Timing of male urethral injury treatment in patients with polytrauma: A retrospective study.

INTRODUCTION: Male urethral injuries are uncommon, and the ideal timing of the definitive treatment remains controversial. This study aimed to compare the outcomes of early and delayed interventions (1 month or more after the injury) for male urethral injuries. PATIENT AND METHODS: We conducted a retrospective review of the medical records of 67 male patients with urethral injuries treated at our institution between 2011 and 2020. We examined patient age, injury severity score (ISS), abbreviated injury scale, mechanism, location and severity of injury, presence of pelvic fractures, surgical interventions, timing of treatment, and complications. We analysed factors associated with urinary complications based on the location of urethral injury. Additionally, we performed a subset analysis of patients with severe injuries (ISS≥16) to assess the impact of delayed surgery. RESULTS: Overall, 47 %, 37 %, and 27 % of patients in the delayed treatment group (N = 30) had urethral stricture (US), erectile dysfunction (ED), and/or urinary incontinence (UI). These rates were greater than the 22 % US, 3 % ED, and 11 % UI rates in the early treatment group (N = 37). The subgroup analysis revealed that patients with anterior urethral injury (AUI) who underwent delayed treatment (N = 18) tended to be more severely injured (ISS, 19 vs 9, p = 0.003) and exhibited higher rates of US (44% vs 21 %, p = 0.193) and ED (39% vs 0 %, p = 0.002) than those who received early treatment (N = 24). In the case of posterior urethral injury (PUI), the delayed treatment group (N = 13) had higher rates of US (50% vs 23 %, p = 0.326), ED (33% vs 8 %, p = 0.272), and UI (42% vs 0 %, p = 0.030) than the early treatment group. Regarding study limitations, more than 45 % of the enrolled patients were severely injured (ISS≥16), which may have potentially influenced the timing of urethral injury repair. CONCLUSIONS: The treatment of male urethral injuries may be delayed due to concurrent polytrauma and other associated injuries. However, delayed treatment is associated with higher rates of urinary complications. Early treatment of urethral injuries may be beneficial to male patients with urethral trauma, even in cases of severe injury.

Incidental Tuberculosis Epididymitis/Epididymo-orchitis: A Retrospective Analysis at a Tertiary Center in Taiwan.

OBJECTIVES: To determine the earliest noticeable manifestation and diagnosis in patients diagnosed with tuberculosis (TB) epididymitis/epididymo-orchitis incidentally and to analyze their responses to surgical and medical treatment. METHODS: Patients who underwent surgery for the preliminary impression of chronic epididymitis/epididymo-orchitis or epididymal/testicular tumor from 2000 to 2019 were included in the study. The clinical presentations, laboratory data, radiological examinations, and operative findings were analyzed retrospectively. The outcomes were assessed by the responses to anti-TB chemotherapy and post treatment radiographic evaluations. RESULTS: All of our 25 patients with a mean age of 60.6 years were diagnosed incidentally with TB epididymitis (48.0%) and TB epididymo-orchitis (52.0%) according to the histopathological findings from their surgeries. The presence of a palpable scrotal mass (76.0%), was the major presentation. Nineteen (76.0%) patients had undergone complete chemotherapy after the surgery and 15 (78.9%) patients showed complete recovery. Four (21.1%) patients had unfavorable outcomes, 3 had TB autonephrectomies and 1 required re-surgery years after complete chemotherapy. Of the 3 (12.0%) patients who did not receive chemotherapy after their surgeries, 1 had a TB relapse in the spine and lung and 1 developed bladder cancer years later. CONCLUSION: Tuberculosis epididymitis/epididymo-orchitis is difficult to diagnose. However, some clinical clues can assist including aged patients, extragenital TB histories, poor responses to antibiotic treatment and scrotal skin lesion. Complete anti-TB chemotherapy is mandatory even after the total removal of TB lesion. Supplemental surgical interventions can be considered when the symptoms are not relieved after chemotherapy. Lifespan follow-up is recommended due to high relapse rate.

Urine metabolic phenotyping in children with nocturnal enuresis and comorbid neurobehavioral disorders.

