The challenges in diagnosing isolated epididymal tuberculosis (TB) in an adolescent male: a case report

BACKGROUND

Genitourinary tuberculosis (GUTB) is a common form of extrapulmonary TB (EPTB) in children. An example of GUTB is epididymal TB, which usually presents unspecific chronic clinical manifestations. Definitive diagnosis can be conducted based on bacteriologic confirmation and histopathologic results, but this is challenging due to the paucibacillary nature of EPTB. Therefore, we reported the challenges in diagnosing isolated epididymal TB in an adolescent male.

CASE PRESENTATION

A 16-year-old male presented to respirology clinic with painful swelling of the left scrotum for 3 months before visiting to the hospital. The symptoms were associated with persistent coughing for 2 months, and physical examination of the left scrotum showed swelling accompanied by cardinal signs. A palpable hard mass was found on the left scrotum, with firm borders, measuring 7 × 4 cm. Laboratory examination and tumor markers were within normal limits, although leukocyturia was found, and the urine culture was negative. Genital ultrasound (US) showed epididymitis sinistra with septal hydrocele, while magnetic resonance imaging (MRI) indicated inhomogeneous left epididymitis with bilateral inguinal lymph node enlargement. Although TB evaluation presented a negative purified protein derivative (PPD) test and bacteriologic examination, chest X-ray (CXR) showed perihilar lymphadenopathy. Based on the clinical and radiologic results suggesting TB, the patient was diagnosed with isolated epididymal TB and received quadruple antituberculosis therapy (ATT) for 6 months. After treatment, the left testicle size started to shrink and was equal to the right testicle, also, there were no signs of inflammation, the body weight increased by 5 kg, and cough disappeared. Sperm analysis at the end of treatment indicated teratozoospermia, which was subsequently treated by the urologic surgery department.

CONCLUSIONS

Biopsy and bacteriologic confirmation for TB epididymitis were challenging to perform in the clinical setting. Epididymal TB should be considered in adolescent males with complaints of chronic scrotal swelling and pain. Clinical judgment based on history taking, physical examination, and radiologic features supporting TB features could be helpful in accurate and fast diagnosis for favorable outcome.

The role of angiotensin receptor blocker (losartan) on decreasing fibrotic process of corpora cavernosa in priapism model of wistar rats

Background

Priapism induces regulation of Transforming Growth Factor-β1 (TGF-β1) expression and collagen-type-1 deposition. This will replace the normal corpora cavernosa with fibrotic tissue which eventually resulted in erectile dysfunction. It is also known that the fibrosis process of corpora cavernosa is related to Renin-Angiotensin II System (RAS). Angiotensin II receptor blockers (ARB), especially losartan, inhibit the inflammation process and fibrotic tissue formation. This study evaluated the effect of losartan in reducing fibrosis in priapism by evaluating TGF-β1 and collagen-type-1 in cavernous tissue and determined the effect of losartan in preventing fibrosis in priapism model of Wistar rats assessed by the metavir score.

Methods

A total of eighteen male Wistar rats mean were divided into five groups. For the priapism models, we applied negative pressure on the penis to make an artificial erection to mimic the priapism process. The control groups were observed and the treatment groups were orally given losartan 15 mg/kg/day. Corpora cavernosa was harvested for TGF-β1 and collagen-type-1 measurement using an enzyme-linked immunosorbent assay (ELISA). The fibrotic tissue of each rat was then collected and assessed histopathologically with the metavir scoring system.

Results

Penile TGF-β1 concentration in the losartan-treated group was not significantly different on day 10 and day 28 of observation (p10=0,30; p28=0,17). Meanwhile, collagen-type-1 concentration was significantly lower compared to control group (p10=0,002; p28=0,01). There was a significant difference in metavir scores in rats that received losartan and those who did not (p<0,05).

Conclusion

Losartan could suppress the fibrosis process in the priapism model. It could decrease the collagen type 1 deposition during corpora cavernosa tissue regeneration. Based on the metavir score, the group receiving losartan therapy was better than the control group.

Preoperative hormonal stimulation in hypospadias: a systematic review

Introduction: Preoperative hormonal stimulation with testosterone or estrogen is an emerging treatment modality for hypospadias, which can potentially improve surgical outcomes and reduce the risk of complications. This review aims to evaluate the current knowledge on preoperative hormonal stimulation in hypospadias. Methods: This study was a combination of a systematic review followed by a meta-regression analysis performed on PubMed, Google Scholar, DOAJ, and Cochrane. The study included randomized controlled trials, prospective and retrospective cohort studies, and before-and-after studies with or without control. The search was performed in English and was limited to articles published between January 1, 2000, and December 31, 2020. Results: The database search yielded 188 articles, which were systematically eliminated, leaving 15 relevant articles. The analyzed articles showed that testosterone is the most commonly used hormonal treatment in hypospadias, followed by dihydrotestosterone (DHT) and estrogen. Testosterone may be given in topical, parenteral, or oral formulations, while DHT is most often used in topical form. Conclusions: Preoperative stimulation with testosterone or DHT is associated with increased penile length and glans circumference before surgery, which may ease the reconstruction process. In addition, testosterone and DHT increase the rate of neovascularization and reduce the risk of postoperative complications.

