The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging

ABSTRACT Introduction and objective To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP). Materials and Methods From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP. Results The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin. Conclusions The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.

The association between the outcomes of extraperitoneal laparoscopic radical prostatectomy and the anthropometric measurements of the prostate by magnetic resonance imaging.

INTRODUCTION AND OBJECTIVE: To determine the association between the anthropometric measurements by magnetic resonance imaging (MRI) and perioperative outcomes of extraperitoneal laparoscopic radical prostatectomy (ELRP). MATERIALS AND METHODS: From 2008 to June 2016, 86 patients underwent preoperative MRI prior to undergoing ELRP for localized prostate cancer. We analyzed the associations between anthropometric measurements of MRI and the perioperative outcomes of patients who underwent ELRP. RESULTS: The mean patient age was 69.61±8.30 years. The medians of operating time and blood loss were 2.30 hours and 725.30ml, respectively. The total post-surgical complication rate was 1.16%. The median hospital stay was 6.50 days. The pathological stages for T2 and T3 were 45.74% and 34.04%, respectively. The rate as positive surgical margins (PSMs) was 18.09% (pT2 and pT3; 6.38% and 9.57%). The angles between pubic bone and prostate gland (angle 1&2), were significantly associated with operative time and hospital stay, respectively (p<0.05). There was no correlation between the pelvimetry and positive surgical margin. CONCLUSIONS: The findings of the present study suggest that anthropometric measurements of the MRI are related to operative difficulties in ELRP. This study confirmed that MRI planning is the key to preventing complications in ELRP.

Effects of 8-Year Treatment of Long-Acting Testosterone Undecanoate on Metabolic Parameters, Urinary Symptoms, Bone Mineral Density, and Sexual Function in Men With Late-Onset Hypogonadism.

INTRODUCTION: The long-term effects of long-acting testosterone undecanoate (TU) and androgen receptor CAG repeat lengths in Thai men with late-onset hypogonadism (LOH) have not been reported. AIM: To analyze the 8-year follow-up effects of intramuscular TU therapy on metabolic parameters, urinary symptoms, bone mineral density, and sexual function and investigate CAG repeat lengths in men with LOH. METHODS: We reviewed the medical records of 428 men with LOH who had been treated with TU and 5 patients were diagnosed with prostate cancer during TU therapy. There were 120 patients (mean age = 65.6 ± 8.9 years) who had 5 to 8 years of continuous TU supplementation and sufficiently completed records for analysis. Genomic DNA was extracted from peripheral blood and the CAG repeat region was amplified by polymerase chain reaction. Fragment analysis, sequencing, electropherography, and chromatography were performed. MAIN OUTCOME MEASURES: The main outcome measure was dynamic parameter changes during testosterone supplementation. RESULTS: TU did not improve all obesity parameters. A statistically significant decrease was found in waist circumference, percentage of body fat, glycated hemoglobin, cholesterol, low-density lipoprotein, and International Prostate Symptom Score (P < .05). TU did not produce differences in body mass index, high-density lipoprotein, triglyceride, or the Aging Male Symptoms score from baseline. However, a statistically significant increase was found in the level of testosterone, prostate-specific antigen, hematocrit, International Index of Erectile Function score, and vertebral and femoral bone mineral density (P < .05). No major adverse cardiovascular events or prostate cancer occurred during this study. The CAG repeat length was 14 to 28 and the median CAG length was 22. There was no association between CAG repeat length and any of the anthropometric measurements. CONCLUSION: Long-term TU treatment in men with LOH for up to 8 years appears to be safe, tolerable, and effective in correcting obesity parameters.

Transrectal ultrasound (TRUS) findings of the prostate gland in late onset hypogonadism with testosterone supplementation in correlation with clinical outcome.

