Consensus of Experts on the Treatment of Sexual Dysfunction after Surgery for Prostate Cancer in Taiwan.

According to the Taiwan Cancer Report, in 2018, prostate cancer was one of the top five cancers reported in men. Each year, many patients with prostate cancer undergo radical prostatectomy (RP) therapy. One of the most common RP complications is erectile dysfunction (ED). Although consensus guidelines for the management of sexual dysfunction after prostate cancer surgery have been developed for many Western and Asian countries, no such clinical practice guidelines have been developed for Taiwan. The consensus opinions expressed in this article were discussed by numerous experienced physicians in Taiwan, based on both existing international guidelines and their individual experiences with clinical trials and providing advice to clinical physicians on how to inform patients of the risk of ED prior to surgery. This review also discusses how recovery and rehabilitation may be affected by socioeconomic status, the existence of an intimate relationship, comorbidities, or the need for cancer adjuvant therapy and how to determine rehabilitation goals and provide appropriate treatments to assist in the recovery of both short- and long-term sexual function.

A rare noncancerous but life-threatening tumor in urinary bladder.

IMT is a rare but sometimes life-threatening tumor. Although presenting with muscle invasion, local surgical resection with TURBT and close follow-up are adequate with bladder function and life quality preservation compared to partial cystectomy.

Low-intensity shock wave therapy ameliorates erectile dysfunction in men with pelvic fractures associated with urethral injury.

Erectile dysfunction (ED) is common in patients with pelvic fractures associated with urethral injury (PFUI). We aim to assess the efficacy and safety of low-intensity shock wave therapy (LiSWT) in ED treatment related to PFUI. Forty-three consecutive patients with PFUI who underwent surgical repair between January 2014 and March 2017 were sampled in Kaohsiung Medical University Hospital, Kaohsiung, Taiwan. ED onset following surgical repair was initially treated with oral phosphodiesterase type 5 inhibitors (PDE5i) for six months. PDE5i non-responders were referred for LiSWT of six weekly sessions. Erectile function was evaluated by the International Index of Erectile Function-5 (IIEF-5) and Erection Hardness Score (EHS). Forty-three consecutive patients were enrolled in our study. ED was observed in 79.1% (34/43) patients following surgical repair. These 34 patients were given oral PDE5i (Tadalafil® 5 mg) daily treatment, 64.7% (22/34) patients restored erectile function to normal range (EHS: 3.4 ± 1.3, IIEF-5: 21.7 ± 1.0). The other twelve PDE5i non-responders were referred for LiSWT. Seven patients (58.3%, 7/12) remained unable to maintain the rigidity for full sexual intercourse. The other five patients reported allowing full sexual intercourse. Based on our results, LiSWT may ameliorate the ED in men with PFUI and shift PDE5i non-responders to responders.

Efficacy of Low-Intensity Extracorporeal Shock Wave Therapy on Men With Chronic Pelvic Pain Syndrome Refractory to 3-As Therapy.

Managing patients with chronic pelvic pain syndrome (CPPS) refractory to the traditional 3-As therapy (antibiotics, alpha-blockers, and anti-inflammatories) is a challenging task. Low-intensity extracorporeal shock wave therapy (LI-ESWT) was recently reported to be able to improve pain, urinary symptoms, and even sexual function by inducing neovascularization and anti-inflammation, reducing muscle tone, and influencing nerve impulses. This study evaluates whether combined treatment with LI-ESWT can restore clinical ability and quality of life (QoL) in patients refractory to 3-As therapy. This was an open-label, single-arm prospective study. Patients with CPPS without more than a 6-point decrease in the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) total score under the maximal dosage of 3-As therapy were enrolled. LI-ESWT treatment consisted of 3,000 shock waves administered once weekly for 4 weeks. The NIH-CPSI, visual analog scale (VAS) score, International Prostate Symptom Score (IPSS), and the five-item version of the International Index of Erectile Function (IIEF-5) were used to evaluate efficacy at 1, 4, and 12 weeks after LI-ESWT. Thirty-three patients were enrolled in this study. After LI-ESWT treatment, 27 of the 33 patients (81.82%) had a successful response to LI-ESWT, with a decrease of 3.29 and 5.97 in the VAS score and total IPSS at the 3-month follow-up. Waist circumference was the only significant predictor of a successful response to LI-ESWT. LI-ESWT can serve as a salvage therapy for patients with CPPS refractory to traditional 3-As therapy. Further studies are needed to determine an adequate therapeutic protocol and important predictors in patients with different CPPS etiologies.

