Outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus: A subgroup analysis.

OBJECTIVES: To estimate the surgical and quality-of-life outcomes of artificial urinary sphincter implantation in patients with diabetes mellitus (DM). Subanalyses were performed using the same population as that in our previous multicenter, prospective, observational study. METHODS: A total of 135 male patients who underwent primary artificial urinary sphincter implantation were divided into two groups: those with and without DM. The revision-free rates, that is, the percentage of patients who did not require revision surgery, were compared between patients with and without DM. The number of urinary pads required per day, International Consultation on Incontinence Questionnaire-Short Form, and King's Health Questionnaire were used to compare the continence status and quality of life (QOL) between the two groups preoperatively and at 1, 3, and 12 months after surgery. RESULTS: Revision-free rates were significantly lower in the DM group (83.9%, 77.4%, and 67.8% at 1, 2, and 3 years after implantation, respectively) than in the non-DM group (95.5%, 92.5%, and 85.5% at 1, 2, and 3 years after implantation, respectively). Both continence status and QOL, assessed by questionnaires, markedly improved after surgery in patients with and without DM. CONCLUSIONS: Despite differences in the durability of the artificial urinary sphincters, patients with DM can obtain as much benefit from artificial urinary sphincter implantation regarding continence and quality-of-life improvement as patients without DM. Therefore, DM was not considered a comorbidity that contraindicated artificial urinary sphincter implantation. Additional large-scale studies are required to verify our findings.

Night-Time Urinary Frequency Is Increased after the Great East Japan Earthquake along with Seasonal Variation: A Five-Year Longitudinal Study in Kesennuma City.

Disasters influence various health conditions; however, little has been reported about urinary symptoms. The objective of this study is to evaluate whether night-time urinary frequency was influenced by the Great East Japan Earthquake (GEJE) in March 2011. We also evaluated seasonal variation of night-time frequency, which may affect the primary objective. A retrospective chart review was conducted on 300 evaluable patients who resided in the impacted area: 263 men with benign prostatic hyperplasia and/or overactive bladder and 37 women with overactive bladder. Data concerning night-time frequency were collected repeatedly every three months from March 2009 until March 2014, then compared yearly and seasonally among same patients. In addition, night-time frequency was analyzed for potential relations to sex, age, comorbidities, and whether residences had been destroyed. There was a significant increase of night-time frequency during 2011-2013 when compared yearly with 2009 and 2010. In seasonal comparisons of the entire period, night-time frequency was greater during autumn and winter compared with summer. In quarterly comparisons, a sudden increase was not observed after the GEJE, but night-time frequency was increased significantly in spring, summer and autumn in 2011 when compared with the corresponding seasons in 2010. While hypertension was related to exacerbation of night-time frequency during winter, we did not find any factors associated with increase after the disaster out of sex, age, comorbidities or residential situations. In conclusion, night-time urinary frequency is increased shortly after the GEJE and remains elevated for the following three years along with seasonal variation.

Surgical and Patient Reported Outcomes of Artificial Urinary Sphincter Implantation: A Multicenter, Prospective, Observational Study.

PURPOSE: We performed a multicenter, prospective, observational study to assess outcomes, including changes in continence status and quality of life, after artificial urinary sphincter implantation. MATERIALS AND METHODS: Prospectively enrolled in this study were 135 patients who underwent primary AMS 800™ implantation between 2011 and 2014 at 1 of 5 institutions. Perioperative complications were categorized according to the Clavien-Dindo classification. We estimated the revision-free rate, that is the incidence of patients who did not undergo artificial urinary sphincter revision surgery. Cox regression analysis was performed to identify patient risk factors for revision surgery. The number of pads needed per day, ICIQ-SF (International Consultation on Incontinence Questionnaire-Short Form) and KHQ (King's Health Questionnaire) were used to estimate continence status and quality of life preoperatively, and 1, 3 and 12 months postoperatively. RESULTS: The artificial urinary sphincter was implanted without major complications. The revision-free rate 1, 2 and 3 years after implantation was 94%, 88% and 81%, respectively. Diabetes mellitus and poor preoperative American Society of Anesthesiologists® physical status were significant risk factors for revision surgery. Continence status and quality of life were markedly improved after surgery. However, ICIQ-SF and some KHQ items showed slight but significant deterioration at 12 months compared with scores 1 month after surgery. CONCLUSIONS: Artificial urinary sphincter implantation is a safe and durable procedure that substantially improves patient continence status and quality of life soon after surgery. Our results indicate that patients start to experience slight but noticeable deterioration in continence status and quality of life relatively early (within 1 year) after surgery. This finding might be helpful with appropriately counseling patients who undergo artificial urinary sphincter implantation.