OBJECTIVE: To determine the TRUS findings of the prostate and correlation of ultrasoundfindings with clinical outcomes in late-onset hypogonadal (LOH) men with testosterone supplementation. MATERIAL AND METHOD: Between January 2007 and September 2010, TRUS findings and clinical outcomes of 16 from 226 subjects were studied The demographic data, ultrasound parameters as prostate volume and vascularity, and clinical parameters were evaluated Correlation between ultrasound and clinical parameters were analyzed using Pearson correlation analysis. RESULTS: During mean time follow-up of 6.48 months, the volume of the central gland (CG) significantly increased (p = 0.02), the volume of the total gland (TG) increased, and the volume of the peripheral zone (PZ) slightly decreased. The vascularity of the TG, CG, and PZ were significantly increased. The periurethral region vascularity was not significantly increased (p = 0.06), whereas total serum testosterone, prostate specific antigen (PSA), and PSA density were increased The International Prostate Symptom Score (IPSS) was significantly decreased (p < 0.001). There was a significant correlation between increased prostate volume and increased serum PSA. CONCLUSION: Testosterone supplementation in LOH men was found to cause an increase in TG volume during the first six months. The preferentially increased CG volume and prostatic vascularity might be due to exogenous testosterone. The authors observed a significantly increased PSA with a strong correlation between serum PSA and prostate volume.

Laparoendoscopic single-site nephrectomy for patients with dialysis-dependent end stage renal disease.

OBJECTIVE: Assess the feasibility, safety, and outcome of laparoendoscpic single-site (LESS) nephrectomy in high-risk patients with end-stage renal disease (ESRD), who have undergone continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD) treatment. MATERIAL AND METHOD: Between October 2009 and January 2010, a 62-year-old female and a 36-year-old male that had undergone CAPD and HD, respectively, consecutively underwent LESS nephrectomies. The medical records of the two patients were retrospectively reviewed. The indications for nephrectomy were that the non-functioning kidney was associated with a ureteric stone and distal ureteric stricture, respectively. Parameters examined were patient demographics, medical co-morbidities, operative outcomes, and complications. RESULTS: All procedures were completed successfully via transumbilical LESS laparoscopy. The operative times were 160 and 200 minutes, blood loss 200 and 50 mL, and postoperative hospital stay 6 and 14 days, respectively. No intraoperative complications were reported. The first patient who used CAPD before LESS nephrectomy for whom CAPD was successfully reinstated within two weeks postoperatively. No other catheter-related complications occurred. The second patient required a reoperation to evaluate the active bleeding on the fifth post-operative day, but could not find any blood vessel injuries. The bleeding was stopped from the platelet replacement. Pathological evaluation revealed chronic glomerulonephritis in each case. CONCLUSION: Less nephrectomy is a feasible technique with the advantages of less pain, shortened convalescence, improved cosmesis, and absence of wound complications.

The efficacy and safety of oral Tamsulosin controlled absorption system (OCAS) for the treatment of lower urinary tract symptoms due to bladder outlet obstruction associated with benign prostatic hyperplasia: an open-label preliminary study.

AIMS: Tamsulosin, a superselective subtype alpha 1a and 1d blocker, is used for the treatment of male lower urinary tract symptoms (LUTS) commonly caused by benign prostatic hyperplasia (BPH). This prospective study evaluated the efficacy and safety of a new formulation, Tamsulosin OCAS® (Oral Controlled Absorption System), for LUTS associated with BPH in Thai patients. MATERIALS AND METHODS: Fifty one patients over 40 years old with complaints of LUTS associated with BPH were recruited. Patients received an 8 week course of once daily 0.4 mg tamsulosin OCAS®, and were followed up at 2 (visit 3), 4 (visit 4) and 8 (visit 5) weeks post-treatment. At each visit, patients were assessed using the International Prostate Symptom Score (IPSS), Nocturia Quality of Life (N-QoL) Questionnaire, QoL Assessment Index (IPSS-QoL), and International Index of Erectile Function (IIEF). The primary outcome was efficacy of Tamsulosin. The secondary outcomes included change in the mean number of nocturia episodes, hours of undisturbed sleep (HUS) and uroflowmetry measurements. RESULTS: Total IPSS significantly decreased at week 8 from baseline (from 19.52 to 6.08; p < 0.001). Similarly, the voiding and storage subscores of IPSS also continued to improve significantly starting from the second and third visits, respectively (p < 0.001 versus baseline). The IPSS-QoL and N-QoL scores significantly improved at visit 3 through end of study. In addition, we observed significant nocturia and HUS improvement in their last clinic visit. Uroflowmetry parameters, Qmax and Qave, improved significantly at 3rd clinic visit. Three patients experienced mild dizziness. CONCLUSION: Tamsulosin OCAS® treatment led to significant improvements in LUTS, HUS and QoL in Thai patients with bladder outlet obstruction from BPH with few side effects.