Low-Intensity Extracorporeal Shockwave Therapy Can Improve Erectile Function in Patients Who Failed to Respond to Phosphodiesterase Type 5 Inhibitors.

Managing patients with erectile dysfunction (ED) who failed to respond to phosphodiesterase type 5 inhibitors (PDE5is) is a challenging task. Recently, low-intensity extracorporeal shockwave therapy (LI-ESWT) was reported to improve ED by enhancing perfusion of the penis. The current study was performed to evaluate whether combined treatment with LI-ESWT and PDE5is can restore erectile function in patients who failed to respond to PDE5is alone. This was an open-label single-arm prospective study. ED patients with an erection hardness score (EHS) ≦2 under a maximal dosage of PDE5is were enrolled. Sociodemographic information and detailed medical history were recorded. LI-ESWT treatment consisted of 3,000 shockwaves once weekly for 12 weeks. All patients continued their regular PDE5is use. The EHS and the 5-item version of the International Index of Erectile Function (IIEF-5) were used to evaluate the change in erectile function 1 and 3 months after LI-ESWT. A total of 52 patients were enrolled. After LI-ESWT treatment, 35 of the 52 patients (67.3%) could achieve an erection hard enough for intercourse (EHS ≧ 3) under PDE5is use at the 1-month follow-up. Initial severity of ED was the only significant predictor of a successful response (EHS1: 35.7% vs. EHS2: 78.9%, p = .005). Thirty-three of the 35 (94.3%) subjects who responded to LI-ESWT could still maintain their erectile function at the 3-month follow-up. LI-ESWT can serve as a salvage therapy for ED patients who failed to respond to PDE5is. Initial severity of ED was an important predictor of a successful response.

Lower SHBG level is associated with higher leptin and lower adiponectin levels as well as metabolic syndrome, independent of testosterone.

In addition to testosterone (T), the emerging role of sex hormone-binding globulin (SHBG) in pathogenesis of metabolic syndrome (MetS) has been noted recently. However, reports of associations with serum adipocytokine levels are still limited. Therefore, we conducted this study to evaluate whether serum T and SHBG levels are independent predictors for the risk of MetS that are associated with adiponectin and leptin levels in 614 Taiwanese men over 40 years old collected from a free health screening. Subjects in the lowest quartile of TT and SHBG levels are exposed to a 1.58 and 3.22 times risk of developing MetS, as compared to those in the highest quartile of TT and SHBG levels. However, SHBG retains its significance independent of TT as a MetS risk predictor, but not vice versa. In addition, SHBG was significantly correlated with both adiponectin and leptin levels even after adjusting for TT levels. In conclusion, SHBG served as a major predictor for the risk of MetS and was correlated with serum adiponectin and leptin levels that are independent of T. Further studies are needed to elucidate the true role of SHBG in the pathogenesis of MetS and possible mechanisms associated with serum adiponectin and leptin levels.

Associations of VEGF Gene Polymorphisms With Erectile Dysfunction and Related Risk Factors.

BACKGROUND: Repeated evidence from animal models suggests a strong link between vascular endothelial growth factor (VGEF) and penile vasculature and erectile function because VEGF can alter the physiologic pathways involved in the regulation of penile vasomotor tone. AIM: To investigate three VEGF polymorphisms and their link to erectile dysfunction (ED). METHODS: We enrolled 688 Taiwanese men with a mean age of 55.6 years (SD = 4.5) during a free health screening. All participants provided complete medical histories and underwent physical examinations. Fasting blood samples were obtained for biochemical analysis and hormone profiling. The allelic discrimination of three VEGF gene polymorphisms (460T/C [rs833061], 1154G/A [rs1570360], and 2578A/C [rs699947]) was performed using validated TaqMan single-nucleotide polymorphism genotyping assays. OUTCOMES: Subjects underwent assessment using the simplified five-item International Index of Erectile Function to diagnose and assess ED severity. RESULTS: The results showed that diabetes mellitus (odds ratio [OR] = 3.27, P < .01), hypertension (OR = 3.47, P < .01), and having the VEGF 2578A allele (OR = 1.54, P = .01) were the three most independent risk factors for ED. In univariate analysis, all three VEGF polymorphisms (460C, 1154A, and 2578A) were significantly associated with a higher prevalence of coronary artery disease (P < .01) and greater frequencies of hypertension were found in carriers of the 1154A allele and the 2578A allele (P = .01). Multiple logistic regression analysis showed a significant association between VEGF 2578A allele carrier status and ED (OR = 1.54, 95% CI = 1.10∼2.15, P = .01). Furthermore, the prevalence and severity of ED were significantly increased with an increment of the 2578A allele number (P < .05). CLINICAL IMPLICATIONS: VEGF 2578C/A gene polymorphisms could be a genetic susceptibility factor for the development of ED. STRENGTH AND LIMITATION: This is the first study to investigate the genetic susceptibility of VEGF polymorphisms to ED. This study was cross-sectional with a lack of functional and molecular production investigations. Data on the association among conditions might not allow definitive conclusions about causal links. CONCLUSION: This study showed that VEGF 2578A allele carriers in a Taiwanese population are at greater risk for ED. Lee Y-C, Huang S-P, Tsai C-C, et al. Associations of VEGF Gene Polymorphisms With Erectile Dysfunction and Related Risk Factors. J Sex Med 2017;14:510-517.

