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World Chinese Urological Society Meeting.doc

  1. 1. Welcome to WCUS meeting 2007 Dear Colleagues and Friends: On behalf of the scientific committee, it is our great pleasure to invite you to attend the 2 nd AUA World Chinese Urological Society (WCUS) meeting which will be held at the Hilton Anaheim hotel in Anaheim, California on May 19, 2007. The 1st AUA WCUS meeting held in Atlanta, Georgia in 2006 was a great success with more than 300 Chinese-speaking urologists and urologic scientists attending the meeting. The 2007 meeting in Anaheim promises to be an even more exciting event. The meeting will begin with a series of lectures by the presidents of the urological associations of China, Taiwan, Singapore, Hong Kong and Macao on the “Highlights of Chinese Urology.” Following these lectures, experts in various fields – including benign prostatic enlargement, bladder cancer, endourology, pediatric urology, Nanomedicine and urinary stones – will lecture on “Practical Approaches to Patient Management.” In light of the tremendous advancements in basic and clinical research from the countries and regions mentioned above, we have also invited many accomplished urologists and scientists to present their findings and discoveries. In addition, the conference will feature a poster session that will provide yet another venue for discussion with the experts. The purpose of the AUA WCUS meeting is to facilitate exchange of ideas and experiences and foster communication and collaboration among Chinese-speaking urologists and urological scientists. Our goal is to attract the best and brightest Chinese scholars to attend and present at the annual AUA meetings. Although the presentations will be in Mandarin, the slides and posters will be in English. We welcome anyone with an interest in Chinese urology to attend the meeting. Tom F. Lue, MD, FACS Chairman, Scientific Committee Run Wang, MD, FACS Executive Chairman, Scientific Committee Guiting Lin, MD, PhD Secretary
  2. 2. Scientific Committee Tom F. Lue, MD, FACS-Chair (USA) Yutian Dai, MD, PhD (Nanjing) Department of Urology Department of Urology University of California at San Francisco Nanjing University Medical College USA Nanjing tlue@urology.ucsf.edu China ytdai@hotmail.com Run Wang, MD, FACS-Executive Chair (USA) Department of Urology Joseph Chin, MD (Canada) University of Texas Medical School at Houston Department of Urology University of Texas MD Anderson Cancer University of West Ontario Center London USA Canada Run.Wang@uth.tmc.edu Joseph.Chin@lhsc.on.ca Yinghao Sun, MD, PhD (Shanghai) Eugen Yuhui Wang, MD, PhD (Sweden and Department of Urology Norway) The 2nd Military Medical University Department of Urology Shanghai Aker University China Oslo sunyh@medmail.com.cn Norway yuhuiwang@msn.com Hong Li, MD (Chengdu) Department of Urology Shu Tung, MD (USA) Sichuan University Division of Urology Chengdu University of Texas Medical School at Houston China USA hy7580@126.com Tung.Shu@uth.tmc.edu Ningchen Li, MD (Beijing) Philip Li, MD (USA) Beijing Urology Institute Department of Urology Beijing University Cornell University Medical School Beijing New York China USA ningchenli@yahoo.com psli@med.cornell.edu Liqun Zhou, MD (Beijing) Jun Chen, MD (Taiwan) Beijing Urology Institute chenjun@ha.mc.ntu.edu.tw Beijing University Beijing In-Hei Lee, MD (Taiwan) China yhlee@mail.chimei.org.tw zhoulqmail@china.com 2
  3. 3. Ian Lap Hong, MD, PhD (Macau) Hui Ming Tan, MD (Malaysia) Department of Urology Kuala Lumpur CHCSJ Hospital Malaysia Macau perandro@streamyx.com China ianlap@macau.ctm.net Keong Foo, MD (Singapore) keongfoo@yahoo.com Tak-Hing Bill Wong, MD, FRCS (Hong Kong) Department of Urology Leland Chung, PhD (USA) Chinese University of Hong Kong Emory University Hong Kong Atlanta China USA billwong@pedderclinic.hk lwchung@emory.edu Apichat Kongkanand, MD (Thailand) K K Chew, MD, PhD (Australia) Bangkok Perth Thailand Australia Kongkanand@yahoo.com kewkimchew@hotmail.com 3
  4. 4. World Chinese Urological Society Meeting Theme: State-of-World Chinese Urology Saturday, May 19, 2007 The Anaheim Hilton & Towers, Anaheim, California, USA 8:00 am - 8:07 am Welcome and introduction Tom F. Lue, USA 8:07am – 8:10am Report from Scientific Program Committee Run Wang, USA 8:10 am – 9:10 am Session I: Highlight on Chinese Urology Moderators: Chung Lee, USA; Luke S. Chang, Taiwan; Tak-Hing Bill Wong, Hong Kong 8:10-8:20am Yanqun Na, President, Chinese Urological Assoc. 8:20-8:30am Han-Sun Chiang, President, Taiwan Urological Assoc. 8:30-8:40am Christopher Cheng, President, Singapore Urological Assoc. 8:40-8:50am Wai Sang Wong, President, Hong Kong Urological Assoc. 8:50-9:00am Son Fat Ho, President, Macao Urological Assoc. 9:00-9:10am WCUS awards 9:10 am -10:30 am Session 2: Scientific Program: Practical approach to patient management Moderators: Yanqun Na, China; Leland Chung, USA; Apichat Kongkanand, Thailand 9:10-9:30am Revisit balloon dilation for BPH: 10-year experience Yinglu Guo, Liqun Zhou, China 9:30-9:50am How do I manage patient with bladder cancer? Joseph Chin, Canada 4
  5. 5. 9:50-10:10am Minimally Invasive Surgery for Vesicoureteric Reflux Chung Kwong Yeung, Hong Kong 10:10-10:30am Tricks on Management of Urinary Stone Disease Marshall Stoller, USA 10:30 am -10:45 am Tea and Coffee Break 10:45 am -12:00 noon Session 3: Scientific Program: Basic science forum Moderators: Dalin He, China; Philip Li, USA; Hui Meng Tan, Malaysia 10:45-11:00am Nanotechnology, Nanomedicine, and Nanosurgery: An Urologist’s Perspective Joseph C. Liao, USA 11:00-11:15am Intravesical and intraprostatic botulinum toxin administration in rat models of interstitial cystitis and non-bacteria prostatitis Yao-Chi Chuang, Naoki Yoshimura, Chao-Cheng Huang, Po-Hui Chiang, Pradeep Tyagi, and Michael B. Chancellor, Taiwan and USA 11:15-11:30am Effect of changes of detrusor-original excitability on the overactive detrusor Bo Song, China 11:30-11:45am Bladder primary sensory neuron block: animal and clinical application Zhichen Guan, China 11:45-12:00am Discussion 12 Noon-1 pm: Box Lunch and Viewing of Posters and Videos 1:00 pm - 2:00 pm Session 4: Scientific program: Discussion of posters and videos Moderators: Shujie Xia, China; Eugen Y. Wang, Sweden; Jun Chen, Taiwan Upper urinary tract 1:00-1:03pm Pyeloplasty: retroperitoneal laparoscopic vs. open approaches 5
  6. 6. Xu Zhang, China 1:03-1:06pm Graft Outcome of Living Donor Renal Transplantation in the Elderly Recipients Feng-Pin Chuang, Andrew C Novick, Guang-Huan Sun, Michael Kleeman, Stuart Flechner, V. Krishnamurthi,Charles Modlin, Daniel Shoskes, David A.Goldfarb, Taiwan and USA 1:06-1:09pm Laparoscopic repair of injury to the inferior vena cava-report of three cases (Video) Liqun Zhou, China 1:09-1:12pm Retroperitoneal laparoscopic Radical Nephrectomy and regional lymphadenectomy for Renal Cell Carcinomas Wei Zhang, China 1:12-1:15pm Correlation of COX-2 Expression in Stromal Cells with High Stage, High Grade and Poor Prognosis in Urothelial Carcinoma of Upper Urinary Tracts Chih-Hsiung Kang, Po-Hui Chiang, Shun-Chen Huang, and Hsuang-Lan Yu, Taiwan 1:15-1:18pm Endoluminal ureteroplasty for ureteroenteric stricture – a feasibility study in porcine model. Victor Chia-Hsiang Lin, Allen W. Chiu, Mihir M. Desai, Inderbir S. Gill,Taiwan and USA 1:18-1:21pm Laparoscopic radical nephroureterectomy with concomitant radical cystectomy for multi-focal transitional cell carcinoma in uremic patients: initial experience Victor C. Lin, Allen W. Chiu, Y. H. Lee, T. J. Yu, Taiwan Prostatic diseases 1:21-1:24pm Prostate cancer management consensus and guidelines between china and taiwan Chih-cheng Lu, Chia-Ho Lin, Dennis Chian-Shiung Lin, Eric W. Fan, Tse-Chou Cheng, Taiwan 1:24-1:27pm The guidelines or consensus in managing benign prostatic hyperplasia among china, singapore and taiwan Chih-cheng Lu, Chia-Ho Lin, Dennis Chian-Shiung Lin, Eric W. Fan, Tse-Chou Cheng, Taiwan 1:27-1:30 Hemospermia associated with prostatic cyst: diagnosis by transrectal ultrasonographic finding and endorectal coil MR imaging. Twenty four case reports 6
  7. 7. Wei-Dong Song, Liang Chen, Zhong-Cheng Xin, Long Tian, Bao-Xing Liu, Xiao- Jun Wu,China Andrology 1:30-1:33pm China experience of penile prosthesis implantation for sever erectile dysfunction Zhong Cheng Xin, Zhi Chao Zhang, Wei Dong Song, Long Tian, china 1:33-1:36pm Sural Nerve Grafting During Laparoscopic Radical Prostatectomy---Initial experiences of two patients Xin Gao, China 1:36-1:39pm Erectile Dysfunction Following Transurethral Electrovapor Resection for Different Sized Prostates Chih-Kuang Liu, Ming-Chung Ko, Huey-Sheng Jeng, Wen-Kai Lee, Hong-Jeng Yu, Han-SunChiang, Taiwan 1:39-1:42pm A mode of treatment for penilie incarceration ----an unusual complication of masturbation Jesun Lin, Gin-Bow Chang, Herng-Jye Jiang, Mon-I Yang, Huai-Long Tai, and Bai-Fu Wang, Taiwan 1:42-1:45pm Effect of Cox7a2 on LH induced testosterone production and expression of StAR protein, P450scc and 3β-HSD enzymes in TM3 mouse Leydig cells Liang Chen,Zhong-Cheng Xin , Long Tian, Yi-Ming Yuan, Gang Liu , Ying-Lu Guo, China 1:45-1:48pm Association of the phenotype of seminal vesicles and cftr gene mutation in patients with congenital bilateral absence of the vas deferens Chien-Chih Wu, Chia-Hung Liu, Han-Sun Chiang, Taiwan Urinary bladder 1:48-1:51pm Proteomic analysis of human urinary cancer proteome using reverse phase nano- high-performance liquid chromatography / electrospary ionization tandem mass spectrometry. Tan Lia-Beng, Liao Pao-Chi, and Guo Haw-Ran, Taiwan. 1:51-1:54pm Survival Analysis of Patients with Bladder Transitional Cell Carcinoma after Open or Laparoscopic Radical Cystectomy Allen W. Chiu, Thomas Y. Hsueh, Steven K. Huan, Yi-Hsiu Huang, Taiwan 7
