Transrectal Ultrasonography: Error of Prostatic Measurement / 대한비뇨기과학회지

PURPOSE: Transrectal ultrasonography is known to be an effective tool for the determination of prostatic volume. But the irregularity of shape and the limitation of reliability by intra-observer and inter-observer bias may influence over the results. I would like to represent several factors for the error of transrectal ultrasonographic measurement of prostatic volume. MATERIALS AND METHODS: Errors for transrectal ultrasonographic volume determination of the prostate, based on the principle of HWL(Height x Width x Length x pi/6) are presented. Some artificial prostatic models were made and compared between the real volumes and calculated results. The intra-observer error was determined in 39 cases by repeated measurements. The inter-observer error was also determined in 32 cases by repeated measurements of different observer. RESULTS: There were significant discrepancies between real volumes and calculated results and the range of error by shape was -19?38%. The ranges of intra-observer and inter-observer errors with 95% confidence interval were -7.4?6.1% and 2.7?9.9%. CONCLUSIONS: Errors by several factors should be considered for the clinical application of measured prostatic volume by ultrasonography irrespective of its statistical validity and reliability.

Role of Growth Factors in Benign Prostatic Hyperplasia / 대한비뇨기과학회지

PURPOSE: The enlargement of a prostate afflicted with benign prostatic hyperplsia(BPH) is known to be caused by the proliferation of prostatic cells under the influence of androgen, growth factors and interaction among cells. However, their roles are not yet to be clearly identified. Thus, we studied about the role of the growth factors in development of BPH. MATERIALS AND METHODS: We randomly selected 46 patients who received transurethral resection of prostate(TURP) due to prostatic enlargement and were confirmed as BPH pathologically. Their prostatic sizes were measured using transurethral ultrasonography. Paraffin embedded specimens from the TURP were stained with H&E (hematoxylin-eosin). Point count method was applied to obtain the ratio among the sizes of stroma, epithelium, and glandular lumen. Immunohistochemical stain was conducted on bFGF(basic fibroblast growth factor: goat polyclonal antibody), and TGF-beta 2(transforming growth factor-beta2: rabbit polyclonal antibody). The intensity of fluorescence (stroma; 0+1+,2, glandular epithelium 0,+1,+2,+3) of bFGF and TGF-beta2 was obseNed in 20 low power field under the light microscope, then measured to get an average. RESULTS: The mean sixte of prostate was 44.2(+/-21.0)ml and the ratio among the sizes of stroma, glandular epithelium, and gladular lumen was 5.6:4:2.1, meaning that stroma took up the largest part of a prostate. The degree of expression of bFGF and TGF-beta2 was significantly different between actively proliferating group and inactively proliferating group(when the proliferation rate was less than 3%, n=26). CONCLUSIONS: This study showed that growth factors such as bFGF and TGF-beta2 affected the proliferation rate, with individual differences and differences in time. We think they play different roles in influencing the rate according to cellular components such as stromal and glandular epithelial cells.

The Significance of Urinary Nuclear Matrix Protein ( NMP22 ) Measurement in Patients with transitional Cell Carcinoma of the Bladder / 대한암학회지

PURPOSE: The objective of this study was to evaluate an immunoassay for urinary nuclear matrix protein (NMP22) as an indicator for transitional cell carcinoma of the bladder. MATERIALS AND METHODS: Three groups of subjects attended the trial of NMP22. First group was 27 patients with transitional cell carcinoma of the bladder, second group was 24 patients with other urinary cancer consisted of prostate cancer and renal cell carcinoma, and third group was 24 healthy volunteers. NMP22 was determined using a commercial test kit, which is based on an enzyme-linked immunosorbent assay. RESULTS: In normal healthy volunteers and other urinary cancer group median NMP22 levels were 2.24 and 3.27 U/ml, respectively. Median urinary NMP22 levels in patients with transitional cell carcinoma of the bladder were 54.30 U/ml. It was significantly greater than other two groups. Median NMP22 levels according to the tumor stage and the tumor grade did not show the significant difference statistically. CONCLUSIONS: Urinary NMP22 is a useful marker that is more specific for bladder cancer thsn for other urinary cancer. Further tests are required to clarify the influence of other spe- cific conditions, such as urinary tract infection, and intravesical drug instillation or procedure.

