Shyh-Chyan Chen

Tubularized incised plate urethroplasty for proximal hypospadias

Objective To review our experience of using the tubularized incised plate (TIP) urethroplasty (useful in the treatment of distal hypospadias) to treat proximal hypospadias.

Determining the appropriate length of a double-pigtail ureteral stent by both stent configurations and related symptoms.

PURPOSE To evaluate whether stent length affects the symptoms after stent insertion and to determine the appropriate stent length according to the stent configurations and the related symptoms simultaneously. PATIENTS AND METHODS A total of 87 patients who underwent ureteroscopic lithotripsy (URSL) and double-pigtail ureteral stent (22, 24, or 26 cm) insertion were enrolled. The stent configurations on the images were reviewed to determine whether the length was appropriate. All patients completed a questionnaire to assess the symptoms related to stent insertion. The incidence and severity of the symptoms were compared among the patients with different stent lengths. RESULTS The demographic data were similar among the three groups with different stent lengths (22, 24, or 26 cm). The stent length was associated with the position of the distal loop (P = 0.02), while it was not associated with the position of the proximal loop (P = 0.50). The use of a longer stent was significantly associated with a higher incidence of urinary frequency (P = 0.04) and urgency (P = 0.02). Also, the use of a longer stent was also significantly associated with higher symptom scores of urinary frequency (P < 0.01) and urgency (P < 0.01). CONCLUSIONS The stent length is associated with the position of the distal loop and the related urinary symptoms. A longer stent causes an overlong intravesical segment and more irritative symptoms. On the other hand, the stent length is not associated with either the position of the proximal loop or flank pain. Based on the analysis of both stent configurations on images and related symptoms, a 22-cm stent is more appropriate for those whose height ranges from 149.5 cm to 178.5 cm with a median of 161.9 cm.

Laparoscopic Adrenalectomy Using Needlescopic Instruments for Adrenal Tumors Less Than 5 cm in 112 Cases

OBJECTIVE To examine the safety and efficacy of laparoscopic adrenalectomy with needlescopic instruments for most adrenal tumors less than 5cm. METHODS Transperitoneal laparoscopic adrenalectomy with needlescopic instruments for 112 patients with presumptively benign adrenal tumors < 5cm were enrolled from July 2000 to February 2005. Operative time, blood loss, conversion and complication rates, and postoperative data were analyzed by appropriate statistical methods. RESULTS All 112 operations were completed without any mortality or reoperation. Mean operative time was 151min and mean blood loss was 30ml. Only one patient required a blood transfusion and application of a hand-assisted device. Conversion to conventional laparoscopic instruments was necessary in another five patients (4.5%). The operative time of the latter 100 cases (147+/-5.1min, mean+/-standard error of mean) was significantly shorter than that of the initial 12 cases (183+/-8.8min, p=0.001). Larger tumors, previous abdominal surgery, and pheochromocytoma group were independent risk factors of a longer operative time. Except for one leiomyosarcoma, all other tumors were benign adrenal pathologies (57 aldosterone-producing adenomas, 23 Cushings adenomas, 12 pheochromocytomas, and 20 incidentalomas). CONCLUSION The safety and effectiveness of laparoscopic adrenalectomy employing needlescopic instruments for most adrenal tumors less than 5cm was feasible with acceptable operative time. Pheochromocytomas can also be managed with a longer operative time. Patients with previous upper midline or ipsilateral upper quadrant open surgery might not be suitable candidates for such a technique.

Modified approach of hand-assisted laparoscopic nephroureterectomy for transitional cell carcinoma of the upper urinary tract

Objectives. To report a modified approach for hand-assisted laparoscopic nephroureterectomy (HALNU).Methods. Seven patients with localized transitional cell carcinoma of the upper urinary tract underwent unilateral HALNU. Patients were placed in a 60 degrees oblique position during the entire procedure. Via a 7-cm Gibson incision on the lesion side, the distal ureterectomy and bladder cuff excision were done by an open method without opening the bladder. Then, with the surgeons hand inserted into the peritoneal cavity by way of the same wound, HALNU was performed with two to three additional laparoscopic ports. The perioperative parameters were compared with those of 15 cases of conventional open nephroureterectomy.Results. Patients in the HALNU group had significantly less mean blood loss (140 versus 455 mL) and earlier resumption of oral intake (33 versus 61 hours), required fewer narcotics (38 versus 70 mg of morphine sulfate equivalent), and were discharged earlier (7.33 versus 9.1 days), with a faster convalescence to normal activity (3.7 versus 5.6 weeks; all P < 0.05). The total mean surgical time was 3.7 hours for the HALNU group.Conclusions. Our approach used the same incision to both excise the distal ureter and apply the hand-assist device. It also preserved the benefits of the minimal invasiveness of laparoscopic surgery compared with its open counterpart.