  8. 8. Stem cells 1:54-1:57pm Characterization and Differentiation of Human Muscle Derived Stem Cells. Shing-Hwa Lu, An-Hang Yang, Chou-Fu Wei, Kuang-Kuo Chen,Luke S. Chang, Taiwan 1:57-2:00pm Brief Break 2:00 pm - 2:40 pm Session 5: CUA Lectures Moderators: Liqun Zhou, China; Shu Tung, USA; Shaw W. Zhou, USA 2:00-2:20pm Endourology in China: Current status and future direction Yinghao Sun, China 2:20-2:35pm Evidence-based Urology: report from China Qiang Wei, China 2:35-2:40pm Discussion 2:40 pm - 2:50 pm Tea and Coffee Break 2:50 pm – 3:50 pm. Session 6: Scientific Program: Clinical Research Moderators: Hong Li, China; Po-Hui Chiang, Taiwan; Ningchen Li, China 2:50-3:05pm The Incidence and Clinical Significance of High-Grade Prostatic Intraepithelial Neoplasia on Prostate Biopsy in Taiwanese Asian Men Yen-Hwa Chang, Yi-Chun Chiu, Chin-Chen Pan, Kuang-Kuo Chen and Luke S. Chang, Taiwan 3:05-3:15pm Prostate cancer in Macau S.A.R Lap hong Ian, Macau 3:15-3:30pm Efficacy and Safety of Tolterodine and/or Tamsulosin in Men with Lower Urinary Tract Symptoms (LUTS) Including Overactive Bladder (OAB): Results from a Four-Arm, Placebo-Controlled Trial Zhonghong (Eric) Guan, USA 3:30-3:40pm Laparoscopic Radical Cystectomy with Orthotopic Ileal Neobladder: A Report of 85 Cases 8
  9. 9. Jian Huang, China 3:40-3:50pm Discussion 3:50 pm - 4:00 pm Closing remark Yanqun Na, China & Luke S. Chang, Taiwan ABSTRACTS 1. Revisit balloon dilation for BPH: 10-year experience -----The Treatment of BPH by Muti-Balloon Dilation (MBD) Yinglu Guo M.D Department of Urology, First Hospital of Peking University, Urologist Training College of Peking University. Beijing, 100034,P.R China While China has stepped into the aged society, there are more then several ten millions people are suffering from the BPH. An effective and economic therapy method is eagerly required for those people of BPH because there is no good method to prevent and to eliminate it totally in China nowadays. Also, lots of other factors have blocked the process to reach this aim in China, such as equipments, skilled urologist, and the economic condition of those patients in the rural areas. The single balloon dilation, a method for treating BPH that had been applied in the clinic in the middle of 80s’, was an effective approaches to treat those patients with minimum symptoms, although it has been abounded for bleeding after the dilation and the long-term effects. Ten years later, this technique has been improved into another effective method, the muti-ballon dilation (MBD), which was applied in the clinic successfully with an excellent outcome. There are several key techniques were developed for 9
  10. 10. the muti-balloon dilation. To stop the bleeding after (TUR) should include biopsy of tumor base. Since dilation, the period of dilation has been prolonged to 24 approximately 50% will recur and 15 - 25% recur with hr, which resulted the necroses and apoptosis of glands higher grade disease, the key question is whether and and sympathetic nerve ending in the prostate. To increase when to institute intravesical therapy. the effectiveness of dilation, several other tissues have My criteria for intravesical therapy after initial TUR in been recruited in, such as bladder neck and urethral non-invasive disease include : sphincters. It is need to be noticed that the balloon on the 1. Presence of CIS, 2. T1 disease, 3. Presence site of urethral sphincters was released immediately after of multiple tumors, 4. large initial tumor (>3 dilation in case of the incontinence. cm.diameter), 5. Grade 3 disease. The muti-balloon dilation has been applied to treat those BPH patients with residual urine. Five days later after the A second TUR is performed within 6 weeks if the dilation, all the patients regained the urination although initial TUR failed to include muscularis propria in the some of them with temporary stress incontinence. The specimen or if there is doubt about the completeness urination was successfully improved during the post of the initial resection. dilation period. The maximum urinate rates were reached Fluorescence-Assisted TUR may be useful in cases of to 11ml/s in all those patients and some of them reached suspected carcinoma in situ, to detect “occult”. to 20ml/s even after 12 years of dilation. In case of early recurrences (within 2 -3 moths), To explore the mechanism of this new method, the animal intravesical therapy with BCG would be instituted experiments and more clinic trails will be applied. Also, promptly. Another indication for intravesical therapy the catheter and the balloon will be improved for the best is presence of unresectable superficial TCC due to outcome. difficult anatomy and location. High Risk Non-Invasive Cancers 2. How do I manage patient with bladder cancer? Since 80% of T1 Grade 3 disease, with or without concomitant CIS, will recur and since up to 45% of Joseph Chin, MD these may develop invasion and eventually become Professor of Surgery, UWO, Head, Surgical Oncology, London Health metastatic, T1G3 disease has to be regarded as high- Sciences Centre risk and treated aggressively. Intravesical therapy is Victoria Hospital, Canada used early in the disease course. The threshold for The goals of therapy for non-invasive transitional cell radical cystectomy should be low, if there is any early bladder cancer are (1) Prevent recurrence and progression, sign of failure of conservative therapy. (2) Minimize morbidity and expense e.g. with cystectomy Intravesical Therapy and (3) Identify refractory/progressive disease before it BCG is usually used as first-line with a 6 week- becomes metastatic. One should remember that only 2% course. Maintenance regimen is routinely used of TaG1-2 cancers progress. However, 50% of Tis monthly for 3 months. Occasionally, more intensive progress and that 25% of T1G3 die of TCC without and longer maintenance regimens (e.g. as per Dr. extirpative therapy. Sixty percent of such patients are 60% Lamm) are used. Second-line therapy commonly sued cured with radical cystectomy if they have timely are Mitomycin and low-dose BCG plus interferon. aggressive intervention. Approximately 50% of those Invasive Disease and Failed Treatment in Non- who pursue bladder–sparing therapy can be cured with Invasive Disease radical radiotherapy with or without systemic Radical Cystectomy is usually undertaken in these chemotherapy, but 40% require salvage cystectomy circumstances, provided the patient’s operative risks Low-Risk Non-Invasive Cancers are reasonable. A bladder-sparing approach, with a Approximately 60% of newly diagnosed cases are low- combination of external beam radiotherapy and risk (Grade 1 - 2, Stage Ta, T1). Transurethral resection systemic chemotherapy may be used, especially if the 10
  11. 11. patient has high risks with medical co morbidities. children. However, this approach necessitates The choice of urinary diversion depends on (1) patient transgression of the peritoneal cavity and can be age, (2) co-morbidities, (3) tumor stage/type/location, (4) technically difficult in the small pelvis of a young patient preference. My personal break-down is infant. In addition, a significant proportion of children approximately 65%/35% ileal conduit/Studer ileal with bilateral reflux undergoing bilateral extravesical neobladder. ureteral reimplantation developed voiding dysfunction Advanced Disease and urinary retention post-operatively. From a pilot Neoadjuvant chemotherapy (most commonly cis platinum animal model using piglets we have found that under and Gemcitabine combination) is used occasionally to carbon dioxide insufflation of the bladder at around 10 downsize locally advanced bulky cancers in patients mm Hg pressure, a large potential working space being considered for aggressive surgical therapy. The could be obtained that would allow various alternative is to proceed with cystectomy first and then intravesical procedures, including a Cohen’s type of institute adjuvant chemotherapy in those deemed to likely cross-trigonal ureteral reimplantation, to be easily benefit from adjunctive systemic therapy. conducted endoscopically using standard laparoscopic instruments. The endoscopic procedure was preceded by distension 3. Minimally Invasive Surgery for Vesicoureteric of the bladder with saline and insertion of a 3-5 mm