The Impact of Pathologic Upgrading of Gleason Score 7 Prostate Cancer on the Risk of the Biochemical Recurrence after Radical Prostatectomy

OBJECTIVE

To investigate the impact of pathologic upgrading of Gleason score (GS) 7 prostate cancer on the risk of the biochemical recurrence.

MATERIALS AND METHODS

A total of 1678 patients with postoperative GS 7 prostate cancer without lymph node metastasis were reviewed retrospectively. The patients were categorized into four groups depending on pathologic upgrading: upgraded GS 3+4, nonupgraded GS 3+4, upgraded GS 4+3, and nonupgraded GS 4+3. Kaplan-Meier multivariate model was created.

RESULTS

The mean age was significantly higher in the nonupgraded GS 4+3 group than in other groups, whereas the mean prostate-specific antigen (PSA) level was lower in the upgraded GS 3+4 group. Pathologic findings, such as extracapsular extension, seminal vesical invasion, and the surgical margin rate, were different from each other. Five-year biochemical recurrence-free survival rate was 85%, 73%, 69%, and 60% in upgraded GS 3+4, nonupgraded GS 3+4, upgraded GS 4+3, and nonupgraded GS 4+3 group, respectively. There was significant difference between the nonupgraded 4+3 and upgraded 4+3 group, as well as between upgraded 3+4 and nonupgraded 3+4 group. However, the two middle patient groups, that is, the nonupgraded GS 3+4 group and the upgraded GS 4+3 group, did not show the statistical difference (Log-rank test, p value = 0.259).

CONCLUSION

The information on pathologic upgrading in the biopsy reports of patients could help to provide more detailed analysis for the biochemical recurrence of GS 7 prostate cancer.

Long-term oncologic outcomes after radical prostatectomy in clinically localized prostate cancer: 10-year follow-up in Korea

PURPOSE

The clinical behavior of prostate cancer differs by race and ethnicity; however, data on the Korean population are scarce. We assessed the long-term oncologic outcomes of clinically localized prostate cancer after radical prostatectomy in Korean men.

MATERIALS AND METHODS

We analyzed 786 clinically localized prostate cancer patients who underwent radical prostatectomy, from June 1993 to June 2008. Kaplan-Meier survival curve analysis and log-rank test were used to assess the oncologic outcomes.

RESULTS

The mean age of the patients was 64.9±6.6 years. Pelvic lymph node dissection was performed in 373 patients. Pathologic T and N stage cancer with local advancement and invasion were detected by radical prostatectomy in 307 and 22 patients, respectively. In total, 38 patients who underwent adjuvant therapy were excluded from the analysis of progression after biochemical recurrence (BCR), which occurred in 261 men. In total, 219 patients underwent salvage treatment. Local recurrence and distant metastasis occurred in 109 and 42 patients, respectively; 36 patients experienced metastasis with local recurrence. Castration-resistant prostate cancer developed in 22 patients, and overall and disease-specific mortality was noted in 148 and 23 patients, respectively. The median duration from operation to BCR, BCR to metastasis, and metastasis to disease-specific death was 25, 40, and 22 months, respectively.

CONCLUSIONS

We demonstrated the long-term prognosis of localized prostate cancer after radical prostatectomy among Koreans. Our results differ from those reported in the Western literature, with a lower prevalence of distant metastasis and shorter time to metastasis after BCR.

Comparison of voiding parameters in men and women with lower urinary tract symptoms

AIM

The aim of this study was to compare voiding parameters by using urodynamic investigations in men and women with lower urinary tract symptoms (LUTS).

METHODS

A total of 164 individuals (76 men and 88 women) completed the International Prostate Symptom Score (IPSS) and underwent a detailed urodynamic investigation. Patients were stratified by voiding function, which included bladder voiding efficiency (BVE) of < 80% and of >or= 80%.

RESULTS

IPSSs were similar in the men and women except for voiding symptoms for those with a BVE of >or= 80% (12 for men vs. 9 for women, P=0.016). When voiding parameters were compared according to BVE in men and women, respectively, maximum flow rate (Q(max)) (P=0.002), average flow rate (Q(ave)) (P=0.003), voided volume (P=0.037), post-void residual (PVR) (P<0.001), and bladder outlet obstruction index (P=0.016) were different for men with a BVE of < 80% and men with a BVE of >or= 80%. However, for women with a BVE of < 80% or >or= 80%, PVR (P<0.001), detrusor pressure at maximum flow rate (P=0.022), and opening detrusor pressure (P=0.024) were different.

CONCLUSIONS

The voiding parameters of women differ from those of men according to voiding function. The present results show that a pressure-flow study may represent a difference according to BVE in women as well as in men. Our findings suggest that opening detrusor pressure in women reflects the urethral and detrusor during voiding phase accurately as detrusor pressure at maximum flow rate does.