Expression of Stathmin in Localized Upper Urinary Tract Urothelial Carcinoma: Correlations With Prognosis

OBJECTIVES To investigate the expression of stathmin in upper urinary tract (UUT) urothelial carcinoma (UC) in human tissues and to determine whether the level of stathmin expression was correlated with prognosis because overexpression of stathmin has been observed in various malignancies. METHODS We first analyzed stathmin mRNA level in 5 UUT-UC paired fresh specimens (tumor and nontumoral urothelium) by RT-PCR. Besides, a total of 58 patients with localized UUT-UC (pT1-3N0M0) treated by nephroureterectomy were enrolled. The stathmin expression in UUT-UC specimens was analyzed by immunohistochemical (IHC) staining. Stathmin IHC score was defined as the proportion of positive staining tumor cells from each patients specimen. The stathmin IHC score > or = 0.5 was defined as strong (+) immunoreactivity and < 0.5 as weak (-) immunoreactivity. RESULTS Significant differences in stathmin mRNA between UUT-UC and paired normal urothelium were noted in 5 of the patients. Of the 58 UUT-UC specimens, stathmin immunoreactivity (strong [+] vs weak [-]) was significantly associated with pT stage (P = .006) as well as with recurrence-free and cancer-specific survival. In multivariate analysis, stathmin IHC score was a significant predictor for both recurrence-free survival (hazard rates: 22.4; P = .001) and cancer-specific survival (hazard rates: 39.8; P = .0012). CONCLUSIONS The stathmin immunostaining is a novel prognosticator for patients with localized UUT-UC stathmin may be a help identify such patients with poor outcomes to benefit from receiving close follow-up and early adjuvant therapy.

CLIPLESS LAPAROSCOPIC ADRENALECTOMY WITH NEEDLESCOPIC INSTRUMENTS

PURPOSE We describe our experience with clipless laparoscopic adrenalectomy using needlescopic instruments. We compared the results with those of a contemporary series of conventional laparoscopic adrenalectomy. MATERIALS AND METHODS In 12 patients clipless laparoscopic adrenalectomy was performed with needlescopic instruments in an 8-month period. The technique included 2 or 3 subcostal 2 mm. ports and 1 umbilical 5/12 mm. port for the telescope and ultimate specimen extraction. Adrenal vessels were controlled by bipolar coagulation without endoscopic clips. Outcome data were retrospectively compared with those on 20 recent conventional laparoscopic adrenalectomies done at the same institution. The 2 types of laparoscopic adrenalectomy were performed transperitoneally. RESULTS Patients in the clipless group had a lower mean analgesic requirement (7.5 versus 15.3 mg. morphine sulfate equivalent, p = 0.02), lower mean pain and scar scores (3.1 versus 5.3 and 1.1 versus 4.2, respectively, p <0.05) and more rapid convalescence (1.6 versus 3.3 weeks, p <0.01) but longer operative time (183 versus 136 minutes, p = 0.04). Similar blood loss, time to oral intake and hospital stay were noted in the 2 groups. No major complications, open conversions or postoperative secondary bleeding occurred in either group. A 2 mm. port was converted to a 10 mm. port in only 1 case in the clipless group due to the inability to retract a bulky liver properly with a needlescopic instrument. CONCLUSIONS Clipless laparoscopic adrenalectomy with needlescopic instruments is feasible for most benign adrenal tumors. In addition to the benefits of conventional laparoscopic surgery, clipless needlescopic laparoscopic adrenalectomy further decreased postoperative pain, shortened convalescence and improved wound cosmesis.

Clinical and pathological data of 10 malignant pheochromocytomas: Long-term follow up in a single institute

Background:  Malignant pheochromocytomas are rare. Many controversies still exists in clinical practice. We report the clinical and histological data of long‐term follow up in 10 patients with malignant pheochromocytoma.

Down-regulation of glucose-regulated protein (GRP) 78 potentiates cytotoxic effect of celecoxib in human urothelial carcinoma cells.

Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor that has been reported to elicit anti-proliferative response in various tumors. In this study, we aim to investigate the antitumor effect of celecoxib on urothelial carcinoma (UC) cells and the role endoplasmic reticulum (ER) stress plays in celecoxib-induced cytotoxicity. The cytotoxic effects were measured by MTT assay and flow cytometry. The cell cycle progression and ER stress-associated molecules were examined by Western blot and flow cytometry. Moreover, the cytotoxic effects of celecoxib combined with glucose-regulated protein (GRP) 78 knockdown (siRNA), (−)-epigallocatechin gallate (EGCG) or MG132 were assessed. We demonstrated that celecoxib markedly reduces the cell viability and causes apoptosis in human UC cells through cell cycle G1 arrest. Celecoxib possessed the ability to activate ER stress-related chaperones (IRE-1α and GRP78), caspase-4, and CCAAT/enhancer binding protein homologous protein (CHOP), which were involved in UC cell apoptosis. Down-regulation of GRP78 by siRNA, co-treatment with EGCG (a GRP78 inhibitor) or with MG132 (a proteasome inhibitor) could enhance celecoxib-induced apoptosis. We concluded that celecoxib induces cell cycle G1 arrest, ER stress, and eventually apoptosis in human UC cells. The down-regulation of ER chaperone GRP78 by siRNA, EGCG, or proteosome inhibitor potentiated the cytotoxicity of celecoxib in UC cells. These findings provide a new treatment strategy against UC.

Metabolic syndrome associated with reduced lower urinary tract symptoms in middle-aged men receiving health checkup.

OBJECTIVE To investigate the impact of metabolic syndrome on lower urinary tract symptoms in a sample of middle-aged men receiving a health checkup. METHODS Subjects aged 45 years or older who voluntarily underwent a medical checkup were enrolled. Participant demographics and health history were collected by a self-administered questionnaire. All participants were stratified into 2 groups by the presence of metabolic syndrome, as defined according to the updated National Cholesterol Education Programs Adult Treatment Panel III. Prostate volume and prostate-specific antigen levels were used for subgroup analysis. RESULTS During January through December of 2010, 708 subjects with a mean age of 55.6 ± 9.72 years were enrolled into the study. Compared to the nonmetabolic syndrome group, the metabolic syndrome group had lower total international prostatic symptoms score (7.89 ± 6.63 vs 6.85 ± 6.52, P = .05) and lower severity of weak urinary stream (1.24 ± 1.60 vs 0.95 ± 1.50, P = .021). In the higher prostate volume group (prostate volume ≥ 30 mL), total international prostatic symptoms score, storage score, and urinary frequency, urgency and incomplete emptying were lower in men vs those without metabolic syndrome (all P < .05). The negative association between voiding score, severity of lower urinary tract symptoms, and metabolic syndrome became particularly pronounced as the number of metabolic syndrome factors increased (P for trend < .01). CONCLUSION We confirmed that metabolic syndrome had favorable effects on lower urinary tract symptoms, including voiding and storage symptoms in healthy middle-aged men. This beneficial effect was most significant in men with enlarged prostate and/or high prostate specific antigen levels.

Retroperitoneoscopic nephropexy for symptomatic nephroptosis

AbstractsBackground: Open nephropexy for nephroptosis creates significant morbidity. We describe our technique for retroperitoneoscopic nephropexy and evaluate its efficacy. Methods: Twenty-five renal units in 23 patients with symptomatic nephroptosis underwent retroperitoneoscopic nephropexy by suturing the posterior renal capsules and transfixing them to the back muscles. The diagnosis and postoperative assessment were made by typical symptoms (via patient questionnaire) and findings of intravenous urography (IVU) when the position was changed from supine to erect. Results: Mean operative time was 188 min (range, 90–330). Mean narcotic use was 15.6 mg morphine. Complete resolution of symptoms occurred in 84% (21/25) renal units; 12% (three of 25) achieved partial improvement (>75% decrease of preoperative symptoms). Follow-up IVU showed that 88% of patients had a renal descent of <2 cm on standing; the others had a descent of 2–4 cm. All of the five renal units with hydronephrosis resolved completely after the operation. Conclusions: This modified technique of retroperitoneoscopic nephropexy is a minimally invasive, feasible, and highly successful option for treating patients with symptomatic nephroptosis.