Is preoperative anemia a risk factor for upper tract urothelial carcinoma following radical nephroureterectomy?

PURPOSE: We aimed to identify the effect of preoperative anemia on oncologic outcomes in patients with upper tract urothelial carcinoma (UTUC) who had different levels of renal function. METHODS: Between 2000 and 2013, we enrolled 370 patients who underwent radical nephroureterectomy for nonmetastatic UTUC. Preoperative anemia was defined as hemoglobin <130g/l in men and <120g/l in women based on the World Health Organization classification. Kaplan-Meier method was applied to estimate the effect anemia on survival, and hazard ratios (HR) of anemia and other clinicopathological parameters were evaluated by Cox regression model. The analyses were also performed in patients with different chronic kidney disease (CKD) stages. RESULTS: In all, 242 (65.4%) patients were anemic before surgery. Those with preoperative anemia had worse CKD stage (P<0.001) and higher pathological tumor stage (P = 0.023). In univariate analysis, metastasis-free and cancer-specific survival rates were not significantly associated with preoperative anemia (HR = 1.51, 95% CI: 0.93-2.44, P = 0.093 and HR = 1.59, 95% CI: 0.93-2.72, PP = 0.094, respectively). However, in patients without stage 5 CKD, those with preoperative anemia had apparently inferior metastasis-free and cancer-specific survival than those without (HR = 1.88, 95% CI: 1.14-3.01, P = 0.014 and HR = 2.03, 95% CI: 1.16-3.56, P = 0.010, respectively). A multivariate Cox proportional hazards model indicated that preoperative anemia was an independent predictor for both metastasis-free (HR = 2.17, 95% CI: 1.21-3.90, P = 0.010) and cancer-specific survival (HR = 2.21, 95% CI: 1.15-4.21, P = 0.017). CONCLUSIONS: Among patients without stage 5 CKD, preoperative anemia was a significant prognostic factor to predict metastatic progression and cancer-specific death in UTUC following radical nephroureterectomy. It was important to be aware of patients׳ renal function while evaluating the effect of anemia on outcome of UTUC.

The association of endothelial nitric oxide synthase (eNOS) G894T gene polymorphism with responsiveness to a selective α1 -blocker in men with benign prostatic hyperplasia related lower urinary tract symptoms.

OBJECTIVE: To prospectively investigate the association of endothelial nitric oxide synthase (eNOS) G894T gene polymorphism with responsiveness to a selective α1 -blocker in men with benign prostatic hyperplasia related lower urinary tract symptoms (BPH/LUTS), as nitric oxide has recently gained increasing recognition as an important neurotransmitter of functions in the lower urinary tract. PATIENTS AND METHODS: In all, 136 men with BPH/LUTS were recruited from urology outpatient clinics in a university hospital. Oral therapy with doxazosin gastrointestinal therapeutic system (GITS) 4 mg once-daily was given for 12 weeks. The drug efficacy was assessed by the changes from baseline in the total International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax ) and post-void residual urine volume (PVR) at 12 weeks of treatment. The 'responders' to doxazosin GITS were defined as those who had a total IPSS decrease of >4 points from baseline. eNOS G894T polymorphism was determined using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: Patients had statistically significant improvements in total IPSS, quality of life score, and Qmax (P < 0.01) after a 12-week period of treatment. Using multiple logistic regression analysis adjusted for age and IPSS, our results showed that being a eNOS 894T allele carrier was an independent risk factor for being a drug non-responder (P = 0.03, odds ratio 4.19). Moreover, a decreased responder rate (P = 0.01), as well as the lower improvements in IPSS (P = 0.02) and Qmax (P = 0.03) were significantly associated with increment in the T allele number. CONCLUSIONS: The presence of the eNOS 894T allele had a significantly negative impact on responsiveness to a selective α1 -blocker in BPH/LUTS treatment, suggesting that eNOS G894T gene polymorphism may be a genetic susceptibility factor for α1 -blocker efficacy in men with BPH/LUTS.