Prognostic Role of Neutrophil-to-lymphocyte Ratio-based Markers During Pre- and Postadjuvant Chemotherapy in Patients With Advanced Urothelial Carcinoma of Upper Urinary Tract

PURPOSE

The aim of the present study was to assess the prognostic significance of neutrophil-to-lymphocyte ratio (NLR)-based markers before and after adjuvant chemotherapy (ACH) in patients with urothelial carcinoma of the upper urinary tract (UTUC) undergoing radical nephroureterectomy (RNU) and ACH.

MATERIALS AND METHODS

The data from 112 patients with advanced UTUC who had undergone first-line ACH after RNU from 1994 to 2012 were reviewed. After excluding 22 patients, the clinicopathologic data for 90 patients were analyzed, in particular, the NLR and derived NLR (dNLR) preoperatively and before and after ACH. Cancer-specific survival (CSS) and overall survival (OS) outcomes were measured using Kaplan-Meier analysis. To identify the predictors for the oncologic outcomes, a multivariate Cox regression model was used.

RESULTS

Patients with a higher preoperative NLR, pre-ACH dNLR, and post-ACH dNLR had poorer CSS and OS than their counterparts with lower values. After adjustment of various clinicopathologic factors, age at surgery (≥ 65 years; hazard ratio [HR], 3.13) and higher post-ACH dNLR (HR, 3.06) remained significant predictors for CSS. Similarly, age (≥ 65 years; HR, 2.90) and elevated post-ACH dNLR (≥ 2.3; HR, 2.89) were also identified as predictors of OS on multivariate analysis.

CONCLUSION

A higher post-ACH dNLR was independently predictive of poor CSS and OS in patients with advanced UTUC receiving systemic ACH after RNU. From the obtained data, we propose that the NLR-based marker could be a readily available and valuable biomarker for predicting oncologic outcomes after chemotherapy.

Impacts of the quinazoline-based alpha1-antagonist, terazosin, and of the sulfonamide derivative, tamsulosin, on serum prostate-specific antigen and prostate volume

The aim of this study was to compare the impacts of terazosin and tamsulosin, on prostate activity, i.e., serum prostate-specific antigen, total prostate volume (TPV), and transition zone volume (TZV). A total of 90 patients who presented with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), ranging in age from 52 to 83 yr (median 65 yr), were included in the study. Patients were given 0.2 mg tamsulosin, 2 mg terazosin, or 4 mg terazosin once daily for an average of 14 months (range, 6-56 months). Subjective (International Prostate Symptom Scores, I-PSS) and objective (maximal flow rate and post-void residual) parameters were assessed both at baseline and at treatment cessation. Serum prostate-specific antigen (PSA) levels were found to be unaffected by treatment (1.2 and 1.3 ng/mL). In total patients, multivariate analysis showed that baseline TPV was the only independent predictor of treatment-related TPV reduction. Moreover, baseline TPV > or =30 g was found to be associated with a higher likelihood of TPV reduction (odds ratio [OR], 3.939; 95% confidence interval [CI], 1.506-10.304; p=0.005), and a baseline TZV of > or =10 g was associated with a 7.1-times greater chance of TZV reduction (OR, 7.100; 95% CI, 2.428-20.763; p<0.001). The same model showed that patients on 2 mg terazosin had a 10.8-fold greater likelihood (OR, 10.770; 95% CI, 1.409-82.323; p=0.022) and that those on 4 mg terazosin had a 9.0-fold greater likelihood (OR, 9.001; 95% CI, 1.724-46.995; p=0.009) of a TZV reduction than those on 0.2 mg tamsulosin. In addition, symptoms improved regardless of prostate activity after taking alpha1-blockers. Our findings suggest that terazosin reduces TZV and demonstrate that the relief of symptoms associated with BPH may not be due to a prostate activity reduction induced by apoptosis in the prostate gland.

Significance of predicted tumor volume as a predictor of pathologic stage in patients undergoing radical prostatectomy

PURPOSE

The purpose of this study was to evaluate whether predicted tumor volume could predict pathologic stage in patients undergoing radical prostatectomy.

MATERIALS AND METHODS

The clinical and pathologic data of 236 patients who underwent a 12-core needle biopsy followed by radical prostatectomy were obtained from our database and reviewed retrospectively.

RESULTS

Observed tumor volume correlated best with serum prostate-specific antigen (PSA) level (r=0.677, p<0.001) and the number of positive biopsy cores (r=0.489, p<0.001). Stepwise multiple linear regression analysis was used to develop a model for predicting tumor volume before radical prostatectomy. All explanatory variables except PSA and the number of positive biopsy cores were eliminated, yielding the equation ([predicted tumor volume]=0.381x[PSA]+0.921x[No. of positive biopsy cores]-0.992). Tumor volume predicted by this equation correlated strongly with observed tumor volume (r=0.722, p<0.001). This was also true when a different cohort of 159 patients was analyzed (r=0.638, p<0.001). The areas under the receiver operating characteristic curves of predicted tumor volume were 68.5% for extracapsular extension, 75.7% for seminal vesicle invasion, and 70.4% for positive surgical margin. Kaplan-Meier curves revealed that predicted tumor volume correlated significantly with biochemical recurrence-free survival (p<0.001; log-rank test).

