Laparoscopic Partial Adrenalectomy: Surgical Technique and Outcome

PURPOSE: To examine the perioperative surgical and long-term outcomes of laparoscopic partial adrenalectomy (LPA) by comparing the results of laparoscopic total adrenalectomy (LTA). MATERIALS AND METHODS: A total of 132 transperitoneal laparoscopic adrenalectomies were performed for adrenal gland tumor between May 2006 and April 2019. All surgeries were performed by a single surgeon. Seventy patients underwent LTAs and 54 underwent LPAs. The data were collected retrospectively through review of the medical charts. We compared the perioperative and long-term outcomes between the 2 surgical methods. RESULTS: A total of 70 patients, including 4 patients with bilateral tumors, underwent LTA. In contrast, 54 patients, including 4 patients with bilateral masses, underwent LPA. There were no differences between the 2 groups with regard to mean age at presentation, mean tumor size, or postoperative stay. However, the mean operating time was significantly shorter in the LPA group than that of the LTA group. The mean estimated blood loss in the LPA group was significantly higher than that in the LTA group. However, none of the LPA patients required blood transfusion. The biochemical markers and laboratory values normalized postoperatively in all patients with functional adrenal tumors. There was no local recurrence during the follow-up period. CONCLUSIONS: Our data demonstrate that the surgical outcomes and perioperative complications in LPA group are similar to those of LTA. When LPA is performed for small adrenal lesions, most patients remain steroid independent, as well as recurrence-free at long-term follow-up.

Routine Use of Single Instillation of Epirubicin after Transurethral Resection of Bladder Tumor - Should It Be Done in Korean Patients?

To study the impact of single instillation of epirubicin (SIE) on the cancer recurrence of non-muscle invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT) in Korean patients. The major inclusion criteria were NMIBC patients. The major exclusion criteria were muscle invasive bladder cancer, metastatic bladder cancer, combined urinary upper tract tumor, and carcinoma in situ. SIE group received 50 mg epirubicin within 6 hours after TURBT. Non-SIE group did not receive epirubicin. This study enrolled a total of 214 patients diagnosed as having NMIBC during the period from October 2003 through January 2010 at the single institutions. Follow-up of the patients was conducted through January 2012. The median age of patients was 63.4 years. Of 112 evaluable patients in the SIE group, cancer recurrence rate was 33.9% and in non-SIE group, cancer recurrence rate was 62.7% (p<0.001). The recurrence-free survival duration was longer in Group SIE compared with Group non-SIE (p<0.001). Multivariate analysis revealed that SIE was significantly associated with cancer recurrence (HR 0.213, p<0.001). We confirmed the impact of SIE on the cancer recurrence in the Korean patients who underwent TURBT for NMIBC. Single instillation of chemo-agent after TUR-B might be recommended in Korean patients for reduce bladder cancer recurrence and provide longer recurrence-free survival duration.

Anastomosing Hemangioma Mimicking Renal Cell Carcinoma

Anastomosing hemangioma (AH), a rare benign vascular tumor, is a newly recognized variant of capillary hemangioma. In the microscopic examination, this tumor has characteristic feature of the unique anastomosing sinusoidal capillary sized vessels. It can be misdiagnosed as a malignancy such as renal cell carcinoma or angiosarcoma. Herein, we report a case of AH originating in the right kidney of a 43-year-old man, which was initially considered as cystic renal cell carcinoma on computed tomography (CT). The patient underwent laparoscopic radical nephrectomy, but pathologic result was AH of the kidney. There was no evidence of recurrence or metastasis 5 months after the surgery.

Ureteral Penetration Caused by Drilling During Internal Pelvic Bone Fixation: Delayed Recognition / 대한배뇨장애요실금학회지

A 49-year-old man was referred to our department with profuse serous fluid discharge from a Penrose drain after undergoing internal fixation with metal screws for multiple pelvic bone fractures. A definite ureteral penetration was identified that was orientated from the lateral to the medial aspect of the right distal ureter. The patient was surgically treated with excision of the 2-cm injured ureteral segment, end-to-end ureteroureterostomy, and double J ureteral stent placement. To our knowledge, a penetrating ureteral injury caused by bone drilling has not been reported previously in the published literature. This case shows that surgeons who do pelvic surgery, including orthopedic surgeons, should be familiar with the anatomical relationship of the ureter and its potential injuries.

