Small bowel obstruction caused by cryptorchidism in an adult

Small bowel obstruction (SBO) is a common complication after abdominal surgery, and can occur due to many reasons. However, cryptorchidism can cause SBO in patients with no history of abdominal surgery. We report the case of a 67-year-old man with SBO caused by adhesions between an undescended testis and the terminal ileum.

Analysis of NF-κB and Clinical Prognostic Factors in Clear Cell Renal Cell Carcinoma

PURPOSE: A multi-subunit transcription factor NF-κB is associated with anti-apoptotic signals in several cancers including renal cell carcinoma (RCC). In this study, we investigated whether the expression levels of the NF-κB were related to the clinical properties of human renal cell carcinoma such as nuclear grade, TNM stage, and recurrence free survival. MATERIALS AND METHODS: Patients who were diagnosed with clear cell RCC between January 2006 and February 2013 were included. Clinicopathological data and survival were investigated. The expressions of NF-κB were investigated by performing immunohistochemical staining on 61 clear cell RCC. The expression levels of NF-κB were divided two groups by the expression levels. RESULTS: Results on the expression of NF-κB were not significant. Analysis of NF-κB expressions is not associated with any of the clinical properties including age, nuclear grade and TNM stage (p=0.613, p=0.059, p=0.107, p=0.570, and p=0.760, respectively). Also, a statistically correlation was not observed between recurrence free survival and NF-κB expression levels (p=0.573). CONCLUSIONS: The expressions of the NF-κB were not associated with the clinical properties of clear cell RCC such as age, nuclear grade, TNM stage, and recurrence free survival.

Analysis of factors affecting spontaneous expulsion of ureteral stones that may predict unfavorable outcomes during watchful waiting periods: What is the influence of diabetes mellitus on the ureter?

PURPOSE: The aim of our study was to evaluate the association of several factors with spontaneous stone expulsion, including ureteral stone characteristics (size, location, hydronephrosis, perinephric stranding), types of medications prescribed (alpha-blocker, low-dose steroid), and other possible demographic and health-history factors (gender, age, serum creatinine, underlying diabetes mellitus [DM], and hypertension). MATERIALS AND METHODS: A total of 366 patients with ureteral stones were enrolled. All patients underwent watchful waiting without any invasive procedures. Initial diagnoses of ureteral stones were confirmed by computed tomography scans, which were taken at approximately 1-month intervals to check for stone expulsion. Univariate and multivariate analyses were conducted to identify significant factors that contributed to stone expulsion. RESULTS: Among 366 patients, 335 patients (91.5%) experienced spontaneous stone passage during a mean follow-up period of 2.95+/-2.62 weeks. The patients were divided into two groups depending on the success of spontaneous stone passage. Univariate analyses revealed that stone location (p=0.003), stone size (p=0.021), and underlying DM (p<0.001) were significant predictors of stone passage. Multivariate analyses confirmed that stone size (p=0.010), stone location (p=0.008), and underlying DM (p=0.003) were independent predictive factors affecting stone passage. CONCLUSIONS: Stone size, location, and underlying DM were confirmed to be significant predictive factors for spontaneous passage of ureteral stones. Urologists should consider active procedures, such as shock wave lithotripsy or ureteroscopy, rather than conservative management in patients presenting with proximally located stones, large ureteral stones, or underlying DM.