CONCLUSIONS

Our findings suggest that tumor volume predicted on the basis of PSA levels and number of positive biopsy cores may predict pathologic stage with reasonable accuracy.

Systemic chemotherapy in patients with indwelling ureteral stenting

BACKGROUND

We investigated whether systemic chemotherapy increased episodes of acute pyelonephritis (APN) in patients with an indwelling double-J stent due to non-urological malignant ureteral obstruction.

METHODS

A retrospective study was performed on a total of 74 patients (16 men and 58 women; median age, 53.0; range, 34-84 years) with non-urological malignant ureteral obstruction, who were managed by double-J stenting between October 1997 and December 2001. The patients were divided into those who received (33 patients, group I) and those who did not receive systemic chemotherapy (41 patients, group II) during the stent indwelling period (median, 7.0; range, 1-44 month). Routine antibiotic prophylaxis was not administered to any patient. Median follow-up was 10.5 (range, 1-45) months. Clinical features, including the incidence of febrility and APN, were compared between the two groups.

RESULTS

Of the 74 patients, 18 patients (24.3%) experienced acute febrile episodes during ureteral stenting, but only five (6.8%) patients were diagnosed as having APN. No significant difference in the incidence of fever or APN was found between the two groups (P = 1.000 and P = 0.651, respectively). Univariate logistic analysis indicated that only the duration of follow-up was a risk factor for an episode of fever. Other parameters had no clinical significance.

CONCLUSION

Our findings suggest that systemic chemotherapy may not predispose the risk of acute pyelonephritis in patients with an indwelling ureteral stent due to non-urological malignant ureteral obstruction.

Development of Decision Support Formulas for the Prediction of Bladder Outlet Obstruction and Prostatic Surgery in Patients With Lower Urinary Tract Symptom/Benign Prostatic Hyperplasia: Part II, External Validation and Usability Testing of a Smartphone App

PURPOSE

We aimed to externally validate the prediction model we developed for having bladder outlet obstruction (BOO) and requiring prostatic surgery using 2 independent data sets from tertiary referral centers, and also aimed to validate a mobile app for using this model through usability testing.

METHODS

Formulas and nomograms predicting whether a subject has BOO and needs prostatic surgery were validated with an external validation cohort from Seoul National University Bundang Hospital and Seoul Metropolitan Government-Seoul National University Boramae Medical Center between January 2004 and April 2015. A smartphone-based app was developed, and 8 young urologists were enrolled for usability testing to identify any human factor issues of the app.

RESULTS

A total of 642 patients were included in the external validation cohort. No significant differences were found in the baseline characteristics of major parameters between the original (n=1,179) and the external validation cohort, except for the maximal flow rate. Predictions of requiring prostatic surgery in the validation cohort showed a sensitivity of 80.6%, a specificity of 73.2%, a positive predictive value of 49.7%, and a negative predictive value of 92.0%, and area under receiver operating curve of 0.84. The calibration plot indicated that the predictions have good correspondence. The decision curve showed also a high net benefit. Similar evaluation results using the external validation cohort were seen in the predictions of having BOO. Overall results of the usability test demonstrated that the app was user-friendly with no major human factor issues.

CONCLUSIONS

External validation of these newly developed a prediction model demonstrated a moderate level of discrimination, adequate calibration, and high net benefit gains for predicting both having BOO and requiring prostatic surgery. Also a smartphone app implementing the prediction model was user-friendly with no major human factor issue.

Voiding patterns in men and women with lower urinary tract symptoms combined with nocturia

AIM

We evaluated differences between men and women with lower urinary tract symptoms (LUTS) combined with nocturia.

METHODS

A total of 71 age-matched female-male pairs (median 58, range 20-81 years) who had moderate to severe LUTS and nocturia of more than once per night were enrolled in this study.

RESULTS

In the younger group (<50 years), the International Prostate Symptom Score (I-PSS) results of the sexes were not significantly different. However, although total I-PSS results in the elderly group (> or =50 years) were not significantly different, quality of life index scores for women were higher (P = 0.002). On frequency-volume (FV) charts, mean total daytime voided volume (DVV) was significantly higher in younger men than in younger women (P = 0.017), but the mean nocturnal polyuria index (NPi) for women was higher than that for men (P = 0.047). However, maximum DVV (P = 0.009), mean DVV (P < 0.0001), total DVV (P < 0.0001), and mean nocturnal urine volume (P = 0.009) were significantly higher in elderly men than in elderly women. However, numbers of daytime voids were not different.

