Testis is an organ with both endocrine and exocrine functions. The former stands for testosterone release, and the latter represents sperm production. Spermatogenesis is a process highly depending on adequate supply of testosterone by the Leydig cells of the testis. In men at the reproductive age, more than 90% of testosterone produced is used for spermatogenesis. In men with diminished testosterone secretion in testis, or hypogonadism, the spermatogenesis process is impaired. Testosterone can be converted into estradiol through the catalyzation of aromatase, a cytochrome P450 enzyme presented in the peripheral tissue. Blocking the activity of aromatase causes an elevation of serum testosterone and a decrease of serum estradiol levels. These effects result in an increase of testosterone-to-estradiol ratio. Infertile males with dysfunction of spermatogenesis may demonstrate a low testosterone-to-estradiol ratio. Studies have shown that aromatase inhibitors (AIs) are beneficial to treat patients with impaired spermatogenesis, by demonstrating improvement of the semen parameters in men with oligoasthenoteratozoospermia. Besides, AIs can also be applied in other health issues, such as hypogonadism-related erectile dysfunction, short statue, depression, or male breast cancer. There are two different types of AIs: steroidal and nonsteroidal. Steroidal AI (e.g., testolactone) is an irreversible, but weaker inhibitors, while nonsteroidal AIs (e.g., letrozole and anastozole) are potent reversible inhibitors. Both types of AIs demonstrate plausible effects to improve semen parameters. In this review, the physiological action of aromatase and the indications of AIs treatment are discussed in detail, especially focusing on the function of spermatogenesis in infertile men.

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This review article aims to summarize the recent advancement in basic research on lower urinary tract dysfunction (LUTD) following spinal cord injury (SCI) above the sacral level. We particularly focused on the neurophysiologic mechanisms controlling the lower urinary tract (LUT) function and the SCI-induced changes in micturition control in animal models of SCI. The LUT has two main functions, the storage and voiding of urine, that are regulated by a complex neural control system. This neural system coordinates the activity of two functional units in the LUT: the urinary bladder and an outlet including bladder neck, urethra, and striated muscles of the pelvic floor. During the storage phase, the outlet is closed and the bladder is quiescent to maintain a low intravesical pressure and continence, and during the voiding phase, the outlet relaxes and the bladder contracts to promote efficient release of urine. SCI impairs voluntary control of voiding as well as the normal reflex pathways that coordinate bladder and sphincter function. Following SCI, the bladder is initially areflexic but then becomes hyperreflexic due to the emergence of a spinal micturition reflex pathway. However, the bladder does not empty efficiently because coordination between the bladder and urethral sphincter is lost. In animal models of SCI, hyperexcitability of silent C-fiber bladder afferents is a major pathophysiological basis of neurogenic LUTD, especially detrusor overactivity. Reflex plasticity is associated with changes in the properties of neuropeptides, neurotrophic factors, or chemical receptors of afferent neurons. Not only C-fiber but also Aδ-fiber could be involved in the emergence of neurogenic LUTD such as detrusor sphincter dyssynergia following SCI. Animal research using disease models helps us to detect the different contributing factors for LUTD due to SCI and to find potential targets for new treatments.

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Purpose: The purpose was to investigate the risk of subsequent malignancies in patients with renal cell carcinoma (RCC) using hospital-based cancer registry database and a nationwide health insurance database. Materials and Methods: We used the following three databases: Cancer Registry Database of National Taiwan University Hospital (NTUH), National Health Insurance Research Database (NHIRD), and registry for catastrophic illness patients, a subset from NHIRD. We identified patients with RCC and analyzed the risk of subsequent malignancies in these patients. Results: Of the 1188 patients with RCC treated at NTUH, 141 (11.9%) had subsequent malignancies. Cancers in the colon, liver, prostate, lung and stomach were the five most common other primary malignancies. The nationwide analysis showed that 4.68% of the RCC patients had subsequent malignancies. The percentage was significantly higher than that in the general population in Taiwan. The five most common subsequent malignancies in patients with RCC were bladder, liver, colon, lung, and prostate cancer. The risk of developing these subsequent cancers in RCC patients was also significantly higher than that in the general population. Conclusion: Subsequent malignancies were noted in a high proportion of patients with RCC in Taiwan. It is a multifactorial process and the mechanism is still uncertain. This important issue warrants further studies to elucidate the mechanism.