Serum luteinizing hormone concentration is significantly associated with recovery of urinary function after radical prostatectomy.

OBJECTIVE: To perform a longitudinal investigation of the correlation between functional recovery and sex hormone concentrations after radical prostatectomy (RP). PATIENTS AND METHODS: A total of 72 consecutive patients undergoing RP between January 2012 and June 2013 were prospectively included and serially followed after surgery for comparative analysis. Their luteinizing hormone (LH) and total testosterone (TT) concentrations were measured before surgery and 3 and 12 months after surgery. They also filled out a health-related quality of life questionnaire before and at 1, 3, 6 and 12 months after surgery. RESULTS: The mean LH concentration increased from 4.28 U/L at baseline to 5.53 U/L at 3 months and remained high at 12 months after RP (both P < 0.001). There were no significant changes in the TT concentration after RP. LH at baseline was negatively correlated with the urinary function (UF) score at 3 and 12 months after RP (P = 0.030 and 0.032, respectively). After RP, subjects with high baseline LH (n = 37) were more likely than those with low LH concentrations to report lower UF scores (P = 0.014). Multivariate analysis of variance in an interaction of time × LH concentration for UF scores indicated a significant relationship between changes in UF score and LH concentration (P = 0.004). CONCLUSIONS: Radical prostatectomy affects sex hormones by increasing LH concentrations, while TT concentrations remain stable after surgery. Baseline LH concentrations are significantly associated with the recovery of urinary outcomes after RP.

Chemotherapy with Gemcitabine and Cisplatin for Advanced Ductal Adenocarcinoma of the Prostate: Clinical Courses of Two Patients.

Ductal adenocarcinoma is an unusual variant of adenocarcinoma of the prostate with a poorly understood natural history, and its treatment is not well defined. Ductal adenocarcinoma is often diagnosed at an advanced stage, because no specific tumor markers are known. Docetaxel has been used for acinar adenocarcinoma of the prostate, a common type of prostate cancer, but it is largely ineffective for ductal adenocarcinoma. Earlier studies suggested that the chemotherapy with gemcitabine and cisplatin might be effective for ductal adenocarcinoma. Here we report two patients with ductal adenocarcinoma of the prostate that did not respond to docetaxel, but responded to the gemcitabine/cisplatin chemotherapy. Patient 1 was a 59-year-old man who had lung metastasis despite androgen deprivation therapy with undetectable levels of prostate-specific antigen and who presented with brain metastasis during docetaxel chemotherapy. Pathological examination of the resected brain tumor revealed ductal adenocarcinoma with positive immunostaining for carcinoembryonic antigen. The gemcitabine/cisplatin chemotherapy achieved partial response of the lung metastasis with serum carcinoembryonic antigen levels decreasing from 11.4 ng/mL to 2.9 ng/mL. Patient 2 was a 69-year-old man with lung metastasis. Local progression appeared during androgen deprivation therapy, and the subsequent transurethral biopsy revealed ductal adenocarcinoma with positive immunostaining for neuron-specific enolase. Bone and distant lymph node metastasis appeared despite docetaxel chemotherapy. Six courses of the gemcitabine/cisplatin chemotherapy achieved partial response of metastatic lesions, with serum neuron-specific enolase levels decreasing from 118 ng/mL to 2.6 ng/mL. The gemcitabine/cisplatin chemotherapy is a potential option for treatment of advanced ductal adenocarcinoma of the prostate.

Long-term quality of life after radical prostatectomy: 8-year longitudinal study in Japan.

