spontaneous, 1 (2%) by intrauterine insemination, and 11 (26%) by in-vitro fertilisation. Among 20 patients with severe preoperative oligospermia (<5 million/mL), statistically significant improvements occurred in postoperative mean sperm concentration, motility and morphology (all P<0.001), and five (25%) of them achieved a spontaneous pregnancy. There was one intra-operative injury to the testicular artery with immediate repair and no testicular atrophy. Five (12%) of the patients had recurrences. No preoperative factors appeared predictive of a pregnancy ensuing. CONCLUSIONS In couples with male infertility due to varicoceles, subinguinal microsurgical varicocelectomy was shown to improve sperm concentrations, motility and morphology, and the likelihood of a pregnancy. Spontaneous pregnancy was achieved in 25% of the couples in which the man had severe oligospermia.

Metastatic carcinoma of breast in the urinary bladder.

Less than 5% of breast cancers present as metastasis, and urinary bladder secondaries were only sporadically reported in the literature. However, they may even be responsible for the initial presentation, for which reason they can pose a diagnostic challenge. We present here what we believe is the first such case in Hong Kong, with a review of this entity.

Impact of skeletal-related events on survival in patients with metastatic prostate cancer prescribed androgen deprivation therapy.

OBJECTIVE To investigate the impact of skeletal-related events on survival in patients with metastatic prostate cancer prescribed long-term androgen deprivation therapy. METHODS This historical cohort study was conducted in two hospitals in Hong Kong. Patients who were diagnosed with metastatic prostate cancer and prescribed androgen deprivation therapy between January 2006 and December 2011 were included. Details of skeletal-related events and mortality were examined. RESULTS The median follow-up was 28 (range, 1-97) months. Of 119 patients, 52 (43.7%) developed skeletal-related events throughout the study, and the majority received bone irradiation for pain control. The median actuarial overall survival and cancer-specific survival for patients with skeletal-related events were significantly shorter than those without skeletal-related events (23 vs 48 months, P=0.003 and 26 vs 97 months, P<0.001, respectively). Multivariate analysis revealed that the adjusted hazard ratio of presence of skeletal-related events on overall and cancer-specific survival was 2.73 (95% confidence interval, 1.46-5.10; P=0.002) and 3.92 (95% confidence interval, 1.87-8.23; P<0.001), respectively. A prostate-specific antigen nadir of >4 ng/mL was an independent poor prognostic factor for overall and cancer-specific survival after development of skeletal-related events (hazard ratio=10.42; 95% confidence interval, 2.10-51.66 and hazard ratio=10.54; 95% confidence interval, 1.94-57.28, respectively). CONCLUSIONS Skeletal-related events were common in men with metastatic prostate cancer. This is the first reported study to show that a skeletal-related event is an independent prognostic factor in overall and cancer-specific survival in patients with metastatic prostate cancer prescribed androgen deprivation therapy. A prostate-specific antigen nadir of >4 ng/mL is an independent poor prognostic factor for overall and cancer-specific survival following development of skeletal-related events.

Androgen deprivation therapy and fracture risk in Chinese patients with prostate carcinoma

Objective Androgen deprivation therapy (ADT) increases fracture risk in men with carcinoma of the prostate, but little is known about the fracture risk for different types of ADT. We studied the fracture risk amongst Chinese patients with carcinoma of the prostate prescribed different ADT regimens. Subjects and methods This was a single-centered observational study that involved 741 patients with carcinoma of the prostate from January 2001 to December 2011. Results After a median follow-up of 5 years, 71.7% of the study cohort received ADT and the incidence rate of fracture was 8.1%. Multivariable Cox regression analysis revealed that use of ADT was significantly associated with risk of incident fracture (Hazard Ratio [HR] 3.60; 95% Confidence Interval [95% CI] 1.41–9.23; p = 0.008), together with aged >75 years and type 2 diabetes. Compared with no ADT, all three types of ADT were independently associated with the risk of incident fracture: anti-androgen monotherapy (HR 4.47; 95% CI 1.47–13.7; p = 0.009), bilateral orchiectomy ± anti-androgens (HR 4.01; 95% CI 1.46–11.1; p = 0.007) and luteinizing hormone-releasing hormone agonists ± anti-androgens (HR 3.16; 95% CI 1.18–8.43; p = 0.022). However, there was no significant difference in the relative risks among the three types of ADT. Conclusions Fracture risk increases among all types of ADT. Clinicians should take into account the risk-benefit ratio when prescribing ADT, especially in elderly patients with type 2 diabetes.

How can the R.E.N.A.L. nephrometry scoring system aid management of a solid renal mass

OBJECTIVES. To investigate use of the R.E.N.A.L. nephrometry score in relation to the choice of treatment and postoperative complications for renal masses. DESIGN. Case series. SETTING. A tertiary referral hospital in Hong Kong. PATIENTS. Data of patients undergoing nephrectomy were collected retrospectively from a clinical database and analysed. A R.E.N.A.L. nephrometry score was allocated to each renal tumour by a blinded qualified radiologist, utilising computerised imaging systems. Patient demographics, choice of surgery (radical vs partial), and approaches (open vs minimally invasive) were analysed with respect to their R.E.N.A.L. score. RESULTS. In all, 74 patients were included during the study period, of which 38 underwent partial nephrectomy and 36 underwent radical nephrectomy. No differences between the groups were found with respect to patient demographics. There were significant differences between the partial and radical nephrectomy groups in terms of their mean nephrometry score (6.9 vs 9.3, P<0.001). The mean nephrometry sum was also significantly different in the open approach versus the minimally invasive approach in patients having partial nephrectomy (7.8 vs 6.0, P=0.001). There was no difference in the postoperative 90-day morbidity and mortality in the partial nephrectomy and radical nephrectomy groups. CONCLUSIONS. The R.E.N.A.L. nephrometry score of a renal mass correlated significantly with our choice of surgery (partial vs radical) and our approach to surgery (open vs minimally invasive surgery), particularly in the partial nephrectomy group. It does not, however, correlate with postoperative complications. The nephrometry score provides a useful tool for objectively describing renal mass characteristics and enhancing better communication for the operative planning directed at renal masses.

