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Background: The value of lymphadenectomy in the management of renal cell carcinoma (RCC) remains controversial. Most would agree that lymphadenectomy (LD) provides accurate pathologic staging for prognostic data. The question remains whether there is any significant therapeutic benefit from extensive lymph node dissection with radical nephrectomy. The aim of this study was to compare outcomes in sampled lymphadenectomy (SLD) and extensive lymphadenectomy (ELD) with radical nephrectomy for RCC., Methods: One hundred and thirty-seven patients with RCC were enrolled in this study from Oct. 1982 to Dec. 1996. Eighty-one patients received radical nephrectomy with SLD (stage I: 43, II: 16, III: 22). Fifty-six patients received radical nephrectomy with ELD (stage I: 30, II: 11, III: 15)., Results: The mean number of lymph nodes removed by SLD was 4 (ranged from 1 to 8). The mean number of lymph nodes removed by ELD was 16.1 (ranged from 9 to 32). Overall 5-year survivals for SLD in stages I, II and III were 98%, 80% and 38%, respectively. Overall 5-year survivals for ELD in stages I, II and III were 92%, 84% and 40%, respectively., Conclusions: There is no significant therapeutic benefit from ELD in patients with RCC receiving radical nephrectomy.

Primary renal sarcoma represents approximately one per cent of all primary tumors of the kidney in adults. We report an unusual case of primary renal sarcoma with inferior vena cava (IVC) thrombus. This patient presented with hemorrhagic shock due to tumor rupture. Emergent radical nephrectomy and vena caval thrombectomy were performed. Histological examination proved a clear cell sarcoma.

A rare case of ureteral stump metastasis 3 months after nephrectomy for a renal cell carcinoma is presented. A 62-year-old female had undergone right radical nephrectomy 3 months earlier because of renal cell carcinoma in our hospital, and she came back due to gross hematuria. Cystoscopy revealed a papillary mass with a vascular pedicle protruding from the right ureteral orifice. Transurethral resection of the bladder tumor over right ureteral orifice was performed and the pathologic result showed clear cell adenocarcinoma, which argued in favor of a metastatic lesion from the previous renal cell carcinoma. Ureterectomy and a bladder cuff excision were then adopted for this patient, but no residual tumor was found over the remaining ureter. Nevertheless, the patient died of cancer 36 months after the event of ureteral stump metastasis.

Background: Irrigating fluid is necessary for transurethral resection of the prostate (TURP). Initially, distilled water was used as irrigating fluid and some advantages and complications were noted. Although other solutions were used to substitute for distilled water, we collected data for changes in electrolytes and hematocrit (Hct) during surgery to evaluate the safety of distilled water as irrigating fluid for TURP with suprapubic trocar cystostomy., Methods: Fifty-three patients who underwent TURP using distilled water as irrigating fluid were investigated. TURP was performed with suprapubic trocar cystostomy routinely. Preoperative and postoperative blood samples were collected and analyzed for electrolytes and Hct to study any changes during surgery., Results: The change in plasma sodium concentration was not statistically significant, but the decreases in blood Hct and plasma potassium concentration were statistically significant. There was no major operative complication and no clinical-evident related postoperative renal impairment., Conclusions: Distilled water is a relatively safe solution as an irrigating fluid for TURP under drainage with suprapubic trocar cystostomy, but attention must be paid to the inevitable blood loss during surgery.