Reflux Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and C.K.YEUNG, MD, FRCS, FRACS, FACS insufflated with carbon dioxide to 10-12 mm Hg Chair Professor of Paediatric Surgery of Pediatric Urology, pressure, with a suction catheter inserted per urethra to Director, Minimally Invasive Surgery Centre occlude the internal urethral meatus. A 5 mm 30 Chinese University of Hong Kong, Hong Kong degree scope was used to provide intravesical vision. Over the past few years, there have been remarkable Two more 3-5 mm working ports were then inserted improvements in both skills and technology in Minimally on the lateral bladder wall on either side. Endoscopic Invasive Surgery (MIS) in children. We are now having intravesical mobilization of the ureter, dissection of a much better optics and finer instruments, specially submucosal tunnel and a Cohen’s type of cross- tailored for work in small infants, and along with trigonal ureteric reimplantation using interrupted 5- improved surgical as well as anaesthetic techniques, we zero monofilament sutures was then performed under have seen explosive expansion both in the scope and videoscopic guidance. Bladder drainage with urethral complexity of the work that one can do. In addition, the catheter was maintained for 24 hours post-operatively. advent of the computer-assisted or robotic technology Using this technique, we have successfully performed over the past 3-4 years, has given further major impetus ureteric reimplantation in over 180 patients with gross for new developments of MIS in all aspects of operative VUR since 1999. Our experience illustrates that paediatric urology. endoscopic intravesical ureteric mobilization and Various minimally invasive surgical techniques are now cross-trigonal ureteric reimplantation can be very available for the management of vesicoureteral reflux safely and effectively performed with routine (VUR). These include cystoscopic subureteric injection laparoscopic surgical techniques and instruments of various types of bulking agents, endoscopic ureteral under carbon dioxide insufflation of the bladder, advancement and trigonoplasty, and endoscopic ureteric achieving a very high success rate in reflux resolution reimplantation through a transperitoneal extravesical that is at least equivalent if not better than the open approach. With the advent of laparoscopic surgery, technique, but with much less post-operative pain and extravesical laparoscopic ureteral reimplantation for VUR bladder spasm, and much faster recovery. utilizing the Lich-Gregoir technique has been reported in With this early experience, we have established a 11
  12. 12. combined MIS treatment protocol for VUR, with a and higher success rate by eliminating the risk of prog selective use of dextranomer/hyaluronic acid copolymer ressive renal damage. Moreover, this treatment is (Deflux) subureteic injection for mild grades or easily acceptable by patients and parents as there is uncomplicated VUR and pneumovesicoscopic ureteric much less trauma to the child, and its high cure rate implantation for severe grades or complicated VUR alleviating the need for long-term follow-up of the patient with radiological investigations and antibiotic Since 2001, children presenting with primary treatment vesicoureteral reflux (Grade 1 to Grade V) were prospectively recruited. At entry, each patient had a 4. Tricks on Management of Urinary Stone voiding cystourethrogram (VCUG), renal ultrasonogram Disease (US), isotopic renogram (DMSA).The minimally invasive management protocol included 1) pneumovesical ureteric Marshall Stoller, reimplantation and 2) endoscopic sub-ureteric injection. Department of Urology, University of California at San Francisco. Children with severe dilating primary vesicoureteral USA reflux, (Grade IV bilateral to Grade V) associated with Percutaneous nephrolithotomy (PNL) recurrent urinary tract infections and multiple Positioning and Set up: pyelonephritic renal scarring underwent endoscopic 1. Flexible cystoscopy on gurney Cohen’s cross-trigonal ureteral reimplantation with 2. Placement of localizing ureteral catheter carbon dioxide pneumovesicum. Endoscopic sub-ureteric 3. Connect ureteral catheter to extension tubing (12-14 injection was given to the children with milder grade (Gra inches), then a syringe of contrast (flush tubing, de II to Grade III and Grade IV Unilateral Resolution of careful not to get contrast into catheter) VUR at a minimum follow up period of 6 months after 4. Secure to Foley the procedure was then evaluated. 5. Flip patient prone onto bolsters (made of rolled up Using this combined MIS treatment protocol, 117 children blankets, gel rolls can compromise X-ray/images) were prospectively treated and followed up. Endoscopic 6. Shoulders and elbows flexed less then 90 degrees cross-trigonal ureteric reimplantation was successfully 7. Pad all pressure points and secure patient to table performed in ninety three children (M/F: 72/21, Mean 8. Ensure easy access to syringe for retrograde age: 5.1 + 5.61) with dilating primary vesicoureteral contrast injection reflux (42 bilateral; 135 refluxing ureters) and endoscopic Imaging: sub-ureteric injection has given to 24 children (M/F: 8/16, 1. Lower room lights and bring patient as close to C- Mean age: 5.75 + 3.61yrs) with milder grade VUR (- arm sensor (beam should come from under the bilateral; - refluxing ureters). Follow-up cystogram table to reduce radiation exposure) showed complete resolution of VUR in 91 of 93 patients 2. Take scout film (97.8%) and in 22 of 24 patients (92%) undergoing 3. Under active fluoroscopy, inject contrast via ureteric reimplantion and subureteric Deflux injection localizing catheter at a slow rate respectively. VUR was downgraded in the remaining 2 4. Understand stone and renal collecting system patients who underwent ureteric reimplantation. VUR anatomy grade remained unchanged in 2 patients (8.3%) treated 5. Lower pole inferior calyx is typically no the most with subureteric injection and they were treated inferior successfully by repeat injection. Access: 1. Goal is to access the posterior calyx at its tip to In summary, our new treatment algorithm with minimally minimize the distance of renal tissue traversed invasive treatment offers effective cure for children with (this will minimize bleeding) all grades of VUR. The treatment aims at an early cure 2. The access tract should be straight onto the stone 12
  13. 13. 3. 18ga needle with removable cutting inner Tip of radiomarker advanced just into tip of calyx obturator/stylet Dilate to 24 or 30F under fluoroscopy Anatomy & Puncture Site: Advance sheath to the “waist” of the balloon 1. th Identify the 11 and 12 rib th Careful not to over advance sheath onto the “cone” 2. Identify the paraspinous muscles portion of the balloon 3. Start with X-ray in AP view Alken- 4. For lower pole punctures, Ensure tight and snug fit of all dilators in set Do not a. Enter skin 2cm later to the lateral edge of the skip a dilator size paraspinous muscles and 2cm inferior to the Control tip of dilator at all times rib (Petit’s Triangle) Amplatz b. Enter at 30 degrees from the skin surface and Dotter catheter must be placed over wire first aim towards contralateral nipple Dotter tip just into collecting system c. rotate C-arm sensor towards you to assess Sequential dilation must not go too medial depth of puncture Working sheath to the “waist” of the dilator d. If the needle is under the stone your needle is Careful not to over advance sheath onto the “cone” too superficial portion of the dilator 5. For upper pole punctures, Initial Entry: a. Select either medial or lateral calyx 1. Rigid nephroscope must have adjustable suction b. Enter directly over stone (“bull’s eye”) (e.g., ultrasound lithotrite) when first entering c. Use packing forceps to direct needle and collecting system2. Look up at 12 o’clock if can reduce radiation exposure not find your way in d. Rotate C-arm sensor away from you to assess Operative hints: puncture depth 1. Suction management 6. Aberrant anatomy may require ultrasound guidance 2. Irrigation management (both from nephroscope or CT imaging and from retrograde ureteral catheter Tract Dilation: 3. Use a broad front for larger stones 1. Once in collecting system, pass J-tip, flexible wire 4. Use room temperature saline for irrigation (set at into collecting system 30-40 cm above kidney) to help reduce fogging of a. Do not spend much time trying to get guidewire down camera/lens ureter and into bladder Physiology, minimizing bleeding 2. If wire does not pass easily, you may be in an anterior 1. Avoid hypothermia, use active warming blanket calyx system 3. In general, only dilate into a posterior calyx 2. Mannitol 12.5 g IV can decrease venous bleeding 4. Dilate tract via 8F fascial dilators (can increase by swelling kidney stiffness by soaking in ice-slush) 3. Avoid excessive torque and force on kidney (safer 5. “Push/Pull” technique. As you advance the dilator, to use second puncture or flexible nephroscope) actively push and pull wire 1-2mm to keep wire Nephrostomy Tube Placement straight (this avoids kinking of the working wire) 1. Direct a stiff wire or a 5F ureteral catheter into 6. Repeat process for the 8/10F safety wire introducer desired location 7. Place a second, safety, wire when possible 2. Cut off the tip of any Foley catheter 1mm distal to 8. If significant bleeding is encountered during dilation, the balloon place nephrostomy tube and clamp it to tamponade 3. “Push/Pull” the Foley catheter into desire location bleeding, reassess after 5 minutes (confirm with contrast in the balloon, then with a Balloon system- nephrostogram) 13