The efficacy and safety of oral Tamsulosin controlled absorption system (OCAS) for the treatment of lower urinary tract symptoms due to bladder outlet obstruction associated with benign prostatic hyperplasia: an open-label preliminary study

AIMS: Tamsulosin, a superselective subtype alpha 1a and 1d blocker, is used for the treatment of male lower urinary tract symptoms (LUTS) commonly caused by benign prostatic hyperplasia (BPH). This prospective study evaluated the efficacy and safety of a new formulation, Tamsulosin OCAS® (Oral Controlled Absorption System), for LUTS associated with BPH in Thai patients. MATERIALS AND METHODS: Fifty one patients over 40 years old with complaints of LUTS associated with BPH were recruited. Patients received an 8 week course of once daily 0.4 mg tamsulosin OCAS®, and were followed up at 2 (visit 3), 4 (visit 4) and 8 (visit 5) weeks post-treatment. At each visit, patients were assessed using the International Prostate Symptom Score (IPSS), Nocturia Quality of Life (N-QoL) Questionnaire, QoL Assessment Index (IPSS-QoL), and International Index of Erectile Function (IIEF). The primary outcome was efficacy of Tamsulosin. The secondary outcomes included change in the mean number of nocturia episodes, hours of undisturbed sleep (HUS) and uroflowmetry measurements. RESULTS: Total IPSS significantly decreased at week 8 from baseline (from 19.52 to 6.08; p < 0.001). Similarly, the voiding and storage subscores of IPSS also continued to improve significantly starting from the second and third visits, respectively (p < 0.001 versus baseline). The IPSS-QoL and N-QoL scores significantly improved at visit 3 through end of study. In addition, we observed significant nocturia and HUS improvement in their last clinic visit. Uroflowmetry parameters, Qmax and Qave, improved significantly at 3rd clinic visit . Three patients experienced mild dizziness. CONCLUSION: Tamsulosin OCAS® treatment led to significant improvements in LUTS, HUS and QoL in Thai patients with bladder outlet obstruction from BPH with few side effects.

Treatment with a uroselective α1-blocker improves voiding and sexual function: a study in Thai men with lower urinary tract symptoms.

INTRODUCTION: Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) negatively affect quality of life. The α1-blockers are effective for LUTS suggestive of benign prostatic hypertrophy. AIM: To analyze the effect of a uroselective α1-blocker on both voiding and sexual dysfunction in Thai men with LUTS. METHODS: Of 488 men with LUTS who received 10 mg alfuzosin monotherapy once daily (OD) at a men's health clinic, 313 men (64%) completed 8 months of alfuzosin treatment and filled the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function (IIEF)-5 questionnaires. MAIN OUTCOME MEASURE: The relationships among the IPSS, IIEF-5 score, and select clinical characteristics were analyzed using multiple regression analysis. To identify changes from the baseline, the chi-square or Fisher's exact test was used for categorical or dichotomous variables and a paired Student's t-test was used for continuous variables. RESULTS: The 313 men were followed up for a mean (standard deviation [SD]) of 35.6 (2.2) weeks. LUTS were categorized by IPSS as moderate in 100 patients (31.9%) and severe in 213 patients (68.1%). ED was graded according to the IIEF-5 as normal in 46 patients (14.7%), mild in 29 patients (9.3%), mild to moderate in 81 patients (25.9%), moderate in 47 patients (15.0%), and severe in 110 patients (35.1%). ED is associated with LUTS (P=0.008). After 8 months of alfuzosin treatment, the mean (SD) IPSS and IIEF-5 score significantly improved from 19.95 (6.4) to 11.13 (4.6) (P<0.001) and from 11.5 (6.9) to 14.9 (5.7) (P<0.001), respectively. However, the IIEF-5 score did not improve significantly in patients with severe LUTS as determined using the IPSS. The most common adverse event with alfuzosin treatment was mild (dizziness, 2.2%). CONCLUSION: Treatment with 10 mg alfuzosin OD is safe and effective in improving voiding and sexual function in Thai men with LUTS and ED.

Iatrogenic disease in the elderly: risk factors, consequences, and prevention.

The epidemiology of iatrogenic disease in the elderly has not been extensively reported. Risk factors of iatrogenic disease in the elderly are drug-induced iatrogenic disease, multiple chronic diseases, multiple physicians, hospitalization, and medical or surgical procedures. Iatrogenic disease can have a great psychomotor impact and important social consequences. To identify patients at high risk is the first step in prevention as most of the iatrogenic diseases are preventable. Interventions that can prevent iatrogenic complications include specific interventions, the use of a geriatric interdisciplinary team, pharmacist consultation and acute care for the elderly units.