Application of Stem Cell in Human Erectile Dysfunction - A Systematic Review

Introduction

Erectile dysfunction is a health problem that arises from various conditions and causes an impaired quality of life with a significant health burden. Regenerative and stem cell therapies are some of the potential treatments for erectile dysfunction. This study aimed to review the available information in the literature regarding the use of stem cells in the treatment of erectile dysfunction.

Methods

This study is a systematic review conducted based on the PubMed, Google Scholar, Cochrane, and DOAJ databases. Literature searching was conducted in English and included articles from 2000 to 2020.

Results

The result was a total of 318 articles. Following the elimination process, 9 articles remained in the final analysis. The analyzed studies included 164 patients with erectile dysfunction with various medical conditions. Several stem cell types have been used for treating erectile dysfunction, including mesenchymal stem cell, placental matrix-derived stem cell, mesenchymal stem cell-derived exosome, adipose-derived stem cell, bone marrow-derived mononuclear stem cell, and umbilical cord blood stem cell. Generally, stem cell therapy showed a good efficacy and safety profile, although not enough studies on the protocol, dosage, and mechanism of action.

Conclusion

Stem cell therapy has a good therapeutic potential in erectile dysfunction, the available data from the literature could be the base of usage of stem cells in the treatment of erectile dysfunction although need more research for broader usage.

Congenital anterior urethrocutaneous fistulas with chordee: A case report

Congenital anterior urethrocutanous fistula is a rare genitourinary malformation with unknown etiology and may present as an isolated form or in association with hypospadias or chordee. We describe a case of congenital anterior urethrocutanous fistula with chordee variants in a 5-year-old boy. The patient successfully underwent chordectomy and urethroplasty with no adverse outcomes. We report a review of the literature about the etiology and surgical intervention especially with chordee variants. The congenital anterior urethrocutanous fistula is a rare anomaly with unkown etiopathogenesis.

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A 5-year-old boy admitted with passage urine from an abnormal opening in ventral surface of the penis and a distal patent urethra.

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Chordectomy and urethroplasty was performed.

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Surgical approach for criptospadias has 90 % success rate.

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Imaging investigation may help to decide the best treatment options.

Microsurgical varicocelectomy effects on sperm DNA fragmentation and sperm parameters in infertile male patients: A systematic review and meta-analysis of more recent evidence

Background: Varicocele is known to have impacts in infertility cases and sperm quality. This review aimed to evaluate the effects of microsurgical varicocelectomy on sperm DNA fragmentation index (DFI) and sperm parameters. Methods: Open full English text articles from January 2017 to October 2021 were searched from online database including PubMed, EMBASE, Scopus, Cochrane Library and Google Scholar. Results: Systematic search resulted in 277 potential papers. After throughout paper analysis, 5 studies were included in this review. From all five analyzed studies, microsurgical varicocelectomy was statistically proven to reduce DNA fragmentation index by 5.46% (mean difference -5.46; 95% CI: -4.79, -6.13; p < 0.00001). Moreover, the procedure also significantly improved other sperm parameters (sperm concentration +8.23%, sperm motility +7.17%, sperm progressive motility +2.77%, sperm morphology +0.64%). Conclusion: Microsurgical varicocelectomy significantly improves spermatogenesis as reflected by biomarkers of infertile men including semen parameters and sperm DNA fragmentation (SDF).

Antioxidant Supplementation on Sperm DNA Fragmentation and Sperm Parameters: A Systematic Review and Meta-Analysis

OBJECTIVE

Infertility affects about 15% of couples in reproductive age worldwide. Male factors are the main causes for this condition. Antioxidants have long been used for infertility treatment as they are easily available with a low cost. In this systematic review, we focused on the relation between antioxidant supplementation and sperm DNA fragmentation and other sperm parameters.

MATERIAL AND METHODS

An online search from PubMed and ScienceDirect databases was conducted by 2 reviewers. We reviewed full-text articles to obtain detailed information.

RESULTS

Nine articles were included in this study. Four studies revealed a statistically significant reduction of sperm DNA fragmentation and five studies revealed an insignificant decrease of sperm DNA fragmentation. Sperm concentration, sperm motility, and morphology were also increased after antioxidant supplementation. Pregnancy rates were reported in 3 studies; the rates increased in 2 studies, and similar rate to placebo group was observed in 1 study.

CONCLUSION

Antioxidant supplementation can counteract against oxidative stress and improve spermatogenesis process reflected by decrease of DNA Fragmentation Index (DFI), improvement of sperm parameters, and elevation of pregnancy rates confirmed by those included studies.

Testicular Epidermoid Cyst: A Rare Case Report

INTRODUCTION AN IMPORTANCE

Testicular epidermoid cysts (TECs) are rare benign testicular neoplasms. Recently, testicular epidermoid cysts (TECs) are listed as teratoma of prepubertal type, however it is still difficult to differentiate the epidermoid cyst from malign testicular tumor. Therefore, we would like to report testicular epidermoid cyst at our institution.

