Prognostic factors of primary resected retroperitoneal soft tissue sarcoma: Analysis from a single asian tertiary center and external validation of gronchi's nomogram.

BACKGROUND: Surgery is the potentially curative treatment for retroperitoneal sarcoma (RS), but complete resectability is frequently a challenge. This study aimed to characterize the clinical features, prognostic factors and treatment outcomes. METHODS: A cohort of 144 patients with RS was surveyed retrospectively from January 1st, 2000 to July 30th, 2011. The prognostic influence of clinicopathological characteristics as well as treatments on local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS), were examined by univariate and multivariate analyses. A histology-specific nomogram developed by Gronchi et al was used for validation. RESULTS: Liposarcoma, leiomyosarcoma, and malignant peripheral sheath tumor (MPNST) were the most common histologies (70%). Multivariate analysis revealed FNCLCC tumor grade was the most significant prognostic factor for OS (P = 0.001) and DMFS (P < 0.001) and complete resection was the only significant prognostic factor for LRFS (P = 0.043). Incomplete resection of grade 3 tumor was significantly associated with a worse OS. Despite some differences in characteristics between our patients and Gronchi's cohort, external validation of Gronchi's nomogram demonstrated excellent concordance in predicting survival. CONCLUSIONS: Our study demonstrated tumor grade and surgical margins had significant prognostic influence and the Gronchi's nomogram has an excellent applicability in predicting survival of STS patients. J. Surg. Oncol. 2016;113:355-360. © 2016 Wiley Periodicals, Inc.

Vapoenucleation of the prostate using a high-power thulium laser: a one-year follow-up study.

BACKGROUND: Prostate vaporization and enucleation is a novel treatment option for bladder outlet obstruction caused by benign prostate enlargement. This surgical technique, however, has not yet been standardized. We present our findings of using a high-power thulium laser to accomplish vapoenucleation of the prostate (ThuVEP). METHODS: We prospectively collected and analyzed data from 29 patients who underwent ThuVEP between August 2010 and May 2012. The control group included 30 patients who underwent traditional transurethral resection of the prostate (TURP). Operative variables, patient profiles, preoperative and postoperative urine flow rates, prostate volume (measured using transrectal ultrasonography), and the international prostate symptom score (IPSS) were recorded and analyzed using a two-tailed Student's t-test and analysis of variance. RESULTS: The ages (mean ± SD) of the patients were 76.1 ± 9.4 and 72.6 ± 7.4 years (p = 0.28) in the ThuVEP and TURP groups, respectively. The average urinary flow rates before and 12 months after the operation (volume/maximum flow/average flow) were 243.3/10.5/5.0 and 302.8/17.6/9.4 (in mL, mL/s, mL/s, respectively) in the ThuVEP group and 247.2/10.8/4.6 and 369.9/20.8/12.0, respectively, in the TURP group. Preoperative and postoperative IPSSs were 17.1 ± 5.0 and 6.5 ± 3.8, respectively, in the ThuVEP group and 18.2 ± 4.5 and 6.2 ± 3.3, respectively, in the TURP group. The mean ratio of the estimated postoperative residual prostate volume to the preoperative total volume was 0.47 (p = 0.449) in both groups. The overall complication rate was 20.7% in the ThuVEP group and 30.0% in the TURP group. CONCLUSIONS: One year of follow-up showed that ThuVEP and TURP effectively alleviated subjective and objective voiding symptoms with a low rate of complications. Thus, vapoenucleation using a high-power laser is feasible in elderly patients. TRIAL REGISTRATION: ISRCTN registry with study ID ISRCTN52339705 . Date assigned: 06/03/2015.

Non-bladder conditions in female Taiwanese patients with interstitial cystitis/hypersensitive bladder syndrome.