Risk Factors for Postoperative Hemorrhage After Partial Nephrectomy

PURPOSE: To evaluate the frequency and clinical characteristics of postoperative hemorrhage as a complication of partial nephrectomy. MATERIALS AND METHODS: The demographics, physical statistics, tumor size, R.E.N.A.L. nephrometry score, operative method, warm ischemic time, and presence of postoperative hemorrhage and its severity and method of intervention were examined in 300 partial nephrectomy patients in two medical centers (Stanford Medical Center and Kyung Hee University Medical Center) between March 2000 and March 2012. RESULTS: Of the 300 subjects, 13 (4.3%) experienced postoperative hemorrhage severe enough to require intervention more invasive than transfusion (Clavien grade III or higher). Univariate analysis of the bleeding and nonbleeding groups showed that whereas age, ischemic time, tumor size and stage, body mass index, American Society of Anesthesiologists class, and operative method did not differ significantly, the exophyticity (E) score was significantly higher for severe postoperative hemorrhage (p=0.04). However, multivariate analysis showed none of the factors to differ significantly. In most of the cases requiring intervention, selective embolization was sufficient, but in one case explorative laparotomy and nephrectomy were required. Clinical characteristics varied significantly among severe hemorrhage cases, with time of onset ranging from the first to the 30th postoperative day and symptoms presenting in a diverse manner, such as gross hematuria and pleuritic chest pain. Computed tomography and angiographic findings were consistent with either arteriovenous fistula or pseudoaneurysms. CONCLUSIONS: Severe hemorrhage after partial nephrectomy is rare. Nonetheless, with the great variability in presenting symptoms and time of onset after surgery, surgeons should exercise great vigilance during the postoperative care of partial nephrectomy patients.

A Nationwide Epidemiological Study of Testicular Torsion in Korea

Testicular torsion is a surgical emergency in the field of urology. Knowledge of the epidemiology and pathophysiology is significant to an urologist. However, the epidemiology of testicular torsion in Korea has not been studied. We performed a nationwide epidemiological study to improve knowledge of the epidemiology of testicular torsion. From 2006-2011, the Korean Urologic Association began the patient registry service. The annual number of patients with testicular torsion from 2006 to 2011 were 225, 250, 271, 277, 345, and 210, respectively. The overall incidence of testicular torsion in males was 1.1 per 100,000; However, the incidence in men less than 25 yr old was 2.9 per 100,000. Adolescents showed the highest incidence. Total testicular salvage rate was 75.7% in this survey. There was no geographic difference of testicular salvage rate. Minimizing the possibility of orchiectomy for testicular torsion is important to improve public awareness to expedite presentation and provider education to improve diagnosis and surgery.

Immunoglobulin G4-Related Systemic Sclerosing Disease: A Case Involving the Ureter and Kidney

Immunoglobulin (Ig) G4-related sclerosing disease is a newly defined clinicopathological entity characterized by lymphoplasmacytic infiltration of IgG4-positive plasma cells and varying degrees of fibrosis within affected tissues. Patients usually exhibit multisystem involvement and often respond well to steroid and immunosuppressive therapy. This report presents a case of IgG4-related sclerosing disease involving the ureter and kidney. We hope to bring IgG4-related sclerosing disease to the attention of urologists, because it is an uncommon disease that commonly responds to systemic corticosteroids.

Predictive Value of Preoperative Unenhanced Computed Tomography During Ureteroscopic Lithotripsy: A Single Institute's Experience

PURPOSE: Ureteroscopic stone removal is frequently used to remove ureteral stones. Mucosal edema and bleeding are the two most important obstacles to a successful operation. This study analyzed relationships between unenhanced computed tomography (UECT) findings and ureteroscopic findings to determine whether ureteroscopic results could be predicted preoperatively by using UECT imaging. MATERIALS AND METHODS: From January 2009 to July 2011, 675 patients were diagnosed with ureteral stones through UECT. Among them, we retrospectively reviewed 92 cases of patients who underwent ureteroscopy (URS). We identified findings such as hydronephrosis, rim sign, periureteral fat stranding, and perinephric fat stranding on the UECT and then categorized these findings into four categories (none, mild, moderate, and severe) according to their severity. We also divided the URS findings of mucosal edema and bleeding into four categories (none, mild, moderate, and severe) and compared these findings with the UECT images. RESULTS: A total of 92 study patients were included in this study: 59 were male and 33 were female patients. According to the location of the stone, 31 cases were classified as upper ureteral stones, 15 were midureteral stones, and 46 were lower ureteral stones. Hydronephrosis identified with UECT was correlated with the mucosal edema severity observed during URS (p=0.004). The rim signs identified with UECT were proportional to the grade of mucosal edema (p=0.010). CONCLUSIONS: Hydronephrosis and rim signs observed during UECT can be used as a predictive factor for intraoperative mucosal edema in patients undergoing URS.