CASE PRESENTATION

A 67-year-old man from Indonesia, presented with chronical painless mass of testis since one year ago. On physical examination obtained normal penile structure with descended testicles, palpable intrascrotal mass with size of 10 × 7 × 5 cm, firm consistency, immobile, without any tenderness, and no lymphadenophaty in groin. Scrotal USG showed intratesticular mass, homogenous parenchym, showed no vascularization during Doppler examination. Histopathological examination revealed the specimen of right scrotum with size of 12.5 cm × 8.5 cm × 6.1 cm with red-brownish colored, during lamellation, obtained encapsulated mass with size of 12.2 cm × 7.9 cm × 6 cm, hollowed space filled with porridge-like texture with capsule thickness of 0.1-0.3 cm.

CLINICAL DISCUSSION

Epidermoid cysts are benign lesions occurring on the skin usually, however, it rarely occurs in intratesticular area. Most of the cases (60%) presented with the typical onion-ring phenomenon. Histopathological findings commonly revealed typical well-defined cyst lined by a fibrous membrane. No skin appendages are found in the cyst's lumen and no germ cell neoplasm (GCN) is present in the adjacent testicular parenchyma.

CONCLUSION

All testicular masses are considered malignant until proven otherwise. It is necessary to do accurate diagnosis for the prevention of unnecessary radical orchiectomy.

Role of human adipose-derived stem cells (hADSC) on TGF-β1, type I collagen, and fibrosis degree in bladder obstruction model of Wistar rats

Introduction

Bladder outlet obstruction (BOO) was caused by a series of histological and biochemical changes in the bladder wall, through the inflammation process in the bladder wall, hypertrophy and fibrosis. ADSC has an important role in bladder regeneration.

Methods and materials

This study was an experimental randomized study using male Wistar rats which were monitored at 2 and 4 weeks to determine the effect of ADSC therapy on TGF-β1 type I collagen, and degree of fibrosis.

Result

Rats were divided into 5 groups. In the week 2 BOO group, 1 sample included in the category of moderate fibrosis, 1 sample that was given ADSC with mild fibrosis category, 3 samples included in severe fibrosis category, 3 samples that were given ADSC included in the category of moderate fibrosis. The concentration of TGF-β1 in the hADSC therapy group was significantly lower than the control group at the 2nd and 4th week of monitoring (p2 = 0.048, p4 = 0.048), and also with more type I collagen on 2nd and the 4th week (p2 = 0.048, p4 = 0.048).

Conclusion

ADSC therapy can reduce the concentration of TGF-β1, type I collagen, and degree of fibrosis in the male Wistar BOO model.

The Role of Maternal and Environmental Factors During Pregnancy on the Risk of Hypospadias Occurrence

Introduction and Objectives

Hypospadias is a congenital disorder in boys in which the urethral meatus is located on the ventral penis. The incidence rate of hypospadias is increasing, however, there is still no literature regarding how significant is the role of maternal and environmental factors to the risk of hypospadias, especially in Indonesia. This study aims to analyze the maternal and environmental factors during pregnancy to the risk of hypospadias.

Materials and Methods

This study was an analytical observational study with a case control design. The subjects were mothers who gave birth to children with hypospadias, compared to normal, who visited the urology, pediatric-surgery, plastic-surgery, and pediatric clinic at Hasan Sadikin General Hospital.

Results

A total of 120 samples (60 cases and 60 control) were included in this study. There were 14 maternal factors, which 5 of them found significantly correlated with hypospadias, including maternal occupation as an industrial worker (P = .003; OR:4.789), pregnancy-enhancing drugs usage (P = .004; OR: 5.783), smoking consumption (P = .034; OR: 2.294), mosquito-repellant usage (P = .0001; OR: 82.600), and preterm birth (P = .013; OR: 2.895). There were 2 environmental factors, and one of them was significant, which was the distance from home to industrial/rice fields/waste areas, approximately 780 m (P = .0001; OR: 6.102). Based on multivariate analysis, we found that maternal occupation, mosquito repellent usage, and the distance from home to industrial area had a strong relationship in predicting hypospadias occurrence.

Conclusion

Several maternal and environmental factors were found significantly correlated to hypospadias occurrence. Among these, mosquito-repellant usage was found to be the most significant factor.

The Effect of Intratesticular Injection of Human Adipose-Derived Mesenchymal Cell on Testicular Oxidative Stress and Spermatogenesis Process in the Varicocele Rat Model

Introduction

Varicocele is the predominant cause of male infertility. Reactive oxygen species was found in varicocele which induce the lipid peroxidation process in the plasma membrane of spermatozoa and may cause damage to spermatozoa in semen and seminiferous tubules, disrupting spermatogenesis. Human adipose derived stem cells (hADSC) can suppress oxidative stress in some oxidative injury model. This study investigate the effect of intratesticular hADSC injection on malondialdehyde (MDA) level and spermatogenesis process by histopathological examination in the varicocele rat model.