  14. 14. 4. In obese patients with thick subcutaneous tissue, nanosurgery, as the ultimate minimally invasive place nephrostomy tube as far in as possible (e.g., in surgery, has yet to be realized. Nanomedicine is a an upper-pole calyx for a lower pole puncture; or in a highly translational research area that requires inter- lower-pole calyx for an upper-pole puncture) disciplinary collaboration from engineering, basic 5. In obese patients, a nephroureteral catheter also can science and clinical medicine. Institutional be used commitment towards development of centers of excellence that promote interdisciplinary collaboration 5. Nanotechnology, Nanomedicine, and is not only preferred, but necessary. Participation of Nanosurgery: An Urologist’s Perspective the urologist in the team is essential given the potential for exciting novel diagnostic and therapeutic Joseph C. Liao, M.D. modalities for urological diseases. Department of Urology S-287, Stanford University School of Medicine, 300 Pasteur Dr. Stanford, CA 94305-5118,USA 6. Intravesical and Intraprostatic Botulinum Toxin A Administration in Rat models of Nanotechnology is the understanding and manipulations Interstitial Cystitis and Non-bacteria of natural and manmade materials at dimensions of 1 to Prostatitis 100 nanometers. This is the length scale of biological molecules (e.g. DNA and proteins), where manmade Yao-Chi Chuang 1, Naoki Yoshimura 2, Chao-Cheng Huang 3, Po- materials exhibit unique properties that enable novel Hui Chiang 1, Pradeep Tyagi 2, and Michael B. Chancellor 2 applications. Nanomedicine is the highly specific medical Department of Urology 1, Pathology 3, Chang Gung Memorial intervention at the molecular scale for curing disease or Hospital, Kaohsiung Medical Center, Chang Gung University repairing damaged tissues. Nanomedicine holds the College of Medicine, Kaohsiung, Taiwan and Department of promise of revolutionizing medical diagnostics with Urology, University of Pittsburgh School of Medicine 2, Pittsburgh, ultrasensitive nanosensors for detection of biological Pennsylvania molecules, imaging with nanoparticles for in vivo, real Introduction and Objectives: There is increasing time visualization of disease processes, and therapeutics evidence that botulinum toxin A (BoNT-A) might have through highly precise targeted drug delivery systems. analgesic properties but the mechanisms by which While fundamental understanding of nanoscale research BoNT-A alter pain remains largely unexplored. In the may not be essential for the urologists, it is important to bladder, afferent nerve fibers contain calcitonin gene- grasp basic concepts of nanotechnology as it will related peptide (CGRP), which modulates sensory undoubtedly impact the clinical practice in the near transmission from the bladder. In this study we first future. Proof of concept clinical application of investigated the effect of intravesical BoNT-A nanotechnology and its microscale counterpart— administration on CGRP immunoreactivity and microelectromechanical system (MEMS)—have already bladder hyperactivity in acetic acid -induced bladder been demonstrated in urology. This includes detection of pain model in rats. Second, an animal model for non- urinary pathogens and cancer biomarkers using highly bacterial prostatitis in rats was developed using sensitive micro/nanosensor arrays. Use of lymphotropic intraprostatic injection of capsaicin, an agent thought magnetic nanoparticles in conjunction with MRI have to excite C-afferent fibers and cause neurogenic been demonstrated to improve detection of numerous inflammation. The analgesic and anti-inflammatory urological cancers, including prostate, bladder, and penile. properties of BoNT-A was tested in this model. Therapeutic applications of nanoparticles have also begun to emerge in pre-clinical settings for highly specific, Materials and Methods: For bladder experiments, targeted delivery of chemotherapeutic agents for prostate experimental and control animals were catheterized cancer. Currently, nanomedicine is still at its infancy and and intravesically exposed to protamine sulfate (PS, 1 14
  15. 15. ml, 10 mg/ml) followed by BoNT-A (1 ml, 25 unit/ml, and inhibited CGRP release from afferent nerve Allergan, Irvine, CA) or saline respectively. Three or terminals. Protamine pretreatment allows liquid seven days after intravesical therapy, continuous BoNT-A to be physiological effective. These results cystometrograms (CMGs) were performed under urethane support clinical application of BoNT-A for the anesthesia by filling the bladder (0.08 ml/min) with treatment of PBS/IC. Intraprostatic capsaicin injection saline, followed by 0.3% acetic acid. Bladder induced neurogenic prostatitis and prostatic pain and immunohistochemistry was used to detect CGRP. For may be a useful research model. BoNT-A pretreatment prostate experiments, adult male S.D. rats were injected produced anti-inflammatory and analgesic effects and with varying doses of capsaicin into the prostate. The support clinical evaluation in nonbacterial prostatitis. nociceptive effects of capsaicin were evaluated for 30 min by using a behavior approach and then the prostate was 7. Effect of changes of detrusor-original removed for histology and cyclo-oxygenase (COX)-2 excitability on the overactive detrusor protein concentration measurement. Evans blue (50mg/kg) was also injected intravenously to assess for Bo Song, Longkun Li, Xiyu Jin, Qiang Fang, Gensheng Lu, Weibing plasma protein extravasation. A second set of animals Li were injected with up to 20U of BoNT-A into the Urological center, Southwest Hospital, Third Military Medical prostates 1 week prior to intraprostatic injection of 1000 University, Chongqing, PR China µM capsaicin. Background: Overactive detrusor is due to an un- Results: For the bladder experiments, intercontraction inhibitable detrusor contraction during bladder interval (ICI) was decreased after intravesical acetic acid storage, which always occurs in the pathologic (50.2% decrease, from 22.1±1.8 min to 11.3±1.8 min and changes such as bladder outflow obstruction and 65.0% decrease, from 20.6±2.1 min to 7.2±1.5 min) in the neurogenical bladder. The mechanism is still not well control group at day 3 and day 7, respectively. However, clarified and several hypotheses are presented , the rats that received BoNT-A showed a significantly reduced most popular one is the neurogenical theory. response (ICI 28.6 % decrease, from 26.9±2.4 min to Unfortunately the antimuscarinic drugs are not always 18.2±3.1 min) to acetic acid instillation at day 7. This satisfactory for overactive detrusor according to this effect was not observed at day 3 (ICI 62.2 % decrease, theory. Besides the integrity innervation, is there any from 26.2±0.9 min to 9.9±1.2 min). Increased CGRP myocyte-original regulation on the bladder immunoreactivity was detected from BoNT-A treated excitability, like in the heart or the intestinal organs? group at day 7, which was not detected at day 3. For the Detrusor-original regulation on the bladder excitability prostate study, capsaicin dose-dependently induced pain must have such characteristics: spontaneous behavioral modifications: closing of the eyes, and excitability even undergone denervation; existence of hypolocomotion, and induced inflammatory changes: cell-to-cell excitability transconduction; peacemaker increase of inflammatory cell accumulation, COX-2 cells or peacemaker spots initiating the excitability. To expression and plasma extravasation at the acute stage, our knowledge, there are few reports on it. but completely recovered at 1 week. BoNT-A Materials and methods: Three kinds of rats models pretreatment dose-dependently reversed pain behavior with normal, super-sacral spinal cord transsection and and inflammation. BoNT-A 20U significantly decreased posterior urethral obstruction were constructed, the inflammatory cell accumulation, COX2 expression, and overactive detrusor from the super-sacral spinal cord Evens blue extraction (82.1%, 83.0%, and 50.4%, trans-section and the posterior urethral obstruction respectively), and reduced pain behavior (66.7% for eye models were selected for the studies. 1) The frequency score and 46.5% for locomotion score). and intensity of the detrusor spontaneous contraction Conclusions: Intravesical BoNT-A administration were evaluated with cystometry in vivo, whole- blocked the acetic acid-induced bladder pain responses bladder cystometry in vitro, and detrusor muscle strip 15
