[65-month testosterone replacement therapy for androgen deficiency-induced ED: a case report and review of the literature].

OBJECTIVE: To explore the mechanism of erectile dysfunction (ED) with testosterone deficiency and discuss the feasibility of long-term testosterone replacement therapy (TRT) by observing a case of ED with testosterone deficiency treated by TRT for 65 months. METHODS: We treated an ED patient with testosterone deficiency by TST for 65 months, and evaluated the therapeutic effects by analyzing his IIEF-5 score, dynamic changes in testosterone, PSA, hemoglobin and red blood cell count, and adverse events. RESULTS: The patient was a 46-year-old man, with an IIEF-5 score of 7, baseline serum total testosterone (TT) of 2.79 ng/ml, and no response to phosphodiesterases-5 inhibitors (PDE5i). He was diagnosed with late-onset hypogonadism (LOH) and treated by TRT: testosterone undecanoate at 80 mg bid po for the first 2 weeks and then at 40 mg bid po. Two months after medication, the TT level was increased to normal (3.45 ng/ml), and physical fitness and anxiety symptoms were markedly improved, with no significant improvement in sexual function. Then we administered PDE5i on demand in addition, which elevated his IIEF-5 score to > 21. The combined medication of TRT and on-demand PDE5i lasted for 45 months followed by TRT alone for another 18 months. The patient was restored to normal penile erection and sexual satisfaction, with the IIEF-5 score remaining at > 21. Regular follow-up revealed no significant abnormalities in the testosterone level, PSA, and routine blood tests. CONCLUSION: TRT enhances the effect of PDE5i in the treatment of androgen deficiency-induced ED, and long-term TRT is safe and effective for androgen deficiency.

[Pituitary prolactinoma with severe erectile dysfunction as the initial symptom: diagnosis and treatment of 4 cases].

OBJECTIVE: Pituitary prolactinoma with severe erectile dysfunction (ED) as the initial symptom is often misdiagnosed. This article explores the diagnosis and treatment of severe ED caused by pituitary prolactinoma. METHODS: We retrospectively analyzed the diagnosis and treatment of 4 cases of pituitary prolactinoma with severe ED (IIEF-5 score 5 - 7) as the initial clinical symptom confirmed by MRI. RESULTS: The 4 cases of pituitary prolactinoma-induced severe ED, with serum prolactin 10 times above the maximum normal level, were misdiagnosed for 2 years. All failed to respond to the PDE5 inhibitor therapy, and then 3 of them underwent transnasal hypophysectomy. Twenty-four months of follow-up found the level of prolactin restored to normal in 1 case (IIEF-5 = 19), and reduced to 600 and 768 IU/L respectively (IIEF-5 = 15) in the other 2. Then administration of the PDE5 inhibitor was followed, which produced satisfactory efficacy. One case was treated with oral bromocriptine, which restored the prolactin level to normal at 12 months (IIEF-5 > 21). CONCLUSION: Prolactin detection and brain MRI can help to confirm pituitary prolactinoma with severe ED at the onset. As for its treatment, in case of an extremely high level of prolactin, simple administration of the PDE5 inhibitor is ineffective. When the prolactin level is reduced after surgery or medication, the symptom of ED can be improved and, in case of no obvious relief, administration of the PDE5 inhibitor can be followed, which may achieve satisfactory results.

[Transurethral prostatectomy with the bipolar plasmakinetic technique for benign prostate hyperplasia: a report of 712 cases].

OBJECTIVE: To evaluate the effect and safety of transurethral prostatectomy with the bipolar plasmakinetic technique (PKRP) in the treatment of benign prostate hyperplasia (BPH). METHODS: A total of 712 BPH patients underwent transurethral prostatectomy with the bipolar plasmakinetic technique. The patients averaged 70.6 years of age and 52 g (range 35-102 g) in estimated prostate weight preoperatively. Comparative analyses were made on the maximum urine flow rate (Qmax), residual urine volume and scores on IPSS and QOL obtained pre- and post-operatively. RESULTS: The operations lasted 20-120 minutes (mean 51 min), the resected tissues weighed 15-96 g (mean 46 g), and no transurethral resection syndrome (TURS) occurred. The catheters were removed 4 -5 days after surgery. The patients were followed up for 1 -52 months (mean 27.6 mo). Obvious reduction was observed in the average Qmax from 4.7 ml/s preoperatively to 19. 1 ml/s postoperatively, in the mean IPSS score from 26.6 to 5. 8, and in the mean QOL score from 5.4 to 1.7, all with significant differences (P < 0.01). CONCLUSION: Transurethral prostatectomy with the bipolar plasmakinetic technique is a safe and effective means for the treatment of BPH.