Methods

This is an experimental study. A total sampling of 9 male Wistar rats were divided into three groups. Group I consist of 1 Wistar rats without any treatment or model (sham group), group II consist of 4 Wistar rats with varicocele model without hADSC therapy (control group), and group III consist of 4 Wistar rats with varicocele model and were given injections of 1.0×10⁶ hADSC cells intratesticularly 30 days after model was made (therapy group). Testicular tissue was harvested for evaluation.

Results

In all varicocele model rats (group II and III), the result of MDA level in therapy group (2.53 mol/liter) was significantly lower than the MDA level in control group (4.43 mol/liter) (p = 0.01). On histopathological examination, the average Johnson’s Score in the therapy and control group was 9.77 and 9.18, respectively. The analysis showed Johnson’s score in the intervention group was significantly higher (p = 0.018).

Conclusion

Intratesticular injection of hADSC can help reduce MDA levels and improve spermatogenesis process, which is damaged by varicoceles.

Correlation of Visceral Obesity and Interleukin-6 Level on LUTS Due to Benign Prostatic Enlargement

Background

Benign prostatic enlargement (BPE) is a common condition in older men causing lower urinary tract symptoms (LUTS). Numerous studies have shown correlations of obesity and age as risk factors of LUTS due to BPE. However, there are only a few studies showing the increase of interleukin-6 (IL-6) as a risk factor in LUTS. IL-6 expression is regulated in the prostate. IL-6 was found to be increased in several conditions, such as infection, inflammation, and obesity. The aim of this study is to correlate visceral obesity and IL-6 expression in the prostate with BPE and LUTS.

Methods

We analyzed the correlation of the Visceral Adiposity Index (VAI) and IL-6 of 52 patients with LUTS due to BPE. Statistical analysis was tested using an independent t-test. Data were analyzed with SPSS ver 20.1.

Results

Of 52 BPE subjects, who had not received any therapy, 16 patients presented with severe LUTS (30.77%), while the remaining 69.23% had mild–moderate LUTS complaints. IL-6 examination showed that obese patients and severe LUTS had higher IL-6, with p=0.032 and 0.01, respectively. Correlation analysis showed a weak correlation between IL-6 and obesity (r=0.179, p=0.02). Based on regression study, it was found that the risk for a patient with visceral obesity to develop severe LUTS is 5-times higher than normal (p=0.017).

Conclusion

This study found a correlation between the degree of visceral obesity assessed by VAI and IL-6 levels in BPE patients. In addition, there is also a correlation between the degree of visceral obesity and IL-6 levels on LUTS severity in people with BPE.

Validation of FGSI Scores in Predicting Fournier Gangrene in Tertiary Hospital

Background and Aim

Fournier gangrene (FG) is a necrotizing fasciitis of perineal and/or genital regions that may progressively spread; necrotic tissue may cause morbidity and mortality related to sepsis and multi-organ dysfunction. Surgical intervention required for patients with Fournier gangrene may vary according to the severity of the infection. A Fournier Gangrene Severity Index (FGSI) has been devised to assess the risk of mortality in patients with Fournier gangrene. The aim of this study was to validate the implementation of the FGSI in predicting mortality of FG patients in our hospital.

Methods

A retrospective study was performed on all patients with Fournier gangrene admitted and treated in Hasan Sadikin General Hospital during 2015–2019. Data were collected from the medical records of the emergency room and outpatient clinics. Sociodemographic variables, preexisting comorbidities, outcome, management, and FGSI score were included as variables.

Results

In this study, 83 patients were included from the period 2015–2019, divided into two groups. From the Charlson Comorbidity Index, we found the first group average score was 2.5 (0–9), and the second group this was 2 (1–8). From the FGSI, in the first group, we found the average score was 5.5 (2–15), and the average was 14 (10–19) in the second group, which is significantly higher than the first group (p = 0.001).

Conclusion

We find that the FGSI score system is a good tool for predicting severity of the disease and mortality risk of the patients, which is consistent with findings in other studies.

Torsion Testicular Patient Characteristics

Testicular torsion is an emergency urological condition that is caused by the torsion of the spermatic cord structures, causing disruption of circulation of the affected testicle. This study aimed to describe the characteristics of patients with testicular torsion treated at Dr. Hasan Sadikin General Hospital Bandung from January 2016 to January 2020. This was a retrospective descriptive study on 34 medical records of patients diagnosed and treated for testicular torsion. Nine patients (29.4%) were <20 years old and 25 patients were >21 years old. The onset was mostly between 6 to 24 hours (38.2%), followed by between 2–7 days (23.5%), less than 6 hours (20.6%), between 1–2 weeks (8.8%), and between 2–4 weeks (8.8%). Left testicular torsion were more frequent than the right torsion (61.8% vs. 38.2%). The etiology of the torsion was mostly idiopathic with no identifiable precedent (88%). Orchidectomy was more frequently performed compared to orchiopexy (78.4% vs. 21.6%). All but one patient (97.1%) presented with testicular pain as the main symptom. Patients presented mostly with a high risk TWIST score (64.7%); however, more presented with low risk compared to the intermediate risk TWIST score (26.5% vs. 8.8%). Orchidectomy is the most frequently performed operation on pre-pubertal and adult patients, possibly due to relatively delayed presentation (>24 hours) to the hospital to receive treatment. Patients were mostly younger; predominantly with high TWIST score and affected left testicle.

