Shian-Shiang Wang

Malfunction of the da Vinci robotic system in urology

Objectives:  To analyze the incidence of malfunction of the da Vinci robotic system in a single center and to provide potential solutions.

PSA density as a better predictor of prostate cancer than percent-free PSA in a repeat biopsy

Background: The aim of our study was to identify the optimal predictor of prostate cancer among several prostate‐specific antigen (PSA) derivatives in repeat prostate biopsy. Methods: We retrospectively assessed the repeat prostate biopsy specimens, obtained between 1999 and 2008, of 212 patients with a total PSA (tPSA) of 4–10 ng/ml and normal digital rectal examination. Using a receiver operating characteristic (ROC) analysis, we assessed the predictive power of tPSA, percent free PSA (f/t PSA), PSA density (PSAD), and PSA velocity (PSAV) for the detection of prostate cancer. Results: Repeat prostate biopsy specimens were positive for prostate cancer in the case of 26 patients and negative in the case of 186 patients. The areas under the receiver operating characteristic (ROC) curves for tPSA, f/tPSA, PSAD, and PSAV were 72.7%, 57.9%, 74.4%, and 64.8%, respectively. The ROC curve analysis revealed that PSAD was a better predictor of prostate cancer than f/t PSA. Moreover, when PSAD at an optimal cutoff of 0.18 ng/ml/cc was considered as the predictor, the detection of prostate cancer was found to have a high sensitivity and specificity (77% and 69%, respectively). Conclusion: In a repeat prostate biopsy, PSAD is superior to f/t PSA as a predictor of prostate cancer. And, by assessing this predictor, an unnecessary repeat biopsy of patients with tPSA of 4–10 ng/ml can be avoided.

Trends in treatment for localized prostate cancer after emergence of robotic-assisted laparoscopic radical prostatectomy in Taiwan

Background: Radical retropubic prostatectomy remains the gold standard treatment for localized prostate cancer. However, new minimally invasive techniques have emerged, providing a less invasive approach. Robotic‐assisted laparoscopic radical prostatectomy is the ideal technique, providing good oncologic and functional outcomes. We analyzed the impact of robotic surgical systems on practice patterns among urologists to explain changes in the value of radical retropubic prostatectomy, laparoscopic radical prostatectomy and robotic‐assisted laparoscopic radical prostatectomy in a single institution in Taiwan. Methods: We retrospectively reviewed the records of patients who received prostatectomy by one of the above procedures between January 2004 and November 2009. Decisions to perform these procedures were made by patient preference. Patients who received prostate biopsies at other hospitals were transferred to our hospital specifically for robotic‐assisted prostatectomy. Results: A total of 434 radical prostatectomies were performed, of which 141 (32.49%) were radical retropubic prostatectomies, 59 (13.59%) were laparoscopic radical prostatectomies and 234 (53.92%) were robotic‐assisted laparoscopic prostatectomies. The overall number of prostatectomies has increased over time because of an increase in robotic‐assisted procedures. No decreases were seen in the number of radical retropubic prostatectomies during the evaluation period. Changes in the ratio of robotic‐assisted prostatectomies compared to radical retropubic and laparoscopic radical prostatectomies demonstrated a trend toward robotic‐assisted procedures. The percentage of cases transferred from other hospitals also increased over time from 28.57% to 68.60%. Conclusion: Our experience emphasizes the potential of robotic‐assisted prostatectomy to become the mainstream treatment for localized prostate cancer in Taiwan.

Evidence-based urology in practice: when to believe a subgroup analysis?

Shian-Shiang Wang* † , Yen-Chuan Ou*, Chen-Li Cheng* and Philipp Dahm ‡ for the Evidence Based Urology Working Group *Division of Urology, Department of Surgery, Taichung Veterans General Hospital, † Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan, and ‡ Department of Urology, University of Florida, College of Medicine, Gainesville, FL, USA Accepted for publication 28 July 2009

Nortriptyline induces mitochondria and death receptor-mediated apoptosis in bladder cancer cells and inhibits bladder tumor growth in vivo.