OBJECTIVES: To assess long-term health-related quality of life in patients undergoing radical prostatectomy. METHODS: A total of 120 patients with at least 5 years of follow up after radical prostatectomy were included in the present study. Health-related quality of life outcomes were assessed using three questionnaires, the Short Form 36-Item Health Survey, the University of California, Los Angeles Prostate Cancer Index and the International Prostate Symptom Score. RESULTS: A total of 91 patients (73%) responded at a median follow-up time of 102 months (range 85-123 months). Among general health-related quality of life domains, mental and role composite summary score remained stable throughout the follow-up period. At the final survey, no significant differences were observed in any of the domains compared with the age-matched average score of the Japanese population. Although the slight decrease in urinary function scores and International Prostate Symptom Score beyond 5 years postoperatively compared with 5 years, the differences were not significant. The sexual function summary score showed a substantially lower score just after radical prostatectomy and remained at a deteriorated level (P < 0.001). Responders at the final survey were more likely to report favorable general, urinary and sexual outcomes at 60 months compared with non-responders. CONCLUSIONS: When taking age-related changes into account, general health-related quality of life seems to remain stable in the long term after radical prostatectomy: patients with favorable health-related quality of life outcomes during the first 5 years after radical prostatectomy maintain favorable outcomes thereafter.

Effects of phosphodiesterase type 5 inhibitor, tadalafil, on continence reflex in rats.

INTRODUCTION AND HYPOTHESIS: Effects of tadalafil, a phosphodiesterase type 5 inhibitor, on the urethral continence reflex induced by sneezing were investigated. METHODS: The amplitude of urethral pressure responses during sneezing (A-URS) and urethral baseline pressure (UBP) were measured in female rats using a microtransducer-tipped catheter. Sneeze leak-point pressure (S-LPP), defined as the lowest amount of pressure required to induce fluid leakage from the urethral orifice during sneezing, was measured in rats with stress urinary incontinence (SUI) induced by vaginal distension. Values were determined before and after tadalafil administration. RESULTS: Tadalafil dose dependently and significantly decreased A-URS and S-LPP. At the highest dose tested (6.0 mg/kg), A-URS and S-LPP decreased from 49.7 to 32.3 and from 63.9 to 44.2 cmH2O, respectively, whereas UBP did not significantly change. CONCLUSIONS: Tadalafil attenuated the sneeze-induced urethral continence reflex by relaxing the striated muscles of the external urethral sphincter.

Low-dose maintenance gemcitabine-carboplatin chemotherapy could be an alternative to continuous standard chemotherapy for patients with metastatic urothelial carcinoma.

OBJECTIVES: To examine whether low-dose maintenance gemcitabine-carboplatin chemotherapy is beneficial for patients with metastatic urothelial carcinoma. METHODS: We retrospectively reviewed the records of 36 patients with metastatic urothelial carcinoma who received first-line chemotherapy (gemcitabine/cisplatin, gemcitabine/carboplatin, or methotrexate/vinblastine/adriamycin/cisplatin) between 2006 and 2012. Those who had responded, but were unable to tolerate ongoing first-line chemotherapy, had been switched to low-dose maintenance chemotherapy consisting of 1 g/m(2) of gemcitabine and area under the curve 2-4 of carboplatin given on day 1 of a 6-week cycle, and were continued unless disease progression was seen. RESULTS: After a median of three cycles of first-line chemotherapy, 17 patients had been switched to low-dose maintenance chemotherapy. The median age was 70 years (range 56-79 years), and 12 patients (70.6%) had renal dysfunction (creatinine clearance <60 mL/min). The median number of cycles of low-dose maintenance chemotherapy was six (range 2-22), and the median survival time from initiation of first-line chemotherapy was 12 months (range 4-32 months). Adverse events requiring hospitalization were seen in three patients, but all of them recovered within a few days with conservative treatment. Seven patients discontinued within 9 months, whereas 10 patients continued on low-dose maintenance chemotherapy for ≥9 months. Patients with only lymph node metastases or who had a good response to previous first-line chemotherapy were likely to be able to continue low-dose maintenance chemotherapy. CONCLUSIONS: Low-dose maintenance gemcitabine-carboplatin chemotherapy might represent an alternative for patients with metastatic urothelial carcinoma not tolerating continuous first-line standard chemotherapy regimens.