Significance of margin in nephron sparing surgery for renal cell carcinoma of 4 cm or less.

BACKGROUND: Current surgical practice for nephron sparing surgery allows at least 1 cm margin of normal tissue around the tumour. However, recent studies show that the width of the margin is not important, even simple enucleation is as effective as partial nephrectomy. We explored whether margin size has significant impacts on clinical outcomes in nephron sparing surgery for renal cell carcinoma of 4 cm or less. METHODS: Between 1998 and 2006, 115 patients with sporadic, pathologically confirmed, renal cell carcinoma 4 cm or less (T1a) and normal contralateral kidney were treated by nephron sparing surgery using a margin less than 5 mm. The surgical margin status was evaluated from frozen and permanent paraffin sections. RESULTS: Mean and median tumour diameter were 3.3 cm and 3.5 cm (range 1.0-4.0). The mean margin width was 2.2 mm (median 2.0, range 0-6). In addition, 114 cases had margins 5 mm or less (99.1%), 97 cases (84.3%) had margin 3 mm or less, and 26 cases had margin zero (22.6%). None of the patients had positive surgical margins. No patients died during follow-up (mean 65 months). There were no any major surgical complications and no distant metastasis was detected. Local recurrence was detected in one case (0.9%) at a different site of the kidney. CONCLUSIONS: For early localized renal cell carcinoma of 4 cm or less, as long as tumour is completely excised, the size of margin in nephron sparing surgery is not important. Nephron sparing surgery with 5 mm margin is enough for tumour control. It provides excellent renal function preservation, favourable long term progression free survival and is not associated with an increased risk of local recurrence.

Safety and efficacy of mini-margin nephron-sparing surgery for renal cell carcinoma 4-cm or less.

OBJECTIVES: To explore whether mini-margin nephron-sparing surgery (NSS) is clinically safe and effective for renal cell carcinoma (RCC) of 4 cm or less with a normal contralateral kidney. METHODS: A total of 115 patients with sporadic, pathologically confirmed RCC of 4 cm or less (Stage T1a), with a normal contralateral kidney, were treated by NSS using a mini-margin of less than 5 mm from 1998 to 2006. The surgical margin status was evaluated by both frozen and permanent paraffin section studies. The patients were followed up, and the data were analyzed. RESULTS: The mean and median tumor diameter was 3.3 and 3.5 cm (range 1.0 to 4.0). None of the patients had positive surgical margins detected at either frozen section or final paraffin section analysis. The mean margin width was 2.2 mm (median 2.0, range 0 to 6). Of the 115 patients, 114 had margins of 5 mm or less (99.1%), 97 (84.3%) had margins of 3 mm or less, and 26 had margins of 0 mm (22.6%). At a mean follow-up of 65 months (median 66, range 9 to 105), all patients were alive. No distant metastasis was detected. Local recurrence was detected in 1 patient (0.9%) at a different site in the kidney. No major surgical complications, such as hemorrhage or urinary leakage/urinoma requiring reoperation, occurred. Considering only the 97 patients with follow-up of more than 3 years in the analysis, the mean and median follow-up time was 73 and 69 months (range 37 to 105), respectively. All 97 patients were alive with no evidence of disease at the last visit. CONCLUSIONS: The results of our study have shown that mini-margin NSS is a safe and effective approach for treating early localized RCC of 4 cm or less.

Optimal margin in nephron-sparing surgery for renal cell carcinoma 4 cm or less.