Nortriptyline (NTP), an antidepressant, has antitumor effects on some human cancer cells, but its effect on human bladder cancer cells is not known. In this study, we used a cell viability assay to demonstrate that NTP is cytotoxic to human TCCSUP and mouse MBT-2 bladder cancer cells in a concentration and time-dependent manner. We also performed cell cycle analysis, annexin V and mitochondrial membrane potential assays, and Western blot analysis to show that NTP inhibits cell growth in these cells by inducing both mitochondria-mediated and death receptor-mediated apoptosis. Specifically, NTP increases the expression of Fas, FasL, FADD, Bax, Bak, and cleaved forms of caspase-3, caspase-8, caspase-9, and poly(ADP-ribose) polymerase. In addition, NTP decreases the expression of Bcl-2, Bcl-xL, BH3 interacting domain death agonist, X-linked inhibitor of apoptosis protein, and survivin. Furthermore, NTP-induced apoptosis is associated with reactive oxygen species (ROS) production, which can be reduced by antioxidants, such as N-acetyl-L-cysteine. Finally, we showed that NTP suppresses tumor growth in mice inoculated with MBT-2 cells. Collectively, our results suggest that NTP induces both intrinsic and extrinsic apoptosis in human and mouse bladder cancer cells and that it may be a clinically useful chemotherapeutic agent for bladder cancer in humans.

Application in robotic urologic surgery

Background: The da Vinci robot system has become the mainstay of minimally invasive surgery and has been used in numerous complex reconstructive procedures. Due to the success of this innovative technology, we attempted to expand our practical model and application of the da Vinci robot system into other urologic surgeries, beginning with robotic‐assisted laparoscopic radical prostatectomy (RALRP). Methods: We retrospectively reviewed a total of 683 patients who underwent robotic‐assisted urologic surgery between December 2005 and December 2012. We divided this 8‐year course of device use into three periods, and analyzed the surgical capability of operations in 1 day over different periods through a retrospective analysis. Results: In the first period (2005–2008), 159 cases of robotic‐assisted urologic surgeries were performed. A total of 195 cases were performed in the second group (2009–2010), and 329 cases in the third (2011–2012). Starting with radical prostatectomy in December 2005, we performed various types of procedures such as partial nephrectomy, pyeloplasty, nephroureterectomy with cystoprostatectomy, nephroureterectomy with bladder cuff, radical cystoprostatectomy/cystectomy with ileal conduit reconstruction, partial cystectomy, adrenalectomy, nephropexy, simple prostatectomy, ureteral reconstruction, and pyelolithotomy/ureterolithotomy. The mean operation times of prostatectomy, partial nephrectomy, nephroureterectomy with radical cystectomy/cystectoprostatectomy, and nephroureterectomy were 154, 140, 295, and 129 minutes, respectively. Conclusion: Based on our experience, a robotic system can be applied to many different types of urologic surgeries both safely and efficiently.

Five-year experience of peritoneal dialysis catheter placement.

Background: Peritoneal dialysis (PD) is a widely used renal replacement therapy for end‐stage renal disease (ESRD) patients. Using laparoscopic guidance for PD catheter placement, we have designed a safe method that resulted in a reduction in catheter migration. Methods: We retrospectively reviewed 250 consecutive patients who underwent PD catheter placement from January 2005 to December 2009. The patients were divided into two groups: the conventional open surgery group and the laparoscopic group. All patients received Tenckhoff straight catheters. In the laparoscopic group, the catheter was additionally fixed to the ventral abdominal wall. Data were collected and a statistical analysis was performed to compare patient characteristics, surgical complications and catheter removal between the groups. Results: Overall surgical complications in the laparoscopic group were lower than those in the conventional group (3.8% vs. 19.4%, p < 0.001), and the majority of catheter migrations and omental wraps occurred in the conventional group. Patients in the conventional group had higher American Society of Anesthesiologists scores than those in the laparoscopic group. There was no difference in the incidence of previous abdominal operation or follow‐up periods in the groups. Conclusion: Our laparoscopy‐assisted PD catheter insertion method using an intraperitoneal fixation loop is safeand can be a valuable tool in prevention of catheter migration and omental wraps.