Background: Experience suggests that tumor growth is dependent on angiogenesis. The intensity of angiogenesis in human cancer is reported to be predictive of the probability of metastasis in many types of cancer. The aims of this study were 1) to determine the relationship of microvessel density (MVD) in renal cell carcinoma to pathologic stage, and 2) to evaluate the role of MVD in metastasis., Methods: Paraffin-embedded tumor specimens were reviewed from 34 unselected patients with RCC who had undergone surgery from 1986 to 1990 at Taichung Veterans General Hospital. The pathology findings and clinical records were reviewed to note relationships between pathologic stage and whether or not metastasis had occurred. Specimens were studied from 16 cases (eight Stage I cancers, five Stage II and three Stage III) without metastasis and from 18 cases (two Stage I, six Stage II, six Stage III and four Stage IV) in which metastasis later developed. Microvessels were highlighted by immunostaining endothelial cells for factor VIII-related antigen. Microvessels were counted in a x-400 field (0.1885 mm2/field) in the most active areas of neovascularization., Results: The 16 patients without metastasis have survived for between 65 and 136 months (mean, 94.5 months), up to the present time. Of the 18 patients with metastasis, 15 died and three survived, with mean survivals of 42.8 months (range, 12-99 months). Mean overall MVD was 99.6 vessels; mean MVD was 98.5, 96.2, 109.3 and 90.0 in Stages I, II, III and IV tumors, respectively. Mean MVD was 99.3 in patients without metastasis and 99.9 in patients with metastasis., Conclusions: MVD does not correlate with pathologic stage and is of no prognostic significance in renal cell carcinoma.

Background: The aim of this study was to compare outcomes in patients with symptomatic and incidental renal cell carcinoma (RCC)., Methods: From October 1982 to December 1996, 200 patients with RCC were enrolled in this study. Their medical records were reviewed for symptoms, tumor stage, and lymph node and metastatic status. Symptomatic and incidental RCCs were compared by the overall survival rate of patients. The survival rate was determined by the Kaplan Meier method. Log rank testing was used to analyze the statistical difference in the survival period between both groups., Results: The proportion of incidental RCC was 21% (42/200). The majority of cases (73.8%) were diagnosed primarily by abdominal ultrasonography. Incidental RCCs were smaller in size than symptomatic RCCs (5.1 +/- 2.0 cm vs. 7.5 +/- 1.8 cm, p = 0.001). Incidental RCCs were of a lower stage, and patients with incidental RCCs had significantly longer overall survival rates than those with symptomatic RCCs (p < 0.001)., Conclusions: Ultrasonography is a useful tool for the detection of incidental RCC. Improvement in the overall survival rate of incidental RCC patients suggests that when these tumors are identified earlier, treatment results are better.

Background: The aim of this study is to compare the application of gaseous retroperitoneoscopic (GR) and gasless retroperitoneoscopy-assisted (GLRA) unroofing of renal cysts., Methods: Fourteen patients with symptomatic simple renal cysts had undergone unroofing of the cyst with GR in seven cases and GLRA in seven others. Three trocars (10 mm, 10 mm and 5 mm) were inserted in the GR procedure. A 3 cm flank muscle-split incision was made and retroperitoneoscopy was performed through the same incision in the GLRA procedure. Then, the cyst was unroofed., Results: The mean operative time was 104.3 minutes in the GR group and 52.1 minutes in the GLRA group, respectively (p = 0.001). The mean requirement of postoperative meperidine hydrochloride injection was 21.4 mg in the GR group and 71.4 mg in the GLRA group, respectively (p = 0.017). In the GR group, the mean postoperative stay was 3.7 days, and the time needed for return to normal activity was 7 days. In the GLRA group, the mean postoperative stay was 4.6 days, and the time needed for return to normal activity was 8 days., Conclusions: GR and GLRA techniques for unroofing of renal cysts are safe, effective and minimally invasive. GLRA is easy to perform and a more time-saving procedure when compared to GR, however, the patients of GLRA suffered more postoperative pain than after GR. GLRA is recommended in patients who had received retroperitoneal surgery or who have multiple renal cysts.