Effect of osteoporotic fractures on overall survival in patients with non-metastatic prostatic cancer having androgen deprivation therapy

This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012As experience of laparoendoscopic single-site surgery (LESS) expanded, the indications of LESS grew more technically challenging procedures, such as partial nephrectomy. However, because of the loss of triangulation and instrument clashing, difficulties persist even with the use of specialized instruments intended for LESS. With its Endowrist technology (Intuitive Surgical, Sunnyvale, CA, USA) affording seven degrees of freedom of motion, its three-dimensional vision, and motion scaling to eliminate tremors, the DaVinci (Intuitive Surgical, Sunnyvale, CA, USA) surgical robotic platform has gained popularity in urology, particularly in prostatectomy and partial nephrectomy. Its advantage in partial nephrectomy is it allows accurate and expeditious intracorporeal suturing of the renal defect, keeping ischemia time and intraoperative blood loss at a minimum. We utilized novel single-site incision with robotic technology to perform robotic laparoendoscopic single-site surgery (R-LESS). Between December 2008 and August 2010, we performed 76 consecutive R-LESS. These included simple nephrectomy (n=1), radical nephrectomy (n=2), partial nephrectomy (n=56), nephroureterectomy (n=12), adrenalectomy (n=2), prostatectomy (n=3). For R-LESS, with the patient in 45-degree flank position, a 30-degree robotic laparoscope was inserted over a 12mm port inserted through one of the fingers of the glove and fixed to the uppermost portion of the home-made port toward the same side as the lesion. Two 8-mm robotic ports were likewise inserted through fingers of the glove and fixed inferolaterally on both sides to allow maximum distance between the ports. A 10mm port was inserted to another finger of the glove for insufflation and as assistant port. For partial nephrectomy and prostatectomy, however, we have found that it is very difficult to use this assistant port without getting caught in between the robotic arms. Hence, we place another 10mm assistant port 8cm from the umbilicus toward the symphysis pubis, through which we pass laparoscopic bulldog clamps or ultrasound probes for TilePro (Intuitive Surgical, Sunnyvale, CA, USA) intraoperative monitoring. Mean patient age was 53 years, mean operative time was 190.8 minutes, and mean estimated blood loss was 204 ml. Complications include open conversion (n=2), transfusion (n=6), ureteral injury (n=1). In conclusions R-LESS is technically feasible and another option for various urologic diseases. However, surgical experience and further robotic platform development are needed to develop robotic laparoendoscopic single-site surgery.This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012

Efficacy of a Urology Nurse-led Clinic in Queen Mary Hospital of Hong Kong

This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012As experience of laparoendoscopic single-site surgery (LESS) expanded, the indications of LESS grew more technically challenging procedures, such as partial nephrectomy. However, because of the loss of triangulation and instrument clashing, difficulties persist even with the use of specialized instruments intended for LESS. With its Endowrist technology (Intuitive Surgical, Sunnyvale, CA, USA) affording seven degrees of freedom of motion, its three-dimensional vision, and motion scaling to eliminate tremors, the DaVinci (Intuitive Surgical, Sunnyvale, CA, USA) surgical robotic platform has gained popularity in urology, particularly in prostatectomy and partial nephrectomy. Its advantage in partial nephrectomy is it allows accurate and expeditious intracorporeal suturing of the renal defect, keeping ischemia time and intraoperative blood loss at a minimum. We utilized novel single-site incision with robotic technology to perform robotic laparoendoscopic single-site surgery (R-LESS). Between December 2008 and August 2010, we performed 76 consecutive R-LESS. These included simple nephrectomy (n=1), radical nephrectomy (n=2), partial nephrectomy (n=56), nephroureterectomy (n=12), adrenalectomy (n=2), prostatectomy (n=3). For R-LESS, with the patient in 45-degree flank position, a 30-degree robotic laparoscope was inserted over a 12mm port inserted through one of the fingers of the glove and fixed to the uppermost portion of the home-made port toward the same side as the lesion. Two 8-mm robotic ports were likewise inserted through fingers of the glove and fixed inferolaterally on both sides to allow maximum distance between the ports. A 10mm port was inserted to another finger of the glove for insufflation and as assistant port. For partial nephrectomy and prostatectomy, however, we have found that it is very difficult to use this assistant port without getting caught in between the robotic arms. Hence, we place another 10mm assistant port 8cm from the umbilicus toward the symphysis pubis, through which we pass laparoscopic bulldog clamps or ultrasound probes for TilePro (Intuitive Surgical, Sunnyvale, CA, USA) intraoperative monitoring. Mean patient age was 53 years, mean operative time was 190.8 minutes, and mean estimated blood loss was 204 ml. Complications include open conversion (n=2), transfusion (n=6), ureteral injury (n=1). In conclusions R-LESS is technically feasible and another option for various urologic diseases. However, surgical experience and further robotic platform development are needed to develop robotic laparoendoscopic single-site surgery.This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012This journal suppl. is Special Issue: Abstracts of the 11th Asian Congress of Urology of the Urological Association of Asia, Thailand 2012