Laparo-endoscopic single site (LESS) management of benign kidney diseases: evaluation of complications.

BACKGROUND: To present our experience with Laparo-Endoscopic Single Site (LESS) management of benign kidney diseases. MATERIAL AND METHOD: Between September 2008 and November 2009, 18 patients underwent single port transumbilical laparoscopic surgery for nephrectomy for a nonfunctioning kidney (7 cases), cyst decortications for symptomatic renal cyst (10 cases), and redo-dismembered pyeloplasty with previously failed laparoscopic surgical repair (1 case). Patients underwent surgery through a single 2-cm infraumbilical incision with the triport laparoscopic-port. All pathological reports of LESS nephrectomy and cyst decortications confirmed with chronic pyelonephritis and simple cysts, respectively Histology of xanthogranulomotus pyelonephritis showed two cases of the nephrectomy procedure. RESULTS: Mean patient age and BMI were 61 +/- SD 14.2 years and 24.75 +/- SD 11.2 kg/m2, respectively Mean operating time was 187.7 +/- SD 71.4 min. LESS was a possible and safe approach in 77.8% of patients. All LESS cyst decortications and redo-pyeloplasty were completed without major complications or conversion to open surgery. However, there was one case each of LESS cyst decortication and pyeloplasty requiring an additional 3-mm port for suturing due to bleeding and an instrument error. For LESS nephrectomy, two (28.6%) with higher waist circumference were converted to standard laparoscopic nephrectomy due to failure to progress. One post operative complication of incisional hernia occurred in a patient with chronic bronchitis and asthma. CONCLUSION: LESS for the management of benign kidney diseases is an effective and safe treatment option with selected patients and experienced surgeon.

Predictors of hemorrhage after laparoscopic partial nephrectomy.

OBJECTIVES: To identify risk factors associated with hemorrhage during laparoscopic partial nephrectomy (LPN), and to determine the impact of hemorrhage on hospital course. METHODS: We retrospectively analyzed prospective data from 335 LPNs to identify clinicopathologic factors associated with hemorrhagic complications (blood loss requiring ≥ 1 U transfusion) and extended length of hospitalization (≥ 3 days). We excluded patients with a coagulopathy or perioperative vascular injuries. RESULTS: We identified 23 patients (7%) undergoing LPN with hemorrhagic complications (group 1 and 312 patients (93%) without complications (group 2). Mean age was 64.1 ± 14.4 vs 57.6 ± 12.7(P = .006), American Society of Anesthesiologists (ASA) score ≥ 3 seen in 61% vs 37% (P = .02), mean tumor size (cm) was 2.90 ± 2.02 vs 2.59 ± 1.15 (P = .93), mean total operative time (min) was 250.1 ± 116.1 vs 191.8 ± 69.2 (P = 0.006), and mean hospital stay (days) was 4.7 ± 3.4 vs 3.1 ± 3.0 (P = .0002), for groups 1 and 2, respectively. Hypertension, diabetes mellitus, chronic renal insufficiency, obesity, smoking, and coronary artery disease-congestive heart failure were present in group 1 vs group 2: 39.1% vs 31.4% (P = .4), 17.4% vs 8% (P = .12), 8.7% vs 1.9% (P = .09), 4.3% vs 3.5% (P = .57), 17.4% vs 5.4% (P = .04), and 8.7% vs 2.2% (P = .11), respectively. On multivariate analysis, smoking (P < .0437) and ASA score ≥ 3 (P < .0233) were associated with hemorrhagic complications. Hemorrhagic complications were 3.5 times more likely in smokers than nonsmokers (95% confidence interval, 1.0-11.7), and 2.9 times more likely with an ASA class ≥ 3. Only age (P < .0002) and operative time (P < .0001) were associated with longer hospitalization. CONCLUSIONS: High ASA scores and smoking are risk factors for hemorrhagic complications during LPN. Hemorrhagic complications did not significantly affect hospitalization length.

Treatment of 161 men with symptomatic late onset hypogonadism with long-acting parenteral testosterone undecanoate: effects on body composition, lipids, and psychosexual complaints.

