Yi-Hsiu Huang

High failure rate using allograft fascia lata in pubovaginal sling surgery for female stress urinary incontinence

OBJECTIVES To present our unfavorable experiences using allograft fascia lata. Allograft fascia lata is an attractive sling material providing less pain, a shorter operation time, and a reported effectiveness equal to autologous fascia. METHODS A total of 18 women (mean age 51.7 years, range 37 to 76) underwent pubovaginal sling surgery for stress urinary incontinence between March 1999 and July 1999 and were enrolled in this study. Solvent dehydrated gamma-irradiated human fascia lata with a size of 7 x 2 cm was used as the sling. The results were collected with a questionnaire survey. RESULTS All patients were followed up for a mean of 9.2 months (range 6.9 to 11.6). Thirteen patients considered the surgery successful or to have provided improvement, with a mean of 82.5% (range 50% to 100%) subjective improvement. Five patients (27.8%) had significant failure with full recurrence of incontinence within 3 to 6 months. CONCLUSIONS Solvent dehydrated gamma-irradiated allograft fascia is not reliable in pubovaginal sling surgery. The high failure rates within a short period prohibit its use in the operative management of stress urinary incontinence.

Clinical experience of laparoscopic-assisted radical cystectomy with continent ileal reservoir.

Introduction: Laparoscopic-assisted radical cystectomy with continent ileal reservoir reconstruction is a challenging procedure. We report our experience learned from a hand-assisted laparoscopic technique in our transition to a pure laparoscopic approach. Materials and Methods: Eighteen consecutive patients underwent laparoscopic-assisted radical cystectomy with continent ileal reservoir. Hand-assisted laparoscopy was used for the first 11 patients and pure laparoscopy was performed for the subsequent 7 patients in radical cystectomy. Continent ileal reservoir reconstruction was performed extracorporeally via the hand port wound or trocar extension wound. Surgical outcome was analyzed in a retrospective review of the medical records. Results: In the hand-assisted and pure laparoscopic groups, the mean operative time for cystectomy was 2.5 and 2.3 h, for continent ileal reservoir reconstruction it was 4.0 and 3.7 h, and for bilateral lymph node dissection it was 0.8 and 0.6 h, respectively. Mean intraoperative blood loss was 286 ml for the hand-assisted and 179 ml for the pure laparoscopic group. There were no major intraoperative complications nor need for conversion in any of the procedures. Bowel movement was regained in a mean of 3 days and the mean length of postoperative hospital stay was 7 days. Conclusions: The hand-assisted laparoscopic experience of radical cystectomy learned from the initial 11 patients effectively helped us in the transition to a pure laparoscopic approach. A comparable surgical outcome was found in both groups of patients.

Standardized analysis of laparoscopic and robotic-assisted partial nephrectomy complications with Clavien classification

Background: Laparoscopic partial nephrectomy (LPN) and robotic‐assisted partial nephrectomy (RPN) are accepted as alternatives of open partial nephrectomy for managing renal tumors. However, LPN and RPN are technically challenging procedures. This report analyzed, according to the Clavien classification, the complications after LPN and RPN. Methods: We analyzed consecutive LPN (n = 85) and RPN (n = 93) cases at our institution between April 1994 and December 2012. The data were retrospectively reviewed from a prospectively collected database. All complications that occurred within 3 months postoperatively were recorded and classified according to the modified Clavien classification system. Results: The mean tumor size was 3.90 ± 1.77 cm. The mean operative time was 255.0 ± 83.5 minutes, and the mean warm ischemia time was 31.6 ± 22.0 minutes. The overall complication rate was 18.5%. Clavien Grades I, II, IIIa, and IIIb complications accounted for 3.93%, 11.2%, 2.81%, and 1.69% of patients, respectively. The most common complication was perioperative hemorrhage that required blood transfusion. Delayed bleeding occurred in seven patients, and four patients underwent angiographic embolization. The proportions of intermediate and high PADUA (Preoperative Aspects and Dimensions Used for an Anatomical) score (≥8) and RENAL (Radius/Exophytic/Nearness to collecting system/Anterior/Location) score (≥7) were 70.8% and 74.2%, respectively. A higher PADUA or RENAL score was associated with a significantly greater complication rate (p = 0.024 and p = 0.02, respectively). Conclusion: The overall complication rate in the present study was comparable to that reported in previous studies, although our patients had a larger mean tumor size and higher‐complexity procedures.