Tadalafil once daily for lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a randomized placebo- and tamsulosin-controlled 12-week study in Asian men.

OBJECTIVES: To examine the efficacy and safety of tadalafil in Asian men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. METHODS: Asian men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia were randomized to once-daily placebo (n=154), tadalafil 2.5 mg (n=151), tadalafil 5.0 mg (n=155) or tamsulosin 0.2 mg (active control, n=152) for 12 weeks. RESULTS: Total International Prostate Symptom Score least-squares mean changes from baseline to end-point significantly improved with tadalafil 2.5 mg (-4.8, P=0.003) and 5 mg (-4.7, P=0.004) versus placebo (-3.0). Significant improvement in the International Prostate Symptom Score versus placebo was observed earlier (week 2) for tadalafil 5.0 mg than for tadalafil 2.5 mg (week 8). Significant improvements (P<0.05) in both tadalafil groups versus placebo were observed for the International Prostate Symptom Score voiding subscore, International Prostate Symptom Score Quality of Life, and for Patient and Clinician Global Impressions of Improvement. Significant improvements versus placebo were observed in the International Prostate Symptom Score storage subscore for tadalafil 5.0 mg (-1.7, P=0.021), but not tadalafil 2.5 mg (-1.5, P=0.072). No significant improvements in benign prostatic hyperplasia Impact Index or improvements in peak urinary flow rates were observed with tadalafil 2.5 mg or 5.0 mg versus placebo. Tamsulosin treatment resulted in significant improvements versus placebo across all efficacy parameters, except for peak urinary flow rates. Safety results were consistent with the known tadalafil and tamsulosin safety profiles. CONCLUSIONS: Tadalafil once daily represents an effective and well tolerated medical treatment for Asian men presenting with lower urinary tract symptoms suggestive of benign prostatic hyperplasia.

Emphysematous prostatic abscess: case series study and review.

OBJECTIVES: To report three cases of emphysematous prostatic abscess (EPA) and review the literature on this rare entity. METHODS: All relevant articles published in English over the last 50 years (1961-2011) were identified using a MEDLINE search for keywords 'emphysematous prostatitis' and 'emphysematous prostatic abscess'. A total of 12 patients were evaluated for their age, race, underlying disease, pathogens, diagnosis tool, treatment options, and clinical outcome. RESULTS: EPA is a high mortality disease (25%) and has an association with diabetes mellitus. The most common pathogen in the 12 cases was Klebsiella pneumoniae. CONCLUSIONS: The mortality of EPA is higher than that of emphysematous cystitis and emphysematous pyelonephritis. Timely recognition and prompt drainage are very important.

The impact of androgen receptor CAG repeat polymorphism on andropausal symptoms in different serum testosterone levels.

INTRODUCTION: In addition to a depletion of androgen, attenuated action of androgen receptor (AR) might also contribute to andropausal symptoms. AIM: To evaluate the interaction of AR cytosine adenine guanine (CAG) repeat polymorphism and serum testosterone levels and their effect on andropausal symptoms in aging Taiwanese men. METHODS: From August 2007 to April 2008, a free health screening for men older than 40 years was conducted by a medical center in Kaohsiung City, Taiwan. All participants received physical examination, answered questionnaires to collect their demographic information and medical histories, completed the Androgen Deficiency in the Aging Male (ADAM) questionnaire, and provided 20-cm(3) whole blood samples for biochemical and genetic evaluation. MAIN OUTCOME MEASURES: The ADAM questionnaire was used to evaluate andropausal symptoms. Serum albumin, total testosterone (TT), and sex hormone-binding globulin levels were measured. Free testosterone level was calculated. AR gene CAG repeat polymorphism was determined by direct sequencing. RESULTS: Seven hundred two men with the mean age of 57.2 ± 6.5 years were included. There was no significant association between TT levels and the distribution of AR CAG repeat polymorphism. When TT levels were above 340 ng/dL, subjects with AR CAG repeat lengths ~25 showed significantly higher risk of developing andropausal symptoms, as compared with those with AR CAG repeat lengths ~22 (P = 0.006), but this was not observed when TT levels were 340 ng/dL or below. Age and number of comorbidities were also independent risk factors for andropausal symptoms. CONCLUSION: In subjects with normal TT concentration, those with longer AR CAG repeat lengths have a higher risk of developing andropausal symptoms. Age and number of comorbidities can also influence the appearance of andropausal symptoms. In clinical practice, a multifactorial approach to evaluate andropausal symptoms and the interactions between those risk factors is suggested.

