Urological Science

Inguinal hernia after a radical prostatectomy for localized prostate cancer

Jungle Chi-Hsiang Wu, Yen-Chuan Ou — 2012-01-24

Abstract: Since prostate-specific antigen (PSA) screening began in the 1980s in Taiwan, there has been a significant increase in the detection of prostate cancers (PCs) at an earlier stage. For clinically localized PC, a radical prostatectomy (RP) remains the gold standard treatment. However, patients undergoing a RP for PC are at risk of onset or worsening of inguinal hernias (IHs). We reviewed the current status of IHs after a RP. We reviewed literature published from PubMed using the key words of “inguinal hernia”, “prostatectomy”, and “prostate cancer”. The postprostatectomy mechanism was illustrated. The incidences of various prostatectomies were recorded. The prediction and prevention of postprostatectomy IHs were analyzed. Disruption of the transversalis fascia caused by surgical procedures was proposed as contributing to postprostatectomy-related IH formation because it assaults the anatomic-physiological balance in the abdominal wall. The myopectineal orifice is traversed by the spermatic cord and femoral vessels, and its inner surface is sealed by the transversalis fascia. A body mass index of <23 kg/m2 and a history of previous IH repair were significant risk factors for postoperative IH. The incidence of IHs after surgery was reported to range from 12.4% to 23.9%, and most IHs occur within 6–24 months postprostatectomy. The incidence of IHs is greater with the extraperitoneal approach than with the transperitoneal approach. A preoperative abdominal computed tomography (CT)-scan might identify asymptomatic IHs, but the test lacks sensitivity and is inferior to a simple physical examination (PE). A PE of the groin should be performed before a RP, and careful surgical manipulation is essential to prevent postoperative IHs. The concurrent repair of any detectable IHs at the time of a prostatectomy could significantly reduce the incidence of postoperative IHs.

Urolithiasis update: Evaluation and management

Yung-Tai Chen — 2012-02-10

Abstract: Urolithiasis is a worldwide disease which has affected humans from ancient eras to modern times. Recently, societal changes have altered the epidemiology of urinary calculi. The incidence of urolithiasis is higher in industrialized countries. Obese people are known to have a higher risk of stone formation. Metabolic syndrome has resulted in an increasing rate of nephrolithiasis among women. There are many useful tools for diagnosing urolithiasis, including conventional plain radiography, intravenous urography, ultrasonography, computed tomography (CT), and nuclear medicine. Nonenhanced CT has high sensitivities and specificities. It can be rapidly performed without intravenous administration of contrast material and can therefore be used in patients with severely impaired renal function. Beyond that, it can reveal extraurinary causes of flank pain. However, concerns about radiation exposure and costs remain. Since ancient times, hundreds of natural plant extracts and more recently, synthetic chemicals have been proposed to eliminate urinary calculi. Clinical trials demonstrated that calcium channel blockers and adrenergic antagonists are effective in enhancing stone passage. Shock wave lithotripsy (SWL) can successfully treat renal calculi. A meta-analysis study revealed that SWL is more effective in treating urinary calculi with a lower-frequency mode. Highly dense stones are more refractory to SWL. The stone composition can be evaluated by preoperative CT attenuation values. Patients with preoperative Houndsfield units (HUs) of >750 have a 10.5-times greater chance of needing three or more sessions of SWL treatment compared to patients whose HUs are <750. Ureteroscopy is a safe treatment for managing ureter stones when performed by experienced hands and ureteroscopy is preferred over SWL in patients with a larger upper-ureter stone, those who are pregnancy, and those with bleeding diathesis.