Background: Primary aldosteronism (PA) is a rare but potentially curable cause of hypertension. Between October 1982 and November 1994, 30 patients of PA received unilateral adrenalectomy with a long-term follow up (mean:60.3 months). Nineteen (63.3%) cases were cured (Group 1); 11(36.7%) cases were improved (Group 2). The purpose of this study was to determine prognostic factors after surgery in patients with PA., Methods: A retrospective analysis was performed regarding age and sex of the patients, duration of hypertension, family history of hypertension, preoperative blood pressure, plasma aldosterone concentration (PAC), plasma renin activity (PRA) and efficacy of spironolactone on blood pressure between both groups. End-organs (including kidney, heart, retina and brain) involvement was evaluated and compared. Adrenalectomy and renal biopsy specimen for pathology were similarly evaluated., Results: The duration of hypertension was longer in Group 2 than in Group 1 (8.18 +/- 4.94 vs 5.21 +/- 4.24 years). The efficacy of spironolactone on blood pressure (BP) was positive in 81.8% of Group 1 and 16.7% of Group 2. Adrenal cortical adenoma in 24 cases with a cure rate of 70.8% (17/24) and adrenal cortical macronodular hyperplasia in 6 cases with a cure rate of 33.3% (2/6) were noted. Group 2 had more end-organs involvement than Group 1. The severity of histopathological change of the renal biopsy was similar., Conclusions: This study suggests that preoperative response of blood pressure to spironolactone administration predicts the postoperative prognosis of hypertension in patient with PA. Long duration of hypertension and involvement of two or more end-organs were poor prognostic factors. Excellent results can be achieved by unilateral adrenalectomy in adrenal cortical adenoma and fair results, in adrenal cortical macronodular hyperplasia.

From 1985 to 1993, five male patients with posterior urethral valves were treated at our hospital; they included three newborns, a 32-month-old and a 10-year-old child. On initial examination, all patients showed severe bilateral hydronephrosis and hydroureter on sonographic findings, dilatation of the prostate urethra and trabeculation of the bladder wall in the voiding cystourethrogram; only one patient showed vesicoureteral reflux. Type I urethral valves were present in all patients. Retrograde transurethral ablation of the valves was performed in four patients with good preoperative renal function. The postoperative courses were smooth except for vesicoureteral reflux in one patient and systemic fungus infection in another. Reimplantation of the ureter was done for the vesicoureteral reflux, and the fungus infection was treated by amphotericin B. Cutaneous vesicostomy was performed for a newborn since the urethral orifice was small. He presented with poor renal function and ascites. Delayed antegrade ablation of the valves per vesicostomy and closure of the vesicostomy were done three months later after restoration of the renal function. Renal function returned to normal after operation in all patients, but the function of the upper urinary tract and bladder continence need long-term follow-up.

From May 1983 to January 1993, 162 patients received renal transplantation at Taichung Veterans General Hospital. Two patients developed bowel perforation after this surgery. One was proved at 21 days and another, at 13 days after renal transplantation. Both patients died as a direct result of the perforation. From a review of literature, the average incidence is 2.7%, and the average mortality rate is 56.5%. Because of this high mortality rate, a high clinical suspicion, prompt and adequate surgical intervention, reduction of immunosuppressive agents and effective antibiotic coverage should contribute to a decline in mortality.

Background: The best response to surgical treatment of primary aldosteronism occurs in patients with an aldosterone-producing adenoma (APA), so pre-operative localization of the lesion is necessary., Methods: A comparison was made of five localizing modalities-computed tomography (CT) of the adrenal gland, magnetic resonance imaging (MRI), dexamethasone suppression-131I-19-cholesterol adrenal scintiscan (DS, NP-59 adrenal scan), adrenal venography (venography) and adrenal venous sampling for aldosterone content (AVS) in 22 patients (12 women, 10 men) with primary aldosteronism; all had undergone operative confirmation within the past 9 years. The age at diagnosis ranged from 27 to 67 years (mean: 39.7)., Results: Unilateral adrenalectomy resulted in normal blood pressure without medication in 63.6% (14/22), and in improvement in 36.4% (8/22). Correct localization of the lesion was obtained in 95% (20/21) by CT, 100% (7/7) by MRI, 80% (12/15) by DS,NP-59 adrenal scan, 100% (6/6) by AVS and 78% (7/9) by venography., Conclusions: This experience would advocate CT of the adrenals as the initial means of localizing an APA on an outpatient basis because it is comfortable, safe, inexpensive and gives immediate results. The major role of MRI in the evaluation of adrenal adenoma should be complementary to CT. DS, NP-59 adrenal scan can be an adjuvant method for localization if CT scan results are not definitive. Adrenal venous catheterization with blood sampling for aldosterone content could be reserved for patients whose biochemical finging suggests the presence of an APA, and for whom CT or MRI of the adrenals and DS, NP-59 adrenal scan are inconclusive.