OBJECTIVES: To detect non-bladder conditions in patients with interstitial cystitis/hypersensitive bladder syndrome. METHODS: A total of 122 female interstitial cystitis/hypersensitive bladder syndrome patients and a control group of 122 age-matched female patients with stress urinary incontinence completed screening questionnaires for irritable bowel syndrome, temporomandibular disorder, multiple chemical sensitivities, tension and migraine headache, localized myofascial pain disorder, and fibromyalgia. Interstitial cystitis/hypersensitive bladder syndrome patients also completed questionnaires on interstitial cystitis/hypersensitive bladder syndrome symptom severity, including the O'Leary-Sant symptom index, and the visual analog scale for pain and urgency. RESULTS: Interstitial cystitis/hypersensitive bladder syndrome patients were more likely to meet diagnostic criteria for irritable bowel syndrome than controls (37.5% vs 11.5%), and tension/migraine headache (38.7% vs 15.7%; all P < 0.001). The prevalence of temporomandibular disorder, multiple chemical sensitivities, localized myofascial pain disorders and fibromyalgia did not reach a statistical significant difference between the two groups. In the multivariate model, associations were also observed for irritable bowel syndrome (odds ratio 2.546; 95% confidence interval 1.136-5.704) and tension/migraine headache (odds ratio 2.684; 95% confidence interval 1.233-5.842). Patients with more comorbid conditions had more severe and bothersome interstitial cystitis/hypersensitive bladder syndrome symptoms as measured by the visual analog scale of pain (P = 0.008) and O'Leary-Sant bother index (P = 0.035). CONCLUSIONS: Interstitial cystitis/hypersensitive bladder syndrome patients are more likely to have multiple non-bladder conditions. These conditions correlate with the severity of interstitial cystitis/hypersensitive bladder syndrome symptoms.

Are there useful CT features to differentiate renal cell carcinoma from lipid-poor renal angiomyolipoma?

OBJECTIVE: This study was an attempt to identify key CT features that can potentially be used to differentiate between lipid-poor renal angiomyolipoma and renal cell carcinoma (RCC). MATERIALS AND METHODS: We conducted an analysis of patients who received nephrectomy or renal biopsy from 2002 to 2011 with suspected RCC. We included tumors smaller than 7 cm with a completed three-phase CT examination. A radiologist and a urology fellow, blinded to histopathologic diagnosis, recorded the imaging findings by consensus and compared the values for each parameter between lipid-poor angiomyolipoma, RCC subtypes, and RCC as a group. Multivariate logistic regression analysis was performed for each univariate significant feature. RESULTS: The sample in our study consisted of 132 patients with 135 renal tumors, including 51 men (age range, 26-84 years; mean age, 57 years) and 81 women (age range, 29-91 years; mean age, 57 years). These tumors included 33 lipid-poor angiomyolipomas, 54 clear-cell RCC, 31 chromophobe RCC, and 17 papillary RCC. Multivariate analysis revealed four significant parameters for differentiating RCC as a group from lipid-poor angiomyolipoma (angular interface, p = 0.023; hypodense rim, p = 0.045; homogeneity, p = 0.005; unenhanced attenuation > 38.5 HU, p < 0.001), five for clear-cell RCC, two for chromophobe RCC, and one for papillary RCC. Lipid-poor angiomyolipoma and clear-cell RCC showed early strong enhancement and a washout pattern, whereas chromophobe RCC and papillary RCC showed gradual enhancement over time. CONCLUSION: Specific CT features can potentially be used to differentiate lipid-poor renal angiomyolipoma from renal cell carcinoma.

The clinical characteristics of uterine tumor-related bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the clinical characteristics of bladder outlet obstruction caused by uterine tumors. METHODS: We collected and analyzed data for eight patients who visited our urologic clinic due to voiding difficulty or acute urinary retention in the early morning and whose final, corroborated diagnoses were uterine tumors. Another eight patients with uterine tumor but without voiding symptoms were included as the controls. RESULTS: In group 1, six patients experienced acute early-morning urinary retention and two patients experienced severe early-morning voiding difficulty. This voiding difficulty lessened significantly during the day. All patients in group 1 received urodynamic studies which indicated a high detrusor voiding pressure (median, 28.5 cmH(2)O). The uroflowmetry test performed during the day showed a good maximal flow rate (median, 27 ml/s). Seven patients in group 1 who underwent surgery no longer had early-morning emptying symptoms. All tumors were located in the posterior uterine wall, in contrast to the control group whose tumors were located in fundus or anterior wall. CONCLUSIONS: Early-morning urinary retention or voiding difficulty can be considered as an important symptom of a uterine tumor obstructing the bladder outlet.

Coprescription of Chinese Herbal Medicine and Western Medications among Prostate Cancer Patients: A Population-Based Study in Taiwan.