A Rare Case of Upper Ureter Rupture: Ureteral Perforation Caused by Urinary Retention

Perforation of the ureter is a rare condition that causes a series of problems including retroperitoneal urinoma, urosepsis, abscess formation, infection, and subsequent renal impairment. There are causative factors that induce ureteric rupture, including malignancy, urinary calculi, idiopathic retroperitoneal fibrosis, recent iatrogenic manipulation, external trauma, degenerative kidney conditions, urography with external compression, and spontaneous causes. We report a rare case of ureteric rupture caused by urinary retention. The patient was treated with temporary percutaneous drainage and antibiotics. The present case illustrates that urinary retention can induce not only bladder rupture, but also ureteric rupture. It is thus of paramount importance to effectively manage patients with voiding problems.

Risk factors for postoperative ileus after urologic laparoscopic surgery / 대한외과학회지

PURPOSE: Although its incidence has decreased with the widespread use of less invasive surgical techniques including laparoscopic surgery, postoperative ileus remains a common postoperative complication. In the field of urologic surgery, with the major exception of radical cystectomy, few studies have focused on postoperative ileus as a complication of laparoscopic surgery. The present study aims to offer further clues in the management of postoperative ileus following urological laparoscopic surgery through an assessment of the associated risk factors. METHODS: The medical records of 267 patients who underwent laparoscopic surgery between February 2004 and November 2009 were reviewed. After excluding cases involving radical cystectomy, combined surgery, open conversion, and severe complications, a total of 249 patients were included for this study. The subjects were divided into a non-ileus group and an ileus group. The gender and age distribution, duration of anesthesia, American Society of Anesthesiologists Physical Status Classification Score, body mass index, degree of operative difficulty, presence of complications, surgical procedure and total opiate dosage were compared between the two groups. RESULTS: Of the 249 patients, 10.8% (n = 27) experienced postoperative ileus. Patients with ileus had a longer duration of anesthesia (P = 0.019), and perioperative complications and blood loss were all correlated with ileus (P = 0.000, 0.004, respectively). Multiple linear regression analysis showed that the modified Clavien classification was an independent risk factor for postoperative ileus (odds ratio, 5.372; 95% confidence interval, 2.084 to 13.845; P = 0.001). CONCLUSION: Postoperative ileus after laparoscopic urologic surgery was more frequent in patients who experienced more perioperative complications.

Laparoscopic Orchiopexy for a Nonpalpable Testis

PURPOSE: We evaluated the efficacy and the availability of laparoscopic orchiopexy to manage a nonpalpable intra-abdominal testis and studied outcomes including the testicular survival rate and associated complications. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 67 children (86 testicular units) who underwent laparoscopic orchiopexy for a nonpalpable intra-abdominal testis between 1996 and 2008. The mean patient age was 2.4 years (median, 1 year; range, 0.5-9 years), and the mean follow-up period was 21.8 months (range, 0.3-138.4 months). Testicular viability and orchiopexed positioning were evaluated within 1 month and beyond 3 months. RESULTS: Of 86 testes, 69 testes were treated with primary laparoscopic orchiopexy (PLO) sparing the internal spermatic vessel, 14 testes were treated with one-stage Fowler-Stephens laparoscopic orchiopexy 1, and 3 testes were treated with two-stage Fowler-Stephens laparoscopic orchiopexy 2. The testicular survival rates were 97.7% (84/86) within 1 month and 93.7% (59/63) beyond 3 months. Of 59 viable testes followed up beyond 3 months, 48 (81.4%) testes were positioned in the lower scrotum and 11 (18.6%) testes in the mid to high scrotum. CONCLUSIONS: Laparoscopic orchiopexy was successful for a nonpalpable intra-abdominal testis with a high testicular survival rate irrespective of the location from the internal ring. However, atrophy of the testis or upward migration of the testis can occur during follow-up, so we suggest watchful, periodic follow-up evaluating the viability and location of orchiopexed testes that are located in the lower scrotum in the immediate postoperative period or during short-term follow-up.