The Direct Anti-Cancer Effect of a Single Instillation of Epirubicin after Transurethral Resection of Bladder Tumor for Non-Muscle-Invasive Bladder Cancer

PURPOSE: To evaluate the direct anti-cancer effect of a single instillation of epirubicin (SIE) after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) by analysis of immediate urine cytology (IUC). MATERIALS AND METHODS: We reviewed the records of 158 patients who had IUC after TURBT for NMIBC. Fifty-six patients were treated with SIE after TURBT and 102 patients were not treated with SIE. The direct anti-cancer effect of SIE was compared in the two groups according to the result of IUC. The relationship between SIE and IUC in NMIBC was analyzed by use of multivariate Cox proportional hazards regression models. RESULTS: The IUC-positive rate was 33.9% in the SIE group and 42.1% in the non-SIE group (p=0.005). The IUC-positive rate was lower in the SIE group than in the non-SIE group for each factor, including tumor stage, tumor grade, tumor size, tumor multiplicity, and preoperative urine cytology. Multivariate Cox proportional hazards regression analysis revealed that SIE was significantly associated with a negative IUC result in patients with NMIBC (HR, 0.163) (p<0.001). CONCLUSIONS: These results indicate the direct anti-cancer effect of SIE in patients who undergo TURBT for NMIBC.

Cavernous Hemangiolymphangioma of the Testis without Cutaneous Hemangiomatosis in an Elderly Patient

Hemangiolymphangioma is an extremely rare malformation of both the lymphatic and blood vessels. To date, however, there are no reports in the literature of a hemangiolymphangioma of the testis. An 84-year-old man visited our hospital for investigation of a 1-month episode of a rapidly growing mass in his right scrotum. Scrotal ultrasonography revealed a multilobulated mass with septation in the testis. Testicular tumor markers were within the normal limit. Radical orchiectomy was performed. At surgery, a red, wide-based, nodular tumor was found on the testis. Histological examination of the resected specimen showed it to be a cavernous hemangiolymphangioma. Here we report this first case of a cavernous hemangiolymphangioma of the testis without cutaneous hemangiomatosis in an elderly patient.

Floating Hem-o-Lok Clips in the Bladder without Stone Formation after Robot-Assisted Laparoscopic Radical Prostatectomy

Hem-o-Lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) are widely used in robot-assisted laparoscopic radical prostatectomy because of their easy application and secure clamping. To date, there have been some reports of intravesical migration of these clips causing urethral erosion, bladder neck contractures, and subsequent calculus formation. We report the first case of bladder migration of Hem-o-Lok clips without stone formation after robot-assisted laparoscopic radical prostatectomy. The Hem-o-Lok clips were found during urethral dilation with a guide wire for bladder neck contracture under cystourethroscopy. The Hem-o-Lok clips were floating in the bladder without stone formation and were removed by a cystoscopic procedure.

Intraperitoneally Placed Foley Catheter via Verumontanum Initially Presenting as a Bladder Rupture

Since urethral Foley catheterization is usually easy and safe, serious complications related to this procedure have been rarely reported. Herein, we describe a case of intraperitoneally placed urethral catheter via verumontanum presenting as intraperitoneal bladder perforation in a chronically debilitated elderly patient. A 82-yr-old male patient was admitted with symptoms of hematuria, lower abdominal pain after traumatic Foley catheterization. The retrograde cystography showed findings of intraperitoneal bladder perforation, but emergency laparotomy with intraoperative urethrocystoscopy revealed a tunnel-like false passage extending from the verumontanum into the rectovesical pouch between the posterior wall of the bladder and the anterior wall of the rectum with no bladder injury. The patient was treated with simple closure of the perforated rectovesical pouch and a placement of suprapubic cystostomy tube.