Effect of M-VAC(Methotrexate, Vinblastine, Adriamycin and Cisplatin) Chemotherapy in Locally Invasiue T3a/T3b) Transitional Cell Carcinoma of the Bladder / 대한비뇨기과학회지

PURPOSE: Since a significant number of patients with locally invasive bladder tumor(T3a/T3b) subsequently develop distant metastases, there have been lots of controversies in deciding treatment modalities. In the past decade, progress has been made in the development of effective chemotherapy for the treatment of advanced transitional cell carcinoma of the urothelium. Thus, we reviewed the effectiveness of the M-VAC(methotrexate, vinblastine, adriamycin, and cisplatin) chemotherapy for locally invasive transitional cell carcinoma (TCC) of the bladder. MATERIALS AND METHODS: We reviewed 36 patients who were diagnosed as T3a/T3b TCC and treated with aggressive transurethral resection of the bladder tumor(TURBt) and M-VAC chemotherapy Remission was defined in case of complete disappearance of the tumor or downstaging, and progression was defined in case of persistent disease or upstaging. RESULTS: Mean age of the patients was 60.4 years old(33 males; 3 females), and mean follow up was 12.2 +/- 8.9 months. Response rate considering loss of follow up according to the Kaplan-Meyer's method, was 79, 49, 44, 37% at 6, 12, 18, 24th month, respectively. Disease progressions were found in 19 patients during follow up, and the mean duration to progression was 9.2 +/- 5.0(1-19)months. 79% of the patients with disease progression showed progression within 12 months. Lymph node metastases or distant metastases were confirmed in 68% of progressed patients. CONCLUSIONS: M-VAC chemotherapy after aggressive TURBt is limited, but erective treatment modality, and it is also useful in deciding the prognosis of cancer with its responsiveness.

Proliferation and Apoptosis in Prostatic Hypertrophy / 대한비뇨기과학회지

PURPOSE: Volumetric change of prostate is the result of unbalanced proliferation and apoptosis. We investigated the characteristics of proliferation and apoptosis in hypertrophic prostate. MATERIALS AND METHODS: Proliferative and apoptotic rates were quantitated with immunoprofiles of proliferative cell nuclear antigen(PCNA) and apoptotic body with 46 paraffin-embeded BPH specimen. When the rate of proliferation was higher than that of apoptosis, we defined as proliferation active group. RESULTS: Proliferation and apoptotic rates of stromal and epithelial cells were 4.5%, 2.9% and 1.9%, 1.1%, respectively(p 0.05). CONCLUSIONS: These results demonstrate that stromal proliferation is the main cause of prostatic hypertrophy. The unbalance between proliferation and apoptosis of prostatic cells seems to be unsteady in time.

Prevalence and Characteristics of Prostatism in Korea: Application of I-PSS / 대한비뇨기과학회지

Recently the use of I-PSS (International prostate symptom score) is highly recommended for the evaluation of symptomatic benign prostatic hyperplasia (BPH) and many linguistic translations have been made. Regardless the validity and reliability of linguistic translation, there might be several social and cultural factors which affect to the symptom severity in BPH. We tried to show the prevalence of prostatism and the effect of social and cultural background which could affect to the results I-PSS questionnaire in Korea. A total of 841 men (40~79 years) who visited 4 health care center were included. Because of 107 men had medico-surgical history relating to voiding, final eligible subjects were 734. Total symptom scores increased by age decades (40~49, 50~59, 60~ 69, 70~79; median 7, 8, 11, 12 respectively). The rate of mild (0~7); moderate (8~19); and severe (20~35) symptom in 40th, 50th, 60th and 70th were 55.5%; 39.3%; 1.2%, 45.4%; 46.5%; 8.1%, 30.4%; 53.9%; 15.7% and 28.1%; 43.8%; 28.1% respectively. One cause of these high prevalence of prostatism in Korea is relatively very small proportion of readily treated BPH patients in general population (0.5%). Another factor of the high prevalence of prostatism is thought to be the different social and cultural concept to voiding status. These factors limit comparability of I-PSS questionnaire between different countries.

