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Excessive ammonia is harmful to the body. It is mostly hepatic in origin. Hyperammonemia due to urinary tract infection (UTI) is rare. We report a case of hyperammonemia with UTI and urinary retention. A 94-year-old female arrived at our hospital with impaired consciousness that lasted for a day. On arrival, her Glasgow Coma Scale was E1V1M5, blood ammonia was 272 ng/dl, and urinalysis revealed a large number of white and red blood cells. Abdominal computed tomography scan revealed a distended bladder and wall thickness with no hydronephrosis. Urine cultures were positive for urease-producing Corynebacterium, Escherichia coli, and Staphylococcus aureus. The patient was diagnosed with hyperammonemia with UTI and urinary retention. After urinary catheterization, blood ammonia levels normalized, and consciousness improved. We need to consider ammonia toxicity in UTI patients with urine retention presenting with altered consciousness.

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Purpose: The aim of the study was to evaluate the link between subclinical hypothyroidism (SCH) and erectile dysfunction (ED). Materials and Methods: Seventy-two male patients aged 23–41 years with SCH compared with 25 healthy matched subjects were recruited, and they were divided into Group A: healthy controls (n = 25), Group B: patients with SCH with ED (n = 43), and Group C: patients with SCH without ED (n = 29). Thyroid function test and hormonal assay included total testosterone (TT), sex hormone-binding globulin, free androgen index, and prolactin (PRL) were measured; erectile function was assessed by the 5-item version of the International Index of Erectile Function (IIEF-5) questionnaire. Results: Free triiodothyronine serum level and thyroid uptake were lower in patients with SCH with ED (240.31 ± 23.85 pg/dL) as compared with patients with SCH without ED or the controls (P = 0.008 and P = 0.004, respectively). Thyroid-stimulating hormone (TSH) serum levels differed significantly; they were normal in the control group (2.86 ± 1.86 mIU/L), higher in patients with SCH with ED (12.41 ± 4.73 mIU/L), and relatively low in patients with SCH without ED (7.32 ± 4.81 mIU/L) (P = 0.001). TT serum level was low in patients with SCH with ED as compared with the controls, but this level was high in patients with SCH without ED as compared with those with SCH with ED (P = 0.001). PRL serum level was high in patients with SCH with or without ED as compared with the controls (P = 0.001). IIEF-5 score was low in patients with SCH with ED (11.73 ± 5.79) as compared with the controls (P = 0.001, 95% confidence interval [CI] = 14.3985–7.8215) or patients with SCH without ED (P = 0.001, 95% CI = 13.1152–6.7448). Conclusion: SCH-induced ED is related to the elevated PRL and reduced TT and TSH serum levels more than 10 mIU/L. Furthermore, the high TSH serum level was linked with the low IIEF-5 scores; therefore, the severity of SCH is correlated with the severity of ED.

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Purpose: Penile fracture may affect erectile dysfunction (ED) and overall sexual satisfaction. This study aimed to compare the long-term effects of immediate versus delayed surgical repair of penile fractures on postoperative ED, fibrous tunica plaques, and chordee formation. Materials and Methods: This is a prospective observational study conducted between January 2016 and June 2018, which included patients with penile fracture. Details of injury, symptoms, treatment, and long-term outcomes (up to 12 months) were collected. Data were presented using summary statistics. Results: A total of 21 patients (early surgical repair [Group A], n = 13; delayed surgical repair [Group B], n = 8) were enrolled in this study. The common cause of penile fracture was masturbation (n 1 = 5 [early presentation]; n 2 = 5 [delayed presentation]) and sexual intercourse (n 3 = 7 [early presentation]; n 4 = 4 [delayed presentation]) in Groups A and B, respectively. Penile ecchymosis/swelling and pain were present in all the patients of Group A (n = 13), while typical pop-up sound was heard by eight patients (61.54%) of Group A and six patients (75.00%) of Group B. The most common reason for delay in presentation was fear/embarrassment (75.00%). Penile paresthesia (n = 2) and penile curvature (n = 3) were observed in Group A, while penile paresthesia (n = 3) was also reported in Group B. None of the patients from both groups reported ED. All the three patients with urethral injury repaired had mild degree of ventral chordee with a satisfactory erection and a good penetration. Conclusion: The results showed that delayed repair did not affect the long-term outcome with no major impact on erectile function and overall sexual satisfaction.