Impact of prostate size on urinary quality of life scores after open radical prostatectomy: a single-center experience.

OBJECTIVE: The aim of this study was to assess the effects of prostate size on long-term health-related quality of life (HRQoL) and functional outcomes after radical prostatectomy (RP). MATERIAL AND METHODS: A total of 207 consecutive patients who underwent RP for localized prostate cancer was stratified by pathological prostate gland weight into group 1, patients with prostate glands weighing less than 30 g; group 2, those with prostates weighing 30-50 g; and group 3, those with prostates weighing more than 50 g. Urinary HRQoL was assessed before surgery and at 1, 3, 6, 12, 18, 24, 36, 48 and 60 months after RP using a Japanese version of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. RESULTS: Baseline urinary function was significantly (p < 0.05) reduced in patients with the largest glands (group 3), as demonstrated by EPIC urinary domain summary and subscale scores, including scores for urinary bother, irritation and obstruction, compared with patients with smaller glands (groups 1 and 2). At follow-up ranging from 18 to 36 months, patients in group 3 had improved EPIC urinary domain summary and subscale scores, including scores for urinary irritation and obstruction and urinary bother subscale scores, compared with their baseline scores (p < 0.05). CONCLUSIONS: In patients with large prostate glands, postoperative improvement was observed in HRQoL and functional outcome after RP. Thus, RP may be beneficial in patients with large prostates.

Encrusted cystitis causing postrenal failure.

Encrusted cystitis is characterized by chronic inflammation of the bladder with encrustation of the mucosa, induced by urea-splitting bacterial infection. However, encrusted cystitis in itself is not well known. We report a case of encrusted cystitis causing postrenal failure. An 81-year-old man with pneumonia complained of pollakisuria, micturition pain, and gross hematuria. Bladder calculi were found, and transurethral lithotripsy was performed. However, because his symptoms did not improve, he was referred to our hospital. His urine pH was 8.5, and urine culture grew Corynebacterium and Proteus. Computerized tomography and cystoscopy revealed bladder "encrustation," caused by bladder wall calcification, and bilateral hydronephrosis. Hence, he was diagnosed with postrenal failure resulting from encrusted cystitis. Immediate bilateral nephrostomy was constructed, with continuous bladder perfusion with an acid solution for acidification of his urine, followed by intravenous administration of ceftriaxone. After 2 weeks of treatment, the calcification disappeared and his bladder mucosa was normalized. The postrenal failure also improved and thus the nephrostomy tubes were removed. Encrusted cystitis is curable by prompt treatment with acidification of urine. Therefore, precise diagnosis and therapy are critical.

Salvage chemotherapy with docetaxel, ifosfamide and nedaplatin (DIN) for patients with advanced germ cell tumors: a preliminary report.

OBJECTIVE: We investigated the efficacy and toxicity of a docetaxel, ifosfamide and nedaplatin regimen as salvage therapy for patients with advanced testicular germ cell tumor. METHODS: Eleven patients with advanced germ cell tumor refractory or relapsed after cisplatin-based chemotherapy were treated using docetaxel, ifosfamide and nedaplatin. The docetaxel, ifosfamide and nedaplatin regimen comprised docetaxel (75 mg/m(2)) on Day 1, ifosfamide (2 g/m(2)) on Days 1-3 and nedaplatin (75 mg/m(2)) on Day 2 of a 3-week cycle. RESULTS: Ten (91%) of the 11 patients achieved favorable responses, including complete response in one case and partial response in nine cases. Nine (81%) of the 11 patients have continued to show no evidence of disease after docetaxel, ifosfamide and nedaplatin therapy followed by subsequent surgical resection, with a median follow-up period of 52 months. One patient died of the disease 3 months after completing docetaxel, ifosfamide and nedaplatin chemotherapy. One patient was lost to follow-up with a status of alive with disease. Ten (91%) of the 11 patients developed Grade 4 leukopenia, which was managed using granulocyte colony-stimulating factor. No patients developed sensory neuropathy or renal dysfunction. CONCLUSIONS: The docetaxel, ifosfamide and nedaplatin regimen was efficacious and well-tolerated as salvage chemotherapy for patients with advanced germ cell tumor.