Use of herbal medicine is popular among cancer patients. This study aimed to explore the coprescription of CHM and WM among prostate cancer patients in Taiwan. This cross-sectional retrospective study used a population-based database containing one million beneficiaries of National Health Insurance. Claims and prescriptions were analyzed. In 2007, 218 (22.4%) prostate cancer patients were CHM users. Among CHM users, 200 (91.7%) patients with 5618 (79.5%) CHM prescriptions were on coprescription of CHM and WM. A total of 484 types of CHM and 930 types of WM were used. The most commonly used CHMs on coprescription were Shu Jing Huo Xue Tang, Ma Zi Ren Wan, and Xue Fu Zhu Yu Tang. The most commonly used WMs on coprescription were magnesium oxide, amlodipine, and aspirin. The average number of prescriptions per user per year was 261.2 versus 151.7 in all (P < 0.001), 123.6 versus 76.9 in WM (P = 0.033), and 34.8 versus 5.1 in CHM (P < 0.001) for patients with and without coprescription, respectively. In conclusion, use of CHM among prostate cancer patients was popular in Taiwan. Most CHMs were used with WM concurrently. The potential drug-herb interactions should be investigated, especially for patients with more prescriptions.

Characterization of smooth muscle differentiation of purified human skeletal muscle-derived cells.

The purpose of this study is to characterize the smooth muscle differentiation of purified human muscle-derived cells (hMDCs). The isolation and purification of hMDCs were conducted by modified preplate technique and Dynal CD34 cell selection. Smooth muscle cell differentiation was induced by the use of smooth muscle induction medium (SMIM) and low-serum medium. The gene expressions at the mRNA and protein levels of undifferentiated and differentiated hMDCs were tested by RT-PCR, Western blot and immunofluorescence studies. Western blot and immunofluorescence studies demonstrated the purified hMDCs cultured in SMIM for 4 weeks and expressed significant amount of smooth muscle myosin heavy chain (MHC) and α-smooth muscle actin (ASMA). The cells cultured in low-serum medium for 4 weeks also expressed ASMA, while the control group did not. RT-PCR analysis showed increased gene expression of smooth muscle markers, such as ASMA, Calponin, SM22, Caldesmon, Smoothelin and MHC when purified hMDCs were exposed to SMIM for 2 and 4 weeks when compared to the controls. In conclusion, we confirmed the smooth muscle differentiation capability of purified hMDCs. The gene expression of smooth muscle differentiation of purified hMDCs was characterized. These cells may be potential biomaterials for human tissue regeneration.

Use of Chinese medicine among prostate cancer patients in Taiwan: a retrospective longitudinal cohort study.

The National Health Insurance (NHI) covers Western medicine and Chinese medicine (CM) in Taiwan. The present study aimed to investigate the trends and characteristics of CM use among prostate cancer patients before and after diagnosis. A retrospective longitudinal cohort study was carried out using the NHI research database. The present study cohort consisted of 4720 prostate cancer patients diagnosed in 2004. Claims of CM services of these patients between 2003 and 2008 were analyzed. The prevalence of CM use of this cohort was 25.8%, 26.8%, 23.6%, 22.4%, 22.0% and 21.1% in 2003-2008, respectively. Overall, 52.6% of this cohort had ever used CM. In the first year of diagnosis, there was the greatest increase of new CM users (12.1%). The total number of CM users and visits reached the peak in 2004 and decreased in the subsequent years (2005-2008). The average number of CM visits per user was 6.7, 6.7, 7.0, 7.1, 7.3 and 7.2 in 2003-2008, respectively. The most frequently recorded principal diagnosis of CM visits was musculoskeletal diseases (21.4%), symptoms/signs (17.6%) and neoplasms (11.7%). Chinese herbal medicine (75.1%) was the most commonly used, followed by acupuncture/traumatological manipulative therapies (29.7%). Patients using CM before diagnosis tended to be CM users after diagnosis. The increase of CM use over the first year of prostate cancer diagnosis can be primarily attributed to an increase of new CM users, rather than of CM visits per users.

Efficacy of a decision support intervention for reducing decisional conflict in patients with elevated serum prostate-specific antigen: A randomized controlled trial.