The association of eNOS G894T polymorphism with metabolic syndrome and erectile dysfunction.

INTRODUCTION: Accumulated evidences have outlined the potential relation between insulin resistance and endothelial dysfunction. The impaired ability of endothelium to synthesize or release nitric oxide may provide a common pathophysiological mechanism in the development of metabolic syndrome (MtS) and erectile dysfunction (ED). AIM: The aim of this article was to investigate the genetic susceptibility of endothelial nitric oxide synthase (eNOS) G894T polymorphism underlying the development of both disorders. METHODS: A total of 590 subjects with a mean (standard deviation) age of 55.3 years (4.1) were enrolled during a free health screening. Complete clinical data and questionnaires were taken for all subjects. Multivariate logistic regression analysis was used to determine the independent predictors of MtS and ED. The eNOS G894T polymorphism was determined using a polymerase chain reaction-restriction fragment length polymorphism method. MAIN OUTCOME MEASURES: The definition of MtS was according to the modified criteria developed by the Bureau of Health Promotion in Taiwan. Patients with ED were defined as those having a five-item International Index of Erectile Function (IIEF-5) <21. RESULTS: Our results showed that the eNOS 894T allele carriers had significantly higher prevalence of MtS and ED (odds ratio [OR]=1.64, 95% confidence interval [CI]=1.05∼2.56, P=0.02 and OR=1.76, 95% CI=1.11∼2.80, P=0.01, respectively) after adjustment for each other and age. Also the T allele carriers had significantly lower IIEF-5 score and more MtS components than G allele carriers (P<0.01 and P<0.01, respectively), which were significantly associated with an increment of the T allele number (P<0.05). CONCLUSIONS: The eNOS 894T allele carriers are at greater risk for both MtS and ED, suggesting that eNOS G894T gene polymorphism might play an implication as a common genetic susceptibility factor to develop both disorders.

The comparison of the aging male symptoms (AMS) scale and androgen deficiency in the aging male (ADAM) questionnaire to detect androgen deficiency in middle-aged men.

The prevalence of androgen deficiency in men increases with aging. Two common instruments, the Aging Male Symptoms (AMS) scale and the Androgen Deficiency in the Aging Male (ADAM) questionnaire, are often used to screen for androgen deficiency in clinical practice. The aim of this study is to compare the capability of the AMS scale and the ADAM questionnaire to detect androgen deficiency in middle-aged Taiwanese men. In April 2008, a free health screening was conducted by Kaohsiung Medical University Hospital. All participants completed a health questionnaire and had blood samples drawn between 8:00 am and noon. Serum total testosterone (TT), albumin, and sex hormone-binding globulin levels were measured. The level of free testosterone (FT) was calculated. Clinical symptoms associated with androgen deficiency were screened by using the AMS scale and ADAM questionnaire. Androgen deficiency was defined as TT < 300 ng/dL or both TT < 300 ng/dL and FT< 5 ng/dL. In total, 339 men were included in the final analysis, with the mean age of 54.6 ± 4.9 years (range, 47-65 years). Androgen deficiency was found in 75 men (22.1%) based on the criteria of TT < 300 ng/dL, and in 54 men (15.9%) based on the criteria of TT < 300 ng/dL and FT < 5 ng/dL. When detecting participants with both TT < 300 ng/dL and FT < 5 ng/dL, the sensitivity and specificity of the AMS scale were 57.4% and 48.1%, compared with 66.7% and 25.6% for the ADAM questionnaire. In a sample of middle-aged Taiwanese men, neither the AMS scale nor the ADAM questionnaire had sufficient sensitivity and specificity to detect androgen deficiency. In addition to using those 2 screening instruments, a thorough physical and biochemical workup should still be conducted in patients at risk or suspected of androgen deficiency.