Surgical indication and outcome in patients with postoperative retethered cord syndrome.

OBJECT: After untethering of spinal dysraphism, some patients present with neurological deterioration, defined as retethered cord syndrome. It is known that surgical untethering is an option for improving the symptoms of retethered cord syndrome. Previous reports have shown that postoperative improvement in retethered cord syndrome was noted in the majority of patients presenting with pain, and in more patients with motor weakness than in those with urological symptoms. The authors speculate that subjective symptoms may be detected while symptoms are still reversible. In contrast, changes in urological function are less easy to diagnose, and delays in treatment may be complicated by advanced symptoms. In this study, patients with retethered cord syndrome were evaluated to investigate the benefits of performing routine urodynamic study to detect detrusor overactivity, which is considered to be a subclinical change of urological function, and to investigate the efficacy of early untethering surgery on the symptoms of retethered cord syndrome. METHODS: Surgical indications and outcomes of 78 untethering operations (20 for myelomeningocele, 58 for spinal lipoma) for retethered cord syndrome were examined. Diagnosis of retethered cord syndrome was defined by a multidisciplinary spina bifida team, and included routine urodynamic study. RESULTS: Preoperative symptoms included urological symptoms (70%), lower-extremity symptoms (45%), and others. The most frequent urological symptom was detrusor overactivity detected by urodynamic study (88.7%). Urinary incontinence was only found in 9.4% of patients. Postoperatively, progressive motor weakness improved in all patients, and sensory symptoms improved in 94%. Urological symptoms improved in 80% of the patients with urinary incontinence and in 75% of the patients with detrusor overactivity. Postoperative urodynamic study showed a significant increase in bladder volume (p < 0.05). The most common complication was temporary lower leg paresthesia that recovered at follow-up. Aggravated dysuria was noted in 3 patients. CONCLUSIONS: Early untethering operations offer symptomatic relief to patients with retethered cord syndrome. Urodynamic study findings, especially detrusor overactivity, are considered to be the most significant indicators for early diagnosis of retethered cord syndrome.

Individualized radical hysterectomy procedure using intraoperative electrical stimulation for patients with cervical cancer.

OBJECTIVE: In this study, by monitoring the varied distributions of nerve fascicles using intraoperative electrical stimulation (IES), we sought to establish an individualized operation based on the patient's unique nerve distribution pattern, and to determine whether this technique would result in a higher preservation rate. MATERIALS/METHODS: Radical hysterectomy was performed from 2002 to 2010. Patients in group A are the 48 cases from 2002 to 2007 in which nerve-sparing radical hysterectomy using IES as our previous report was performed. Patients in group B are the 38 cases from 2008 to 2010 in which we used our new method, which was individualized to each patient. Urodynamic study (UDS) was used to confirm nerve preservation. Nerve preservation was defined as confirming distinct detrusor contraction during urinary voiding. RESULTS: In group B, nerve preservation rate was higher than in group A (75% vs 9 0%, P = 0.067). We classified the case-by-case nerve anatomy as whether the nerve fascicle was mainly on the medial side or on the lateral side of the deep uterine vein. The lateral type anatomy was observed unilaterally in 6 cases and bilaterally in 1 case. In summary, the lateral type anatomy was observed in 8 (29%) of 28 sides. In the cases evaluated by UDS, the positive predictive value of IES was 95% in group A and 100% in group B. CONCLUSIONS: Our method of IES showed a high positive predictive value of nerve preservation as confirmed by UDS. By delineating the nerve tract in detail using IES, it is possible to individualize the operation based on each patient's anatomy, with an improved nerve preservation rate.

Extraperitoneal laparoscopic retroperitoneal lymph node dissection after chemotherapy for nonseminomatous testicular germ-cell tumor: surgical and oncological outcomes.