Perycit (Pentaerythriol Tetranicotinate), a slow releasing drug, is one of the drugs used for treating hyperlipemia. Patients with erectile dysfunction (impotence) associated with hyperlipemia increasingly seek help at urological services. This study investigates the clinical effect, both objective and subjective of Perycit on anti-hyperlipemia as well as on impotence. Twenty patients with a more than one year history of impotence with hyperlipemia were enrolled in this randomized, single-blind study. Decrease of total cholesterol, and triglyceride, as well as the increase of high density lipoprotein cholesterol in the study group (Perycit, 500 mg, tid, for 3 months) were significantly different from the pre-treatment period and in the control group (Trental, 100 mg, tid, for 3 months) (p < 0.05 or p < 0.01). Moreover, improvement in sexual function was shown to be better in the study group than in either the pretreatment period and control groups, objectively and subjectively (p < 0.05 or p < 0.01). Tolerable facial flush was found in 3 of these 20 patients, but no major side effects were encountered. In conclusion, this study indicates Perycit is effective for anti-hyperlipemia as well as for aiding improvement of sexual dysfunction. Since it is a slow-releasing preparation, the side effect is minimal. It is recommended for patients with hyperlipemia alone, or those who suffer from combined erectile dysfunction.

Since its introduction, extracorporeal shock-wave lithotripsy (ESWL) has become the treatment of choice in patients with urinary calculi. But the pain during ESWL is intolerable for many patients. Tramadol HCL resembles morphine in that it depresses motor and sensory responses of the spinal nociceptive system by a spinal and a supraspinal action. The side effects of tramadol are less than morphine. A prospective study was performed to determine the effect of tramadol in ESWL for the patients with urinary tract calculi. Ninety patients were randomized divided into three groups. Group A 40 patients (male:female = 31:9) received oral tramadol HC1 100 mg; group B 17 patients (male:female = 12.5) received multi-vita; group C 33 patients (male:female = 26:7) received analgesic (contained aspirin 399 mg and codeine phosphate 15 mg). The patients took the drugs 30 minutes before ESWL. The patients with renal calculi > 2 cm in diameter or ureteral calculi > 1 cm in diameter were excluded. The lithotriper used in our hospital is Siemens Lithostar. According to the description of the patients postoperatively, the pain intensity during ESWL was identified with Verbal Scale and Visual Analogue Scale (VAS). The statistical method is one-way ANOVA. Statistical difference is significant when p < 0.05. The mean age of patients group A is 46.5 +/- 17.1, group B 45.5 +/- 14.4, and group C 50.5 +/- 14.6. The mean diameter of urinary calculi of group A is 0.98 +/- 0.41 cm, group B 1.09 +/- 0.33, and group C 1.06 +/- 0.43.(ABSTRACT TRUNCATED AT 250 WORDS)

Transrectal fine needle aspiration and biopsy were performed on 100 patients with suspicious prostatic lesions using 22 gauge aspiration needles and 18 gauge biopsy needles. These collections were made from January 1990 to June 1991. Sufficient prostate tissue for cytological and histological diagnosis were obtained in 97% (97/100) and 99% (99/100), respectively. Thirty-nine patients (39%) were diagnosed having cancer with an accuracy rate of 89.7% (35/39) by histology and 69.2% (27/39) by cytology. One patient with a normal cytological aspiration was found to have an atypical biopsy, therefore, the biopsy was repeated and the prostate showed adenocarcinoma. Our results indicate that the needle aspiration cytology has a less accurate diagnosis rate than the needle biopsy histology. Fine needle aspiration is a safe and effective outpatient procedure but there is a definite learning curve before its use can be fully exploited. It is important to have experienced urologists and pathologists to perform these aspirations until sufficient experience is accumulated.