  16. 16. test in vitro. The effect of the activators of autonomic urodynamic, neurotransmitter (substance p) and nerves on the three models were accessorily detected. 2) histological changes after bladder instillation of The gap junctional intercellular communication in the Capsaicin. Consequently, three studies including 102 overactive detrusor was observed with fluorescent bleach patients were carried out using intravesical capsaicin technique. 3)To find out the interstitial cells of Cajal or resiniferatoxin (RTX). The intravesical (ICC)-like cell with histochemistry, which may behavior concentration of capsaicin was 1uM – 2MM/L and as the peacemaker in gastrointestinal. The action potential RTX was 100nM /L. of the ICC-like cell was also studied with patch-clamp. Result During the first 35 minutes, multiple Results and Conclusions: 1) The stretch load which can spontaneous bladder contractions were elicited in induce the contraction in overactive detrusor was much 85.71% and 50% of dogs after 100 uM and 1 uM less than that in normal detrusor, but with no significant capsaicin bladder instillation, respectively. A difference between the overactive detrusor models in significant increase in the bladder volume at leakage neurogenic and bladder outflow obstruction; the activators point (82.93+3.51 cc vs. 122.22+11.32 cc) was noted. of autonomic nerves were effective on the frequency of The SP concentration was 2.88+0.55pg/g in control detrusor-original contraction secondary to the stretch load, group and the SP concentration were 1.54+0.25 pg/g but cannot eliminate the contraction. Moreover, even and 1.29+0.16 pg/g in 1 uM and 100 uM groups after tetrodotoxin cannot eliminate the stretch-induced 12 weeks bladder instillation, respectively. Capsaicin spontaneous detrusor contraction. 2) The gap junction can reversibly abolished the bladder instability, improved transfer the cell-cell communication, and this function bladder function and increased the ability to was enhanced in overactive detrusor myocytes, which compensate in rats with partial bladder outflow indicated the existence of the detrusor-original gap obstruction. In a study of 30 OAB cases, RTX junctional intercellular communication. 3) ICC-like cell instillation didn’t cause vesical irritation and no local exists in bladder, and with the similar potential anaesthesia was required. The symptoms were characteristic as the heart peacemaker, which implied a improved immediately in all the patients after 1 day of potential peacemaker in bladder excitability. RTX intervention. The decreases in both diurnal (5 to Prospect: Bladder excitability is always thought as one 15 times, mean 8.9 times) and nocturnal (0 to 5 times, thing between the autonomic and non-autonomic. Our mean 3.0 times) frequencies were significant series of studies verified the existence of detrusor-original (p<0.001) according to voiding diaries at 1 week and 1 element in excitability regulation, and also verified the month after treatment. importance of detrusor-original excitation in the Conclusion The experimental and clinical evidence occurrence of overactive detrusor. But the role of demonstrated that vanilloids regulated the volume detrusor-original excitability in normal bladder still need threshold for eliciting micturition reflex, improved further studies. bladder response to partial bladder outflow obstruction, had long lasting effects on overactive 8. Bladder primary sensory neuron block: animal bladder resulting from a variety of reason. RTX, and clinical application which produced both an immediate and a prolonged desensitization, appeared to be less irritating than Zhichen Guan M.D. capsaicin and it may be more useful clinically. Department of Urology, Peking University Shen Zhen Hospital, China Objective To study the role of primary sensory neurons 9. Pyeloplasty: retroperitoneal laparoscopic vs. block using intravesical vanilloids (capsaicin and open approaches resiniferatoxin) both in animal and human. Material and Method From 1994 to 2004, six studies Xu ZHANG*, Hong-Zhao LI, Xin MA, Tao ZHENG, Bin LANG, Jun using 27 dogs and 123 rats were done to evaluate the ZHANG, Bin FU, Kai XU 16
  17. 17. Departments of Urology, Tongji Hospital (XZ, XM, BL, JZ, BF, KX), Cleveland, Ohio, USA;2 Division of Urology, Department of Tongji Medical College, Huazhong University of Science and Surgery, Tri-Service General Hospital, NationalDefense Medical Technology, Wuhan 430030, Xiangya Hospital of Central South Center, National Defense College, Taipei, Taiwan, R.O.C. University (HZL), Changsha and Xiangfan Central Hospital (TZ), Background. Living donor renal transplantation is a Tongji Medical College, Huazhong University of Science and treatment option for patients on dialysis in view of the Technology, Xiangfan,. ever-growing transplantation waiting lists and the Purpose: We evaluated the clinical value of stagnation in the number of deceased donors. In the retroperitoneal laparoscopic dismembered pyeloplasty for past, advanced age has been considered to be not a ureteropelvic junction good candidate for living donor renal transplantation. obstruction compared with open surgery. The aim of this study is to Materials and Methods: The clinical data of 56 patients analyze whether old age affects the outcome of living who underwent retroperitoneal laparoscopic dismembered donor renal transplantation. pyeloplasty were retrospectively compared with those of Methods. 527 first-time living donor kidney 40 patients who underwent open dismembered transplants were performed between January 1, 1995 pyeloplasty through a retroperitoneal flank approach. and January 1, 2006. The patient population was Student t-test, Pearson Chi-square test and Mann-Whitney divided into two subgroups base on the patient’s age at rank sum test were applied for statistical analysis as the time of transplant. Old patients were all recipients appropriate. age 60 years old and above at time of transplant; the Results: Patient's demographic data were similar between control group was all other patients. the two groups. In the laparoscopic group, operative time Results. There is a significant difference in (80 vs 120minutes), estimated blood loss (10 vs 150mL), readmission rate (p= 0.031) and patient survival rate recovery of intestinal function (1 vs 2days), analgesic (p< 0.001) between two groups. There is not a requirements (75 vs 150mg), incision length (3.5 vs significant difference in graft survival rate (p=0.808), 21cm), and postoperative hospital stay (7 vs 9days) were acute rejection rate (p= 0.7), serum creatinine level better than in the open group (p<0.001 for all). No and length of stay between these two groups (t=1.75, intraoperative complications occurred in either group. The p=0 .083). incidence of postoperative complications (2 of 56, 3.6% Conclusions. Living donor renal transplantation has vs 3 of 40, 7.5%, p =0.729) and success rates (55 of 56, been controversial in elder recipients. From the 98.2% vs 39 of 40, 97.5%, p = 0.058) were equivalent in clinical reviews, our results confirm that many older the 2 groups. patients may benefit from living donor renal Conclusions: Retroperitoneal laparoscopic dismembered transplantation. pyeloplasty is a minimally invasive, safe and effective therapy for ureteropelvic junction obstruction with low 11. Laparoscopic repair of injury to the inferior morbidity, shorter convalescence and excellent outcomes vena cava-report of three cases (Video) and can be accomplished reasonably quickly in experienced hands. Liqun Zhou*, Zhisong He, Ningchen Li, Ming Li.. Department of Urology, Peking University First Hospital 10. Graft Outcome of Living Donor Renal The Institute of Urology, Peking University Transplantation in the Elderly Recipients 8 Xi Shi Ku Street, West District, Beijing 100034, China Introduction and Objective: During laparoscopic Feng-Pin Chuang 1,2, Andrew C Novick 1, Guang-Huan Sun 2, Michael surgery, the injury to large vessels, such as inferior Kleeman,Stuart Flechner 1, V. Krishnamurthi 1,Charles Modlin 1, vena cava (IVC), often leads to open procedure for Daniel Shoskes 1 , David A.Goldfarb 1 repair to avoid bleeding in large amount. We report 1 Glickman Urological Institute, Cleveland Clinic Foundation, our primary experience of 3 cases to repair IVC injury 17