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Purpose: World Health Organization has declared coronavirus disease 2019 (COVID-19), a global pandemic in March 2020. Nations around the world enact prevention measures such as lockdowns, quarantines, massive testing, and tracing policies. Prevention measures against the pandemic may result in less opportunities for urology residents to learn. This study aims to investigate the difference in urology residency in Indonesia before and during the COVID-19 pandemic. Materials and Methods: This research is a cross-sectional study. Authors analyzed 147 urology residents across five urology education centers in Indonesia who fulfilled a self-administered online questionnaire. Participants were asked about their objective and subjective experience regarding urology residency, before and during the COVID-19 pandemic. Results: Change in urology education paradigm in Indonesia during the COVID-19 pandemic is agreed upon by 95.91% participants, 57.82% thinks it brings negative causes negative consequences. Anxiety toward competence level is felt by 70.06% of participants. Reduced opportunities to learn, especially surgical skills may lead to this result. Overall mental health condition of participants does not significantly change. Multiple factors may contribute to this result. Conclusion: As changes and adaptations are inevitable, more attention should be brought to residents' competence level while maintaining COVID-19 prevention protocol. This is the first nationwide survey showing the effects of the COVID-19 pandemic on urology education system in Indonesia. Authors suggest a larg-scale study, with more detailed questionnaire to further elaborate the causes and effects of each variable observed.

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Purpose: The aim was to assess the results of balloon dilation in patients with bladder neck contracture (BNC) after endoscopic surgery for benign prostatic hyperplasia (BPH). Materials and Methods: The study involved 120 patients with recurrent BNC after transurethral interventions for BPH. All patients underwent transurethral resection (TUR) of the bladder neck and were divided into two groups: Group A (n = 45) included men who, after TUR, additionally underwent repeated balloon dilation, whereas the control group B (n = 75) included men who were treated with alpha-blockers alone. Results: In 9 months after TUR and 3 months after the 4^th balloon dilation procedure in Group A, the mean international prostate symptom score (IPSS) decreased from 20.1 ± 8.4 to 17.2 ± 7.4, and the IPSS-quality of life was 4.2 ± 1.2 (P > 0.05). In Group B, they were 21.7 ± 7.7 and 4.7 ± 1.1 (P > 0.05), respectively. In addition, the mean flow rate in Group A was 13.2 ± 5.4 ml/s, whereas in Group B, it was 8.7 ± 4.9 ml/s (P < 0.05). There was a significant decrease in the postvoid residual urine volume from 76.2 ± 96.1 ml to 37.6 ± 55.1 ml in Group A, whereas, in Group B, it increased from 63.0 ± 36.9 ml to 79.4 ± 71.6 ml (P > 0.05). Furthermore, 28.0% of patients of Group B and 13.3% of patients of Group A underwent repeated TUR of the bladder neck in 9 months follow-up period (P < 0.05). Conclusion: Balloon dilation is a safe less invasive procedure and can reduce the possibility of BNC recurrence and thus the rate of repeated transurethral interventions.

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Purpose: Laparoscopic living-donor nephrectomy is the main technique at high-volume renal transplant centers. Laparoendoscopic single-site donor nephrectomy (LESS-DN) is s an evolutionary minimally invasive surgery, which could be performed by transperitoneal or retroperitoneal approaches. We present a retrospective analysis of our single-institution donor nephrectomy series comparing the transperitoneal to retroperitoneal LESS-DN regarding operative outcomes. Materials and Methods: Seventeen patients who underwent LESS-DN from 2017–2020 were enrolled at our center. The same surgeon performed all cases. The two approaches were compared for the operation time, blood loss, warm ischemia time (WIT), postoperative pain, length of stay (LOS), postoperative wound size, postoperative pain, and the postoperative renal function for twelve months retrospectively. Results: Operating time (257 vs. 180 min, P = 0.016) and LOS (6.5 vs. 5 days, P = 0.013) were significantly longer in the transperitoneal group. The postoperative wound size (47.5 vs. 75 mm, P = 0.038) was substantially smaller in the transperitoneal group. There was no significant difference in other parameters, including blood loss, WIT, complication rate, and postoperative pain from day one to day three. Conclusion: Retroperitoneal LESS-DN results in similar perioperative outcomes as transperitoneal LESS-DN without compromising donor safety and providing a faster operation time, shorter LOS, and a trend toward a shorter WIT. Both approach methods may be safe and effective procedures for living kidney transplantation.