Nocturnal enuresis (NE) is a common problem among 10% school-aged children. The etiologies underlying childhood NE is complex and not fully understood nowadays. Nevertheless, increasing evidence suggests a potential link between neurobehavioral disorders and enuresis in children. In this study, we aimed to explore novel metabolomic insights into the pathophysiology of NE and also, its association with pediatric psychiatric problems. Urine collected from 41 bedwetting children and 27 healthy control children was analyzed by using 1H-nuclear magnetic resonance spectroscopy from August 2017 to December 2018. At regular follow-up, there were 14 children with refractory NE having a diagnosis of attention deficient hyperactivity disorder (ADHD) or anxiety. Eventually, we identified eight significantly differential urinary metabolites and particularly increased urinary excretion of betaine, creatine and guanidinoacetate linked to glycine, serine and threonine metabolism were associated with a comorbidity of neurobehavioral disorders in refractory bedwetting children. Notably, based on physiological functions of betaine acting as a renal osmolyte and methyl group donor, we speculated its potential role in modulation of renal and/or central circadian clock systems, becoming a useful urinary metabolic marker in diagnosis of treatment-resistant NE in children affected by these two disorders.

Endoscopic Treatment for Post-Transplant Vesicoureteral Reflux.

INTRODUCTION: Vesicoureteral reflux (VUR) is one of the most common ureteric complications after kidney transplantation that might cause symptomatic infections which deteriorate graft function. Surgical reimplantation has been the standard treatment; recently, endoscopic injection has been an alternative approach. We report our endoscopic treatment results and analyze the long-term outcome, even in patients with less optimal graft function. MATERIALS AND METHODS: A total of 16 patients and 19 symptomatic VUR were diagnosed at mean time of 88.3 months after their transplantation. The distribution of VUR grade was 1, 2, 8, 6, and 2 for grade I to V, respectively, with a mean VUR grade of 3.26 according to their voiding cystourethrogram images. Endoscopic Deflux injections were performed by a single urologist via rigid cystoscope with a beveled needle system. They were followed monthly thereafter. RESULT: The average number of admissions due to symptomatic urinary tract infection was 2.68/person, and the mean creatinine level before endoscopic treatment was 1.63 mg/dL. The amount of Deflux injection was 0.7 to 1.2 mL per affected ureter; the mean creatinine level after endoscopic treatment was 1.41 mg/dL. The eGFR remained stationary in both eGFR > 60 and eGFR < 60 mL/min groups with a clinical success rate of 75% in both groups. CONCLUSION: Endoscopic dextranomer-hyaluronic acid injection is a safe and feasible treatment option for VUR after kidney transplantation. Our data showed its efficacy in recipients whose eGFR is less than 60 mL/min.

Management of nocturnal enuresis in Taiwan: Consensus statements of the Taiwan enuresis expert committee.

Nocturnal enuresis causes significant psychological distress to affected children and their family and requires appropriate management. A 12-member expert committee of pediatric urologists and pediatric nephrologists in Taiwan with extensive experience in treating enuresis was established to develop consensus statements and a recommended treatment algorithm for the management of patients with nocturnal enuresis in Taiwan after careful consideration of current evidence, existing guidelines, and expert opinion as well as local practice and culture. The finalized consensus statements were reviewed by and have received endorsement from the Taiwan Urological Association and the Taiwan Pediatric Association. Patients with suspected enuresis should undergo a thorough initial assessment to fully evaluate urinary signs and symptoms and to rule out underlying causes of diurnal and nocturnal incontinence. Behavioral therapy is recommended throughout the course of management. Desmopressin in the fast-melting formulation is the recommended first-line pharmacological treatment. Combination therapy may be effective in patients who have failed first-line treatment. These consensus statements and a recommended treatment algorithm were created by the expert committee to provide practical support for clinical decision making by physicians in Taiwan.

The impact of climate factors on the prevalence of urolithiasis in Northern Taiwan.

BACKGROUND: Urolithiasis is a common disease with high prevalence and recurrence. Its incidence varies in different geographic locations, and there are evidences that meteorological factors also affect urinary stone formation. The aim of this study is to analyze the effects of climate parameters on the numbers of shockwave treatments for urinary stones in our hospital, in order to understand the effects of these parameters on the prevalence of urolithiasis in northern Taiwan. METHODS: We retrospectively reviewed the records of extracorporeal shockwave lithotripsy (ESWL) performed in our hospital from December 2006 to November 2011. Repeated ESWL performed in the same patient within 1 month was excluded, and we only counted as one ESWL in our study. Climate data of the corresponding months were collected from Central Weather Bureau. The available monthly meteorological data included highest, lowest, and average temperatures, humidity, rainfall, total rain days, sunshine hours, average atmospheric pressure, and wind speed. RESULTS: Monthly ESWL number was positively correlated to temperature (r = 0.696), sunshine hours (r = 0.515), and wind speed (r = 0.369), while it was negatively correlated to humidity (r = -0.441) and atmospheric pressure (r = -0.568). Average monthly temperature had the strongest correlation to ESWL number (r2 = 0.484). Monthly rainfall and rain days were not significantly correlated to ESWL number. To investigate the climate parameters together, we introduced these correlated factors into the multivariate linear regression model which demonstrated only temperature (ß = 1.438, 95% CI: 3.703-9.144, p < 0.001) and atmospheric pressure (ß = 0.803, 95% CI: 0.790-5.428, p = 0.010) to be independently related to monthly ESWL number. CONCLUSION: Temperature and atmospheric pressure are associated with monthly ESWL number. Ambient temperature is the most important climate factor affecting the prevalence of urolithiasis in northern Taiwan.