Polymorphism of PvuII, Xba1, and SNP 12 Estrogen Receptor 1 (ESR1) in Hipospadias Patients at Tertiary Hospital Center

Introduction

The prevalence of hypospadias ranges between 1: 250 to 300 per live birth. Estrogen exposure has been associated with the increasing incidence of hypospadias in humans and a significant relationship between Estrogen Receptor 1 (ESR1) polymorphisms and hypospadias was determined from the previous study. This study aims to determine the proportion of ESR1 polymorphism.

Methods

This was a descriptive study aimed to find the incidence of ESR1 gene polymorphism in hypospadias patients visiting the Urology Outpatient Unit of the Hasan Sadikin Bandung Hospital who will undergo hypospadias surgery. Deoxyribonucleic acid (DNA) was performed using foreskin of hypospadias patient during the surgery then being extracted and will be analyzed using polymerase chain reaction (PCR) sequencing.

Results

Thirty eight samples of hypospadias were identified, 5 samples were unable to sequence and 33 samples were successfully sequenced using the PCR method. The Pvull ESR1 gene was dominated by the T allele which is a wild-type allele and the genotype containing the T allele, namely TT + TC (57,2%). Normal genotype (TT) were more frequent in distal hypospadias, and Heterozygous polymorphisms (TC) was higher in proximal hypospadias. The ESR1 Xba1 gene polymorphism was dominated by the A allele which is a wild-type allele and the AA + AG genotype (76,1%). Normal genotype (AA) was more frequent in distal hypospadias, and both heterozygous hypospadias (AG) and homozygous hypospadias (GG) were found only in proximal hypospadias. The ESR1 SNP 12 gene polymorphisms were found in the combination of genotypes that played a role, namely GA + AA (81%) and the G allele which is a wild-type allele. Heterozygous polymorphisms (GA) was the most finding genotype and more frequent in proximal hypospadias.

Conclusion

ESR1 gene polymorphisms (PvuII, XbaI, and SNP 12) were found in hypospadias patients. ESR1 polymorphisms may correlate with the severity of hypospadias. Further research with a larger sample and better hypospadias grouping is needed to confirm.

Penile strangulation injury by metallic ring: A study of 4 cases

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Penila strangulation required emergency management to preserve the organ function.

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Each case managed individually according to its clinical finding and operative settings.

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Management depends on the type and size of constricting object, time after incarceration, degree of injury, available instrument, and experience of the physicians.

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Different methods and tools may arise due to circumstance and individual cases differences.

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Surprisingly, there is no erection problem after removing the strangulation.

Penile strangulation by metallic ring is an emergency situation which requires urgent management. Strangulation of the penis usually performed in order to increase sexual performance or because underlying mental disorder or paraphilia. It is an uncommon urological emergency, if not treated as soon as possible it can lead to complications such as gangrene and amputation of the penis. There is no standard of care that has been found to be superior, with each case managed individually according to its clinical findings and operative settings. In this study, we present four cases of penile strangulation in last two years in a tertiary care hospital.

Intratesticular Human Adipose-Derived Stem Cell (hADSC) Transplantation Decreased Oxidative Stress in Testicular Torsion Model of Wistar Rat

Introduction

Testicular torsion is a sudden rotation of the testis towards its axis, which causes the twisting of the spermatic cord. Post-detorsion reperfusion will cause inflammation and trigger oxidative stress, which generates reactive oxygen species (ROS). Malondialdehyde (MDA) is an organic compound formed from ROS frequently used as an oxidative stress biomarker during ischemia and ischemia-reperfusion injury. In some organs, stem cell administration on the damaged organ is essential in preventing cellular damage and death. This study aimed to learn about the effect of hADSC administration on an ischemia-reperfusion injury.

Material and Methods

A total of 22 Wistar rats divided into 5 groups, two groups each consist of 5 male Wistar rats with testicular torsion model without hADSC therapy (group I), while 2 other groups consist of 5 rats with testicular torsion model were given 1.0×10⁶ cells intratesticular hADSC injection 30 minutes after testicular detorsion (group II). Both groups were euthanized at 1 and 4 weeks of observation. The last group consists of 2 rats without any treatment or model (negative control group). Following euthanasia, testicular tissue was harvested for MDA expression measurement using ELISA and histopathological examination. Statistical analysis using an one way ANOVA was done with SPSS version 21.0.

Results

The result of MDA examination using the ELISA method has shown a concentration difference between group I (control) and group II (hADSC treatment). Testicular MDA concentration in the treatment group was significantly lower on the 1st and 4th week of observation (p₂=0.000, p₄=0.016). Post hoc analysis showed no statistically different between therapy and healthy group (p=0.972). On histopathological examination, Johnsen score in the treatment group was significantly higher on the 4th week of observation (p=0.044). Post hoc analysis showed no statistically different between therapy and healthy group (p=0.195).