Comparative Analysis between Immunochemotherapy and Target Therapy for Metastatic Renal Cell Carcinoma: Overview of Treatment-Related Adverse Events and the Dropout Rate in Korea

PURPOSE: To comparatively analyze treatment-related adverse events and the treatment dropout rate between immunochemotherapy and target therapy in Korea. MATERIALS AND METHODS: Forty-nine subjects with metastatic renal cell carcinoma (21 target therapy recipients and 28 immunochemotherapy recipients) who underwent either 6-week cycles of sunitinib treatment (50 mg once daily for 4 weeks on and 2 weeks off) or 8-week cycles of immunochemotherapy (combination of interleukin [IL]-2, interferon [IFN]-alpha, and 5-fluorouracil [FU]) were enrolled. Treatment-related toxicity was objectively graded and quantitative analysis was performed with a scoring system. Patient compliance was categorized into three classes (1: administration as scheduled, 2: dose modification required, 3: discontinuation required). RESULTS: Compared with those of the immunochemotherapy group, subjects of the sunitinib-treatment group had higher occurrence rates of mucositis-stomatitis (43% vs. 10%), hand-foot syndrome (38% vs. 0%), diarrhea (33% vs. 14%), and hypertension (33% vs. 14%). According to the toxicity-grade-based scoring system, the total incidence and severity of toxicities were not significantly different between the two groups (p>0.05), whereas high-grade hematologic toxicities were more frequent in the immunochemotherapy group. The dropout rate of the immunochemotherapy group was significantly higher than that of the sunitinib group (administration as scheduled: 52% vs. 21%, p=0.026; discontinuation required: 19% vs. 50%, p=0.037). CONCLUSIONS: The results of this study are indicative of a comparable treatment-related toxicity profile of sunitinib and greater adherence to the treatment protocol in comparison with immunochemotherapy in patients with metastatic renal cell carcinoma (mRCC).

A Hybrid Treatment for Large Bladder Stones: Laparoscopic Cystolithotomy with Combined Direct Visual Lithotripsy

There are diverse surgical methods for treating large bladder stones, such as transurethral cystolithotripsy (TUCL), percutaneous suprapubic cystolithotripsy (PCCL), open surgery, and laparoscopic methods. We report here a case of two large bladder stones treated by using a combined surgical method of a laparoscopic approach and direct visual lithotripsy.

The Factors Affecting Non-Urologic Postoperative Complications after Laparoscopic Surgery in the Urologic Area

PURPOSE: Factors related to nonurologic postoperative complications of laparoscopic surgery in the urologic area were examined. The most significant factors were isolated and analyzed to establish ways to reduce the complication rate. MATERIALS AND METHODS: The medical records of 154 patients who had undergone laparoscopic surgery between March 2004 and March 2008 were reviewed. Age, anesthetic time, American Society of Anesthesiologists physical status classification, operative difficulty, blood loss (ml), body mass index (BMI), and complications were assessed. Complications were divided into 5 groups based on the modified Clavien classification. Grade 0 to 1 was defined as a no complication group and grades 2 to 5 as a complication group. The Armitage trend test was performed to study the relations between the factors and the complications. Univariate and multivariate analyses were performed to determine the risk ratio of each of the factors and the most significant factors. RESULTS: Complications tended to increase as the anesthetic risk and anesthetic time increased (p=0.011, 0.013, respectively). Operative difficulty and blood loss were related to complications (p=0.018, p<0.001, respectively). The univariate analysis revealed that blood loss of more than 400 ml compared with less than 200 ml had a risk ratio of 18.2. Moderate and hard operative difficulties had a significant risk ratio of around 4, and high anesthetic risk had a high risk rate of around 5. The multivariate analysis showed that blood loss and high anesthetic risk were independent risk factors of complications. CONCLUSIONS: Blood loss and high anesthetic risk proved to be independent factors that are associated with complications. Surgeons must keep in mind the patient's anesthetic risk and try to minimize blood loss during the operation to reduce complications after a laparoscopic surgery.