Initial experience with extraperitoneal laparoscopic radical prostatectomy after 20 procedures by a single surgeon

Chia-Cheng Su, Steven K. Huan, Ying-Huei Lee, Kun-Hung Shen, Allen W. Chiu — 2012-02-16

Abstract: Objective: Extraperitoneal laparoscopic radical prostatectomy (ELRP) has been established as a minimally invasive and viable alternative to the open procedure. Herein, we summarize the initial experience of single surgeon who performed 20 procedures for clinically localized prostate cancer.Materials and Methods: Between February 2006 and June 2009, 20 patients underwent an ELRP. Demographic data, including age, preoperative prostate-specific antigen (PSA), prostate volume, Gleason score, and ASA score were collected. A five-trocar extraperitoneal technique was used. Surgical parameters, pathological staging, postoperative complications, hospital stay, continence state, and oncological control during follow-up were retrospectively reviewed.Results: The mean age was 67.5 (54–81) years. Mean preoperative PSA was 24.6±15.8ng/mL and prostate volume was 47.8±22.5 (17–92) mL. The mean operative time was 325±58 (220–465) min. Mean blood loss was 450±300 (250–3000) mL. The mean postoperative hospitalization was 10.4±4.9 (5–25) days. The one major complication that occurred was deep-venous thrombosis, and venous filter implantation was applied. In addition, one had anastomosis disruption, and three had bladder neck contracture. All patients had transient stress urinary incontinence but almost 80% were continent 9 months later. Biochemical failure was noted in five patients, and they received adjuvant hormone or radiation therapy. All patients are alive except one who had pelvic lymph node involvement (N1) with bony metastasis; that patient died 34 months postoperatively.Conclusion: A major benefit of ELRP compared to the transperitoneal approach is avoiding potential risks of intraperitoneal injury. In addition, it can also isolate urine leakage due to a negligent interrupted suture at anastomosis. From our 5-year short-term follow-up, it provides equal efficacy in tumor control as does a radical prostatectomy. We think that as experience accumulates, better postoperative oncological and functional outcomes are expected.

A paraganglioma of the organ of Zuckerkandl

Jia-Hwia Wang — 2012-01-24

Extra-adrenal pheochromocytomas are called paragangliomas. Most of these tumors are located in the abdominal sympathetic ganglia, including the organ of Zuckerkandl adjacent to the abdominal aortic bifurcation. Most patients present with paroxysmal hypertension accompanied by headaches, sweating, palpitations, and facial flushing. A diagnosis can be made if elevated levels of serum catecholamines and urine vanillylmandelic acid (VMA) are measured. Detection and localization are essential before surgical resection. Computed tomography (CT) and magnetic resonance imaging (MRI) have good sensitivity for detecting and locating paragangliomas.

Significance of prostatic capsular status in radical prostatectomy

Chin-Chen Pan — 2012-01-30

Staging is always an essential part of pathological examination of resected organs containing cancer. Radical prostatectomy is no exception. The status of capsular invasion, that is, whether the tumor has penetrated the prostatic capsule into the periprostatic connective tissue, is a crucial element in the staging of prostatic cancer in radical prostatectomy specimens. However, this cannot be done properly without fully understanding the normal anatomy of the prostatic capsule and several situations that pathologists may encounter while analyzing the histological features of prostatic cancer as related to the capsule. In this review, relevant features of the prostatic capsule are described and further correlated with clinical significance.

Male lower urinary tract symptoms: The role of urodynamics

Jerry G. Blaivas, Johnson F. Tsui — 2012-03-09

For nearly the entire 20th century, it was believed that lower urinary tract (LUT) symptoms (LUTS) in men were caused by benign prostatic hyperplasia (BPH) which, in turn, caused benign prostatic obstruction (BPO) and that BPH and BPO were synonymous. It is now known that the pathophysiology of LUTS is multifactorial, and that only about two-thirds of men with LUTS have BPO according to urodynamic criteria. LUTS are empirically divided into storage and emptying symptoms. Storage symptoms include urinary frequency, urgency, urge incontinence, nocturia, and bladder/urethral pain. Emptying symptoms are comprised of hesitancy, straining to void, a weak stream, a feeling of incomplete bladder emptying, and urinary retention. Regardless of the symptoms, though, the underlying pathophysiology is limited to five conditions: 1) bladder outlet obstruction (BOO), 2) impaired detrusor contractility (IDC), 3) detrusor overactivity (DO), 4) low bladder compliance (LBC), and 5) sensory urgency (SU). Further, several studies demonstrated a lack of correlation between symptoms and urodynamic data. Accordingly, the only means of assessing the pathophysiology is by urodynamics. Determining the urodynamic abnormalities responsible for LUTS is important so that treatment can be directed at the underlying pathophysiology.