Mixed-type paratesticular rhabdomyosarcoma--a case report.

Rhabdomyosarcoma (RMS) is the most common soft tissue tumor of childhood; about 80% of cases occur before the age of 21 with the remaining 20% evenly spread throughout the remaining decades. A primary paratesticular site is considered to have a good prognosis in comparison with other RMS sites. Histologically, any subtype of RMS, including alveolar, pleomorphic, embryonal, and mixed type, may occur in the paratesticular region, but only a relatively small number of cases are mixed and this variant has a poor prognosis. We report a case of paratesticular RMS (mixed embryonal and alveolar type) in a 16-year-old boy.

The potential impact of metabolic syndrome on erectile dysfunction in aging Taiwanese males.

INTRODUCTION: Recently, metabolic syndrome (MtS) has received increasing attention. However, investigations regarding the potential impact of MtS and its components on erectile dysfunction (ED) have not been completely clarified. AIM: To determine the potential impact of MtS on ED in aging Taiwanese males. MAIN OUTCOME MEASURE: The definition of MtS was according to the modified criteria developed by the Bureau of Health Promotion in Taiwan. The presence and severity of ED were evaluated by International Index of Erectile Function 5 (IIEF-5) scores. METHODS: A total of 639 subjects with a mean age of 60.2 years (range 40-83) were enrolled during a free health screening. All the men had complete clinical data and questionnaires taken. Clinical variables were compared according to MtS and ED prevalence. Multiple logistic regression analysis was used to determine the independent predictors of ED and MtS. RESULTS: Using age-adjusted multivariate logistic regression analysis, our results showed that subjects with ED had significantly higher prevalence of MtS (P<0.01, OR=2.30, 95% CI: 1.44-3.69). The presence of MtS had significant correlation with lower IIEF-5 scores (P<0.01), which were associated with the increment of MtS components number (P<0.01). Among the MtS components, abnormal fasting blood glucose (FBG) was the most significantly independent factor of MtS for ED (P=0.01, OR=1.60, 95% CI: 1.09-2.35). Testosterone levels were significantly lower in subjects with MtS (P=0.05), while inversely correlated with number of MtS components (P<0.01). CONCLUSIONS: In aging Taiwanese males, the presence of MtS is strongly associated with ED and abnormal FBG is the most independent predictor for ED. Low testosterone level might be viewed as another possible common denominator for various pathologies linking MtS to ED.

The impact of physical health and socioeconomic factors on sexual activity in middle-aged and elderly Taiwanese men.

Sexual activity in older people has become a topic of growing interest. The aim of this study is to investigate the effect of physical health and socioeconomic factors on the sexual activity of middle-aged and elderly Taiwanese men. From August 2007 to April 2008, 744 men older than 40 years were enrolled from a free health screening in Kaohsiung, Taiwan. All participants received detailed physical examination and answered questionnaires that collected demographic and lifestyle information, and medical history as well as answered items from the International Prostate Symptoms Score and five-item version of the International Index of Erectile Function (IIEF-5). Overall, 100 (13.4%) participants reported to be sexually inactive in previous 6 months. Older age, lower education levels, loss of a partner, erectile dysfunction, and increased number of comorbidities were found to be independent predictors for sexual inactivity. In conclusion, most middle-aged and elderly Taiwanese men remain sexually active. In addition to erectile dysfunction and loss of a partner, lower education levels and increased number of comorbidities were found to be predictors for sexual inactivity. Further research would need to elucidate whether improvement of those factors could help to preserve sexual activity.

Comparison of laparoscopic adrenalectomy with open surgery for adrenal tumors.