PURPOSE: The study purpose is to test the efficacy of a decision support intervention for reducing decisional conflict, increasing prostate biopsy knowledge, and enhancing decision self-efficacy in patients with elevated serum prostate-specific antigen. METHOD: The study is based on a randomized pre-post test design. A convenience sample of men with elevated prostate-specific antigen was recruited and 1:1 randomized to the intervention and control groups. The intervention group received the decision support intervention and the control group received health education. Data were collected at the baseline and post-test by using self-reported questionnaires, including the Prostate Biopsy Knowledge Scale, the Decision Self-Efficacy Scale, the Decisional Conflict Scale, and questions regarding the prostate biopsy decision (post-test only). Data on prostate-specific antigen levels were collected from the patients' medical records. RESULTS: A total of 110 patients participated in the study. At baseline, the intervention group had significantly higher knowledge scores than the control group. The analysis of the covariance model with the baseline score as a covariate was used to analyze the intervention effect. After controlling for the baseline scores, the mean differences (95% CI) between the two groups were 11.75 (11.17-12.32), 76.45 (72.52-80.37), and -23.53 (-26.31-20.20) for knowledge, decision self-efficacy, and decisional conflict, respectively. The between-group difference in willingness to accept prostate biopsy at the post-test was not statistically significant (χ2= 1.704). CONCLUSIONS: The decision support intervention significantly reduced patients' decisional conflict while improving their knowledge and self-efficacy. However, the intervention did not affect patients' biopsy decision.

Purification of human muscle-derived cells using an immunoselective method for potential use in urological regeneration.

OBJECTIVE: To purify human muscle-derived cells (hMDCs) that could be used for managing urinary incontinence, erectile dysfunction and for bladder reconstitution. MATERIALS AND METHODS: hMDCs isolated by a modified preplate technique (MPT) from skeletal muscles of limbs were purified by CD34 antibody and magnetic Dynabeads cell selection system (MDCSS). The growth-doubling time of the hMDCs and purified hMDCs was measured. The purified hMDCs were characterized by flow cytometry, immunofluorescence and confocal laser scanning microscopy. RESULTS: The growth-doubling time of hMDCs was approximately 24 h, which increased to 35 h after purifying using the MDCSS. There were scanty fibroblasts after purification and the MDCSS-purified hMDCs were identified by high expression of stem cell markers and myoblast markers. The expression proportion of the stem cell marker CD34 and myoblast marker CD56 in the hMDCs was higher after purification (MDCSS) than before (MPT), at 32.13% vs 4.12% and 21.56% vs 8.60%, respectively. CONCLUSIONS: The purification of hMDCs showing high expression of stem cell and myoblast markers is feasible. These purified hMDCs could potentially be used for urological regeneration.

Vibratory perception and female stress urinary incontinence.

PURPOSE: We investigated the value of measuring the vibratory perception threshold with a biothesiometer to clinically evaluate women with stress urinary incontinence. MATERIALS AND METHODS: The study consisted of 3 groups, including group 1--66 women with stress urinary incontinence, group 2--44 age matched women without stress urinary incontinence and group 3--60 younger women without stress urinary incontinence. A total of 50 patients with stress urinary incontinence underwent videourodynamics. Using a biothesiometer the vibratory perception threshold was measured over the middle finger, middle toe and clitoris in all study subjects. A higher threshold indicated lower sensitivity to vibratory stimulation. Motions leading to stress urinary incontinence were also determined. RESULTS: The stress urinary incontinence and age matched control groups were older than the younger control group and had greater parity. The incontinence group had a higher vibratory perception threshold than the younger control group but there was no difference between women with incontinence and age matched women without incontinence. Women in whom incontinence was induced by walking upstairs or downstairs had a higher finger and toe vibratory perception threshold than those without incontinence. The threshold in the groups with and without intrinsic sphincter deficiency did not differ significantly. CONCLUSIONS: Vibratory perception is not related to stress urinary incontinence in females. Finger and toe vibratory perception is less sensitive in patients with stress urinary incontinence while walking upstairs or downstairs.

Correlation between pretreatment serum biochemical markers and treatment outcome for prostatic cancer with bony metastasis.