PURPOSE: To assess the surgical and oncological outcomes of laparoscopic retroperitoneal lymph node dissection (RPLND) after chemotherapy. METHODS: Twenty patients with metastatic nonseminomatous testicular germ-cell tumor underwent extraperitoneal laparoscopic RPLND after chemotherapy. The procedure was not indicated for patients with a pre-chemotherapy mass larger than 5 cm. Morbidity and oncological outcome were reviewed retrospectively. Surgical complications were graded according to the Clavien classification system. RESULTS: Laparoscopic RPLND was completed in all patients, and there was no conversion to open surgery. The median operating time was 223 min (range, 137-399 min). The median blood loss was 20 ml (range, 10-520 ml). There were no intraoperative complications. Postoperatively, 4 patients (20 %) had prolonged lymphorrhea (grade I) and 9 (45 %) had chyle leakage (grade I). Histological examination of the residual mass revealed necrosis in 16 (80 %) and the presence of teratoma with/without viable tumor in 4 (20 %). With a median follow-up of 45 months (range, 24-112), no patient has had disease recurrence. Normal antegrade ejaculation was preserved in all of the 14 patients studied. CONCLUSIONS: Extraperitoneal laparoscopic RPLND can be performed with acceptable morbidity and excellent cancer control in select patients. Surgeons should be aware of relatively high incidence of chyle leakage following this procedure.

The relationships between preoperative sexual desire and quality of life following radical prostatectomy: a 5-year follow-up study.

INTRODUCTION: There were few studies about the relationship between sexual desire (SD) and radical prostatectomy (RP). AIMS: We assessed the relationships between RP and quality of life (QOL) according to the preoperative SD. MAIN OUTCOME MEASURE: General QOL was measured with Short Form 36. Sexual function and bother were measured with the University of California, Los Angeles Prostate Cancer Index (PCI). Changes of postoperative SD were also evaluated using PCI. METHODS: We analyzed data from 285 men who underwent RP and were prospectively enrolled into a longitudinal cohort study. Patients were divided into two groups according to whether they had SD at baseline, which is addressed in the PCI questionnaire: a low SD (LSD) group and a high SD (HSD) group. The assessments were completed before treatment and 3, 6, 12, 24, and 60 months after RP. RESULTS: Of the 244 men, 52% had high or a fair level of SD before RP, whereas 48% reported that the level of their SD was low. The HSD group reported better sexual function and sexual bother scores than the LSD group at baseline (both P < 0.001). Fifty-one percent of the HSD group reported that SD at 3 months was poor or very poor, which did not return to the preoperative level at all postoperative time points. Nearly 20% of the LSD group regained higher SD after RP than the baseline level. The HSD group showed worse sexual bother scores than the baseline throughout the postoperative follow-up (P < 0.001). However, the LSD group demonstrated equivalent sexual bother scores after RP compared with the baseline. CONCLUSIONS: RP adversely affected SD as well as sexual function and sexual bother. The patients who had HSD experienced greater distress concerning their sexual dysfunction postoperatively than those with LSD.

[A case of papillary renal cell carcinoma mimicking a hemorrhagic renal cyst].

A right renal cyst was found in a 69-year-old man with stage IV chronic kidney disease on abdominal ultrasonography performed to investigate a right upper abdominal swelling. Aspiration cytology of the cyst revealed no malignancy, but malignancy could not be ruled out on magnetic resonance imaging because of the cyst's wall thickness and heterogeneous contents. At one-year of follow-up, emergent abdominal surgery was performed due to incidental perforation of ascending colon diverticulitis. At that time, cystic fenestration was performed because the large renal cyst obstructed the operative procedure. Pathological examination showed type-1 papillary renal cell carcinoma, and radical nephrectomy was performed after the patient's general condition improved. Hemodialysis was started after the operation, and there has been no disease recurrence for two years.

Laparoscopic simultaneous bilateral adrenalectomy: assessment of feasibility and potential indications.