INTRODUCTION: Elderly men may suffer from late-onset hypogonadism (LOH). The long-term effects of long-acting testosterone undecanoate (TU) in a large number of LOH men have not yet been reported. Aims. We analyzed the effects of normalization of plasma testosterone (T) in LOH men. METHODS: The records of 161 men with LOH (baseline T<300 ng/dL) were reviewed and 100 men had used parenteral TU for >12 months. The mean duration of treatment was 90.6 weeks (54 to 150 weeks). MAIN OUTCOME MEASURES: Body mass index (BMI), waist circumference, percentage body fat, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, prostate-specific antigen (PSA), and hematocrit were measured. Further the Aging Male Symptoms' scale (AMS) and the International Index of Erectile Function (IIEF-5 and 15) were scored. RESULTS: T therapy was associated with a significant decline in waist circumference (P=0.028) and percentage body fat (P<0.001), but no change of BMI. Total cholesterol and LDL cholesterol declined significantly (P=0.005 and P=0.024, respectively), with no significant changes of HDL cholesterol and triglycerides. The scores of sub-scales of AMS (psychological, somotovegetative and sexual factors) decreased (P=0.044, P=0.200 and P=0.071, respectively). The mean IIEF-5 (P=0.011) and IIEF-15 scores (P=0.021) improved significantly. Erectile function domain, orgasmic function domain, sexual desire domain, intercourse satisfaction domain, and overall satisfaction domain improved. Median PSA rose from 0.95 (0.640; 1.558) ng/mL to 1.480 (1.015; 2.275) ng/mL (P<0.001), with 11 patients >4 ng/mL (4.01-13.21). On biopsy there was no evidence for malignancy. The mean hematocrit level increased significantly from 42.3±3.4% to 47.1±3.8%. CONCLUSIONS: Normalizing serum T in men with LOH resulted in improvement of the metabolic syndrome, mood and sexual functions and appeared acceptably safe.

Sexuality and management of benign prostatic hyperplasia with alfuzosin: SAMBA Thailand.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a common condition among elderly men. The aim of therapy is to improve lower urinary tract symptoms (LUTS) and quality of life (QoL) and to prevent complications. AIM: The primary objective was to assess the effect on ejaculatory dysfunction (EjD) of 6 months treatment with alfuzosin (XATRAL) 10 mg once daily (OD) in men with LUTS suggestive of BPH in Thailand. Secondary objectives were to evaluate the efficacy of alfuzosin on LUTS, bother score (International Prostate Symptom Score [IPSS] 8th question), erectile dysfunction (ED), onset of action, and tolerability. METHODS: Overall, 99 men with moderate to severe LUTS suggestive of BPH (mean IPSS 18.9, bother score 4.3) were enrolled in an open-label study. Sexual function was evaluated at baseline and after 6 months treatment, using the International Index of Erectile Function-5 and the Male Sexual Health Questionnaire (MSHQ) ejaculation score, a new validated questionnaire assessing seven EjD symptoms. MAIN OUTCOME MEASURE: The main outcome measure is mean change from baseline to the end of treatment in the MSHQ Ejaculation score. RESULTS: MHSQ ejaculation score significantly improved from 23.09 at baseline to 21.54 at 6 months (P=0.022). Overall, 70% of patients perceived an improvement in LUTS within 1 week (36.3% within 3 days). IPSS total score significantly improved from 18.93 at baseline to 9.59 at 6 months (P<0.001). IPSS voiding and irritative subscores also significantly improved. The percentage of patients with moderate or severe ED decreased from 35.3% at baseline to 21.8% at 6 months. Most adverse events were dizziness (3%) and orthostatic hypotension (1%) with minor intensity. No significant change in blood pressure and heart rate was observed. CONCLUSIONS: Alfuzosin 10 mg OD administered for 6 months provides a marked and rapid (within 1 week) improvement in LUTS and bother score while improving both ED and EjD.

Laparoscopic excision of urachal cysts in elderly men and woman following pregnancy.