Inguinal hernia with incidental parasitic infection: A case report and literature review

Cheng-Che Wu, Wen-Shan Liao, Min-Shin Kao, Shih-Chieh Huang, Biing-Yir Shen — 2012-01-24

Abstract: Inguinal hernia repair is a common and straightforward surgical procedure. Case reports of postsurgical incidental parasitic infections are very rare. A 72-year-old male presented at our hospital with a swollen mass in the right groin area and underwent right inguinal hernia repair. Unexpectedly, parasitic ova were discovered in the hernial sac. This report describes this rare case, in addition to a review of the literature.

Synchronous primary gastric cancer and renal cell carcinoma: A case report and literatures review

Kung-Ning Hu, Wei-Hong Lai, Po-Tsang Tseng, Wen-Ching Wang, Kun-Hung Shen — 2012-02-13

Abstract: A 73-year-old woman was admitted and treated because of epigastric fullness, palpitation, and tarry stool for 2 days. Gastric cancer was found via panendoscopy. A preoperative abdominal computed tomographic scan revealed a hypervascular mass in the left kidney; renal cell carcinoma (RCC) was the initial impression. A concomitant surgery for subtotal gastrectomy and radical left nephrectomy was performed. The pathological examination confirmed gastric adenocarcinoma (T2a) and RCC (T2b). Convalescence was uneventful and she was discharged in stable condition. There was no evidence of tumor recurrence at a 20-month follow-up examination. Elderly people with early gastric cancers have a relative higher probability of developing a synchronous tumor than younger people. The incidence of synchronous gastric cancer and RCC is quite low, and concomitant surgery is rare. Surgeons need to be aware of the possibility of a synchronous second primary cancer when the initial gastric cancer is diagnosed. A concomitant surgery for gastrectomy and radical nephrectomy can be safely performed in selected patients, which can achieve feasible oncological control.

Simultaneous transurethral resection of a bladder tumor and benign prostatic hyperplasia: Four case reports and literature review

Ching-Hua Lee, Thomas I.S. Hwang, Chung-Hsin Yeh — 2012-02-20

Abstract: To evaluate the recurrence of a bladder tumor on the prostate fossa and bladder neck in patients undergoing simultaneous transurethral resection of a bladder tumor (TUR-BT) and benign prostatic hyperplasia (BPH) in our hospital, we retrospectively studied four patients who underwent simultaneous TUR-BT and transurethral resection of the prostate (TUR-P) in 2001 to 2004. The pathology was confirmed histologically to be transitional cell carcinoma of the bladder tissue or atypia cells and BPH. Two patients had bladder tumor recurrence at 18 and 33 months during the postoperative follow-up period (10–36 months, with a mean of 18.5 months). One at the bladder neck recurred 33 months postoperatively, and the other in the trigone area, near the bladder neck, recurred after 18 months. After another TUR-BT, there were no more recurrences in these two patients. No tumor progressed to the invasive stage. Tumor recurrence on simultaneous TUR-BT and TUR-P patients is a key issue of concern. We present a brief history of the four patients and a literature review. We concluded that conducting the two procedures simultaneously is clinically feasible for selected patients.

Reviewer acknowledgments

2012-03-01

The Editorial Board of Urological Science thanks the following reviewers for their invaluable contribution in 2011. Their support is much appreciated.

CME Test

2012-03-01

Please read this issue of Urological Science and return the postage-paid reply slip with your answers by May 31, 2012. A score of 80% or better will earn three CME credits.