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Purpose: The management of anterior urethral strictures is quite challenging due to high failure rates with many unavoidable postoperative complications. This study aims to elucidate the appropriate surgical techniques, advantages, and disadvantages of the different urethroplasties. Materials and Methods: We retrospectively recorded and analyzed twenty patients' demographics, surgical techniques, postoperative uroflowmetry, and complications. Patients were divided into two groups depending on the length of their strictures. Patients in Group 1 presented a urethral stricture or obliteration length of <3 cm and received excision and primary end-to-end anastomosed urethroplasty. Group 2 consisted of patients with a stricture or obliteration length of more than 3 cm who received buccal mucosa graft (BMG)-augmented dorsal onlay urethroplasty. The success rate and objective parameters following anastomosed or augmented urethroplasties were assessed over an 8-year follow-up period. Results: Despite the longer strictures and different number of complete obliterations, BMG-augmented urethroplasty exhibited comparable success rates (90%) with anastomosed urethroplasty (90%). The mean postoperative peak flow rates in the two groups were more than 15 mL/s, with Group 1 at 27.1 mL/s and Group 2 at 16.9 mL/s. No patients exhibited postoperative complications of incontinence or erectile dysfunction, no perineal wound infections were observed in any patient, and no significant complications were noted in the oral cavity where the buccal mucosa was harvested. Conclusion: Two conclusions were drawn from this clinical surgery experience. The first is that the type of urethral reconstruction should be considered according to the length of the urethral stricture. We suggest that urethral strictures longer than 3 cm are suitable for augmented urethral reconstruction. The second is that anatomical consideration of the urethra is also an important factor in choosing an appropriate urethroplasty. We recommend augmented urethral reconstruction for penile urethral strictures and anastomosed urethral reconstruction for bulbar urethral strictures.

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Purpose: The purpose of this study was to investigate the potential factors for sperm retrieval prediction. Materials and Methods: This is a retrospective and single-operator study at National Taiwan University Hospital. Between January 2009 and December 2017, 66 nonobstructive azoospermia (NOA) patients were collected. They received testicular biopsy and sperm retrieval including microsurgical epididymal sperm aspiration or microdissection testicular sperm extraction. Results: Eleven patients had normal spermatogenesis, with successful sperm retrieval (SSR) 90.9%; 21 patients hypospermatogenesis, with SSR 47.6%; 13 patients maturation arrest, with SSR 30.8%; and 21 patients Sertoli cell-only syndrome, with SSR 0%. SSR declined significantly when follicle-stimulating hormone (FSH) values rise: FSH <10 mIU/ml with SSR 59.1%, FSH 10–20 mIU/ml with SSR 26.3%, and FSH >20 mIU/ml with SSR 6.7% (P = 0.003). Receiver operating characteristic curve to predict SSR by FSH achieved the area under the curve 0.792, with the best cutoff point of FSH being at 6.8 mIU/ml. Conclusion: We concluded that a higher sperm retrieval rate was statistically significantly related to lower FSH, lower luteinizing hormone, and better histology types among the NOA men. In the absence of testicular histopathology before surgery, preoperative FSH can be used for prediction and counseling. FSH ≤6.8 mIU/ml predicts SSR with a sensitivity of 63.2% and specificity of 88.2%.