Predictors of Gleason Score Upgrading after Radical Prostatectomy in Low-Risk Prostate Cancer

PURPOSE: The Gleason score is an important predictor of outcome that is used in conjunction with clinical stage and prostate-specific antigen to guide clinical decision making. The prostate biopsy Gleason grade frequently differs from the radical prostatectomy grade. The aim of this study was to determine the risk factors of Gleason upgrading in patients with low-risk prostate cancer after radical prostatectomy. MATERIALS AND METHODS: We retrospectively analyzed the medical records of 146 patients who underwent radical prostatectomy between 1998 and 2008 in two hospitals of Jeonbuk province in Korea. Pathological Gleason score upgrading was defined as an increase in the Gleason score from or =7 between the biopsy and radical prostatectomy specimen. Pretreatment clinical and pathological parameters were used to identify predictors of pathological upgrading. RESULTS: Of the total 146 patients, 51 (34.9%) were upgraded postoperatively. Small prostate volume (p=0.008), abnormality on the digital rectal examination, and positive surgical margin (p=0.001) were significantly and positively associated with upgrading after radical prostatectomy. A total of 17 of 65 patients with low-risk prostate cancer (26.2%) were upgraded postoperatively. Small prostate volume (<30 ml) was significantly (p=0.026) and positively associated with upgrading after radical prostatectomy in patients with low-risk prostate cancer. CONCLUSIONS: Overall, 26% of patients with low-risk disease were upgraded postoperatively. Small prostate volume was associated with an increased risk for pathological upgrading after radical prostatectomy. These conclusions should be kept in mind when making treatment decisions for men with low-risk prostate cancer.

Newly Discovered Pseudoaneurysm after Embolization of a Renal Arteriovenous Fistula with a Pseudoaneurysm following a Renal Stab Wound

Post-traumatic arteriovenous fistula (AVF) and pseudoaneurysm are rare, and mostly occur in stab wound patients. Suspected AVF and pseudoaneurysm requires angiography, with planned simultaneous embolization. Superselective embolization is generally a safe and effective treatment modality for AVF and pseudoaneurysm with minimal associated morbidity. Rare complications of the embolization do occur, including renal abscess, postembolization syndrome, impaired renal function, pulmonary embolism caused by migration of coils, and allergic reaction. We present here the case of a man who presented with a newly discovered pseudoaneurysm after embolization of a renal AVF with pseudoaneurysm after a renal stab wound.

A Recent Study on the Antimicrobial Sensitivity of the Organisms that Cause Urinary Tract Infection / 대한비뇨기과학회지

PURPOSE: The overuse and misuse of antimicrobial agents have made choosing an appropriate antibiotic more difficult. We studied changes in the antibiotic sensitivities of the causative microorganisms of urinary tract infection (UTI), in 2000 versus 2005, in order to provide useful information and to aid physicians to make better choices of adequate drugs for treating UTI. MATERIALS AND METHODS: We retrospectively analyzed 5,266 uropathogens and their antimicrobial sensitivities in 3,346 patients who were admitted to or they had visited two tertiary hospitals located in Honam province, in 2000 versus 2005. This revealed the isolated causative organisms in the urine cultures. RESULTS: The incidence of UTI shows bimodal peaks in the first decade (22.3%) and 7th decade (18.8%). The common pathogens were E. coli (34.4%), Enterococcus (19.0%), Staphylococcus (10.2%), Pseudomonas (9.9%) and Klebsiella (9.8%). The incidence of Gram positive organisms was increased from 35.7% in 2000 to 38.1% by 2005. For the Gram negative isolates, imipenem and amikacin showed relatively higher sensitivity, while ampicillin and ciprofloxacin showed relatively lower sensitivity. For the Gram positive isolates, vancomycin and teicoplanin showed relatively higher sensitivity, while penicillin and ciprofloxacin showed relatively lower sensitivity. Significant declines for the third-generation cephalosporins' and fluoquinolones' sensitivity to E. coli and Klebsiella isolates were found. CONCLUSIONS: E. coli was the most common single organism causing UTI. We should be concerned about the increase of Gram positive organisms, especially Enterococcus. The use of TMP/SMX and nitrofurantoin as the first choices of treatment for UTI should be reconsidered. It is recommended that fluoroquinolone should be restricted because of the high antibiotic resistance and the economic aspects.