Laparoscopic Partial Nephrectomy: Taipei Veterans General Hospital Experience

Background: Laparoscopic partial nephrectomy (LPN) is a definitive therapy in patients with a small renal tumor. The aim of this study was to present our interim results of LPN with its complications and outcomes. Methods: We conducted a retrospective chart review of 46 LPNs in 45 patients at Taipei Veterans General Hospital from April 2004 to September 2008. The perioperative data were prospectively collected. The follow‐up data, including local recurrence, distant metastasis, and renal function, were recorded. Results: The mean age of these 45 patients was 54.8 years (range, 26‐85 years). Three (6.5%) LPNs were converted to laparoscopic radical nephrectomy. The mean tumor diameter was 3.81 cm (range, 2.0‐7.5 cm). The mean operative time was 319 minutes (range, 180‐660 minutes). The mean blood loss was 501 mL (range, 20‐3,300 mL). Pedicle clamping was performed in 37 (80.4%) cases and the mean warm ischemic time was 56 minutes (range, 24‐100 minutes). There were 17 (40.0%) benign cases and 26 (56.5%) renal cell carcinomas, which were stage pT1a in 19 (73.1%) cases, pT1b in 5 (19.2%) cases, pT2 in 1 (3.8%) case, and pT3a in 1 (3.8%) case. The major complication rate was 4.3% (delayed bleeding in 1 case and urine leakage in 1 case). All margins were free for the malignant cases. Neither distant metastasis nor mortality was found. Local recurrence was found in 1 patient. The mean preoperative creatinine was 1.04 mg/dL (range, 0.6‐2.4 mg/dL) and the mean elevated creatinine level was 0.10 mg/dL at 3 months (p < 0.05) and 0.13 mg/dL at 6 months (p < 0.05) postoperatively. The function of the operated kidney was reduced by a mean of 21.9% at 3 months (p < 0.05) and 27.7% at 6 months (p < 0.05) postoperatively. Conclusion: Although our warm ischemic time and operative time were longer than those of other LPN studies, the interim results of our oncologic and renal functional outcomes were encouraging. Further refinement of the procedure is needed to shorten the warm ischemic time and improve the hemostatic technique. In addition, based on postoperative renal function, LPN does not significantly influence long‐term renal function.

Voiding Pattern of Healthy Taiwanese Women

Aim: Few studies have examined the voiding pattern of healthy females, despite the importance of such research for diagnosing abnormal voiding behavior. This study investigates the voiding behavior of healthy women in Taiwan. Methods: 68 healthy women, aged 19–66 years and claiming to void normally were enrolled. Twenty-two of the subjects (32.4%) were postmenopausal. Each woman completed a 3-day voiding diary. The diary recorded urine volume, voiding frequency, urine volume per voiding for the whole day (24 h), and urine volume during both daytime and nighttime. Age and various other voiding parameters were correlated, and the voiding patterns were compared between premenopausal and postmenopausal women. Results: All women voided 7.34 ± 1.63 times daily. Higher age was associated with higher whole day and daytime voiding frequency. Nocturia was not common for the group as a whole, with a mean nocturnal voiding of 0.25 times per night. However, higher age was significantly associated with a higher nighttime voiding frequency. A significantly positive correlation was also observed between age and whole day urine volume. Compared with regularly menstruating women, postmenopausal women had a significantly higher whole day and nighttime voiding frequency. Menopause and age both independently affect voiding parameters after multivariate analysis. Conclusions: The results of this study provide invaluable baseline data on female voiding behavior. Additionally, this study found that for healthy women, age and menstruation status significantly affect voiding patterns. Analysis of female voiding behavior thus should consider these two factors.