  18. 18. laparoscopically and evaluate the safety and efficacy of Objective: To investigate the feasibility and the such laparoscopic repair. clinical application value of the retroperitoneal Methods: From March of 1992 to August of 2006, we laparoscopic radical nephrectomy and regional have done 1,668 cases of laparoscopic procedures and lymphadenectomy of renal cell carcinoma (RCC). met 3 cases (0.18%) of IVC injury, which were partial Methods: Between July 2000 and May 2006, 242 adrenalectomy, radical nephrectomy and radical patients (159 males and 83 females) underwent ureteronephrectomy. These injuries were caused by retroperitoneal laparoscopic radical nephrectomy of dissection with electrocautery hook and harmonic scalpel RCC, of which 58 cases also underwent regional and 1.2cm, 0.2 cm (2 0.2cm fissures in 1 case) and 0.5cm lymphadenectomy. in length respectively. We repaired the fissures of IVC Result: All cases finished successfully. The mean laparoscopically with intermittent sutures of 3-0 Vincryl operation time was 170 min (range from 150-200 threads. The key point for suturing is to work in suction min); the mean blood lose was 150 ml (range from and needle holder in order to show the fissures clearly and 100-170 ml); the mean tumor diameter ranged from suture them accurately. 3-7cm. No case of local or systemic relapse or adrenal Results: All 3 cases were repaired successfully under metastases, but three cases of lymph node positive and laparoscopy and needed 4, 2 and 1 suture respectively. It five cases of homonymy adrenalectomy were took 21, 13 and 11 minutes and the amount of bleeding observed by a follow-up of 1-5 years. Conclusion: was just 120, 80 and 65ml for repair separately. One case The retroperitoneal laparoscopic and open radical developed partial unconsciousness, language and arm nephrectomy of RCC can achieve the same effect, and disability after operation and computerized tomography the former has the advantages of minimal invasion and showed several small infarction foci in brain, which might quicker recovery; however, the former should obey the be caused by gas embolism. She recovered full same operative principle with the latter. consciousness 1 week later and normal language and arm ability 6 weeks later, but remained the intermittent and 13. Correlation of COX-2 Expression in Stromal slight headache for 3 months. Other 2 cases had no Cells with High Stage, High Grade and Poor complications. There may be no bleeding at all when IVC Prognosis in Urothelial Carcinoma of Upper injury just occurs and can’t be found in time due to much Urinary Tracts higher pressure used for pneumoperitonium (14mmHg) than that of IVC (12cmH2O). It would make more gas Chih-Hsiung Kang, Po-Hui Chiang, Shun-Chen Huang*, and enter into IVC and gas embolism develop, which is more Hsuang-Lan Yu dangerous for patient. Department of Urology and *Pathology, Chang Gung Memorial Conclusion: Laparoscopic repair of IVC injury is safe Hospital, Kaohsiung Medical Center, Chang Gung University, and effective on skilled hands. The earlier the injury is Taiwan found and repaired, the less complications the patient Introduction: To investigate cyclooxygenase-2 develops. (COX-2) expression in carcinoma and stromal cells in patients with urothelial carcinoma of upper urinary 12. Retroperitoneal laparoscopic Radical tracts (UCUUT), and determine whether expression Nephrectomy and regional lymphadenectomy for patterns are associated with clinical characteristics and Renal Cell Carcinomas survival. Methods: Immunohistochemistry for COX-2 was Wei Zhang, Changjun Yin, Wei Zhang, Min Gu, Xiaoxin Meng, Qiang Lv, performed on paraffin embedded tumors from Lixin Hua, Zhengquan Xu, Yuangeng Sui UCUUT specimens from 79 patients. The level of Department of Urology, The First Affiliate Hospital of Nanjing Medical University, Nanjing 210029, China expression in carcinoma cells, the presence of stromal 18
  19. 19. cell expression, and the infiltration of inflammatory cells 3 pigs underwent the procedures in acute setting to were evaluated. establish and standardize the optimal technique. The Results: Strong and moderate expression of COX-2 in latter 6 pigs underwent the operation in chronic setting carcinoma cells was observed in 19 (24.1%) and 46 and were sacrificed 4 weeks later. The serum (58.2%) cases, respectively. In 36 (45.6%) cases COX-2 creatinine, electrolyte, intravenous urography and expression was present in stromal cells. The level of loopgram were performed before reconstruction and before euthanasia. The tissue near ureteroenteric COX-2 expression in carcinoma cells was not correlated junction was sent for histopathologic exams. with pathological stage ( P = 0.22), and not with grade (P Result: The mean operation time for laparoscopic = 0.45). COX-2 expression in stromal cells was correlated cystectomy and ileal conduit were 291.7 minutes. The with high stage (P < 0.0001) and high grade (P < 0.0001). mean operation time for endoluminal ureteroplasty The patient’s survival was reduced if the tumor revealed was 60 minutes. Intravenous urography before strong or moderate expression of COX-2 in carcinoma reconstruction revealed left hydronephrosis and cells (P = 0.03), the presence of COX-2 expression in hydroureter in all 6 pigs with significant in 3, stromal cells (P < 0.0001), and infiltrating inflammatory moderate in 2 and mild in 1. After correction, all the 6 cells (P = 0.0001) by log rank test. Prognosis was poor if pigs revealed patent ureteroenteric junction on loopgram. However, 2 pigs had complication of ileal the tumor was positive for both COX-2 expression in stoma stenosis. stromal cells and inflammatory cell infiltrate (P < Conclusion: Endoluminal endoscopic ureteroplasty is 0.0001). technical feasible, safe and effective. The merits of Conclusion: COX-2 expression in stromal cells shows minimal invasiveness can be maintained without the greater correlation with high stage and high grade than need of new incision and the good full-thickness strong COX-2 expression in carcinoma cells. It is healing with primary intent, minimal urinary suggested that stromal COX-2 expression could be used extravasation can be achieved. We believe the as a marker of poor prognosis in patients with UCUUT. techniques can be spread to human surgery in the near future. 14. Endoluminal Ureteroplasty for Ureteroenteric 15. Laparoscopic Radical Nephroureterectomy Stricture – A Feasibility Study In Porcine Model With Concomitant Radical Cystectomy for Multi-Focal Transitional Cell Carcinoma in Victor Chia-Hsiang Lin1, Allen W. Chiu2, Mihir M. Desai3, Inderbir S. Uremic Patients: Initial Experience Gill3 1E-Da Hospital/I-Shou University, Kaohsiung, Taiwan, 2Chung-Hsiao Victor C. Lin1, Allen W. Chiu2, Y. H. Lee3, T. J. Yu1 Mucinipal Hospital, Taipei, Taiwan, 3Cleveland Clinic, Cleveland, USA 1E-Da Hospital/I-Shou University, Kaoshiung, 2Chung-Hsiao Introduction: We describe a novel technique of Municipal Hospital, Taipei, 3Chi-Mei Medical Center, Tainan, endoluminal endoscopic ureteroplsty for ureteroenteric Taiwan stricture in which the conventional longitudinal incision is Introduction: Transitional cell carcinoma (TCC) is precisely repaired by sutures via the stoma of ileal conduit the most common urinary tract cancer in patients on in a survival porcine model. dialysis in Taiwan. It tends to be multi-focal, high Method: Under general anesthesia, totally 9 farm pigs recurrent, and intolerant to chemotherapy and underwent laparoscopic cystectomy and ileal conduit. radiotherapy. We present our experience of one Left ureteroenteric stricture was created by an additional session en-bloc laparoscopic unilateral or bilateral suture near the ureteroenteric junction. 3-4 weeks later, nephroureterectomy with radical cystectomy to treat these 9 pigs received endoluminal ureteroplasty. The first multifocal TCC in uremic patients. 19
  20. 20. Method: 7 uremic patients who were diagnosed methods, and especially the treatment options. multifocal TCC were enrolled. 4 patients were male and 3 Results: The online guidelines for CaP by CUA were patients were female. 5 had undergone ipsilateral available since July, 2006. The TCOG had the first nephroureterectomy or radical nephrectomy due to edition of CaP practice guidelines since 1999, and the previous history of unilateral upper tract cancer. These 5 second edition in 2003. While China version was patients underwent laparoscopic unilateral made by CUA, the Taiwan version was by nephroureterectomy and concomitant radical cystectomy interdisciplinary experts in TCOG. Magnetic due to multifocal recurrence of urothelial carcinoma. The resonance image (MRI) was suggested before other 2 female patients had simultaneous upper tract and transrectal prostatic biopsy in China but not in TCOG. bladder TCC in the first time diagnosis and both Both agreed to start checking prostate specific underwent one session laparoscopic bilateral antigen(PSA) level when the patient was 45 year-old nephroureterectomy with concomitant radical with a family history of CaP or 50 year-old. PSA cystohysterectomy. 