A Case of Unrecognized Bilateral Renal Cell Carcinoma / 대한비뇨기과학회지

Renal cell carcinoma is a relatively rare tumor, accounting for approximately 3 percent of adult malignancies. Bilateral renal cell carcinoma, either synchronous or asynchronous, very rarely occurs and makes another urological dilemma. We experienced a case of unrecognized bilateral renal cell carcinoma ; which had been treated by radical nephrectomy after diagnosed as a left renal cell carcinoma, Robson stage IIIa, about 18 months later another mass was found in remaining kidney. Therefore, we performed wedge resection of the mass, and it was also diagnosed as a renal cell carcinoma. Reviewing of the initial abdomen-pelvis CF scan, mass in Rt. kidney had already been existed when left. renal cell carcinoma was diagnosed. This case was finally diagnosed with unrecognized bilateral synchronous renal cell carcinoma.

Immunohistochemical Androgen Receptor Change of Relapsed Prostate Cancer After Castration / 대한비뇨기과학회지

We tried to find out any differences between initial characteristics of androgen receptors and of relapse after castration in 6 stage D2 prostatic cancer (mean age, 68.7+/-4.6) (Gleason score 5, 8, 9 ; 1,3, 2 patients respectively), with immunohistochemical expression using the mouse monoclonal antibody against human androgen receptor. The prostate specimens were obtained by either transrectal needle biopsy or transurethral resection at the time of initial diagnosis and of relapse following castration. The age matched 6 benign prostatic hyperplasia (BPH) specimens were used as control. 200 cancer cells were chosen and staining intensity of each nuclei was graded (O-absent, +1-weak, +2-moderate, +3-strong) from randomly selected and photographed from 10 different fields of each specimen. The means of staining intensity of nuclei from BPH and prostatic cancer before treatment were 1.93+/-0.03 and 1.59+/-0.03 respectively (p<0.05). At the time of relapse after bilateral orchiectomy (mean, 24.5+/-5.0 months), the mean staining intensity of nuclei of all cancer patients (1.38+/-0.03) was significantly different from that of before treatment (p<0.05). But in individual comparison, we could find the decrement in only 2 patients. The intervals of relapse from castration of these two patients (29 and 32 months) were longer than the mean of 6 patients. In conclusion, androgen receptors are still expressed significantly after castration in prostatic cancer. In some patients (2/6), castration down regulates the expression of androgen receptors and the down regulation closely correlated with the relapse time."

Change of Renal Function and Morphology in 3/4 Nephrectomized Rats / 대한비뇨기과학회지

To examine the effect renal mass reduction on compensatory renal hypertrophy and progressive glomerular sclerosis, 3/4 nephrectomy was performed in mature male rats. Serial changes in renal histology and function were investigated at weeks 1, 2, 6 and 12 after 3/4 nephrectomy. Mean glomerular diameter increased 29% during the first week thereafter the growth rate of glomeruli was similar to that of sham operated control's. Peak renal function was achieved at 6 weeks and thereafter progressively decreased. The prominent glomerular sclerosis was found at 12th week. These results suggest that renal growth after renal mass reduction is a pathologic process ensuing progressive renal damage.

Translation Validity and Reliability of I-PSS Korean Version / 대한비뇨기과학회지

Recently developed International Prostate Symptom Score(I-PSS) is highly recommended for the evaluation of urinary symptoms in benign prostatic hyperplasia(BPH) and many linguistic translations have been made. English version of I-PSS was translated into Korean. Three groups of urologists and ordinary people participated for the translation and back-translation of I-PSS. A Korean version was finalized and translation validity was assessed by a survey with 48 English speaking Korean aged men. Test-retest reliability was confirmed by an another questionnaire survey with 76 aged men. Translation of I-PSS into Korean was valid. The I-PSS Korean version was internally consistent and sensitive as well as specific for the discrimination of symptomatic groups. Also test-retest reliability was acceptable.

Effect of Extracorporeal Shock Waves on Immature Rat Kidney / 대한비뇨기과학회지

Although extracorporeal shock wave lithotripsy(ESWL) has been used to treat renal stones for several years, little is known of its effect on developing tissue. To study the long-term bio-effects of this mode of treatment on the immature animal, we used 32 Sprague-Dawley rats at 4weeks of age and divided 4 groups which consisted of 8 rats respectively. They were weighted and left nephrectomy was then performed. 10 days later, 3 groups received extracorporeal shock waves (16 kV) of 500, 1,000, 1,500 times respectively to the right kidney using Lithoring(3rd generation pendulum-ESWL), but control group didn't received shock waves. They were allowed to mature, and at 16 weeks of age they were evaluated for weight and serum creatinine. The right kidney was then harvested, weighted and stained with hematoxylin and eosin. There were no significant changes in over-all animal growth, renal growth and renal function in the post-treatment groups when compared to the control group. At comparison of histological changes, the grade of interstitial nephritis was proportional to the number of shock wave received In conclusion, shock waves delivered to immature animals do not significantly affect animal growth, renal growth and function, but it can cause significant permanent histological renal changes even at low doses and further studies are needed with an adult control group in an attempt to delineate whether the immature kidney is, indeed, more vulnerable to the shock waves.