Clinical efficacy of transrectal ultrasound-guided prostate biopsy in men younger than 50 years old with an elevated prostate-specific antigen concentration (>4.0 ng/mL)

Background Prostate cancer (PCa) is not commonly found in men younger than 50 years of age. However, serum prostate‐specific antigen (PSA) concentration has been examined more frequently at a younger age in Asia partially due to an increased awareness of prostate cancer. The purpose of our study was to investigate the efficacy and complication of PSA‐triggered transrectal ultrasonography‐guided prostate (TRUSP) biopsies. We retrospectively reviewed TRUSP biopsies in young men with elevated PSA concentration in Taipei Veterans General Hospital. Methods We reviewed the cases of patients younger than 50 years of age with elevated PSA concentration (>4.0 ng/mL), who received 12 cores TRUSP biopsies at TPEVGH from January 2008–December 2013. The age, family history, digital rectal examination (DRE) results, PSA concentration, free/total PSA ratio, total prostate volume, PSA density, lower urinary tract symptoms and complications after the procedure were reviewed. The pathologic findings of TRUSP biopsy and clinical follow‐up were reviewed and analyzed according to the Epstein criteria. Results A total of 77 patients were included and were divided into 2 groups: 1) the younger group consisted of 20 patients <40 years of age; and 2) the elder group had 57 patients who were 40–50 years of age. The overall detection rate of PCa was 11.69% (9/77), and all of the PCa cases were diagnosed in the elder group (group detection rate: 15.8%). There was a significant difference in the severity of lower urinary tract symptoms (LUTS) between these 2 groups. All PCa patients were clinically significant according to the Epstein criteria. Two patients experienced fever (2.60%) after TRUSP biopsy. Conclusion From our patient cohort, it appears that no benefit was apparent for patients younger than 40 years old who received TRUSP biopsy, even with elevated PSA. However, PCa detected in men between 40 and 50 years of age were all clinically significant. Overall, our results supported current major practice guidelines which recommend an initial PSA checkup at 40 years of age.

Prostate cancer in young adults—Seventeen-year clinical experience of a single center

Background In the general population, prostate adenocarcinoma affects predominately older men. If fact, most current guidelines suggest that males over the age of 50 years should undergo prostate cancer screening. However, the clinical behavior and prognosis of prostate cancer in young adults is not well defined. The aim of this study was to evaluate the clinical behavior, pathological characteristics, and prognosis of prostate cancer in young adults. Methods We retrospectively reviewed the records of young patients (age, ≤50 years) in our hospital with prostate adenocarcinoma between 1997 and 2013. We compared data including initial presentation, cancer cell type, Gleason score, disease stage, prostate‐specific antigen (PSA) level, prostate volume, treatment, and survival between patients both younger and older than 50 years. Data were analyzed using the Kaplan–Meier method to assess survival. Results Twenty‐six patients were enrolled in our study, accounting for 0.55% of all patients with a diagnosis of prostate cancer at our facility. All 26 patients had a pathology diagnosis of adenocarcinoma, with a mean age on diagnosis of 46.8 ± 2.8 years (range, 39–50 years). On initial presentation, patients older than 50 years more frequently displayed lower urinary tract symptoms (LUTS) than younger patients (62.3% vs. 30.4%, p = 0.008). There was no statistical difference in histological grade, disease stage, PSA level, overall survival, and biochemical‐free survival between the two groups. Conclusion The result of our investigation indicated that prostate adenocarcinoma patients younger than 50 years had similar histological grade, disease stage, PSA level, overall survival, and biochemical‐free survival as the older population. However, patients younger than 50 years with prostate cancer less frequently showed initial symptoms of LUTS.

Cognitive MRI-TRUS fusion-targeted prostate biopsy according to PI-RADS classification in patients with prior negative systematic biopsy results.

Background The purpose of this study was to evaluate the prostate cancer yield rate of targeted transrectal ultrasound (TRUS)‐guided biopsy with cognitive magnetic resonance imaging (MRI) registration without concurrent systematic biopsy in patients with previous negative systematic TRUS‐guided biopsy results and persistently elevated prostate‐specific antigen (PSA) levels. Methods In this prospective study conducted from August 2013 to January 2015, patients with at least one previous negative systematic TRUS‐guided biopsy and persistently high PSA (≥4 ng/mL) levels were referred for multiparametric MRI (mpMRI). Those patients with suspicious findings on mpMRI received a subsequent cognitive MRI‐TRUS fusion biopsy. The cancer‐detection rate, tumor location, and Gleason score were confirmed, and PSA‐related data were compared between cancer‐yield and noncancer‐yield groups. Results In total, 48 patients were included in this study. MRI was designated to be four and five in 17 patients. Fifteen patients received a cognitive fusion‐targeted biopsy, and prostate cancers were detected in 10 patients. The cancer‐detection rate was 20.8% (10/48), and the positive‐predictive value of MRI was 66.7%. No significant differences were observed in the PSA level, PSA velocity, or transitional zone volume between the cancer‐yield and noncancer‐yield groups; however, the corresponding difference in PSA transitional zone density was significant (p = 0.025). Conclusion Cognitive MRI‐TRUS fusion‐targeted biopsy without concurrent systematic biopsy can detect significant prostate cancer in patients with previous negative systematic biopsy results and persistently elevated PSA levels. Noncancer‐yield patients should undergo active surveillance and further follow‐ups.