Conclusion

Intratesticular hADSC administration can inhibit ROS formation due to ischemia-reperfusion injury in testicular tissue after testicular detorsion in Wistar rats.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

The effect of intravenous human adipose-derived stem cells (hADSC) on transforming growth factor β1 (TGF-β1), collagen type 1, and kidney histopathological features in the unilateral ureteropelvic junction obstruction model of wistar rats

OBJECTIVE

The fibrotic process of kidney resulting in glomerulosclerosis was found in patients with ureteropelvic junction obstruction (UPJO) who underwent renal biopsy during pyeloplasty. Transforming growth factor β1 (TGF-β1) plays a role in collagen accumulation, resulting in fibrosis. Adipose tissue-derived stem cells (ADSCs) have an anti-apoptotic effect on target cells and enhance the kidney function recovery. We will further investigate the use of ADSC in the prevention of kidney fibrosis in the unilateral UPJO model of Wistar rats.

MATERIAL AND METHODS

A total of twenty-two 12-week-old Wistar rats were divided into three groups. We made the UPJO models using nylon 6-0 inside the left ureter and tied the ureter with nylon 6-0, creating partial ureteral obstruction. The treatment group was then injected with 1.0 × 10⁶ cells of human ADSC via the tail vein of rats. All rats were euthanized after 2 and 4 weeks of treatment. The left kidney used hematoxylin-eosin for histopathological examination. Statistical analysis using one-way analysis of variance (ANOVA) was done with SPSS version 21.0.

RESULTS

TGF-β1 concentration in the treatment group was significantly lower in the 4^th week of observation (p4=0.0001), as well as collagen type 1, which was also significantly lower in the 4^th week (p4=0.0001). There was a significant difference in the glomerulus count between the control group and the human ADSC (hADSC) group therapy in week 2 and week 4 (p2=0.0001 and p4=0.026).

CONCLUSION

Administration of hADSC therapy reduces TGF-β1 and collagen type 1 levels and then improves the histopathological features in the process of renal fibrosis in the UPJO model.

Effect of Intracorporeal Human Adipose-Derived Stem Cells (hADSCs) on Corpora Cavernosa Transforming Growth Factor β1 (TGFβ1) and Collagen Type I Concentration in Wistar Rat Priapism Model

Introduction

The ischemic process in priapism can lead to displacement of normal tissue with fibrotic tissue, due to collagen deposition, and eventually leads to erectile dysfunction. Many studies have identified that the supernatant of adipose tissue–derived stem cells (ADSCs) significantly ameliorates fibrosis of different tissue, but limited attention has been paid to its efficacy on fibrosis of the corpora cavernosa.

Methods

A total of 22 Wistar rats divided into five groups, with two groups each consisting of five male wistar rats with priapism without human ADSC (hADSC) therapy (group I) and two other groups consisting of five rats with priapism, were given 10⁶ cells' intracorporeal hADSC injection after 12 hours of penile clamping (group II) were euthanized after 2 and 4 weeks of observation. The last group consisted of two rats without any treatment or model (group III). Following euthanasia, penises were harvested for TGFβ₁ and collagen type I measurement using ELISA. Statistical analysis using independent-sample t-tests was done with SPSS 21.0.

Results

Penile TGFβ₁ concentration in the treatment group was significantly lower in the second and fourth weeks of observation (p₂=0.004, p₄=0.003), and collagen type I was significantly lower in the second and fourth weeks (p₂=0.003, p₄=0.011).

Conclusion

Intracorporeal hADSC injection limited the fibrosis process in a priapism model. Although the mechanism was unclear, it may be related to the potential of hADSCs to produce various growth factors that could limit TGFβ₁ and collagen production.

The largest adrenal leiomyoma: A case report and literature review

Leiomyoma is a benign tumor of smooth muscle origin. Primary leiomyoma of the adrenal gland is very rare. Adrenal tumors are often diagnosed during the ultrasound or computerized tomography (CT) study as incidentaloma. According to the literature review, up to 2018, the largest size of adrenal leiomyoma which had ever been reported was 12 × 10 × 8 cm in dimension (Maher et al.). Herein, we report the largest adrenal leiomyoma with the tumor mass of 600 g (14,1x11,4x10,1 cm) from a female patient admitted to our hospital.

Common Practice of Hypospadias Management by Pediatric Urologists in Indonesia: A Multi-center Descriptive Study from Referral Hospitals

BACKGROUND:

Hypospadias is the second most common congenital anomalies among human congenital disabilities. There are over 300 surgery techniques being introduced to treat hypospadias. The successful of hypospadias repair is assessed by several outcomes as well as complications following surgery.

AIM:

This study aims to show the multicenter hypospadias data in Indonesia descriptively.

METHODS:

All the data were compiled based on questionnaires, which were distributed to Indonesian pediatric urologists. The questionnaire includes several questions containing demographic aspect, preferred techniques being used, and complications being found regarding hypospadias repair.

RESULTS:

Eighteen Indonesian pediatric urologists from 12 centres involved in this study. The data were collected from June – September 2018 based on the surgeon’s experience throughout 2017. From 591 cases based on the returned questionnaire, penile-type hypospadias was the most common type of hypospadias being treated (35.7%) followed by penoscrotal (28.9%) and scrotal-type (12.9%). Moderate severity of chordee was mostly seen among all cases (40.6%). Tubularised incised plate (TIP), + Thiersch Duplay, was the most common technique being used to treat hypospadias (44.3%), followed by onlay island preputial flap (14.9%) and two-stage technique (14%). The incidence of urethrocutaneous fistulae in this study was 13.9%.