Predictive Factors Affecting Urethral Stricture Development after Transurethral Resection of the Prostate in Patients with Benign Prostatic Hyperplasia

PURPOSE: To evaluate possible factors affecting urethral stricture development after TURP in patients with BPH. MATERIALS AND METHODS: We reviewed retrospectively medical records of patients who underwent TURP for 6 years. All operations were performed by 2 experienced doctors who have minimum 200 practices. Patients were classified into 2 groups. Group A included patients with urethral stricture required periodic urethral dilation or urethrotomy. Group B included those without urethral stricture development after TURP. We analyzed all possible factors such as resection time, prostate volume, resection volume, resectoscope size, preoperative catheterization duration due to AUR, postoperative catheterization duration, preoperative pyuria, prostate needle biopsy performed preoperatively and PSA level, age and co-morbid systemic diseases. RESULTS: 595 patients underwent TURP between 2000 and 2005. 76 of them were excluded because of preexisting urethral stricture or secondary TURP. 110 were categorized into group A and 409 into group B. There was no statistical difference between group A and B with respect to age, preoperative catheterization duration in patients with AUR, postoperative catheterization duration, prostate volume, resection volume, preoperative PSA level, preoperative pyuria, preoperative biopsy history, resectoscope size(22F vs 24F) and anesthesia method (general vs spinal), respectively. However, there is significant difference between group A and B in comparison of resection time(58.5+/-21.6 min vs 48.5+/-23.2 min, p=0.02). CONCLUSION: Our data demonstrate that the shortening of resection time is the most important single factor to decrease urethral stricture formation after TURP in patients with BPH.

Bladder Rupture during Voiding Cystourethrography / 대한비뇨기과학회지

A ruptured bladder, or extravasation from the bladder, is almost always associated with trauma. Spontaneous extravasation, or iatrogenic extravasation, is extremely rare, with only few reported cases. Herein, two cases of bladder rupture, which occurred during voiding cystourethrography (VCUG), one in an 18 month old patient and the other in a 6 week old patient, due to instill dye by high pressure, are presented.

Analysis of Complications and Causes of Revision of Penile Prosthesis / 대한남성과학회지

PURPOSE: Penile prosthesis implantation to correct the irreversible erectile dysfunction is a common. We investigated complications and causes of revision after implantation of the penile prosthesis. MATERIALS AND METHODS: We followed 72 patients who underwent penile prosthesis implantation performed by the same surgeon from January 1993 to July 2006. The medical records of all patients were retrospectively reviewed. The mean follow up duration was 30.3 months, and average age at operation was 56.7+/-11.0 years. RESULTS: The malleable penile prosthesis was implanted on 8 patients. The inflatable penile prosthesis was implanted on 63 patients and Dynaflex was implanted in the one patient. Of the patients implanted inflatable penile prosthesis, complications were developed in the 14 patients and 17 cases of complications were developed. Of the complications, mechanical complications were broken of connecting tubing(7), mulfunction of Dynaflex(1) and difficulty of deflation(1). Of 17 complications, non-mechanical complications were urethral stricture(5), erosion of urethra(1), migration of reservoir into the bladder(1) and SST deformity(1). CONCLUSIONS: Penile prosthesis has high complications rates, and revision rate also is high. Mechanical failure was the most common cause of surgical revision. Although urethral stricture is rare complication, it was developed in the 5 patients due to mal-rotation of the cylinder.

Errors of Rectal Pressure Measurement in Urodynamic Study of Spinal Cord Injured Patients

OBJECTIVE: The intrarectal pressure can make error during urodynamic study and can decrease the accuracy of detrusor pressures. The purpose of this study was to investigate the incidence and cause of the error in measurement of recral pressure. METHOD: Forty-eight patients with spinal cord injury were enrolled. With the patients in the lithotomy position, catheter was placed into the bladder and the rectum, then urodynamic testing began by infusion of normal saline (20~30degrees C) via urethral catheter. The errors by measurement of rectal pressure during urodynamic study were recorded. According to the position of patients and spasticity of hip flexors, difference of rectal pressure was investigated. RESULTS: The error rate of intrarectal pressure during urodynamic study was 41%. Intrarectal pressure was higher in lithotomy position than in lateral lying position. According to modified Ashworth scale of hip flexors, intrarectal pressure in grade 0 was significantly lower than grade 1, 1.5 and 2 (p<0.05). CONCLUSION: There was significant errors in measuring of the intravesical pressure during urodynamic study. These factors might be posture, spasticity of hip flexors, and expelling of the catheter in urodynamic study.