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Purpose: Obesity has been proven to affect the outcomes in open radical prostatectomy. However, the relationship between obesity and the outcomes of robot-assisted radical prostatectomy (RARP) was not conclusive. Herein, we aimed to investigate the impact of obesity on the clinical outcomes after RARP. Materials and Methods: From April 2016 to June 2020, 164 patients underwent RARP by a single experienced surgeon at our institute. Patients with previous transurethral resection of prostate (n = 30), hernioplasty (n = 13), and transperitoneal RARP (n = 26) were excluded. Finally, 105 patients were enrolled and divided into different groups according to their body mass index (BMI) and waist circumference (WC) using the definition of Taiwan National Health Institute. BMI was categorized into three groups (normal: BMI <24, overweight: BMI between 24 and 27, and obese: BMI ≥27 [kg/m²]). WC was categorized into two groups (normal: WC <90 and central obesity: WC ≥90 [cm]). Perioperative outcomes and functional outcomes including preoperative, postoperative erectile function, and postoperative continence status were evaluated. Results: Among BMI groups, 29 patients were normal, 43 patients were overweight, and 33 patients were obese. Console time and sum time showed a significant difference in different BMI groups (P = 0.034 and 0.016, respectively). Of the 101 patients with available magnetic resonance imaging, 74 patients' WC were normal, and 27 patients were central obese. Blood loss in central obesity group was significant more than normal WC group (300 ml vs. 200 ml, P = 0.04). No significant differences were observed in pathological and functional outcomes in both groups. Conclusion: Obesity and central obesity seemed to result in longer operation time and more blood loss in extraperitoneal RARP while functional outcomes can be maintained regardless of the obesity degree. Large-scale studies are necessary to further explore the relationship between obesity and the outcomes of RARP in future.

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Purpose: To assess the outcome and safety of tubeless mini-percutaneous nephrolithotomy (mini-PCNL) and retrograde intrarenal surgery (RIRS) to treat patients with renal and upper ureteral stones between 2 and 3 cm. Materials and Methods: Between July 2017 and June 2020, 140 patients underwent tubeless mini-PCNL and RIRS for renal stone size between 2 and 3 cm were enrolled in this study. The outcome was determined immediately after operation on plain radiograph kidney, ureter, and bladder and sonography. Various patient and stone characteristics including perioperative outcomes and complications were evaluated. SPSS version 16. Institutional Review Board of Ditmanson Medical Foundation Chia-Yi Christian Hospital, approval number 2021037. Results: Stone-free rates after the procedure were achieved in 78.4% of patients for the tubeless mini-PCNL and 36.4% of patients for the RIRS Group (P < 0.001). However, the stone-free rates at 3 months after surgery were 78.4% for the tubeless mini-PCNL and 68.2% of the RIRS Group (P = 0.172). The mean operative time per patient was 88.6 ± 27.4 min in the tubeless mini-PCNL group, and it was 129.1 ± 44.8 min in the RIRS groups (P < 0.001). The average hospital stay is 3.4 ± 2.0 days in the tubeless mini-PCNL group and 1.9 ± 1.8 days in the RIRS group (P < 0.001). The postoperative infection rates for the tubeless mini-PCNL and RIRS groups were 9.5% and 6.1%, respectively (P = 0.456). Blood transfusions were needed in one patient in the tubeless mini-PCNL group. Conclusion: Tubeless mini-PCNL and RIRS are safe and effective methods for medium-sized renal calculi. Tubeless mini-PCNL compared to RIRS offers the better outcome of higher stone-free rate and lower operation time, but with longer hospital stay and stone-free rate (3-month postoperative).

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