CONCLUSION:

This study showed how Indonesian pediatric urologists dealt with hypospadias cases. TIP + Thiersch Duplay procedure being the preferred technique used by most participants and the rate of urethrocutaneous fistulae as one of the complications was comparable with previous studies.

Phalloplasty and urethroplasty in adult with disorder of sex developments

This case report presents our experience on the first phalloplasty and urethroplasty in adult with Development Sex Disorder (DSD) in Indonesia. A 25 years old male with DSD 46 XY planned undergo phalloplasty and urethroplasty with radial forearm free flap (RFFF). Eight months later, there was fistulas repairment due to urethrocutaneus fistulas. Cartilage insertion also was done to make a semi-rigid neophallus. At last, there was no new fistula or stricture developed. Qmax and Qmean were 33,8 ml/s and 14,0ml/s. RFFF only causes minimal complication. The neophallus and neourethra also function properly.

Effect of angiotensin II receptor blocker on TGF-β1, MMP-1, and collagen type I and type III concentration in New Zealand rabbit urethral stricture model

Introduction

Urethral stricture is a disease with a high recurrence rate. Angiotensin II via AT1 receptor increases collagen formation through its effects on TGF-β1 and inhibition of collagenase activity. In this study, we evaluated the antifibrotic effect of angiotensin II receptor blocker on urethral stricture formation by creating a urethral stricture model in a male rabbit.

Material and methods

Thirty three male adult rabbits were separated into 3 groups (control, treatment, and sham). Group I consisted of 15 rabbits with urethral stricture that did not undergo any treatment, group II consisted of 15 rabbits with urethral stricture that were treated with a daily dose of 15 mg/kg losartan, given orally. Group III consisted of 3 rabbits with normal urethra and without any treatment. After 1, 2, and 4 weeks, the urethral tissues were collected, processed, and examined for TGF-β1, MMP-1, collagen type I, and collagen type III using enzyme-linked immunosorbent assay. Data were analyzed using 2-way analysis of variance using SPSS version 20.0.

Results

Urethral TGF-β1 concentration in the treatment group was significantly lower during the 2nd and 4th week of observation (p<0.0001), MMP-1 was significantly higher in the 1st, 2nd, and 4th week of observation (p<0.0001), collagen type I was significantly lower during the 2nd (p=0.001) and 4th week (p<0.0001), and collagen type III concentration was significantly lower in the 2nd and 4th week of observation (p<0.0001).

Conclusion

Angiotensin II receptor blocker could limit the progression of urethral stricture. The mechanism may be related to the AT1 blockage that leads to a decrease in TGF-β1 concentration, eventually resulting in lower collagen concentration due to increased MMP-1 activity.

The effect of long-acting PDE-5 inhibitor on renal ischemia/ reperfusion injury in Wistar rats; a study on serum cystatin C and renal histopathological findings

Background: Ischemia/reperfusion (I/R) is often a complication of bleeding shock, renal dysfunction and renal vessel operation. Nitric oxide (NO) as an important vasodilator is produced by endothelial cells. NO stimulates the generation of cyclic guanosine monophosphate (cGMP). Phosphodiesterase (PDE) is an intracellular enzyme which hydrolyzes cGMP into an inactive metabolite. It effectively decreases cGMP level. PDE is an intracellular enzyme which hydrolyzes cGMP into an inactive metabolite. It effectively decreases cGMP level. Therefore, an inhibition of PDE can increase cGMP level. PDE5 inhibitor is a compound which inhibits or acts antagonistically against biosynthesis or act of PDE. PDE5 inhibitor is now commonly used for the treatment of pulmonary artery hypertension and erectile dysfunction. According to some latest researches, long-acting PDE5 inhibitor (Tadalafil) reduces renal I/R injury in experiments with Wistar rats. Objectives: The purpose of this study was to determine the effect of long-acting PDE5 inhibitor on renal I/R injury in Wistar rats. Materials and Methods: Rats were divided into three groups; sham group, a right nephrectomy was performed. Control group, a right nephrectomy was performed followed by an occlusion on left renal pedicle for 60 minutes and a perfusion was performed for 60 minutes. Tadalafil group; the same treatment was performed as to group control, plus administering tadalafil as a PDE5 inhibitor (10 mg/kg), given by a nasogastric tube 60 minutes before the operation. A left nephrectomy was performed on the mice to determine the value of cystatin C level and histopathology. Results: The mean necrosis of tubular renal cells indicates that highest mean necrosis of tubular renal cells was at group control (mean score, 8.6±0.84), and the lowest mean necrosis of tubular renal cells was at sham group (mean score, 4.4±0.52) which indicates a significant difference between the sham and control groups (P<0.05). For the tadalafil group mean score of renal tubular necrosis cell was 6.9±1.45, which also indicates a significant difference between this group with sham group and control (P<0.05). Highest mean cystatin C levels related to group control, mean score was 1.51 ± 0.13 mg/dL, which indicates a significant difference with the sham group (P<0.05), but there is no significant difference with the tadalafil group. Conclusion: The results of this study showed that the administration of PDE5 inhibitor (tadalafil) improves reperfusion ischemic injury. Although it did not decrease the level of cystatin C, it significantly reduced tubular necrosis.