CONCLUSION

Elderly women with LUTS have lower functional bladder capacities than elderly men, as suggested by their smaller mean voided volumes. However, no significant differences were observed between numbers of daytime voids, which was probably due to the smaller total daytime voided volumes of elderly women. In addition, although NPi for younger women and nocturnal urine volume for elderly men was higher, no other differences were observed in terms of other night-time parameters.

Solitary squamous cell carcinoma in the kidney after metachronous development of esophageal and lung cancer

Solitary metastatic renal tumors are rarely encountered clinically. We report the case of a 65-year-old man who developed a solitary renal metastasis after undergoing an esophagectomy for esophageal cancer and subsequent lobectomy for lung cancer. The present case serves to demonstrate that careful follow-up is needed for esophageal cancer patients with cancer of another organ.

Impact of self-perceived bothersomeness on health-related quality of life in women with overactive bladder symptoms

INTRODUCTION

The objective of this study was to examine the impact of self-perceived bothersomeness of overactive bladder (OAB) symptoms on the health-related quality of life (QOL).

PATIENTS AND METHODS

A total of 92 women with a mean age of 53.3 (range 23-79) years suffering from OAB were included in the study. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and King's Health Questionnaire (KHQ) were used to assess the QOL. The patients were divided into two groups according to the bothersomeness degree of OAB: 'low' and 'moderate' to 'high'.

RESULTS

The SF-36 and the KHQ scores of the patients were significantly different from those of the controls (p <0.05), except for three domains of the SF-36. No difference in the results of the frequency-volume charts was observed between the two patient groups. The scores of the SF-36 and the KHQ domains did not correlate with the data of the frequency-volume charts. Significant differences were found between the two patient groups for most domains of the SF-36 (p <0.05). Significant differences were also detected in most domains of the KHQ (p <0.05).

CONCLUSIONS

Objective data are not a sensitive tool for measuring the QOL in women with OAB symptoms. Our findings suggest that patient-perceived bothersomeness significantly influences QOL and that strategies for assessing bothersomeness should be developed to evaluate the QOL in these patients.

Oncologic Outcomes of Intracorporeal vs Extracorporeal Urinary Diversion After Robot-Assisted Radical Cystectomy: A Multi-Institutional Korean Study

Background: We aimed to compare the oncologic outcomes of intracorporeal urinary diversion (ICUD) and extracorporeal urinary diversion (ECUD) following robot-assisted radical cystectomy (RARC) in patients diagnosed with bladder cancer. Materials and Methods: Medical records of 730 patients who underwent RARC between April 2007 and May 2019 in 11 tertiary referral centers were retrospectively reviewed. We assessed recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) in the two groups using the Kaplan-Meier method. Cox regression models were used to identify factors associated with RFS, CSS, and OS. Results: Among 591 patients, neobladder diversion was performed more frequently in the ICUD group (70.8% vs 52.5%, p = 0.001). The median follow-up duration was shorter in the ICUD group than in the ECUD group (16 vs 26 months, p < 0.001). The rates of overall recurrence (36.5% vs 25.5%, p = 0.013) and pelvic recurrence (12.1% vs 5.9%, p = 0.031) were higher in the ECUD group. However, no differences in 5-year RFS (43.2% vs 58.4%, p = 0.516), CSS (79.3% vs 89.7%, p = 0.392), and OS (74.3% vs 81.4%, p = 0.411) were noted between the two groups. Multivariable analysis revealed that when compared to ICUD, ECUD was not associated with RFS (hazard ratio [HR], 0.982; p = 0.920), CSS (HR, 0.568; p = 0.126), and OS (HR, 0.642; p = 0.124). Conclusion: Although there was a difference in recurrence rate between the two groups, multivariable analysis indicated that the diversion technique after RARC did not affect the oncologic outcomes. Large prospective studies with long-term follow-up are warranted to verify the oncologic outcomes of ICUD and ECUD following RARC.

Scale-Up Evaluation of a Composite Tumor Marker Assay for the Early Detection of Renal Cell Carcinoma