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Purpose: The aim of the study was to compare the outcomes of simultaneous supine percutaneous nephrolithotomy (sPCNL) with semi-rigid ureteroscopic lithotripsy (SR-URSL) (Group A) and SR-URSL (Group B) for treating large proximal ureteral calculus. Materials and Methods: Between January 2015 and April 2019, all patients with large proximal ureteral stones (≥10 mm) who underwent simultaneous sPCNL with SR-URSL or SR-URSL at three medical centers were retrospectively included. Two surgical options were provided based on patients and doctors' decision. The intraoperative and postoperative results, including operating time, hospital stay, need for auxiliary procedures, and complications, were compared between the two groups. Stone-free clearance was defined as the absence of fragments or a single fragment of ≤4 mm on standard radiography 1 month after surgery. Results: A total of 38 and 27 patients were included in Groups A and B, respectively. The mean stone size was 21 mm and 18.2 mm and stone-free rate (SFR) was 97% and 33% in Groups A and B, respectively. Larger ureteral stones (P < 0.001), longer operation time (P < 0.001), prolonged hospitalization (P < 0.001), higher SFR (P < 0.001), and less patients requiring auxiliary procedures (P < 0.001) were observed in Group A. No significant difference regarding complications was observed between groups (P = 0.1). Conclusion: Simultaneous sPCNL with SR-URSL is a feasible and effective treatment for large proximal ureteral stones. Even though larger stone size was observed, simultaneous sPCNL with SR-URSL results in significantly higher SFR and reduced need for auxiliary procedures, without major complications, compared to SR-URSL alone. More clinical studies are required to confirm the outcomes of the present study.

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Purpose: In recent years, single-incision laparoscopic surgery (SILS) became more popular worldwide for its safety and feasibility. This study aims to compare the clinical outcomes of open- and single-incision laparoscopic total extraperitoneal (TEP) hernia repair procedures. Materials and Methods: This retrospective study included 498 consecutive patients undergoing open- and single-incision laparoscopic surgeries for inguinal hernia between January 2012 and December 2016 at Kaohsiung Municipal Ta-Tung Hospital. Results: Open inguinal hernia repairs were performed in 436 patients and SILS-TEP repairs in 62 patients. There were no significant differences between the two groups in patients' characteristics except hernia laterality. Mean operative time was significantly longer in the SILS-TEP compared with the open group (108.9 vs. 87.6 min, P = 0.001), but less mean operative duration was observed when surgeons performed bilateral SILS-TEP repairs. Minor amount of analgesic agent usage was noted in the SILS-TEP group. There were no significant differences between the two groups in bleeding volume and postoperative hospital stay and complications. There were 6/453 (1.3%) recurrences in the open group and no recurrences in the SILS-TEP group at a 1-year follow-up. Conclusion: SILS-TEP is both possibly safe and technically feasible and provides less postoperative pain, acceptable operative implications, and better cosmetic outcomes for patients. It also has less possibility of conversion to laparotomy and recurrence rate.

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Purpose: To assess the outcome and safety of tubeless mini-percutaneous nephrolithotomy (mini-PCNL) to treat patients with renal and upper ureteral stones ≥3 cm. Materials and Methods: Between March 2017 and September 2019, 82 patients who underwent tubeless mini-PCNL at our hospital were evaluated. The patients had renal and upper ureteral stones of a size ≥3 cm in maximal dimension. A 15-Fr operating nephroscope was used. The patients were placed in the prone position. The stones were fragmented using ballistic lithotripter. The outcome was determined immediately after operation through plain radiography of the kidneys, ureters, and bladder and sonography. Various patients and stones characteristics, including perioperative outcomes and complications were evaluated. SPSS version 16 (SPSS, Chicago, IL, USA) was used for data analysis. Results: The mean age of the patients was 57.9 ± 10.5 years, and their body mass index was 26.0 ± 3.8 kg/m^[2]. The mean stone size was 50.3 ± 19 mm. The average operative time was 107.7 ± 41.8 min, and the stone-free rate (SFR) was 54%. The mean postoperative hospital stay was 3.5 ± 1.9 days. The mean hemoglobin decrease was 0.16 ± 0.88 g/dL. None of our patients had organ trauma or any other significant complication. Twenty-one patients had residual fragments and needed subsequent extracorporeal shock wave lithotripsy. The total SFR with an auxiliary procedure was 80%. Blood transfusions were needed in one patient. The average stone size was 46 ± 18 mm in the stone-free group and 55 ± 20 mm in patients without stone-free status, which was statistically significant (P = 0.027). Conclusion: Tubeless mini-PCNL was thus found to be safe and effective, even in patients with renal and upper ureteral stones ≥3 cm. Studies with a larger cohort may be required to finally validate this technique.

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