BACKGROUND AND OBJECTIVE: Persistent urachus rarely presents in the aging male or during pregnancy. The authors report their experience with the laparoscopic excision of urachal cysts in two elderly men with significant co-morbidities and following pregnancy in a 32-year-old female. MATERIAL AND METHOD: The two male patients (65 and 70 years old, respectively) presented with a lower abdominal mass and umbilical discharge, while persistent urachus was identified incidentally during pregnancy; patients were managed with laparoscopic excision at 4 weeks, 6 weeks, and one year after diagnosis, respectively. Using 3 port accesses, the urachus and medial umbilical ligament were clipped and divided In 2 cases, specimens were separated from the bladder dome with a bladder cuff. In one patient, an additional port was required to facilitate intracorporeal freehand suturing of the bladder defect. RESULTS: All procedures were completed successfully via laparoscopy. No intraoperative or postoperative complications were reported Operative time ranged from 120, 180 and 160 minutes, respectively; in-hospital convalescence was 1, 7, and 6 days, respectively. Pathological evaluation revealed a benign urachal remnant in each case. CONCLUSION: Laparoscopic excision of urachal cysts in the aging male or following pregnancy is safe and effective.

Laparoscopic extravesical ureteral reimplantation for iatrogenic distal ureteral stricture.

OBJECTIVE: The authors describe their experience with laparoscopic extravesical neoureterocystostomy for iatrogenic distal ureteral stricture using a transperitoneal intracorporeal freehand suturing technique. MATERIAL AND METHOD: Three patients with distal ureteral strictures underwent laparoscopic transperitoneal extravesical ureteral reimplantation. A 77-year-old male underwent a Lich-Gregoir antireflux ureteral reimplantation following complications arising from transurethral resection of the prostate, and two females, aged 28 and 34 years, underwent refluxing ureteral reimplantation with concurrent psoas hitch after gynecologic surgery. The authors reviewed patient records to assess peri- and postoperative outcomes following definitive laparoscopic management of stricture segments. RESULTS: All procedures were completed entirely using a laparoscopic approach. No intra- or post-operative complications were reported. Operative times ranged between 180-250 minutes and mean blood loss was 50-150 ml. The mean time to restarting oral intake was 12 hours. Pathological evaluation confirmed benign lesions in each case and follow-up imaging confirmed satisfactory functional results. CONCLUSION: Laparoscopic extravesical neoureterocystostomy for iatrogenic distal ureteral strictures is a safe and efficacious procedure. Larger cohorts and longer-term results are required before this technique is considered first-line therapy in this patient group.

Renal subcapular saline injection during percutanoues renal cryoablation to prevent bowel injury.

INTRODUCTION: To evaluate the feasibility of percutaneous injection of saline in the renal subcapsular space to prevent bowel injury and histopathologic effects of bowel cryolesion during renal cryoablation in a porcine model. MATERIAL AND METHOD: Six pigs underwent percutaneous renal cryoablation with two freeze cycles in the lower pole of both kidneys. Six kidneys were injected with 10 ml saline into the renal subcapular space before cryoablation. The bowel was brought into contact with the edge of the ice ball with laparoscopic assistance during renal cryoablation, on the side with saline injection as well as on the control side. One of these animals was kept for survival follow-up and laparotomy for 7 days post cryoablation. The bowel cryolesion sites were observed and compared based on the presence or absence of renal subcapsular saline injection. RESULTS: The mean diameter of acute bowel injury with and without saline renal subcapsular injection was 7.25 +/- 1.26 and 14.5 +/- 0.58 mm, respectively. The influence of injecting a saline buffer was a significant decrease in the bowel cryolesion compared to controls (p = 0.0003). In addition, a pig kept for follow-up confirmed no bowel perforation after 7 days at a site that was cryolesioned on the side with renal subcapsular saline injection, but sustained bowel perforation in another segment lesioned by contact with a kidney without a saline injection. Gross and microscopic pathological examination was consistent with these interpretations. CONCLUSION: Preliminary results in a porcine model show that percutaneous renal subcapsular saline injection is a feasible and promising technique for preventing bowel complications of percutaneous image-guided renal cryoablation.

Laparoscopic ureteral reimplantation: technique and outcomes.

PURPOSE: We describe our experience with laparoscopic ureteral reimplantation in 45 adults, and report success rates and complications at intermediate term followup. MATERIALS AND METHODS: We performed a retrospective chart review of 45 patients who underwent laparoscopic ureteral reimplantation between 1997 and 2007. Demographics, clinicopathological parameters, perioperative course, complications and followup studies were analyzed. RESULTS: Elective laparoscopic ureteral reimplantation was performed in 35 female and 10 male patients with a mean followup of 24.1 months (range 1 to 76). All patients presented with distal ureteral stricture with a mean stricture length of 3 cm and a mean +/- SD preoperative serum creatinine of 0.91 +/- 0.04 mg/dl. Mean patient age was 47.8 +/- 2.2 years (range 17 to 87). Mean American Society of Anesthesiologists score was 2 (range 1 to 3). Median estimated blood loss was 150 ml. The overall success rate, defined as radiographic evidence of no residual obstruction, symptoms, renal deterioration or need for subsequent procedures, was 96%. Two patients had recurrent strictures and 1 underwent nephrectomy for flank pain and preexisting chronic pyelonephritis. CONCLUSIONS: According to intermediate followup data laparoscopic ureteral reimplantation can be performed with an excellent success rate and low morbidity. Our data substantiate this technique as an effective method for managing distal ureteral stricture.