The early detection of renal cell carcinoma (RCC) using tumor markers remains an attractive prospect for the potential to downstage the disease. To validate the scale-up clinical performance of potential tumor markers for RCC (as a single marker and as a composite tumor marker composed of nicotinamide N-methyltransferase (NNMT), L-Plastin (LCP1), and non-metastatic cells 1 protein (NM23A)), the scale-up assay was performed. Patients with RCC from multiple domestic institutes were included in the clinical evaluation for reassessment and improvement of the established triple markers of our product. For the diagnostic performance of the composite markers, the best-split cutoff points of each marker (147 pg/mL for NNMT, 1780 pg/mL for LCP1, and 520 pg/mL for NM23A) were installed. Serum levels of NNMT, LCP1, and NM23A were greatly increased in subjects with RCC (p < 0.0001). In 1042 blind sample tests with control individuals (n = 500) and patients with RCC (n = 542), the diagnostic sensitivity and specificity of the composite three-marker assay were 0.871 and 0.894, respectively, and the resulting AUC (Area under Curve) of ROC (Receiver Operating Characteristic) was 0.917. As a single marker, the diagnostic accuracies of NNMT, LCP1, and NM23A, as estimated by ROC, were 0.833, 0.844, and 0.601, respectively. The composite three-marker assay with NNMT, LCP1, and NM23A is a more improved novel serum marker assay for the early detection of RCC in cases of renal mass or unknown condition. The NNMT, LCP1, and NM23A triple marker assay could be a powerful diagnostic tumor marker assay to screen the early stage of RCC.

Development of Decision Support Formulas for the Prediction of Bladder Outlet Obstruction and Prostatic Surgery in Patients With Lower Urinary Tract Symptom/Benign Prostatic Hyperplasia: Part I, Development of the Formula and its Internal Validation

PURPOSE

As the elderly population increases, a growing number of patients have lower urinary tract symptom (LUTS)/benign prostatic hyperplasia (BPH). The aim of this study was to develop decision support formulas and nomograms for the prediction of bladder outlet obstruction (BOO) and for BOO-related surgical decision-making, and to validate them in patients with LUTS/BPH.

METHODS

Patient with LUTS/BPH between October 2004 and May 2014 were enrolled as a development cohort. The available variables included age, International Prostate Symptom Score, free uroflowmetry, postvoid residual volume, total prostate volume, and the results of a pressure-flow study. A causal Bayesian network analysis was used to identify relevant parameters. Using multivariate logistic regression analysis, formulas were developed to calculate the probabilities of having BOO and requiring prostatic surgery. Patients between June 2014 and December 2015 were prospectively enrolled for internal validation. Receiver operating characteristic curve analysis, calibration plots, and decision curve analysis were performed.

RESULTS

A total of 1,179 male patients with LUTS/BPH, with a mean age of 66.1 years, were included as a development cohort. Another 253 patients were enrolled as an internal validation cohort. Using multivariate logistic regression analysis, 2 and 4 formulas were established to estimate the probabilities of having BOO and requiring prostatic surgery, respectively. Our analysis of the predictive accuracy of the model revealed area under the curve values of 0.82 for BOO and 0.87 for prostatic surgery. The sensitivity and specificity were 53.6% and 87.0% for BOO, and 91.6% and 50.0% for prostatic surgery, respectively. The calibration plot indicated that these prediction models showed a good correspondence. In addition, the decision curve analysis showed a high net benefit across the entire spectrum of probability thresholds.

CONCLUSIONS

We established nomograms for the prediction of BOO and BOO-related prostatic surgery in patients with LUTS/BPH. Internal validation of the nomograms demonstrated that they predicted both having BOO and requiring prostatic surgery very well.

Accuracy of a high prostate-specific antigen level for prostate cancer diagnosis upon initial biopsy in Korean men

PURPOSE

This study aimed to evaluate the cancer detection rate in a Korean population with prostate-specific antigen (PSA) levels greater than or equal to 20.0 ng/mL.

MATERIALS AND METHODS

A total of 174 men 50 to 79 years old (median 69) included in the study. The median prostate volume of the patients was 44.8 mL (range 14.1 to 210.0) and their serum PSA ranged from 20.0 to 9725.0 ng/mL (median 44.8).

RESULTS

Of 174 men 141 (81.0%) were diagnosed with prostate cancer on initial biopsy. In the total number of patients, the positive predictive value (PPV) was 62.9% for PSA 20 to 29.9, 72.7% for PSA 30 to 39.9 and 100% for PSA 40 to 49.9 ng/mL. In patients with an abnormal digital rectal examination (DRE), the values for these PSA ranges increased to 89.5%, 91.7% and 100%, respectively. The PPV was 81.0% for PSA cutoff of 20, 89.2% for a cutoff of 30, 95.4% for a cutoff of 40, and 94.7% for a cutoff of 50 ng/mL. In conjunction with an abnormal DRE, the values for these PSA cutoffs increased to 95.9%, 98.1%, 100%, and 100%, respectively.

CONCLUSION

Our data suggest the ability to predict the presence of prostate cancer reliably on initial biopsy when PSA threshold is greater than or equal to 50 ng/mL. This PSA threshold may be lowered to 40 ng/mL in the presence of an abnormal DRE. In Korean men with high PSA, the detection rate of prostate cancer on biopsy appears to be comparable to that for American men.