Citrate is recognized as one of the inhibitors of urinary stone formation. If the urinary citrate and pH could be elevated by the supply of potassium citrate, the recurrence of stone formation would hopefully be prevented. Urocit-K is a kind of slow releasing preparation of potassium citrate. The pharmacokinetics of Urocit-K is investigated in this study, which included two groups: 1) the hypocitraturia group consisting of twenty patients and 2) the normal volunteer group consisting of ten persons. Urokit-K was administered to patients in 10 mEq doses, t.i.d. for 2 weeks. Comparison of urinary biochemistry was done prior to, and one week after administration of the Urocit-K. In the normal volunteer group, the pharmacokinetics of Urocit-K was determined by urinary pH, K, and citrate. Determinations were made six times a day (every 2-hours for first 8 hours, 7- and 9- hours for the last 16 hours) with Urocit-K for comparison. This study indicated that Urocit-K increases urinary pH, K, and citrate in hypocitraturic patients. In the normal volunteer group, Urocit-K deserves its slow-releasing property shown by a constant increase of urinary pH and K for the first 8 hours; and urinary citrate for almost 24 hours. No apparent complications, such as gastrointestinal upset or cardiopulmonary discomfort were observed. In conclusion, Urocit-K is an excellent preparation of potassium citrate and a good choice for prevention of stone recurrence.

We reported 29 kidneys with angiomyolipoma in 23 patients (14 women and 9 men). One of these cases was associated with tuberous sclerosis. Their age ranged from 20 to 82 years (mean 48.9). Six patients had bilateral renal involvement and 7 had multiple lesions in one kidney. Synchronous renal tumors were noted in three patients. One patient was associated with renal cell carcinoma, and the other two patients with transitional cell carcinoma. Nineteen tumors in 16 patients were larger than 4 cm. Among them 93.8% (15/16 patients) were symptomatic and tumor hemorrhage was found in 57.9% (11/19 kidneys). Of these patients, 17 renal units underwent surgical intervention (including 8 total nephrectomy, 7 partial nephrectomy and 2 enucleation of tumor). Preoperative diagnosis was made in 82.4% (14/17) with combined imaging of sonogram and CT scan. One patient received embolization only. There were two mortalities: one patient with tumor rupture who received emergent nephrectomy but died of irreversible hypovolemic shock, and the other with tuberous sclerosis and pulmonary fibrosis who received embolization for spontaneous rupture of tumor but expired due to respiratory failure. Among nine patients receiving renal preserving operation, the post-operative effective renal plasma flow of the affected kidneys ranged from 96 to 184 ml/min (mean 131.7 ml/min). There was no evidence of recurrence during a mean followup of 2.6 years. Eight asymptomatic patients with 9 renal masses had incidental angiomyolipoma and did not undergo exploration. We did not note any progression of the lesions in the cases under observation for a mean followup of 2.6 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Twenty-four cases of primary carcinoma of the bulbo-membranous were reviewed. While half of them had history of gonorrhea or urethral stricture, most of patients initially presenting with high grade (58%) and high stage (91%) contributed to the poor prognosis of the patients studied. Some patients with clinical localized disease were cured by radical cysto-prostatectomy, penectomy with or without emasculation and resection of inferior pubic rami following with or without preoperative irradiation. The result of radical irradiation is uniformly poor. Based on the small number of cases in this report, we could not conclude that preoperative irradiation would improve the results of excision; however, the recent introduction of neoadjnvant chemotherapy for patients with transitional cell carcinoma warrants further investigation.