Clinical Significance of Measuring Free form of Prostate-Specific Antigen / 대한비뇨기과학회지

Prostate-specific antigen(PSA) in serum exists in several molecular forms that can be measured by immunodetectable assays; free PSA, PSA complexed to alpha1-antichymotripsin and total PSA, which represents the sum of the free and complexed forms. We have determined the amount and ratio of these forms may be seful for increasing the ability of PSA to be used in distinguishing prostate cancer(PCa) from benign prostatic hyperplasia(BPH). We evaluated 117 asymptomatic healthy male controls(mean age 55.8, range 50-71) with no clinical evidence of PCa, 125 men with symptomatic BPH(mean age 67.6, range 52-89) who underwent prostatic surgery(open prostatectomy or TLRP) and 14 men with biopsy-proven, untreated PCa(mean age 71.3 range 54-86). Using ACS-PSA2 assay(Ciba-Corning). we measured the free PSA(F), total PSA(T) and free/total(F/T) ratio. The method utilized was monoclonal-polyclonal immunometric, chemiluminescent assay, using a standardized calibrator 90:10. We also performed total PSA measurement with Tandem-R PSA assay(Hybritech). Correlation between ACS-PSA2 assay and Tandem-RPSA assay was excellent (r2=0.93). Receivr operating characteristics(ROC) analyses between them showed very similar performances. ROC analysis of free to total PSA ratio was more superior than that of free form PSA only. When all subjects were included, the ratio of free to total PSA in controls, BPH and PCa were 0.27, 0.24 and 0.07, respectively. which significantly differentiated between PCa and benign conditions(p<0.01). When the cut-off value (Fr) was set into 0.12, its diagnostic sensitivity and specificity were 86% and 84%, respectively. These findings suggest that free to total PSA ratio may enhance the ability to distinguish benign histologic conditions from cancer.

Growth Hormone Non-dependent Insulin-like Growth Factor-I of Kidney / 대한비뇨기과학회지

Recent studies have revealed that IGF- I produced in kidney are of two fractions; GH dependent and GH nondependent IGF-I. The role of GH nondependent IGF-I is interesting in renal hypertrophy and glomerulosclerosis because GH is clearly related with hypertrophy accompanying glomerulosclerosis is not seen in GH deficient animal. The relationship of the high protein diet and the IGF- I production under the deprivation of GH was studied. In hypophysectomized Sprague-Dawley rat, the level of serum IGF-I was measured using radioimmunoassay, and renal IGF- I production evaluated by immunohistochemistry during both normal and high protein diet. Serum IGF-I of rats on high protein diet was significantly higher than that fed normal protein diet. After unilateral nephrectomy, the level of serum IGF-I was significantly increased in both normal and high protein diet groups. Henle's loop, distal convoluted tubule and collecting duct were weakly stained with normal protein diet. With high protein diet, the staining intensities increased at these portion , and distal part of proximal convoluted tubule and straight tubule were weakly stained. After unilateral nephrectomy, distal convoluted tubule and collecting duct were densely stained with normal protein diet. With high protein diet, the staining intensities increased in distal part of proximal convoluted tubule and Henle's loop. Regardless of the types of protein diet, the specific difference between unilateral nephrectomized rats and sham- operated rats was immunoreactivity of the distal convoluted tubule.. In conclusion, it is suggested that GH non-dependent IGF-I is mainly produced in distal convoluted tubule during compensatory renal hypertrophy, and protein diet mainly affect IGF- I production of distal part of proximal convoluted tubule and Henle's loop.