Laparoscopic Radical Nephrectomy in Obese and Non-Obese Patients: Comparison with Open Surgery

PURPOSE: The aim of this research was to compare surgical outcomes and complications of obese and non-obese patients who underwent open radical nephrectomy (ORN) and laparoscopic radical nephrectomy (LRN). MATERIALS AND METHODS: The data of 26 ORN patients and 30 LRN patients between January 2006 and December 2008 were analyzed. Patients with a body mass index (BMI) of 25.0 kg/m2 or more were defined as obese, and those with a BMI of <25.0 kg/m2 were defined as non-obese. All patients were divided into two groups according to the criteria above to compare demographic and clinical and pathologic parameters. RESULTS: The mean BMIs of the 15 obese patients in the ORN group and the 13 obese patients in the LRN group were 26.8+/-1.1 and 27.7+/-2.4, respectively. LRN was enormously effective for lowering estimated blood loss (EBL) and postoperative days compared with ORN. Operation times and EBL in ORN were affected by obesity, both of which were increased. In contrast, the data of both LRN groups indicated similar outcomes. The perioperative data of obese patients revealed LRN to have reduced blood loss (143.0+/-62.7 vs. 446.7+/-222.4 ml, p=0.001) and not significantly different postoperative days (7.3+/-2.2 vs. 8.4+/-1.5 days, p=0.065). Operation time, however, did not differ significantly among obese patients between ORN and LRN. The complications due to LRN had no relation with obesity, whereas ORN had an increased complications rate (34.6% vs. 3.8%). CONCLUSIONS: This study shows that LRN is more effective than ORN for both obese and non-obese patients with regard to perioperative outcomes and complication rates.

Comparison of the Surgical Outcome and Renal Function between Radical and Nephron-sparing Surgery for Renal Cell Carcinomas / 대한비뇨기과학회지

PURPOSE: We retrospectively evaluated the outcomes of a matched comparison of nephron-sparing surgery(NSS) and radical nephrectomy(RN) for renal cell carcinoma(RCC) that was less than 4cm in size and the renal function after surgery. MATERIALS AND METHODS: Between January 1995 and February 2004, 92 and 200 patients with unilateral RCC and a normal contralateral kidney underwent NSS and RN, respectively. A total 56 patients in each cohort were matched according to the size of tumor, the pathological T stage, the pathological grade and the follow-up time. The Kaplan-Meier method was used to estimate the overall survival, the disease-free survival and the cancer-specific survival. Ninety-seven and 317 patients underwent NSS and RN during the same period, and their impaired renal function after surgery was evaluated. Postoperatively, the impaired renal function was defined as a serum creatinine value greater than 1.6mg/dl. The risk factors for impaired renal function, including diabetes, hypertension, age and the operative method were compared between the two groups. Chi-square tests and Student's t-tests were used to compare the two groups for their renal function after surgery. Multivariate logistic regression analysis was used to evaluate the preoperative risk factors for impaired renal function after surgery. RESULTS: There was no significant difference observed between NSS and RN with respect to overall survival(p=0.63), disease-free survival(p=0.18) and cancer-specific survival(p=0.98). Postoperatively, the impaired renal function was significantly different between the two groups(p=0.045, chi-square). The only preoperative risk factor for impaired renal function after surgery was diabetes(p=0.044). CONCLUSIONS: The surgical outcomes for renal cell carcinoma that's less than 4cm in size were comparable between NSS and RN. The only preoperative risk factor for impaired renal function after surgery was diabetes.