BACKGROUND: This study was undertaken to evaluate whether or not pretreatment serum biochemical markers are prognostic factors for prostatic cancer with bony metastasis in patients on hormonal treatment. METHODS: Between 1983 and 1998, 127 patients with prostatic cancer and bony metastasis were included for evaluation. Serum prostate-specific antigen, alkaline phosphatase, calcium (Ca), lactic dehydrogenase, inorganic phosphate, gamma-glutamine transpeptidase, uric acid, albumin (Alb), iron, cholesterol (Cho), triglyceride, alanine aminotransferase, aspartate aminotransferase, and hemoglobin (Hb) were checked before treatment. The patients were divided into 2 groups according to their response (group 1, good response; group 2, poor response). RESULTS: There were 54 patients in group 1 and 73 patients in group 2. Pretreatment levels of serum Ca, Alb, Cho and Hb were higher in group 1 than in group 2, while the other parameters were lower in group 1 than in group 2; only pretreatment levels of serum Ca, Alb and Hb were significantly different between groups (p < 0.05). When stratified by tumor grading, patients in group 1 still had significantly higher pretreatment levels of Ca, Alb and Hb than those in group 2. CONCLUSION: Higher pretreatment serum levels of Ca, Alb and Hb are good prognostic factors for patients with metastatic prostatic cancer on hormonal treatment, irrespective of tumor grading.

Presentation of female urethral diverticulum is usually not typical.

INTRODUCTION: Symptoms or signs of female urethral diverticulum are usually not typical, thereby resulting in delayed or wrong diagnosis. This paper relates to our experience on the diversity of presenting symptoms and signs of female urethral diverticula. MATERIALS AND METHODS: We reviewed the medical records and conducted telephone interviews of 14 patients with the diagnosis of female urethral diverticulum in our institution. RESULTS: The mean patient age at diagnosis was 47.5 years (range 22-65 years) and the mean duration between symptom presentation and diagnosis was 6.46 years (range 1 month to 30 years). Their presenting symptoms were so diverse that many were initially treated under the diagnosis other than urethral diverticulum. Most patients were treated as uncomplicated urinary tract infection for a long time. Stress urinary incontinence (SUI) was so dominant in 2 patients with big diverticula that they were falsely treated with anti-incontinence surgery. Total incontinence happened in 1 patient with genuine SUI and a big urethral diverticulum. One patient with a huge diverticulum, which had a fistula opening into the vagina, presented with day- and night-time incontinence. Some patients even did not have incontinence, but only had dysuria or a painful anterior vaginal wall nodule. Nevertheless, detailed analysis on symptoms and signs usually may suggest urethral diverticulum. We found that recurrent urinary tract infection, urinary incontinence, palpable suburethral mass, vaginal tenderness, and dysuria are the five major presenting symptoms and signs. The diagnostic rate of voiding cystourethrography during video-urodynamics, double-balloon urethrography and MRI were 10/10 (100%), 6/6 (100%) and 10/11 (90.9%) respectively. CONCLUSIONS: The presenting symptoms and signs of female urethral diverticula are often diverse and easily overlooked. High suspicion of this disorder, detailed history-taking and physical examination are essential for detecting urethral diverticulum in females.

Psychological profile of Taiwanese interstitial cystitis patients.

OBJECTIVES: The correlation between anxiety and interstitial cystitis has, as best we know, not yet been reported on. The present study investigated the psychological profile, including anxiety and depression, of patients suffering from interstitial cystitis (IC). METHODS: A total of 47 IC patients, all of whom met National Institute of Arthritis, Diabetes, Digestive and Kidney Diseases (NIDDK) criteria, plus a group of 31 age-matched, asymptomatic women received a structured interview on depression (Hamilton Rating Scale for Depression) and also on anxiety symptoms (Hamilton Rating Scale for Anxiety). IC patients also completed questionnaires relating to IC symptom severity, including urgency and frequency (visual analog scale) and O'Leary Sant index. RESULTS: A total of 85% of our IC patients featured significant affective symptoms. The average depression scores were 16.6. Fifteen patients (31.9%) featured mild depressive symptoms, five (10.6%) had mild to moderate and 20 (42.6%) had moderate to severe depression symptoms. The mean anxiety score was 21.0, with 21 (44.7%), nine (19.1%) and 17 (36.2%) patients revealing mild, mild to moderate, and moderate to severe anxiety symptoms, respectively. Further, IC patients reported a significantly greater extent of depression and anxiety than was the case for controls. Pain scale and O'Leary Sant index were significantly correlated to anxiety and depression score. CONCLUSIONS: Most of our IC patients feature significant depression and anxiety. The extent of affective symptoms would appear to correlate well with IC symptom severity.

Predictive factors of lower calyceal stone clearance after extracorporeal shockwave lithotripsy (ESWL): the impact of radiological anatomy.