AT1 expression in human urethral stricture tissue

BACKGROUND

Urethral stricture has a high recurrence rate. There is a common doctrine stating that "once a stricture, always a stricture". This fibrotic disease pathophysiology, pathologically characterized by excessive production, deposition and contraction of extracellular matrix is unknown. Angiotensin II type 1 (AT₁) receptor primarily induces angiogenesis, cellular proliferation and inflammatory responses. AT₁ receptors are also expressed in the fibroblasts of hypertrophic scars, whereas angiotensin II (AngII) regulates DNA synthesis in hypertrophic scar fibroblasts through a negative cross talk between AT₁ and angiotensin II type 2 (AT₂) receptors, which might contribute to the formation and maturation of human hypertrophic scars.

OBJECTIVE

This study was conducted to determine the expression of AT₁ receptors in urethral stricture tissues.

METHODS

Urethral stricture tissues were collected from patients during anastomotic urethroplasty surgery. There were 24 tissue samples collected in this study with 2 samples of normal urethra for the control group. Immunohistochemistry study was performed to detect the presence of AT₁ receptor expression. Data were analyzed using Mann-Whitney U test, and statistical analysis was performed with SPSS version 20.

RESULTS

This study showed that positive staining of AT₁ receptor was found in all urethral stricture tissues (n=24). A total of 8.33% patients had low intensity, 41.67% had moderate intensity and 50% had high intensity of AT₁ receptors, while in the control group, 100% patients had no intensity of AT₁ receptors. Using the Mann-Whitney U test, it was found that urethral stricture tissue had a higher intensity of AT₁ receptors than normal urethral tissue with a p-value = 0.012.

CONCLUSION

The results showed that AT₁ receptor had a higher intensity in the urethral stricture tissue and that AT₁ receptor may play an important role in the development of urethral stricture.

The Dutch hospital standardised mortality ratio (HSMR) method and cardiac surgery: benchmarking in a national cohort using hospital administration data versus a clinical database

Objective

To compare the accuracy of data from hospital administration databases and a national clinical cardiac surgery database and to compare the performance of the Dutch hospital standardised mortality ratio (HSMR) method and the logistic European System for Cardiac Operative Risk Evaluation, for the purpose of benchmarking of mortality across hospitals.

Methods

Information on all patients undergoing cardiac surgery between 1 January 2007 and 31 December 2010 in 10 centres was extracted from The Netherlands Association for Cardio-Thoracic Surgery database and the Hospital Discharge Registry. The number of cardiac surgery interventions was compared between both databases. The European System for Cardiac Operative Risk Evaluation and hospital standardised mortality ratio models were updated in the study population and compared using the C-statistic, calibration plots and the Brier-score.

Results

The number of cardiac surgery interventions performed could not be assessed using the administrative database as the intervention code was incorrect in 1.4–26.3%, depending on the type of intervention. In 7.3% no intervention code was registered. The updated administrative model was inferior to the updated clinical model with respect to discrimination (c-statistic of 0.77 vs 0.85, p<0.001) and calibration (Brier Score of 2.8% vs 2.6%, p<0.001, maximum score 3.0%). Two average performing hospitals according to the clinical model became outliers when benchmarking was performed using the administrative model.

Conclusions

In cardiac surgery, administrative data are less suitable than clinical data for the purpose of benchmarking. The use of either administrative or clinical risk-adjustment models can affect the outlier status of hospitals. Risk-adjustment models including procedure-specific clinical risk factors are recommended.

Cardiac surgery in patients irradiated for Hodgkin's lymphoma

Background/Objectives. Therapy for Hodgkin's lymphoma is disease specific and cannot be compared with treatment for other diseases. It often includes more extensive radiotherapy on the mediastinum than for other malignancies. Cardiac morbidity is known to occur in patients previously irradiated. This study describes the postoperative course after cardiac surgery of patients previously irradiated for Hodgkin's lymphoma.Methods. From January 1990 until June 2008, 12 patients underwent cardiac surgery in the University Medical Center Utrecht after previous irradiation for Hodgkin's lymphoma. Data on radiotherapy, surgery and follow-up were collected retrospectively. The postoperative functional status was assessed by a telephone questionnaire.Results. Atrial fibrillation (33%) and pleural effusion (25%) were the most common postoperative complications. After a mean followup of 2.6+/-2.9 years four patients had died. The remaining patients were all in a favourable New York Heart Association and Canadian Cardiothoracic Society class. The estimated one-, two- and four-year survival rates were 83, 69 and 46% respectively.Conclusion. The early postoperative outcome of cardiac surgery in this population is reasonably good. The long-term results may prove to be disappointing, but the cohort is small. (Neth Heart J 2010;18:61-5.).