Increased prevalence of erectile dysfunction (ED): results of the second epidemiological study on sexual activity and prevalence of ED in Thai males.

OBJECTIVE: The aim of this study is to investigate changes in sexual activity and the prevalence of erectile dysfunction (ED) in Thai males. In addition, the treatment-seeking behaviour of Thai patients suffering from ED is also investigated. MATERIALS AND METHODS: In a cross sectional study using a standardized questionnaire with a multi-stage stratified random sampling, 2,269 men aged 40-70 were interviewed. The questionnaire was designed to investigate the effects of socioeconomic factors, medical conditions and unhealthy lifestyles on the development of ED. Furthermore, the questionnaire was designed to characterize the treatment-seeking behaviour of Thai patients suffering from ED. RESULTS: Compared to the first report dated the year 2000, the prevalence of ED has increased from 37.5% to 42.18%. In terms of socioeconomic factors, the highest prevalence of ED was observed among unemployed men (78.51%). Prostatism and/or prostatitis (Odd ratios (OR) = 2.02) and long histories of smoking (more than 30 years, OR = 2.36) were identified as statistically significant risk factors for ED, with p-values of <0.001. It is important to notice that 38.78% of the ED patients wanted to discuss their problem with spouses or partners. Three quarters of the ED patients (74.54%) preferred oral medication as therapy. CONCLUSIONS: The epidemiology of ED in Thailand is changing. An increased prevalence of ED does require further epidemiological studies on a regular basis in order to better understand the etiology of ED and look for measures (such as education) to counter the disease.

Conversion during laparoscopic surgery: frequency, indications and risk factors.

PURPOSE: There are limited data on the indications for open conversion during laparoscopic surgery. The frequency of conversion for various procedures is poorly quantified and the degree to which this changes with time is not well understood. Risk factors for conversion are not defined. We addressed these issues in a large series of laparoscopic operations. MATERIALS AND METHODS: We reviewed our database of 2,128 laparoscopic operations performed between 1993 and 2005, including radical nephrectomy in 549 patients, simple nephrectomy in 186, partial nephrectomy in 347, donor nephrectomy in 553, pyeloplasty in 301, nephroureterectomy in 106 and retroperitoneal lymph node dissection in 86. Open conversions were identified and the frequency of conversion for the total cohort and specific procedures was determined. Trends in conversion with time were assessed and indications analyzed. Clinicopathological features between patients requiring conversion and those who did not were compared. RESULTS: We identified 68 patients (3.3%) who underwent conversion to open surgery (group 1) and 2,011 (96.7%) who did not (group 2). The frequency of conversion was greatest during nephroureterectomy (8.49%), followed by simple nephrectomy (5.91%), retroperitoneal lymph node dissection (4.65%), partial nephrectomy (4.32%), radical nephrectomy (2.91%), donor nephrectomy (2.53%) and pyeloplasty (0.33%). The absolute number of conversions and conversions/cases performed per year decreased significantly with time, reaching a nadir of less than 1% per year. Conversion was inversely related to case volume and cumulative experience. Indications included vascular injury in 38.5% of cases, concern with margins in 13.5%, bowel injury in 13.5%, failure to progress in 11.5%, adhesions in 9.6%, diaphragmatic injury in 1.9% and other in 11.5%. The distribution of indications remained similar with time. There were no differences in patient age, gender, surgical history, American Society of Anesthesiologists score or tumor stage between groups 1 and 2. In groups 1 and 2 mean operative time was 304 vs 219 minutes and estimated blood loss was 904 vs 255 cc (each p <0.0001). CONCLUSIONS: The rate of conversion during laparoscopic surgery is not uniform across procedures and it is important for patient counseling. The most common indication for conversion is vascular injury. Importantly the frequency of conversion is dynamic and likely related to case volume and cumulative experience.