Prognostication in Patients Treated with Radical Cystectomy for Urothelial Bladder Carcinoma: A New Simplified Model Incorporating Histological Variants

PURPOSE

The aim of this study was to evaluate the clinical significance of histological variants (HV) and to develop a new and simple prediction model incorporating variant forms in patients who underwent radical cystectomy for urothelial carcinoma (UC).

MATERIALS AND METHODS

We analyzed the data of 365 patients. We evaluated whether HV were independent predictors of survival. A new scoring model was developed using the regression coefficients from the multivariate Cox proportional hazard model. The patients were divided into three groups on the basis of the score: low-, intermediate- and high-risk. To evaluate the performance of the model, we assessed models in terms of discrimination and calibration.

RESULTS

Patients(median age; 68.5 years) with pure form and squamous differentiation did not differ significantly but statistical analysis of the survival curves of patients with pure form and other variants revealed a statistically significant difference in terms of cancer-specific survival (CSS) (p = 0.005) and overall survival (OS) (p = 0.010). According to the new scoring model HV, the 5-yr CSS rate in each group was 93.3%, 82.9% and 50.5%, respectively. The 5-yr OS rate in each group was 90.0%, 66.3% and 33.2%, respectively. Model discrimination was good for all year models. Calibration was also adequate for the model in all year models.

CONCLUSIONS

HV were found to be important independent prognostic factors in urothelial bladder cancer. This paper presents a new prognostic model incorporating variant forms for predicting CSS and OS in these patients.

Treatment satisfaction after 1 year high-power potassium-titanyl-phosphate photoselective vaporization of the prostate

To investigate the factors that influence treatment satisfaction after high-power potassium-titanyl-phosphate (KTP) laser vaporization of the prostate, we compared the characteristics between patients who were satisfied and those who were not satisfied. In all, 97 patients aged between 53-82 years (median age 67 years) underwent high-power KTP laser vaporization of the prostate for lower urinary tract symptoms due to benign prostatic hyperplasia. At 12 months postoperatively, 60 patients were satisfied with the treatment, whereas 37 were dissatisfied. Although there were no differences in International Prostate Symptom Score (IPSS) values at baseline, the satisfied group scored better in total IPSS at 1, 3, 6, and 12 months postoperatively (P < 0.05). At baseline, the maximum flow rate (Qmax) was lower in the dissatisfied group and remained low throughout the follow-up period, with the exception of 1 month postoperatively (P < 0.05), compared with the satisfied group. There were no differences in other objective data between the two groups, including post-void residual and the number of voids based on the frequency-volume charts. In a multivariate model, a higher bladder contractility index was associated with a greater likelihood of treatment satisfaction 12 months after high-power KTP laser vaporization (odds ratio 1.024, 95% confidence interval 1.001-1.048, P < 0.05). Patients who were not satisfied following the surgery had a smaller improvement in subjective symptoms and Q(max). In addition, our findings suggest that the relative risk of treatment dissatisfaction following high-power KTP laser vaporization was increased in patients with weak detrusor contractility.

A comparative study of patient experiences of conventional fluoroscopic and four-hour ambulatory urodynamic studies

We assessed several emotional variables in patients experiencing conventional urodynamic and ambulatory urodynamic monitoring (AUM) to verify the hypothesis that AUM is tolerated as well as conventional urodynamics. A total of 33 women and 7 men from 23 to 72 years of age who were undergoing both procedures were prospectively included in this study. Prior to and immediately after the procedures, each patient completed a self-administered questionnaire. Answers were given on a visual analogue scale. The degree of anxiety was higher for conventional urodynamics than for AUM (p = 0.045), while the degree of boredom experienced during AUM was higher than that during conventional urodynamics (p= 0.013). There was no significant difference in the degree of shame or bother experienced by the patients during the two procedures. In general, patients tolerated both examinations extremely well. The examiner-rated degree of intolerance during conventional urodynamics was influenced by the subjective pain score (p=0.001), while all other emotional variables except bother were not significantly related with the degree of intolerance during AUM (p=0.007). A total of 74.4% and 84.6% responded that they were willing to repeat conventional urodynamics and AUM, respectively, which were not significantly different. Although AUM produced a significantly higher level of boredom than conventional urodynamics, our data demonstrates that patients are as tolerant of AUM as they are of conventional urodynamic procedures.