Impact of Vesico-ureteral Reflux on Renal Function after a Radical Cystectomy: a Comparison of Refluxing and Antirefluxing Orthotopic Bladder Substitutes / 대한비뇨기과학회지

PURPOSE: We evaluated the incidence and impact of vesico-ureteral reflux(VUR) on renal function after a radical cystectomy and the use of orthotopic bladder substitutes, using refluxing and antirefluxing type uretero-intestinal anastomosis. MATERIALS AND METHODS: Sixty-five patients(124 renal units) had undergone a radical cystectomy with an ileal orthotopic substitute and received postoperative follow-up for longer than 12 months. For these patients, we evaluated the presence and grade of VUR using voiding cystourethrography(VCUG) and measured the individual glomerular filtration rate (GFR) of the corresponding renal units using a (99m)technetium diethylenetetraminepentaacetic acid(DTPA) renal scan. According to the urinary diversion(refluxing or antirefluxing methods), we analyzed the incidence of VUR and the impact of VUR on renal function. The mean follow-up time was 52 months(range 13-132 months) after surgery. RESULTS: The incidence of VUR was higher in the refluxing anstomosis group(group R, 60.3%) of patients than in the antirefluxing group of patients(group NR, 21.7%)(p=0.001). However, the mean GFR was not significantly different(72.5ml/min/m2 for group R patients, 76.4ml/min/ m2 for group NR patients, respectively). Between the refluxing and nonrefluxing renal units, no significant difference of GFR was also noted (38.3ml/min/m2 versus 37.7ml/min/m2). When GFR was stratified by the duration of the diversion, it was not significantly different (38.2, 36.2, and 41.7ml/min/m2 at 12-24, 25-48 and > 48 months, p>0.05, respectively) regardless of the diversion methods. The degree of reflux was not related to the renal function. CONCLUSIONS: Although there was a higher incidence of VUR in the refluxing type than in the antirefluxing type of orthotopic bladder substitutes, VUR developing after a radical cystectomy does not significantly alter renal function regardless of its severity or the methods and duration of the diversion.

Comparison of Treatment Outcomes between Photoselective Vaporization and Transurethral Resection of the Prostate for Benign Prostatic Hyperplasia / 대한비뇨기과학회지

PURPOSE: We prospectively compared the treatment outcomes of photoselective vaporization of the prostate (PVP) with those of the gold standard transurethral resection of the prostate (TURP). MATERIALS AND METHODS: Between October 2004 and April 2006, a prospective clinical trial was performed with 131 and 41 patients treated by PVP and TURP, respectively. The efficacy of the two procedures were compared in terms of the International Prostate Symptom Score, quality of life score, peak urinary flow rate, postvoid residual volume, complications and perioperative outcomes at 1, 3, 6 and 12 months following treatment. RESULTS: The baseline characteristics of the two groups were similar. The operative times, catheter indwelling times and hospital stays were significantly shorter in the PVP group. All efficacy parameters were significantly improved in both groups compared to those obtained preoperatively. In addition, the degrees of improvement in the efficacy parameters were similar between the two groups within 12 months. With respect to the prostatic volume reduction, the difference between the pre- and post-PVP volumes during the study period was less than that of the TURP group (p<0.001). There were no differences in the overall complications between the two groups, with the exception of more common bleeding reguiring a transfusion and capsule perforation in the TURP group. CONCLUSIONS: PVP provides excellent intraoperative and postoperative safety, and facilitates immediate relief from obstructive voiding symptoms; similarly to TURP, but has the advantages of shorter hospital stays and catheter indwelling times. The short-term treatment outcomes 12 months after PVP and TURP were comparable, with the exception of the prostatic volume reduction.