MP95-06 PATIENTS WITH UROLITHIASIS ARE MORE LIKE TO DEVELOP FRACTURE: A NATION-WIDE POPULATION-BASED AND WITH AN 8-YEAR FOLLOW-UP STUDY

INTRODUCTION AND OBJECTIVES: Urinary stone disease (USD) has long been considered a condition afflicting those of working age. As the US population ages, however, it is unclear what impact changing population dynamics may have on care utilization. The objective of our research was to examine trends in health care utilization for USD in the United States by age, with a particular emphasis on older adults. METHODS: We used data from the Nationwide Inpatient Sample (NIS) and the Nationwide Emergency Department Sample (NEDS) to estimate trends for inpatient and emergency department care utilization from 2006 to 2013. Older adults were defined as individuals aged at least 65 years. Encounters for USD were identified using diagnostic codes and established algorithms. We calculated annual number of ED visits and hospitalizations for stones by age group. Linear regression was used to assess changes in utilization over time. RESULTS: An estimated 1.77 million ED visits and 1 million inpatient discharges for USD occurred during the study period for older adults ( 65 years). ED visits with principal diagnosis of USD increased 66% (p <.001) for ages 65-84 and 72% (p <.001) for ages 85+, whereas younger adults (ages 18-64 years) only increased 19% (p <.001) (Figure). Similar trendswere observed for inpatient discharges, with an increase of 15% (p1⁄4 .0014) for ages 65-84 and 34% (p1⁄4 .0049) for ages 85+. Inpatient discharges for younger adults decreased during the study period. In sensitivity analyses examining any diagnosis of USD, similar increases in utilization by older adults were noted. CONCLUSIONS: Health care utilization for USD is growing rapidly among older adults, and faster than any other age group. Further research is required to determine the extent to which this trend reflects changing population dynamics, changing risk of stones among older individuals, or both. Regardless of the underlying causes, it will be imperative to develop approaches for medical and surgical stone care for these older and often frail adults.

Clinical analysis of 48-h emergency department visit post outpatient extracorporeal shock wave lithotripsy for urolithiasis

Background Patients suffering from renal or ureteral stones can undergo significant discomfort, even when timely diagnosed and treated. The aim of this study was to assess the risk factors and safety of outpatient Extracorporeal Shock Wave Lithotripsy (ESWL) in the management of patients with renal or ureteral stones. Methods In this study, our cohort consisted of 844 outpatients who underwent outpatient ESWL treated between February 2012 and November 2014 at Taipei Veterans General Hospital. Patients who visited the emergency room (ER) within 48 h after Outpatient ESWL were included in this article. This article analyzes the stone size, stone shape (long to short axis ratio), stone location, previous medical management, urinalysis data, complications and treatment received in the emergency department. Results Among the 844 initial consecutive patients who underwent outpatient ESWL a total of 1095 times, there were 22 (2%) patients who sought help at our emergency room within 48 h after the outpatient ESWL. Of those 22 patients, the mean age was 54.3 ± 12.6 years, and the BMI was 25.9 ± 3.2. The most common complication complaint was flank pain (55.2%). Other complications included hematuria (13.8%), fever (17.2%), nausea with vomiting (6.9%), acute urinary retention (3.4%) and chest tightness with cold sweating (3.4%). In 22 patients who went back to the ER, 7 patients were admitted to the ward and 1 patient again returned to the ER. All patients received medical treatment without ESWL or surgical management. The meaningful risk factor of ER‐visiting rate following outpatient ESWL within 48 h was stone location, and the renal stones showed statistic significant (p = 0.047) when compared to ureteral stones. Conclusion Our study indicated that renal stone contributed to a significantly higher risk of ER‐visiting rate to patients than did ureteral stone, following outpatient ESWL within 48 h. This study confirmed that Outpatient ESWL is a safe treatment for renal or ureteral stones, while inpatient ESWL is not absolutely necessary.