Temporary vesicostomy-assisted urethroplasty for recurrent obliterated posterior urethral stricture.

BACKGROUND: We report the outcomes of temporary vesicostomy- assisted anastomotic urethroplasty in patients with recurrent obliterated posterior urethral stricture. METHODS: A review of the medical records identified 12 men (mean age 35.8 years) who had undergone anastomotic urethroplasty for recurrent obliterated posterior stricture. Preoperative evaluation of the urethral defect included a simultaneous retrograde urethrogram and cystogram. The mean estimated preoperative radiographic length of the urethral disruption was 4.25 cm. All patients underwent 1-stage bulboprostatic anastomotic repair which was assisted by an intraoperative temporary vesicostomy. RESULTS: The initial objective success rate was 83%. The mean follow-up was 22 months. Voiding cystourethrography performed postoperatively demonstrated a wide, patent anastomosis in all but two cases. Urethroscopy performed 1 month after surgery revealed a patent anastomosis with normal urethral mucosa in all but two patients. The mean peak flow rate at the last follow-up visit was 16.3 ml/s. Two patients developed an anastomotic stricture 6 weeks after surgery that was successfully treated by direct visual internal urethrotomy. Finally, all patients had a patent urethra after salvage treatment postoperatively. CONCLUSION: An open 1-stage temporary vesicostomy- assisted urethroplasty for recurrent obliterated posterior urethral stricture provides satisfactory outcomes and minimal morbidities.

Indirubin, an acting component of indigo naturalis, inhibits EGFR activation and EGF-induced CDC25B gene expression in epidermal keratinocytes.

BACKGROUND: Topical indigo naturalis ointment is clinically proved to be an effective therapy for plaque-type psoriasis. Indirubin, as the active component of indigo naturalis, inhibits cell proliferation of epidermal keratinocytes. However, the detailed underlying mechanism is not fully understood. OBJECTIVE: To further investigate the anti-proliferating effects of indigo naturalis and indirubin on epidermal keratinocytes. METHODS: The decreased expression of CDC25B in indigo naturalis- or indirubin-treated epidermal keratinocytes, as revealed by cDNA microarray analysis, was studied. The CDC25B expression was examined under different serum concentrations and compared between primary and immortalized keratinocytes. The activation of EGFR and the effect of EGF on the cell proliferation and CDC25B expression were also investigated in epidermal keratinocytes. RT/real-time PCR and western blot method were used to analyze the CDC25B expression at the mRNA and protein levels, respectively. RESULTS: Indigo naturalis and indirubin were confirmed to down-regulate CDC25B expression significantly at both the mRNA and protein levels. The growth-dependent expression of CDC25B was demonstrated by the increased expression in serum-stimulated and immortalized keratinocytes. The activation of EGF receptor, known to be highly expressed in psoriatic lesions, was inhibited by indigo naturalis or indirubin. The cell proliferation and CDC25B expression of epidermal keratinocytes were induced by EGF alone and confirmed to be inhibited by indigo naturalis or indirubin. CONCLUSION: Except being a common therapeutic target in various cancers, CDC25B also plays an important role in the hyper-proliferation of epidermal keratinocytes which can be suppressed by anti-psoriatic drug indigo naturalis and its component, indirubin.

The dilemma in the diagnosis of acute scrotum: clinical clues for differentiating between testicular torsion and epididymo-orchitis.