OBJECTIVE: Renal cell carcinoma (RCC) of 4 cm or less is with a low incidence of multicentricity and metastasis and is usually considered suitable for nephron-sparing surgery (NSS). This study was designed to investigate the distance between extra-pseudocapsule cancer lesions and primary tumors, and to suggest the optimal margin of normal parenchyma in NSS for RCC 4 cm or less. METHODS: We prospectively studied 82 kidneys in which RCCs of 4 cm or less were resected by radical nephrectomy. According to UICC TNM classification (1997), all tumors were staged as T1 and classified as conventional RCC in 76 cases and papillary RCC in 6 cases. The kidney samples were first step sectioned at 3mm intervals and examined for multicentricity. Then, on each layer of tissue sectioned, parenchyma margins of 15 mm beyond pseudocapsule were continuously sectioned and examined microscopically to investigate completeness of pseudocapsule and possible presence of extra-pseudocapsule cancer lesions. The greatest distance between extra-pseudocapsule lesions and primary tumors was measured. RESULTS: The diameter of 82 primary tumors was 3.4+/-0.7 mm (range 1.5-4.0 cm). Of them, 31.7% (26/82) were found without intact pseudocapsule. Of the 82 cases, 19.5% (16/82) were with positive cancer lesions beyond pseudocapsule, with invasion into normal parenchyma in 12.2% (10/82), into venule in 2.4% (2/82) and satellite tumors in 4.9%(4/82). The average distance between extra-pseudocapsule cancer lesions and primary tumors was 0.5+/-1.3mm (range 0-5.0mm), with a 95% confidential interval (CI) (0.11, 0.94). No significant difference was found in the incidence of extra-pseudocapsule cancer lesions between the tumors 2.5 cm or less and that greater than 2.5 cm. CONCLUSIONS: These data suggest that when partial nephrectomy is performed in RCC 4 cm or less, a 10mm margin may be too large and go against renal function maintaining. Enucleation alone was associated with a significant risk of incomplete excision, and therefore liable for local recurrence. Thorough inspection of the whole kidney before and during operation may help to avoid leaving over large and distant multifocal lesions.

[Optimal margin in nephron-sparing surgery for renal cell carcinoma 4 cm or less in diameter].

OBJECTIVE: To investigate the optimal margin in nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) 4 cm or less in diameter. METHODS: Eighty-two kidneys with RCC 4 cm or less in diameter resected by radical nephrectomy were prospectively studied. The kidney samples were sectioned at 3 mm interval and examined for multicentricity. On each layer of tissue sectioned, parenchyma margin of 15 mm beyond pseudocapsule was continuously sectioned and examined for completeness of pseudocapsule and extra-pseudocapsule cancer lesion. The farthest distance between extra-pseudocapsule lesion and primary tumor was measured. PCNA expression was detected in 41 patients by using standard SP immunohistochemistry technique. RESULTS: The diameter of 82 primary tumors was 3.4 +/- 0.8 cm (range 1.5 - 4.0 cm). Of these, 31.7% (26/82) were found without intact pseudocapsule and 17.1% (14/82) with positive cancer lesions beyond pseudocapsule. The average distance between extra-pseudocapsule cancer lesion and primary tumor was 0.5 +/- 1.3 mm (range 0 - 5.0 mm), with a confidential interval (CI) of 95% (0.11, 0.94). Statistically, the one side percentile P(95) was 4.9 mm, P(97.5) was 5.0 mm and P(100) was 5.0 mm. The mean PCNA index in the 41 patients with RCC was (29.5 +/- 17.6)%, which was (49.6 +/- 21.5)% in the group with extra-pseudocapsule cancer lesions and (24.6 +/- 12.7)% in the group without (t = 3.162, P = 0.013). The ratio of strong expression was 5/8 in the group with extra-pseudocapsule cancer lesions, and 18.2% (6/33) in the group without the lesions (chi(2) = 6.442, P = 0.011). Logistic regression analysis showed that completeness of pseudocapsule and PCNA index were significant predictors of extra-pseudocapsule cancer lesions (P = 0.019). CONCLUSIONS: These data suggest that when NSS is performed in RCC 4 cm or less in diameter, a margin of more than 5 mm of adjacent parenchyma should be excised with the tumor. Enucleation alone was associated with a significant risk of incomplete excision, and therefore liable for local recurrence. Tumors with incomplete pseudocapsule and(or) high PCNA indices are more likely to have extra-pseudocapsule cancer lesions, so intensive follow-up is necessary after NSS.