Site-specific effect of testosterone on bone mineral density in male hypogonadism

To assess the correlation between the remaining serum testosterone and bone mineral density(BMD), and to determine the effect of exogenous testosterone on BMD in subjects with male hypogonadism, we evaluated the serum testosterone levels and BMDs of the femur neck, Ward's triangle and the spine(L1-4) in 20 subjects with Klinefelter's syndrome and 7 with hypogonadotropic hypogonadism before and after testosterone replacement. BMDs of the femur neck, Ward's triangle and the spine were below the age-matched normal mean at 77.8%(21/20), 74.1%(20/27) and 88.9%(24/27), respectively. There were significant differences in serum testosterone levels and the spinal BMD between the two groups and the BMD of the spine closely correlated with the serum testosterone level (R = 0.63, p < 0.001). Following a mean 11.8 +/- 4.9 months of testosterone replacement, the BMD at all sites increased significantly and the pretreatment difference in spinal BMD between the two groups disappeared. We conclude that, although testosterone may increases the bone density, it has a site-specific effect of maintaining and increasing the bone mass especially at the spine in male hypogonadism.

Morphology and Function of Testis in Growth Deprived Mature and Immature Male Rats / 대한비뇨기과학회지

Growth hormone(GH) plays a major role in growth and its effects are mainly mediated by insulin like growth factor-I ( IGF-I). However the role of GH in the regulation of testicular function especially in spermatogenesis is still under debate. Though there were several studies using GH-deficient mutant mice, results are conflicting. Furthermore they are not proper to find out any exact role of GH in normal adults. We have therefore used somatostatin analogue (Sandostatin) for 1 week to block the effect of GH and it's mediator IGF-I, in mature and immature Sprague-Dawley male rats. In immature rats the delayed maturation was recovered after ceasing somatostatin in several weeks and the testicular parameters became normal after maturation. Post-pubertal rats showed diminished spermatogenesis especially in the number of pachytene spermatocytes and round spermatids of stage VII. These results seems to be associated with decreased systemic IGF-I. But the Leydig cell function in other words, testosterone production, remained normal. Somatostatin administered Leydig cells showed strong positive reactions like normal control on IGF-I immunohistochemical stain. We concluded that GH mediated IGF-I plays a major role in spermatogenesis especially on pachytene spermatocytes of post-pubertal male rats and there are GH independent IGF-I actions in Leydig cells.

Paraffinoma of the penis

Augmentation of the body contour by localized injection of hard and soft paraffin rose to a zenith of popularity in the early 1900s, whereafter the severe destructive consequences of such injections became widely recognized. However in Korea, these injections are still performed much by nonmedical person. Paraffin or other mineral oil injection into body is no more a useful method to change body contour. We reviewed 26 cases of sclerosing lipogranuloma of penis with complications in recent 13 years after mean 18.5 months from previous injection of paraffin or vaseline. We conclude that the public should be informed of detrimental effects of paraffin injections and that the best treatment of penile paraffinoma is complete excision and appropriate penoplasty.

Leydig Cell Transplantation / 대한비뇨기과학회지

It is ordinarily accepted that the synthetic testosterone administration is the choice of treatment for the primary testicular dysfunction. But recently not a few medical scientists reported that the long-standing testosterone replacement is not without side effects. For that reason, we tried to investigate a possibility of in vivo transplantation of Leydig cells as a new biologic androgen substitution therapy. The Leydig cells procured from 6 week-old male Sprague-Dawley rat were auto- transplanted and the level of testosterone secretion and histostructural changes were observed.The results obtained are summarized as follows :1. For the selection of transplantation sites, compared to subcutaneous or scrotal counterparts, renal subcapsular and intraperitoneal transplant showed higher levels of testosterone and the number of transplanted cells was correlated with the level of measured testosterone. 2. Furthermore, if the Leydig cells were transplanted intraperitoneally after the uptake on synthetic collagen, testosterone levels were higher than the ones simply transplanted, resulting in 2.7 times higher at 3 months. 3. The activity of 125-I-hCG decreased 20 to 40% at each month after transplantation compared to the normal levels, but no statistical significance was noted among different periods. 4. Histologic examination revealed neovascularized capillaries and well demarcated uptake of sheet-like group of eosinophilic Leydig cells were observed at 4 weeks. But the evidence of destructive changes such as a focal inflammation with central dystropic ossification was noted after S month. On electron microscopy, the marked indentation of nucleus and presence of lipochrome pigment were seen and the number and size of smooth endoplasmic reticulum and mitochondria were reduced. In conclusion, testosterone output could be increased to the physiologic range by increasing the number of transplant cells or collagen uptake utilizing, etc. However the decrease of testosterone production after 3 months is believed to be a result of focal inflammation and degeneration which in turn caused the decrease in number of secreting Leydig cells and reduced activity of hCG receptors. Further effort is necessary on delaying or preventing the structural and functional decrement of Leydig cells.