Analysis of Prognostic Factors in Patients with Fournier's Gangrene / 감염과화학요법

BACKGROUND: To evaluate prognostic factors such as age, associated disease, laboratory and clinical data, which can affect prognosis of patients with Fournier's gangrene. MATERIALS AND METHODS: 27 patients were included in this study. All underwent treatment during past 15-year in our department. Medical records were reviewed with respect to age at presentation, extent of disease, laboratory data and bacteriology, associated disease, and clinical course. Also involved surface area was measured by the rule used in burn patients. Statistical analysis was made by Mann Whitney U test and Fisher's exact test. RESULTS: Of 27 patients, 4 died and 23 survived. The mean age was 55.4+/-13.7. The most common underlying disease was diabetes mellitus. In comparison of survival and non-survival groups, there were significant differences in duration of symptom before hospitalization, total surface area involved, laboratory data including serum albumin, creatinine, and WBC count on CBC. However, there was no difference in hospital stay, age, underlying disease, serum BUN, infected organisms, and urinary or fecal diversion. CONCLUSION: We conclude that the unfavorable factors affecting survival are duration of symptom before hospitalization, total surface area involved, serum albumin and creatinine level, and WBC count on CBC. The survival was, however, not associated with bacteriological factors, hospital stay, age, urinary or fecal diversion, and underlying diseases such as diabetes, and cancer.

Analysis of Prognostic Factors in Patients with Fournier's Gangrene / 감염과화학요법

BACKGROUND: To evaluate prognostic factors such as age, associated disease, laboratory and clinical data, which can affect prognosis of patients with Fournier's gangrene. MATERIALS AND METHODS: 27 patients were included in this study. All underwent treatment during past 15-year in our department. Medical records were reviewed with respect to age at presentation, extent of disease, laboratory data and bacteriology, associated disease, and clinical course. Also involved surface area was measured by the rule used in burn patients. Statistical analysis was made by Mann Whitney U test and Fisher's exact test. RESULTS: Of 27 patients, 4 died and 23 survived. The mean age was 55.4+/-13.7. The most common underlying disease was diabetes mellitus. In comparison of survival and non-survival groups, there were significant differences in duration of symptom before hospitalization, total surface area involved, laboratory data including serum albumin, creatinine, and WBC count on CBC. However, there was no difference in hospital stay, age, underlying disease, serum BUN, infected organisms, and urinary or fecal diversion. CONCLUSION: We conclude that the unfavorable factors affecting survival are duration of symptom before hospitalization, total surface area involved, serum albumin and creatinine level, and WBC count on CBC. The survival was, however, not associated with bacteriological factors, hospital stay, age, urinary or fecal diversion, and underlying diseases such as diabetes, and cancer.

Short Term Results of Modified Ingelman-Sundberg Denervation Procedure for Female Mixed Urinary Incontinence

PURPOSE: We evaluated the clinical efficacy, safety and satisfaction of patients with modified Ingelman-Sundberg bladder denervation procedure for female mixed urinary incontinence. MATERIALS AND METHODS: Forty two women with mixed urinary incontinence were randomly assigned to the transobturator tape(TOT, n=20), or modified Ingelman-Sundberg bladder denervation procedure(MISD) with TOT (n=22) procedures, between August 2005 and July 2006. Preoperatively, the patients were evaluated with history taking, physical examination, urine analysis, urine culture, voiding diary, uroflowmetry, postvoid residual(PVR) and urodynamic evaluations. The procedures were carried out using a previously established method under spinal anesthesia for 36 patients and under general anesthesia for 6 patients. The postoperative evaluation included a questionnaire, uroflowmetry and PVR. The mean follow-up period was 8.2 months. RESULTS: 20 underwent TOT procedure alone and 22 underwent TOT procedure with MISD. Two groups were similar in their preoperative characteristics. The mean operation time was longer in the TOT procedure with MISD group compared to TOT procedure alone (36 min vs 26 min). There was significant difference between the 2 groups in terms of the success rate(cure+improvement, 30% vs 82%, p=0.03): cure(20% vs 50%), improvement(10% vs 32%), persistent(70% vs 18%) for TOT group and TOT with MISD group, respectively. In addition, the patient satisfaction rate was significantly different between TOT and TOT with MISD group(> or = Satisfied, 20% vs 64%, p=0.04). The main complication was voiding difficulty, including retention, was 10%(n=2) in the TOT group, versus 18%(n=4) in the TOT with MISD group, but this was improved by conservative treatment. CONCLUSION: Despite the short term follow-up period, the modified Ingelman- Sundberg bladder denervation procedure is simple, effective and less invasive for the treatment of mixed urinary incontinence, which is able to perform with TOT procedure in terms of the high success and the low complication rates.