BACKGROUND: Acute painful scrotum is one of the most challenging urological emergencies. Irreversible parenchymal damage will develop if a testicle is twisted. The aim of the study was to determine the importance of different clinical clues to help differentiate the causes of this devastating condition. METHODS: The medical charts of teenagers with acute scrotal pain between January 2003 and December 2008 were reviewed retrospectively. RESULTS: Seventy-six patients were included in this study, including 47 initially suspected of having testicular torsion and 29 suspected of having epididymo-orchitis. Testicular torsion was confirmed in 39 of the suspected 47 cases after surgical exploration. Twnety-one of these 39 testicular torsion patients underwent orchiectomy, and 18 were rescued and underwent orchiopexy. The mean pain duration was significantly longer in the orchiectomy group than the orchiopexy group (38.05 hours vs 14.14 hours, p = 0.009). In the testicular torsion group, fewer patients had elevated C-reactive protein levels no patients had pyuria, and the pain duration was shorter compared with the epididymo-orchitis group (5/11 vs 13/22 [p = 0.045], 0/28 vs 8/28 [p = 0.004] and 27.0 vs 74.5 hours [p = 0.0003], respectively). The sensitivity of color Dopper ultrasound in diagnosing testicular torsion and epididymo-orchitis was 84.09% vs 92.59%. Logistic regression for multivariate analysis showed that left side manifestation and pain duration were significantly different between testicular torsion and epididymo-orchitis with odds ratios of 4.76, p = 0.020 and 0.98, p = 0.029, respectively. CONCLUSIONS: Pain duration and left side manifestation are independent risk factors of testicular torsion. Prompt surgical exploration should be done if testicular torsion is highly suspected.

Waist circumference is an independent risk factor for prostatic hyperplasia in Taiwanese males.

PURPOSE: Benign prostatic hyperplasia is a common disease affecting older males. As obesity becomes an increasing problem worldwide, its role in prostatic hypertrophy has been discussed recently. The purpose of this study is to evaluate the relationship between waist circumferences and prostatic hyperplasia in Taiwan. METHODS: There were 539 men enrolled in the study who had health examinations at the Healthcare Center of Chang Gung Memorial Hospital; 53 were excluded because of history of conditions affecting prostatic volume. Their anthropometry was measured and serum prostate-specific antigen (PSA) levels as well as lipid profiles were analyzed. Prostate volume was measured by transrectal ultrasonography performed by experienced urologists. RESULTS: The mean prostate volume was 26.43 mL, whereas mean body mass index (BMI) was 25.27 kg/m(2) and mean waist circumference (WC) was 90.81 cm. By age-adjusted logistic regression, PSA > 4 ng/mL, WC ≥ 90 cm, and BMI > 24 kg/m(2) are associated with increased risk of developing prostatic hyperplasia; only WC ≥ 90 cm can be validated by multiple logistic regression. Further analysis of obesity patterns showed that abdominal overweight/obesity places patients at increased risk independently rather than high WC or high BMI alone. CONCLUSIONS: Study results showed that waist circumference ≥ 90 cm is an independent risk factor of prostatic hyperplasia in Taiwan. Men with abdominal overweight/obesity (WC ≥ 90 cm and BMI > 24 kg/m(2)) have a twofold risk of developing prostatic hyperplasia.

A simplified preputial covering technique to correct buried penis.

OBJECTIVE: We report on refinements of a technique for preputial covering to prevent complications of redundant prepuce, possibly caused by inadequate surgery for buried penis. PATIENTS AND METHODS: From July 2006 to July 2008, 20 consecutive patients (mean age 4.3 years) underwent surgery for buried penis. The surgical techniques consisted of complete unfurling of the penile shaft, fixation of the penile base skin to Buck's fascia and 1 pedicle flap for skin coverage. Our method for preputial covering is novel in that we create a unique 1-flap covering for the ventral skin defect. Patients were monitored postoperatively at 2 weeks, 1 month and 3 months. RESULTS: All patients had good or excellent outcomes, with fewer postoperative complications. Two patients developed subcutaneous hematomas that resolved in 2 weeks with conservative treatment. The mean increase in length of penile projection after surgery was 1.7 cm, a statistically significant difference. All patients had good cosmetic results, with increased visualization of the penile shaft. CONCLUSIONS: The preputial covering technique we devised avoided postoperative bulky prepuce caused by residual redundant prepuce. Repeat surgery was also unnecessary for our patients. Furthermore, parents judged the cosmetic results as excellent.

Clinical features of testicular torsion and epididymo-orchitis in infants younger than 3 months.