BACKGROUND: This study was carried out to determine whether or not there is a significant relationship between the radiologic anatomy of the lower calyx, as seen on preoperative intravenous urography (IVU), and the outcome of stone clearance after extracorporeal shockwave lithotripsy (ESWL) for lower renal calyceal stones. METHODS: Between June 1998 and April 2007, 112 patients with a solitary lower renal calyceal stone measuring 20 mm or less in size were enrolled in this retrospective study. Pretreatment IVU was reviewed for measuring the anatomical predictors, such as lower pole infundibular length, infundibular width (IW) and infundibulopelvic angle, while the stone location and size were determined on plain abdominal X-ray. All patients were treated with ESWL using a Siemens Lithostar Plus lithotriptor and were followed-up for the outcome of stone clearance 3 months after ESWL with plain abdominal X-ray films and ultrasonography. RESULTS: Three months after ESWL, only 49 (43.7%) patients were stone-free. Under multivariate analysis with logistic regression, smaller stone size (10 mm or less, p = 0.005) and greater IW (4 mm or more, p = 0.029) were significant favourable predictors for better stone clearance. CONCLUSION: In addition to the influence of stone size, lower pole anatomy, especially IW, has a significant impact on stone clearance for lower calyceal stone after ESWL.

Successful use of modified suprapubic catheter to rescue prostatorectal fistula.

Prostatorectal fistula is a complication following radiotherapy. It remains a clinical challenge to treat because most patients experience a poor quality of life. This case report discusses a modified suprapubic catheter for use in a patient with a prostatorectal fistula that developed after radiotherapy for localized prostate cancer. It is an inexpensive, easily available, and more patient-tolerable catheter that improves quality of life. Herein, we describe the development of this catheter.

Renal oncocytoma: clinical experience of Taipei Veterans General Hospital.

BACKGROUND: Renal oncocytoma has been reported mostly in the Western literature, and only a few cases have been reported in Eastern populations. In the present study, we review the clinical course of renal oncocytoma in our institution. METHODS: We obtained the files of 13 cases of renal oncocytoma between 1988 and 2006 from the pathological archives of Taipei Veterans General Hospital. We retrospectively analyzed the patients' characteristics, clinical manifestations, surgical technique and clinical outcome. RESULTS: The study population comprised 10 men and 3 women, and the mean age at diagnosis was 59.6 years (range, 37-75 years). Twelve patients (92%) were asymptomatic at presentation and were incidentally diagnosed to have renal tumor by sonography (9 patients), computed tomography (1 patient) or magnetic resonance imaging (2 patients), and 1 presented with hematuria. The clinical impression of oncocytoma was made preoperatively in only 3 patients by imaging studies, and most of the patients (76.9%) were diagnosed with renal cell carcinoma before surgery. Ten were treated with radical nephrectomy, 2 with partial nephrectomy, and 1 received excisional biopsy. All patients had unilateral solitary renal tumor; the right kidney was involved in 7 cases (54%) and the left in 6 (46%). Mean tumor size was 5.3 cm (range, 2.7-8.5 cm). Three patients were lost to follow-up in our series, and there was no recurrence or death (100% disease-specific survival) in the remaining 10 patients (77%) who were followed-up for a mean duration of 53.2 months (range, 10-117 months). CONCLUSION: Renal oncocytoma has a benign clinical course with excellent long-term outcomes. Currently, nephron-sparing surgery is the mainstay of treatment, especially in patients with small tumors. However, accurate preoperative diagnosis based only on imaging studies is difficult, and radical nephrectomy was performed for most of the patients in our series.

Diagnosis of prostate cancer: repeated transrectal prostate biopsy or transurethral resection.