6 trocar ports were used in our series. normal range was based on Chinese people data with Bilateral nephroureterectomy was performed under lateral age specific consideration by CUA and based on USA position by turning the operation table and the cystectomy data by TCOG. In predicting local staging and lymph was performed under the Tredelenberg position. The nodes, MRI was considered more informative by CUA specimen was retrieved either from vaginal route in than TCOG. The staging system was based on AJCC female patients or from old scar or midline in male 2002 by CUA and AJCC 1997 by TCOG, respectively. patients. At least there were no T2c in AJCC 1997 edition. In Result: Mean time for unilateral nephrectomy was 90 treatment, HIFU(high intensity focused ultrasound) minutes. Mean time to complete radical cystecotmy with and CSAP(cryo-surgical ablation of the prostate) was prostatectomy or hysterectomy was 147 minutes. Mean informed by CUA only. Hormone refractory CaP was blood loss was 530 ml. Mean postoperative hospital stay clearly defined with biochemical data by CUA and was 7 days. mainly based on clinical condition by TCOG. Neither Conclusion: In our initial experience, laparoscopic CUA nor TCOG suggested phytotherapy as an option nephroureterectomy with concomitant radical cystectomy of treatment. for multifocal TCC in uremic patients is a technically Conclusions: In this limited study, we demonstrated feasible, safe and efficacious modality. several varieties in the guidelines between both regions. Urologists should be aware of the differences 16. Prostate cancer management consensus and between the Chinese versions when applying CaP guidelines between china and taiwan guidelines to evaluate the Mandarin speaking patients with prostate cancer. Chih-cheng Lu, Chia-Ho Lin, Dennis Chian-Shiung Lin, Eric W. Fan, Tse-Chou Cheng 17. The Guidelines or Consensus in Managing Divisions of Urology, Department of Surgery, Chimei Foundation Benign Prostatic Hyperplasia among China, Hospital, Liouying, Tainan, Taiwan Singapore and Taiwan Purpose: To compare the clinical practice guidelines in managing prostate cancer(CaP) between China and Chih-cheng Lu, Chia-Ho Lin, Dennis Chian-Shiung Lin, Eric W. Taiwan. Fan, Tse-Chou Cheng Materials and Methods: The printed and online Divisions of Urology, Department of Surgery, Chimei Foundation materials in medical guidelines or consensus for CaP by Hospital, Liouying, Tainan, Taiwan Chinese Urological Association(CUA), and Taiwan Purpose: To analyze the updating guidelines or Cooperation Oncology Group(TCOG) were reviewed. It consensus in managing benign prostatic hyperplasia consisted of published date, revision history, diagnostic (BPH) around the Asian Chinese. It included China, 20
  21. 21. Singapore and Taiwan. Mandarin speaking patients. Also, this updating Materials and Methods: The printed and online comparison could do some help in establishing the materials in guidelines or consensus for BPH by Chinese practice guidelines, which is unpublished, in Urological Association(CUA), Singapore and Taiwanese managing BPH by TUA, since the consensus remains Urological Association(TUA) were reviewed. Several fragmented. statements were compared including published date, revision history, any Chinese translation version, patient selection, diagnostic methods, and treatment options. 18. Hemospermia Associated With Prostatic Cysts: Results: The online guidelines for BPH by CUA were Diagnosised by Transrectile Ultrasonographic available before August 2006. The TUA had the Chinese and Endocrectal Coil MR Imaging translation(complex characters) of International Prostate Symptom Score(IPSS) and consensus of combination SONG Wei-dong, XIN Zhong-cheng, ZHANG Zhi-chao, GAO Bing, medical therapy in February and May 2006, respectively. TIAN Long, LIU Bao-xing, WU Yi-guang, WU Xiao-jun, GUO Ying- The earliest Chinese version of IPSS was published by lu Ministry of Health of Singapore. Both of the Chinese Andrology Center, Peking University First Hospital, Peking version by CUA and Singapore were written in simplified University,Beijing(100009), China characters. Neither CUA nor TUA interpreted precisely Objective: Hemospermia often associated with IPSS, which consists of 8 questions. The summed score 0 prostate cysts or perioprostatic tissues the radiological to 35 is from the 7 urinary indexing symptoms. Among diagnosis of prostatic or periprostatic cysts could be these Chinese editions of IPSS, only the translated title an ideal methods for define the relationship of a cyst was the same. The following 7 urinary symptoms to surrounding structures, such as the vas deferens, indexing questions and the eighth question about quality seminal vesicles, and ejaculatory ducts. To evaluate of life were semantically different. Only in the guidelines the role of transrectal ultrasonography (TRUS) and by Singapore established trans-abdominal prostatic endorectal coil MR in the diagnosis of hemospermia grading and staging systems for BPH as non-invasive associated with prostatic cysts. methods for evaluation and treatment. Either trans- Methods: One hundred twenty patients with abdominal or trans-rectal route for sonography was hemospermia were performed transrectal ultrasound accepted by all. The Age over 50 was announced suitable between August 2005 and March 2007, and 28 cases for guidelines both in CUA and Singapore. There were (23.3%) were found medical prostatic cysts, among of documented industrial support in building the guidelines them 24 cases were further evaluated clinical or consensus; it was Merck for CUA and symptoms and performed endorectal coil MR. Yamanouchi(now as Astellas) for TUA. The CUA Results: Of the 24 men, 16 (67%) complained of considered 5-alpha reductase inhibitors as options of the prostatitis-like symptoms, 12 (50%) with scrotal pain, first line therapy; while the TUA restricted them to be the 7 (29%) with small volume ejaculation, and 5 (21%) second line therapy. The use of 5-alpha reductase with painful ejaculation. All patients had normal inhibitors by TUA was not compatible with the rules set follicle stimulating hormone levels, normal or low by National Health Insurance of Taiwan. Long term of fructose levels in the seminal fluid. On the basis of phytotherapy for clarification was suggested by CUA and MR imaging appearance, 18 (75%) had no anatomic Singapore while no consensus was done by TUA. ejaculatory duct abnormalities. Of the remaining Conclusions: Mandarin is currently used without patients, 4 (17%) had seminal vesicle dilatation, 2 significant difficulty around these regions. People are (8%) had seminal vesicle hypoplasia. Prostatic cysts traveling and communication more and more; the are easily identified on MR imaging by virtue of their urologists should be aware of the differences among the high signal on T2-weighted images and can be Chinese versions when applying IPSS to evaluate the characterized because of their typical locations and the 21
  22. 22. high resolution and multiple imaging planes provided by Conclusion: Different kinds of penile prosthesis MR. implantation was ideal methods for treatment of SED Conclusion: With these results suggested that TRUS and in Chinese patients, and one stage implantation endorectal coil MR are important non-invasive diagnostic AMS700CXM with visual internal urethrotomy seams tools that minimize the need for more invasive studies in safe and effective method for treatment of SED with the evaluation of hemospermia, particularly when urethra stricture. associated with prostatic cysts. TRUS and endorectal coil MR were not only helpful in establishing the diagnosis 20. Sural Nerve Grafting During Laparoscopic but also in determining the choice of treatment. Radical Prostatectomy---Initial experiences of two patients 19. China Experience of Penile Prosthesis Implantation for Sever Erectile Dysfunction Xin Gao, Xiaopeng Liu, Jianguang Qiu, Hengjun Xiao, Tujie Si Dept. of Urology, the Third Affiliated Hospital of Sun Yat-sen Zhong Cheng Xin, Zhi Chao Zhang, Wei Dong Song, Long Tian University, 510630, Guangzhou, China. Andrology Center of Peking University First Hospital, Peking Introduction and Objectives: Sural nerve grafting University, Beijing(100009),China for patients undergoing radical prostatectomy (RP) has Purpose: In order to evaluate the effects of different kinds been previously reported using open and robotic of penile prosthesis implantation for Chinese patients with laparoscopic methods. We report our initial sever erectile dysfunction (SED). experiences with sural nerve interposition during Subjects and methods: Total 98 cases of Chinese laparoscopic radical prostatectomy (LRP). patients with SED were treated by different kinds of Methods:Between April and July 2005, two potent penile prosthesis implantation during Oct. 2001-Jan. 2007 men were underwent sural nerve grafting during LRP were followed up using questionnaire form. Mean age of in our department. The age of patient was 59 and 61, patients was 33.4±10.6 years old and duration of SED respectively. A plastic surgery team harvested 10 to 15 was 5.5±4.5 years. Among of them the vasculargenic SED cm of sural nerve from the left leg. The neurovascular was 63 cases (64.3%), neurogenic ED was 20 cases bundles (NVB) were extensively excised in left side of (20.4%), DM 10 cases(11.2%), Peyronine’s disease 4 patient 1 and both sides of patient 2. With the hem-o- cases(4.1%). Three piece penile prosthesis AMS700 CXM lock located the stump of NVB, sural nerve for 69 cases(70.4%) and Manto alpha I for 3 cases(3.1%) interposition was performed using 2 stitches of each and AMS 650 malleable prosthesis 26 cases(26.6%). end with 6-0 polypropylene. Postoperative sexual Among of them, 3 cases were performed one stage rehabilitation included oral small dosage of sidenafil implantation of AMS700CXM with visual internal (25mg/d) after catheter removed and intracavernosal urethrotomy. Patients and partner’s satisfaction with injection of PGE1 10-30μg, once weekly, which penile prosthesis implantation were followed up with helped the penile engorgement occasionally. questionnaires form. Postoperative potency was defined as the ability to Results: Among of patients 2 cases (2.0%) mechanical penetrate and complete sexual intercourse with or malfunction, 1 case mechanical malfunction with tube without the use of oral agents. The follow-up was rupture in DM patients with sever cacernosum fibrosis 14-18 months. Patients’ potency was evaluated with was reimplanted AMS650 malleable and I case IIEF-5 and NPT test by Rigiscan. malfunction with fluid leakage, however, the patients was Results:The sural nerve grafting through LRP was satisfied with oral medication with PDE5i such as performed successfully in both patients with mean Sildenafil, Tadanafil and Vardenafil. Patients and partner’s operating time of 5.5 hours. During a follow-up of 6 satisfaction with penile prosthesis implantation were months, both patients reported penile engorgement 92.4% and 89.8%. with sidenafil but not sufficient for penetration. At the 22