BACKGROUND/PURPOSE: Testicular torsion (TT) and orchitis/epididymo-orchitis (EO) are confusing and difficult for physicians to diagnose in infants younger than 3 months. The aim of the study was to delineate the etiology and the clinical features of TT and EO in this age group. METHODS: During the period between April 1994 and September 2004, medical charts of infants younger than 3 months with TT and EO were reviewed retrospectively. RESULTS: Sixteen patients were eligible for the study, including 9 with TT and 7 with orchitis/EO. Two infants had postnatal torsion, and the testicles were salvaged by emergent surgery. Eighty-six percent (6/7) of infants with EO/orchitis had either abnormal physical signs (fever or scrotal tenderness) or abnormal laboratory findings (leukocytosis or elevated C-reactive protein level). The sensitivity of color Doppler ultrasound to diagnose TT and EO/orchitis was 88% (7/8) and 100% (6/6), respectively. All infants (6/6) with EO/orchitis who were checked for urinary tract infection and sepsis had positive test results. CONCLUSIONS: Pediatricians should examine the testicles meticulously after a baby is born. Orchitis/EO is highly suspected for patients associated with abnormal physical signs and laboratory findings. Prompt prescription of antibiotics is mandatory to avoid serious sequelae.

Early-onset Escherichia coli sepsis presenting as acute scrotum in preterm infant.

Epididymitis, or epididymo-orchitis, and infected hydrocele are unusual in the neonatal period. It is critical to differentiate them rapidly from testicular torsion to salvage the affected testis and avoid unnecessary surgical exploration. Escherichia coli is an important gram-negative bacteria causing diverse neonatal infections and is also the common bacteria causing epididymo-orchitis from an ascending route. We report the case of a preterm infant affected with epididymo-orchitis and infected hydrocele caused by early-onset E. coli sepsis. We highlight the importance of sampling proper cultures and using suitable antibiotics after excluding testicular torsion in a neonate with an acute scrotum.

Combined surgery for intra-abdominal extra-urinary lesions in patients with renal and/or ureteral malignancies.

BACKGROUND: The standard treatment for patients with renal and/or ureteral malignancies is radical nephrectomy or nephroureterectomy. Frequently, intra-abdominal extra-urinary lesions are noted preoperatively or intra-operatively in the gastrointestinal or gynecologic tract. We reviewed our experience with patients during an 11-year period. METHODS: From 1991 through 2001, 1059 patients underwent radical operations for renal and/or ureteral malignancies. Of these, 37 patients had simultaneous intra-abdominal extra-urinary lesions preoperatively or intra-operatively and underwent surgery for these lesions at the same time as nephrectomy or nephroureterectomy. These patients were designated as group A and were compared with group B patients who underwent only radical urological surgery. RESULTS: The distributions of age, gender, preoperative evaluations, and histology did not differ significantly between the groups. The most common intra-abdominal extra-urinary lesion was located in the gall bladder (51.4%). Although the patients with intra-abdominal extra-urinary lesions tended to have greater intra-operative blood loss (p = 0.8621), longer postoperative hospital stays (p = 0.3414), and higher complication rates (p = 0.208) than those who did not, the differences were not significant. CONCLUSIONS: Given radical operations for renal and/or ureteral malignancies, synchronous surgery for intra-abdominal extra-urinary lesions is feasible and safe with thorough postoperative care.

The role of diuretic renography in the evaluation of obstructed hydronephrosis after pediatric pyeloplasty.

BACKGROUND: The purpose of this study was to clarify the value of renal drainage half-time in the evaluation of pediatric hydronephrosis after dismembered pyeloplasty. METHODS: We reviewed the records of 30 children who underwent dismembered pyeloplasty for unilateral ureteropelvic junction obstruction with no other associated urological abnormality. The follow-up duration was more than 5 years for all patients. Pre- and postoperative evaluation included technetium-99m dimercaptosuccinic acid (99mTc-DMSA) renal scan, technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) diuretic renography, and ultrasonographic examination. According to postoperative renal drainage half-time on diuretic renography, patients were divided into 2 groups: group A with normal renal drainage and group B with prolonged renal drainage for evaluation of their renal functional status. RESULTS: Postoperative diuretic renography revealed normal drainage (group A) in 54% of patients and prolonged drainage (group B) in 46%. The anteroposterior diameter (APD) of the renal pelvis of all patients showed improvement after pyeloplasty. There was no significant difference in improvement of the renal pelvic APD between the 2 groups. Furthermore, 92% of group A and 91% of group B maintained stable or had improved differential renal function (DRF) postoperatively. CONCLUSIONS: Drainage half-time is not a reliable parameter for diagnosing obstructed hydronephrosis after pediatric pyeloplasty. We suggest that the renal pelvic APD and DRF should be considered when postoperative obstructed hydronephrosis is diagnosed using the criterion of prolonged renal drainage half-time on diuretic renography.