OBJECTIVE: To report a single-center experience with laparoscopic simultaneous bilateral adrenalectomy (LSBA) and to evaluate its safety, surgical outcomes, and potential indications of the procedure. METHODS: A total of 21 patients underwent LSBA between 2000 and 2010 at our institution. Four patients had bilateral Cushing's syndrome (CS), two had bilateral pheochromocytoma, and one had a bilateral metastatic tumor. Eleven patients had unilateral or bilateral aldosterone-producing adenoma (APA), associated with CS or subclinical CS. Three patients had unilateral APA with contralateral non-functioning adenoma. Partial adrenalectomy was performed first by using with four ports. After the excision of one gland, the contralateral gland was removed after repositioning of the patient. RESULTS: LSBA was completed in all 21 patients without major complications. Mean operative time was 329.7 min and the estimated blood loss was 94.1 mL. Mean tumor size was 21.8 mm. Of the 16 patients receiving an adrenal-sparing procedure, nine of 11 discontinued glucocorticoid replacement after 2 years. The remaining five patients receiving bilateral total adrenalectomy required 0.5-0.75 mg of dexamethasone permanently. No open conversions, no deaths or no adrenal insufficiencies were encountered. CONCLUSIONS: LSBA represents a safe and viable treatment option for selected patients with bilateral adrenal disease.

Surgical outcomes of laparoscopic adrenalectomy for patients with Cushing's and subclinical Cushing's syndrome: a single center experience.

OBJECTIVE: We retrospectively examined the outcome of patients who underwent laparoscopic adrenalectomy for Cushing's/subclinical Cushing's syndrome in our single institute. PATIENTS AND METHODS: Between 1994 and 2008, a total of 114 patients (29 males and 85 females, median age 54 years) with adrenal Cushing's/subclinical Cushing's syndrome were studied. We compared the outcome of patients who underwent laparoscopic adrenalectomy between intraperitoneal and retroperitoneal approaches. Surgical complications were graded according to the Clavien grading system. We also examined the long-term results of subclinical Cushing's syndrome after laparoscopic adrenalectomy. RESULTS: Laparoscopic surgical outcome did not differ significantly between patients with Cushing's syndrome and those with subclinical Cushing's syndrome. Patients who underwent laparoscopic intraperitoneal adrenalectomy had longer operative time than those who received retroperitoneal adrenalectomy (188.2 min vs. 160.9 min). However, operative blood loss and surgical complications were similar between both approaches. There were no complications of Clavien grade III or higher in either intraperitoneal or retroperitoneal approach. We confirmed the improvement of hypertension and glucose tolerance in patients with subclinical Cushing's syndrome after laparoscopic adrenalectomy. CONCLUSIONS: Laparoscopic adrenalectomy for adrenal Cushing's/subclinical Cushing's syndrome is safe and feasible in either intraperitoneal or retroperitoneal approach. The use of the Clavien grading system for reporting complications in the laparoscopic adrenalectomy is encouraged for a valuable quality assessment.

Renal hypothermia using ice-cold saline for retroperitoneal laparoscopic partial nephrectomy: evaluation of split renal function with technetium-99m-dimercaptosuccinic acid renal scintigraphy.

OBJECTIVES: To evaluate the changes in split renal function after retroperitoneal laparoscopic partial nephrectomy with renal hypothermia using ice-cold saline. METHODS: From June 2002 to October 2009, 32 patients (median age 56 years) underwent retroperitoneal laparoscopic partial nephrectomy with hypothermia using ice-cold saline for the treatment of small renal tumors. The total renal function was monitored using the estimated glomerular filtration rate. Split renal function was evaluated using technetium-99m dimercaptosuccinic acid renal scintigraphy preoperatively and 3 months postoperatively. RESULTS: The median renal ischemic time, including the initial 10 minutes for cooling, was 52 minutes (range 28-101). Of the patients whose renal temperature was monitored, the lowest renal temperature during cooling was 15-25°C. The median decrease in the estimated glomerular filtration rate was 7.2 mL/min/1.73 m(2) (range -16.3 to 33.7). The median decrease in the contribution of the affected kidney to global renal function was 5.3% (range 0.4%-21.1%). On multivariate analysis, a shorter ischemia duration was an independent predictor of a lesser decrease in the contribution of the affected kidney (P = .0032). CONCLUSIONS: The methods we have described are simple and effective to facilitate suboptimal hypothermia. The decrease in the renal contribution of the affected kidney appeared to be minimal, although the ischemic time was relatively longer in our series.