Metabolic Stone Risk Factors Associated with Papillary Calcification on Unenhanced Spiral Computed Tomography / 대한비뇨기과학회지

PURPOSE: Increasing evidence suggests that Randalls plaque contributes to the pathogenesis of urinary stone formation. The purpose of our study is to compare the incidence of the abnormal metabolic stone risk factors between the calcium stone former with papillary calcification and the calcium stone former without papillary calcification on unenhanced spiral computed tomography (CT). MATERIALS AND METHODS: A series of patients with calcium stones (n=49) underwent unenhanced spiral CT and complete metabolic evaluation after they consumed a random diet for 1 month after stone removal. Of the 49 patients, 38 patients showed papillary calcification on unenhanced spiral CT and 11 patients did not. Their blood was evaluated by using a multichannel analysis sequential multichannel autoanalyzer (SMA)-20 and PTH tests. The 24-hour urinary constituents were assayed for calcium, oxalate, citrate, total volume, phosphorus and sodium. We compared the incidence of abnormal metabolic risk factors between the two groups. Statistical analysis was performed by chi-square tests. RESULTS: The incidences of hyperuricemia were 27.3% in the patients without papillary calcification and 31.6% in the patients with papillary calcification. The incidences of hypernatriuria were 18.2% versus 42.1%, the incidences of hypercalciuria were 36.4% versus 26.3%, the incidences of hyperuricosuria were 18.2% versus 18.4%, the incidences of hyperoxaluria were zero versus 28.9%, and the incidences of hypocitraturia were 45.5% versus 44.7%, respectively. The difference between the two groups was statistically significant only for hyperoxaluria (p=0.043). CONCLUSIONS: Hyperoxaluria is the only metabolic risk factor that more frequently occurred in the patients with papillary calcification. Our date suggest that hyperoxaluria may be an important factor in the pathogenesis of papillary calcification.

Biochemical Characteristics of Serum and Urine in the Patients with Uric Acid Stone / 대한비뇨기과학회지

PURPOSE: We investigated the biochemical characteristics of serum and urine in the patients suffering with uric acid stone. MATERIALS AND METHODS: A total of 99 patients suffering with uric acid stone underwent routine urine analysis and 24-hour urine analysis for determining the urinary calculi risk factors. We conducted serum analysis for the stone risk factors and also analysis of the stone analysis. To compare the stone risk factors, 93 patients with calcium stone were identified and then the biochemical risk factors in the serum and urine were evaluated. RESULTS: The mean age of patients with uric acid stone was 56.5+/-12.4 years and the mean age of the patients with calcium stone was 40.2+/-11.5 years. Serum uric acid, cholesterol and triglyceride were all significantly increased in the patients with uric acid stone compared to that in the patients with calcium stone. The patients with uric acid stone showed a lower urinary pH and also lower urinary uric acid and citric acid excretion compared with those patients with calcium stone. The composition of the uric acid stone was mixed with calcium in 63.6 percent of the stones and 36.4% of the stones were pure. CONCLUSIONS: The patients with uric acid stone had higher serum uric acid, cholesterol and triglyceride, and they had a lower urinary pH and lower uric acid and citric acid excretion as compared with the patients with calcium stone. Uric acid-calcium mixed stone was most common in the patients with uric acid stone. There is a great likelihood of uric acid stone in the patients with stone who have one or more of the above mentioned biochemical characteristics. Therefore, these factors are important to conduct metabolic evaluation for preventing stone recurrence.