Impacts of CA9 gene polymorphisms on urothelial cell carcinoma susceptibility and clinicopathologic characteristics in Taiwan.

Background Carbonic anhydrase 9 (CA9) is reportedly overexpressed in several types of carcinomas and is generally considered a marker of malignancy. The current study explored the effect of CA9 gene polymorphisms on the susceptibility of developing urothelial cell carcinoma (UCC) and the clinicopathological status. Methodology and Principal Findings A total of 442 participants, including 221 healthy people and 221 patients with UCC, were recruited for this study. Four single-nucleotide polymorphisms (SNPs) of the CA9 gene were assessed by a real-time PCR with the TaqMan assay. After adjusting for other co-variants, the individuals carrying at least one A allele at CA9 rs1048638 had a 2.303-fold risk of developing UCC than did wild-type (CC) carriers. Furthermore, UCC patients who carried at least one A allele at rs1048638 had a higher invasive stage risk (p< 0.05) than did patients carrying the wild-type allele. Moreover, among the UCC patients with smoker, people with at least one A allele of CA9 polymorphisms (rs1048638) had a 4.75-fold (95% CI = 1.204–18.746) increased risk of invasive cancer. Conclusion The rs1048638 polymorphic genotypes of CA9 might contribute to the prediction of susceptibility to and pathological development of UCC. This is the first study to provide insight into risk factors associated with CA9 variants in carcinogenesis of UCC in Taiwan.

Effect of CD44 gene polymorphisms on risk of transitional cell carcinoma of the urinary bladder in Taiwan

The carcinogenesis of transitional cell carcinoma (TCC) of the urinary bladder involves etiological factors, such as ethnicity, the environment, genetics, and diet. Cluster of differentiation (CD44), a well-known tumor marker, plays a crucial role in regulating tumor cell differentiation and metastasis. This study investigated the effect of CD44 single nucleotide polymorphisms (SNPs) on TCC risk and clinicopathological characteristics. Five SNPs of CD44 were analyzed through real-time polymerase chain reaction in 275 patients with TCC and 275 participants without cancer. In this study, we observed that CD44 rs187115 polymorphism carriers with the genotype of at least one G were associated with TCC risk. Furthermore, TCC patients who carried at least one G allele at CD44 rs187115 had a higher stage risk than did patients carrying the wild-type allele (p < 0.05). In addition, The AATAC or GACGC haplotype among the five CD44 sites was also associated with a reduced risk of TCC. In conclusion, our results suggest that CD44 SNPs influence the risk of TCC. Patients with CD44 rs187115 variant genotypes (AG + GG) exhibited a higher risk of TCC; these patients may possess chemoresistance to developing late-stage TCC compared with those with the wild-type genotype. The CD44 rs187115 SNP may predict poor prognosis in patients with TCC.

Impacts of ICAM-1 gene polymorphisms on urothelial cell carcinoma susceptibility and clinicopathologic characteristics in Taiwan.

Intercellular adhesion molecule (ICAM)-1, a cell adhesion molecule, is reportedly overexpressed in several cancers and may contribute to tumorgenesis and metastasis. The current study explored the effect of ICAM-1 gene polymorphisms on the susceptibility of developing urothelial cell carcinoma (UCC) and the clinicopathological status. A total of 558 participants, including 279 healthy people and 279 patients with UCC, were recruited for this study. Four single-nucleotide polymorphisms of the ICAM-1 gene were assessed by a real-time polymerase chain reaction with the TaqMan assay. After adjusting for other covariants, the individuals carrying at least one G allele at ICAM-1 rs5498 had a 1.603-fold risk of developing UCC than did wild-type (AA) carriers. Furthermore, UCC patients who carried at least one G allele at rs5498 had a higher invasive stage risk (p < 0.05) than did patients carrying the wild-type allele. In conclusion, the rs5498 polymorphic genotypes of ICAM-1 might contribute to the prediction of susceptibility to and pathological development of UCC. This is the first study to provide insight into risk factors associated with ICAM-1 variants in carcinogenesis of UCC in Taiwan.