Testosterone productivity and histostructural changes of autotransplanted rat Leydig cells

To investigate the possibility of in vivo transplantation of Leydig cells as a new biologic androgen replacement therapy, the Leydig cells procured from 6 week-old male Sprague-Dawley rats were autotransplanted, and the level of testosterone secretion and histostructural changes were observed. The renal subcapsular and intraperitoneal transplant showed higher levels of testosterone compared to subcutaneous or scrotal counterparts, and the number of transplanted cells was correlated with the level of measured testosterone. Furthermore, if the Leydig cells were transplanted intraperitoneally after the uptake on synthetic collagen, testosterone levels were higher than the ones simply transplanted without synthetic collagen uptake, resulting in 27 fold increase at 3 months. The activity of 125I-hCG decreased 20 to 40% at each month after transplantation compared to the normal levels, but no statistical significance was noted among different periods. The histologic examination revealed neovascularized capillaries and well demarcated sheet-like group of eosinophilic Leydig cells were observed at 4 weeks. But the evidence of destructive changes such as a focal inflammation with central dystropic ossification could be noted after 3 month. On electron microscopy, the marked indentation of nucleus and presence of lipochrome pigment were seen, and the number and size of smooth endoplasmic reticulum and mitochondria were reduced after 3 month. In conclusion, testosterone output could be increased to the physiologic range by increasing the number of transplant cells or utilizing collagen uptake but further effort is necessary on delaying or preventing the structural and functional decrement of Leydig cells.

Treatment response with transurethral radiofrequency thermotherapy for symptomatic benign prostatic hyperplasia

One hundred and two patients with benign prostatic hyperplasia were treated by transurethral radio-frequency thermotherapy (TURT) device (Thermex-II, Direx, Israel) with 47.5 degrees C in single session for 2 hours and 30 minutes from November 1992 to October 1993. Among them, 83 patients, who were followed up for more than 3 months were included in this study. Twenty-seven (32.5%) patients had a history of acute retention. Pretreated values of the mean Madsen-Iversen symptom score, maximum urine flow rate, postvoiding residual urine volume, prostate volume and prostate specific antigen (PSA) were 15.4, 6.5 ml/sec, 61.3ml, 43.2ml and 0.77 ng/ml respectively. Madsen-Iversen symptom score, maximum urine flow rate were measured at 2 weeks, 1, 3 and 6 months after TURT. The residual urine volume, prostate volume and PSA level were measured at 3 and 6 months after TURT. During the follow up, the symptom score started to decrease significantly at 1 month (9.9, p< 0.01) after TURT, and gradually decreased up to 6.9 at 3 months. The maximum flow rate showed initial significant improvement at 2 weeks (8.1 ml/sec., p< 0.01), but no significant interval change was observed thereafter. The residual volume decreased significantly at 3 months (41.3 ml, p< 0.01) and no decrement was noted until 6 months. Neither the prostate volume nor PSA value changed significantly at 3 or 6 months after TURT. The improvement, which was defined as a change of 50% or more in at least one of subjective or objective symptoms showed in 63.9% (53/83) at 3 months and 57.1% (32/56) at 6 months. Both subjective and objective improvements at 3 and 6 months after treatment showed in 24.1% and 19.6%, respectively.

Endoscopic teflon injection in vesicoureteral reflux / 대한비뇨기과학회지

Twenty vesicoureteral reflux patients with 31 reflux renal units were treated with endoscopic Teflon injection. Twenty one reflux renal units were cured and the success rate after first injection was 67.7 %. In 5 more renal units the second injection was done and the refluxes were subsided in all cases. The overall success rate was 83.9 %. Teflon injection was also effective in vesicoureteral reflux with neurogenic bladder. There are many benefits of endoscopic Teflon injection in the treatment of vesicoureteral reflux but long term follow-up is needed and we must consider the possibility or complication especially in child.