Significance of tension in tension-free mid-urethral sling procedures: a preliminary study

We report the results of the release and tape-shortening techniques in polypropylene pubovaginal slings. Of female patients who had undergone mid-urethral sling procedures [tension-free vaginal tape procedure and suburethral polypropylene (SPARC)], in cases in which postoperative retention occurred, the patients were offered release or tape cutting. Women reporting postoperative urinary incontinence underwent a tape-shortening procedure. In these patients, the tape was shortened by the use of clips. Mean follow-up time after the release and/or the shortening operations was 9.9 months (range 6-18). A total of 15 women, ranging from 41 to 75 years old (mean 58.3) were included in this study. Upon the latest follow-up, six women exhibited prolonged urinary retention and subsequently underwent a release procedure (n=5) or a tape-cutting procedure (n=1). After the release procedure, all patients remained continent, but one patient's urinary retention issues were not resolved, and she subsequently underwent a tape-cutting. Both of the patients who underwent the cutting procedure then developed recurrent stress urinary incontinence. The tape-shortening technique was conducted with nine patients. Seven of these patients recovered their continence, and no one patient experienced any urinary retention or other voiding difficulties. Two patients reported only minimal stress leakage and elected to undergo no further interventions. Our findings suggest that tension plays a substantial role in tension-free mid-urethral sling procedures.

Impact of perioperative blood transfusion on oncologic outcomes in patients with nonmetastatic renal cell carcinoma treated with curative nephrectomy: A retrospective analysis of a large, single-institutional cohort

PURPOSE

To evaluate the impact of perioperative blood transfusion (PBT) on oncologic outcomes after surgery in patients with nonmetastatic renal cell carcinoma (RCC).

MATERIALS AND METHODS

This retrospective review included 2,329 patients who underwent partial or radical nephrectomy for localized RCC in a single institution from 2000 to 2014. PBT was defined as transfusion of allogeneic packed red blood cells (pRBCs) during nephrectomy or within the preoperative or postoperative hospitalization period. Oncologic outcomes of interest were recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS).

RESULTS

PBT was performed in 275 patients (11.8%). In the multivariable logistic regression analysis, symptomatic presentation, advanced age at surgery, higher preoperative serum creatinine, and lower preoperative hemoglobin were independent preoperative risk factors for PBT (all p<0.05). Kaplan-Meier plots revealed that transfused patients showed poorer 5-year RFS (65.1% vs. 91.2%, p<0.001), OS (71.4% vs. 92.8%, p<0.001), and CSS (74.0% vs. 95.5%, p<0.001) than nontransfused patients. However, in the multivariable Cox regression analyses, PBT was not significantly associated with RFS, OS, or CSS. In multivariable analyses involving transfused patients only (n=275), an higher number of pRBC units was an independent predictor of worse OS (hazard ratio [HR], 1.043; 95% confidence interval [CI], 1.008-1.078; p=0.016) and CSS (HR, 1.066; 95% CI, 1.033-1.100; p<0.001).

CONCLUSIONS

The results of this study are inconclusive in that the influence of PBT on survival outcomes could not be determined in the multivariate analysis. However, increasing pRBC units in transfused patients might be a concern in light of worse OS and CSS. Therefore, efforts to limit PBT overuse seem necessary to improve postoperative survival in patients with RCC.

Second-Line Systemic Treatment for Metastatic Urothelial Carcinoma: A Network Meta-Analysis of Randomized Phase Clinical Trials

Purpose: We aimed to evaluate and compare relative impacts of various second-line treatments on overall survival (OS) in metastatic urothelial carcinoma (mUC). Method: A literature search was conducted in PubMed, Embase, and the Cochrane Library for all articles published prior to December 2018 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Seven randomized controlled trials with phase III design that met study eligibility criteria were selected for final analysis. A Bayesian framework network meta-analysis (NMA) was applied to indirectly compare the effect of each treatment on OS. Results: In NMA, atezolizumab (HR, 0.90; 95% CI, 0.57-1.40) and pembrolizumab (HR, 0.77, 95% CI, 0.48-1.20) showed no significant effect on OS improvement compared to vinflunine. Gemcitabine/paclitaxel combination (HR, 1.30; 95% CI, 0.80-1.90) and lapatinib (HR, 0.95; 95% CI, 0.57-1.60) was not significantly associated with OS improvement compared to atezolizumab and best supportive care, respectively. However, results of rankograms revealed that pembrolizumab and atezolizumab were the first and second rank therapeutic agents for OS improvement in post-platinum mUC. Conclusions: Our NMA results are inconclusive. The optimal second-line treatment for OS improvement could not be determined because there were no significant OS differences among evaluated therapeutic agents. However, the use of immunotherapeutic agents such as atezolizumab and pembolizumab may have priority for improving OS in second-line setting of mUC.

Differences in Pathologic Results of Repeat Transurethral Resection of Bladder Tumor (TURBT) according to Institution Performing the Initial TURBT: Comparative Analyses between Referred and Nonreferred Group

OBJECTIVE

Although transurethral resection of bladder tumor (TURBT) is a standard treatment and determines staging for nonmuscle invasive bladder cancer, many deficiencies persist. There is a risk of upstaging and residual cancer when repeat TURBT is performed. Authors compared the results of repeat TURBT by institution performing the initial TURBT.