The role of laparoscopy in the management of adrenal tumors is well established. However, there are very few head-to-head comparisons between laparoscopic and open methods at the same institution. We retrospectively evaluated the operative and postoperative parameters of laparoscopic adrenalectomy for adrenal tumors and compared the results with those of traditional open adrenalectomy. Eighty-eight patients with adrenal tumors underwent adrenalectomy between January 1997 and October 2008 at our institute. Clinical data were retrospectively collected after assigning the patients into Group I (n = 51), who underwent the laparoscopic method, and Group II (n = 37), who underwent the traditional open method, by reviewing the patients' charts and related data. Patients in Group I experienced significantly less blood loss (88.6 +/- 93.0 mL vs. 321.4 +/- 265.4 mL, p < 0.01), shorter hospital stay (6.7 +/- 4.3 days vs. 11.3 +/- 5.4 days, p < 0.01) and earlier oral intake (1.5 +/- 0.6 days vs. 2.2 +/- 0.8 days, p < 0.01) postoperatively. In Group I, eight patients had adrenal tumors larger than 6 cm and no statistically significant differences were found compared with the other patients in Group I. Two patients in Group I had malignancies and no local or port site recurrence was found at regular follow-up. There was no mortality in either group. Laparoscopic adrenalectomy is a safe, effective and minimally invasive approach with the advantages of better cosmesis, less blood loss, shorter hospital stay and more rapid recovery. We recommend that laparoscopic adrenalectomy is considered as the gold standard procedure for adrenal tumors, irrespective of whether the tumor is benign or malignant.

The associations among eNOS G894T gene polymorphism, erectile dysfunction, and benign prostate hyperplasia-related lower urinary tract symptoms.

INTRODUCTION: A number of literature has now identified the role of impaired nitric oxide synthase/nitric oxide pathway in the endothelium as the central to the development of erectile dysfunction (ED) and benign prostate hyperplasia-related lower urinary tract symptoms (BPH/LUTS). Recently a few studies have reported the associations between endothelial nitric oxide synthase (eNOS) G894T gene polymorphisms and ED. However, there has been no report investigating the eNOS G894T genetic susceptibility factor for both ED and BPH/LUTS. AIM: To investigate the possible associations among eNOS G894T polymorphism, ED, and BPH/LUTS in a Taiwanese population. MAIN OUTCOME MEASURES: Patients with ED were defined as those having a 5-item International Index of Erectile Function-5 <21. METHODS: In all, 372 Taiwanese men underwent a free health screening were enrolled. All the men had complete clinical data and questionnaires taken. The eNOS G894T polymorphisms were determined using the polymerase chain reaction-restriction fragment length polymorphism method. RESULTS: Three hundred seventy-two men had a mean (standard deviation) age of 60.2 (8.8) years. With multivariate analysis, our data identified that aging, diabetes mellitus (DM), and eNOS G894T gene polymorphism were three independent common risk factors for both ED and BPH/LUTS (P < 0.001, P = 0.036, and P = 0.039 for ED; P = 0.034, P = 0.004, and P = 0.016 for BPH/LUTS, respectively). The eNOS 894T allele carriers had significantly higher prevalence of ED (77.9% vs. 60.4%, P = 0.012) and higher International Prostate Symptom score (IPSS) (13.3 +/- 10.7 vs. 9.3 +/- 7.8, P = 0.001) than G allele carriers. CONCLUSIONS: Our results showed that aging, DM, and eNOS 894T allele carrier gene polymorphism were the three independently common risk factors for both ED and BPH/LUTS in the Taiwanese population. The eNOS 894T allele carriers had significantly higher frequencies of ED and higher IPSS, suggesting that eNOS G894T gene polymorphisms may play an implication as a genetic susceptibility factor for both ED and BPH/LUTS.

Epithelioid angiomyolipoma of the kidney mimicking renal cell carcinoma: a clinicopathologic analysis of cases and literature review.

Classical renal angiomyolipoma (AML) is a common tumor that, in most cases, follows a benign course and has clearly defined radiologic and histological characteristics. However, rare cases of clinically aggressive or malignant AML, the epithelioid variant of AML (EAML), have been reported. Here, we review the five cases of EAML diagnosed since 2000 at our institution to highlight the spectrum of clinical, radiological and histological characteristics. In all cases, renal lesions seen on computed tomography (CT) were considered as suspicious for renal cell carcinoma (RCC) without tumor extension or metastasis. One of the two patients with definitive tuberous sclerosis complex had a small conventional AML with fat content in the other kidney. Histologically, these tumors can resemble sarcomatoid RCC or high grade RCC. The final diagnosis is established by the presence of perivascular epithelioid cells and immunohistochemistry markers. There was no evidence of local recurrence or metastatic disease found by sonography, CT and magnetic resonance imaging during the follow-up period. EAMLs are capable of aggressive or malignant clinical behavior. Approximately one third of the reported EAMLs show advanced disease; therefore, we recommend that it is important to treat and closely follow-up such cases, similar to that for RCC, because of its malignant potential.