  23. 23. 12th month, patient 1 reported spontaneous erection (p=0.32), 17.3±2.9 versus 18.7±3.2 (p=0.037) at 3 without any help, erectile number was 1-2/night, erection months, and 17.9±2.7 versus 18.7±3.0 (p=0.17) at 1 time was 13±3.5min (70-80%rigidity or greater). Patient 2 year postoperatively, respectively. The deterioration of was potent enough to penetrate with oral sidenafil, erectile function at baseline and 3-month erectile number was 0-1/night, and the erection time was postoperatively were observed (p < 0.001) for both 25±6.5min (20-40%rigidity). groups. The percentage of retrograde ejaculation Conclusions:Sural nerve graft interposition during LRP is between two groups were not significant (p=0.33) at technically feasible and benefits for postoperative 3-month postoperatively. erection. Post-operative sexual rehabilitation is safe and Conclusions: Our study reveals that higher useful for potency recovery. intraoperative rectal temperature difference caused by transurethral electrovapor resection for treatment of 21. Erectile Dysfunction Following Transurethral symptomatic prostatic hyperplasia might affect the Electrovapor Resection for Different Sized postoperative erectile function, particularly in a small Prostates prostate. Chih-Kuang Liu1, 3, Ming-Chung Ko1, 3, Huey-Sheng Jeng1, 2, Wen-Kai 22. A Mode Of Treatment For Penilie 1 2 Lee , Hong-Jeng Yu , Han-SunChiang 3 Incarceration – An Unusual Complication Of 1 2 Department of Urology, Taipei City Hospital, Department of Urology, Masturbation National Taiwan University Hospital, 3College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan Jesun Lin, Gin-Bow Chang, Herng-Jye Jiang, Mon-I Yang, Objective: To assess and compare the relationship Huai-Long Tai,and Bai-Fu Wang between erectile function and intraoperative rectal temperature changes of potent patients with different Department of Urology, Changhua Christian Hospital, prostate sizes undergoing transurethral electrovapor resection treatment (TUVRP). Changhua, Taiwan Patients and Methods: 86 potent patients with lower urinary tract symptoms (LUTS) secondary to benign Purpose: We investigated a technique for releasing prostatic hyperplasia (BPH) were recruited. Patients were an incarcerated penis from the hole of a thick steel divided to group1-small prostates (<40 ml), and group 2- plate with minimal invasion. large prostates (≧40 ml) as determined by transrectal Material and Methods: The patient had his penis ultrasound (TRUS) measurement. The intraoperative incarcerated in a 2 cm diameter hole with 2 cm thick rectal temperature was evaluated by transrectal steel plate. We aspirated the congested blood from the thermosensor and the temperature differences (the highest glans penis and incised the edema and ecchymosis intraoperative temperature minus the preoperative prepuce to facilitate the escape of subcutaneous temperature) were recorded. The erectile function at congestion blood and fluid. A rubber band was baseline, 3 months and 1 year postoperatively were wrapped around the penile shaft immediately distal to assessed by the International Index of Erectile Function-5 the thick steel plate. A fine mosquito hemoclamp was (IIEF-5) Questionnaire. then inserted to grasp the end of the rubber band Results: The intraoperative rectal temperature differences through the hole. The thick steel plate was gradually were 0.54±0.24 ℃ in the group 1 (n=45) versus worked along the penile shaft until it was free from 0.44±0.20 ℃ in the group 2 (n=41), (p=0.04). The erectile incarceration. function data were available for 84 and 78 patients at 3 Results: This mode can be used to release the penis and 12 months, respectively. The IIEF-5 scores were from incarcerating objects in emergency situation. The 20.9±1.6 (group1) versus 20.6±1.6 (group 2) at baseline method can be performed in an operating room with 23
  24. 24. minimal equipments and simple technique. The penis is 24. Association of the phenotype of seminal able to sustain very little injury. vesicles and CFTR gene mutation in the Discussion: The penile incarceration in a thick steel plate. patients with congenital bilateral absence of It is impossible to cut the thick steel without injury of the the vas deferens penis in an emergency state. The patient has been followed up for more than ten years and no any deficit in Chien-Chih Wu1,2, Chia-Hung Liu2, Han-Sun Chiang1,3 sexual or urinary condition. 1 Department of Urology, School of Medicine, Taipei Medical Conclusion: We recommend this procedure for the University, Taipei, Taiwan treatment of penile incarceration in similar conditions 2 Department of Urology, Taipei Medical University Hospital, because it is simple and effective. Taipei, Taiwan 3 Fu Jen Catholic University, Taipei, Taiwan Purpose: Cystic fibrosis (CF) is caused by the 23.Effect of Cox7a2 on LH induced testosterone mutation of cystic fibrosis transmembrane production and expression of StAR protein, conductance regulator (CFTR) gene; different P450scc and 3β-HSD enzymes in TM3 mouse composition of the mutated genes resulted in varied Leydig cells degrees of anomaly in phenotype. Among these, congenital bilateral absence of the vas deferens Liang Chen, Zhong-Cheng Xin,,Long Tian, Yi-Ming Yuan, Gang Liu (CBAVD) is recognized as a mild form of CF. Besides , Ying-Lu Guo the defect of bilateral vas deferens in CBAVD Andrology Center, Peking University, First Hospital, Peking University, patients, there are various anomalies in the expression Beijing 100009, China of seminal vesicles, including agenesis, hpoplasia, and Objective: The cloning of Cox7a2 one respiratory chain even normal expression. This study is to analyze the related gene showed highly expressed in aging male testis association of seminal vesicle phenotype and the tissue in previous study and the effect of Cox7a2 on mutation spectrum of CFTR gene in CBAVD patients. steroidogenesis and the involved mechanism was investigated. Materials and Methods: DNA samples were Methods: In the present study, TM3 cells are over- collected from 20 CBAVD patients. Temporal expressed Cox7a2 by transient transfection of temperature gradient gel electrophoresis (TTGE) recombinant Cox7a2 cDNA plasmid. LH-induced followed by DNA sequencing was used to screen testosterone production is observed by ELISA, and the CFTR mutation for all collected DNA samples, which expression of StAR, P450scc and 3β-HSD was were then classified into homozygous (the same investigated by Western blotting in TM3 cells over- mutations both in 2 alleles), compound heterozygous expressing Cox7a2 fusion protein. (2 different mutations separately in each allele), Results: Cox72 inhibited the LH-induced testosterone in heterozygous (one mutation in one of the 2 alleles), TM3 mouse Leydig cells. In the results of Western and wild (no mutation detected in both alleles). blotting, the expression of StAR protein decreased in Transrectal ultrasound was applied for these 20 TM3 cells over-expressed Cox7a2, but the expression of CBAVD patients to record the phenotype of the P450scc and 3β-HSD did not altered obviously. seminal vesicles, the results were classified into Conclusion: Data presented here reveal an unknown role agenesis, hypoplasia, and present. of Cox7a2 in the regulation of the expression of StAR protein, and in its consequent mediating androgen Results: The CFTR mutations were homozygous in 4 biosynthesis. In TM3 cells, the negative regulatory effect of the patients, and their seminal vesicles showed of Cox7a2 on steroidogenesis is, at least, a result of the agenesis in 2 of them (50%), hypoplasia in the other 2 decreased expression of StAR protein. (50%). The CFTR mutations were heterozygous in 9 24

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