BACKGROUND: Transrectal ultrasound-guided biopsy of the prostate is the major method by which prostate cancer is diagnosed. However, many patients might be overlooked with the initial biopsy. Not uncommonly, patients need repeated biopsies when they continue to exhibit suspicious clinical signs. This may cause psychological stress to both patients and doctors. The purpose of this study was to determine how many repeat transrectal biopsies are adequate for prostate cancer detection and when to switch to transurethral resection. METHODS: We retrospectively studied a cohort of 2,996 patients who had undergone prostate biopsy. If the biopsy specimen was negative for malignancy, patients were given the choice of either being managed with observation or undergoing transurethral resection of the prostate (TURP) if indicated. If there was a high suspicion of cancer, patients were advised to undergo additional biopsies. The primary endpoint of this study was a diagnosis of cancer. RESULTS: The cancer detection rate was 22.9% (685 of 2,996 patients) in specimens taken during the first transrectal biopsy, 8.7% in those taken during the second biopsy (32 of 336 patients), and 6.1% in those taken during the third biopsy (6 of 98 patients). The cancer detection rate of TURP after 1 negative biopsy result was 9.3% (35 of 375 patients), and that after 2 negative biopsy results was 17.1% (6 of 35 patients). TURP-derived specimens that were pathologically diagnosed as malignant had lower Gleason grade on average, no matter how many repeat biopsies there were in patients whose previous transrectal biopsy specimens were negative for malignancy (p=0.002 for 2 negative biopsy results and p=0.007 for 3 negative biopsy results). CONCLUSION: The chance of detecting malignancy beyond a third transrectal biopsy procedure is low. TURP, therefore, might be an alternative procedure for obtaining tissue for pathologic diagnosis, especially in patients with rising prostate-specific antigen levels and comorbid illnesses such as obstructive symptoms.

Prepubertal testicular germ cell tumors: 25-year experience in Taipei Veterans General Hospital.

BACKGROUND: Due to the rarity of testicular tumors in the prepubertal population, adequate information about their biological course is difficult to document well in a single institution. The purpose of this study was to focus on prepubertal males in an attempt to evaluate clinical features and optimal management among various testicular germ cell tumors with long-term follow-up. METHODS: We retrospectively reviewed the records of children younger than 12 years of age with primary testicular germ cell tumors between February 1981 and December 2005 at Taipei Veterans General Hospital. Thirty-four children were diagnosed with adequate clinical and pathologic data. The stage of the disease was determined according to the staging system used by the Children's Oncology Group. Mean follow-up time was 139 months (range, 2-283 months). RESULTS: All of the 34 prepubertal patients were diagnosed initially with a painless scrotal mass. The mean age of the patients at diagnosis ranged from 6 months to 84 months (mean, 20.5 months). All patients underwent radical orchiectomy as an initial treatment. Twenty-nine (85.3%) patients had yolk sac tumors, and 5 (14.7%) had mature teratomas. Of the 29 patients with yolk sac tumor, 26 (89.7%) were diagnosed as stage I, 1 (3.4%) as stage III, and 2 (7.0%) as stage IV. Five (19.2%) of the 26 stage I yolk sac tumors progressed to metastasis after radical orchiectomy, and all of these 5 patients later received chemotherapy. One patient initially with stage III yolk sac tumor and 2 patients with stage IV yolk sac tumor were also treated with chemotherapy. Eventually, 1 patient with stage IV yolk sac tumor died due to tumor progression; the remaining 28 patients with yolk sac tumor all survived without tumor relapse after appropriate treatment. In the 5 patients with teratomas, there was no tumor relapse after radical orchiectomy with a mean follow-up time of 139.1 months. The 5-year survival rates for yolk sac tumor and teratomas were 96.5% and 100%, respectively. CONCLUSION: The most common prepubertal malignant testicular tumor is yolk sac tumor, and the most common benign testicular tumor is teratoma. Children with testicular germ cell tumors have excellent long-term survival rates after appropriate treatment.

Laparoscopic radical cystectomy combined with bilateral nephroureterectomy and specimen extraction through the vagina.

Radical cystectomy is the gold standard for muscle-invasive urothelial carcinoma of the bladder because this operation provides excellent local cancer control. Laparoscopic radical cystectomy with different urinary diversions has been reported since 1992 and proposed as an alternative to open radical cystectomy. However, the reconstruction part of the operation is time-consuming and challenging. For a patient already under dialysis, concomitant radical cystectomy with bilateral nephroureterectomy could obviate the need to create urinary diversion and treat upper urinary tract tumors at the same time. Generally the specimen has to be removed through a mini-laparotomy. But for female patients, specimen extraction through the vagina has been reported to be safe and efficient. Thus, patients with multiple comorbidities can benefit from the avoidance of mini-laparotomy. Herein, we present a 65-year-old female with invasive urothelial carcinoma of the urinary bladder and end-stage renal disease who underwent laparoscopic radical cystectomy combined with bilateral nephroureterectomy, where the specimen was extracted transvaginally.