METHODS

We retrospectively reviewed the medical records of 289 patients who underwent repeat TURBT within 2-6 weeks after initial TURBT between 1998 and 2013. The patients were divided into the referred group and the nonreferred group by institution performing the initial TURBT. And we analyzed the intergroup differences in residual tumor and upstaging rate and the factors significantly correlated with residual tumor.

RESULTS

The mean age was 69.6 ± 11.1 years and the mean follow-up was 49.7 (range: 0-191) months. The referred group included 69 patients, while the nonreferred group included 220 patients. The referred group included 57 (82.6%) patients with residual tumor after repeat TURBT. Overall upstaging occurred in 15 (21.7%), and upstaging to T2 occurred in 11 (15.9%) of the initial Ta and T1 patients. In the nonreferred group, there were 123 (55.9%) patients with residual tumor. Overall upstaging occurred in 10 (4.5%) and upstaging to T2 occurred in 7 (3.2%) patients.

CONCLUSIONS

Gross hematuria, grade, and tumor quantity and size were significantly associated with residual cancer on multivariate analysis. In the referred group, repeat TURBT and restaging are necessary.

Prostate cancer-specific mortality after radical prostatectomy: value of preoperative MRI

BACKGROUND

Although magnetic resonance imaging (MRI) is currently indispensable in the preoperative setting of biopsy-proven prostate cancer, the value of preoperative MRI for predicting prostate cancer-specific mortality (PCSM) is not well known.

PURPOSE

To evaluate the value of MRI for predicting PCSM in patients who underwent radical prostatectomy (RP) for localized prostate cancer.

MATERIAL AND METHODS

A total of 318 patients underwent MRI followed by RP. MRI was assessed for the presence of clinically significant cancer using a five-point Likert scale, where ≥4 was considered positive. Cox proportional hazards regression analyses was used to determine the relationship of preoperative factors with PCSM. PCSM was calculated using the Kaplan-Meier method and compared between factors using the log-rank test.

RESULTS

After a median follow-up of 104 months, 11 (3.5%) patients died of prostate cancer. One hundred and four (32.7%) patients had clinically significant prostate cancer on MRI. Univariate analysis revealed that Gleason grade, greatest percentage of involved core length (GPCL), and clinically significant cancer on MRI were significantly related to PCSM (P = 0.001-0.003). Multivariate analysis showed that GPCL (hazard ratio [HR], 1.028; 95% confidence interval [CI], 1.000-1.057; P = 0.048) and clinically significant cancer on MRI (HR, 10.903; 95% CI, 1.287-92.374; P = 0.028) were independent predictors of PCSM. The 5 - and 10-year PCSM rates were 0.6% and 1.3% in patients with GPCL <50% and 5.1% and 8.6% in those with GPCL ≥50% (P = 0.012). Patients without clinically significant cancer on MRI showed 5 - and 10-year PCSM rates of 0% and 0.5%, respectively, whereas those with clinically significant cancer on MRI showed rates of 8% and 14.2%, respectively (P < 0.001).

CONCLUSION

Preoperative MRI and GPCL may be used to predict PCSM after RP.

Long-term oncologic outcomes of hand-assisted laparoscopic radical nephrectomy for clinically localized renal cell carcinoma: a multi-institutional comparative study

BACKGROUND

We aimed to assess the long-term oncologic outcome of hand-assisted laparoscopic radical nephrectomy (HLRN) compared with open radical nephrectomy (ORN) in patients with clinically localized renal cell carcinoma (RCC).

PATIENTS AND METHODS

We retrospectively reviewed the data from 1098 patients who underwent radical nephrectomy at five institutions in Korea between 2000 and 2011 for clinically localized RCC. One hundred ninety-seven patients in the HLRN group were compared with 901 patients in the ORN group. Univariate and multivariate analysis assessed the effects of operative method on oncologic outcomes.

RESULTS

The median duration of follow-up was 69 months for the HLRN group and 63 months for the ORN group. No statistically significant difference was found in the operative time (170.2 minutes versus 168.9 minutes, P=.793) between the HLRN and ORN groups. However, estimated blood loss was significantly lower in the HLRN group than in the ORN group (245.9 mL versus 422.4 mL, P<.001). The pathological T stage was significantly higher in patients in the ORN group: 79.9% of patients in the HLRN group derived from pT1, versus 54.7% of those in the ORN group (P<.001). A statistically significant difference was found in the 5-year disease-free (90.6% versus 79.6%, P<.001), cancer-specific (95.7% versus 91.1%, P=.019), and overall (93.4% versus 85.4%, P<.001) survival between the HLRN and ORN groups. However, multivariate analysis by Cox's proportional hazards model does not retain surgical methods as an independent predictive factor for cancer-related death or recurrence.

CONCLUSIONS

HLRN may be a preferable minimally invasive surgical treatment for clinically localized RCC with comparable long-term oncologic outcomes.