Should intravesical Bacillus Calmette-Guerin (BCG) treatment be administered to patients with T0 after repeat transurethral resection of bladder tumor in patients with high-risk non-muscle invasive bladder cancer?

We evaluated the effect of intravesical Bacillus Calmette-Guerin (BCG) and BCG maintenance therapy on the prognosis of patients with T0 after repeat transurethral resection of bladder mass (TURBT). This retrospective analysis involved 427 patients who underwent repeat TURBT within 6 weeks after initial TURBT from 2007 to 2016. Repeat TURBT was performed in patients with high-risk criteria. Patients who achieved T0 after repeat TURBT did or did not receive intravesical BCG therapy. Patients were divided into three groups: non-BCG, BCG induction, and BCG maintenance groups. The study included 106 patients who achieved T0 after repeat TURBT. The median follow-up was 63 months. There were no significant differences in T stage among the three groups. High grade ratio (p = 0.001) and concomitant CIS ratio (p = 0.037) were significantly higher in the BCG maintenance than in the other two groups. The recurrence rates in the non-BCG, BCG induction, and BCG maintenance groups were 46.2%, 28.3%, and 19.2%, respectively (p = 0.043). Recurrence-free survival was significantly higher in the BCG maintenance group than in the BCG induction group (p = 0.032). Progression-free survival was also higher in the BCG maintenance group than in the BCG induction group, but the difference was not significant (p = 0.056). Multivariate Cox regression analysis showed that only intravesical BCG maintenance therapy was significantly associated with recurrence (hazard ratio 0.016, p = 0.016). In high risk NMIBC patients, intravesical BCG maintenance treatment is required even at T0 after repeat TURBT. Intravesical BCG maintenance therapy of patients with T0 after TURBT reduces recurrence.

Infected hydrocele in a neonate

A case of infected hydrocele in a neonate is presented. We describe this unusual condition, and discuss the diagnosis, pathophysiology and treatment.

Emphysematous pyelonephritis recovered by ureteral stenting in a functionally solitary kidney

A 62-year-old male diabetic presented with emphysematous pyelonephritis and contralateral atrophic kidney. He failed to improve with a supportive management, and we placed a double-J stent instead of performing percutaneous nephrostomy or nephrectomy with marked improvement. We report a case of emphysematous pyelonephritis recovered by ureteral stenting.

Establishment of Novel Intraoperative Monitoring and Mapping Method for the Cavernous Nerve During Robot-assisted Radical Prostatectomy: Results of the Phase I/II, First-in-human, Feasibility Study

BACKGROUND

Potency preservation often does not meet expectation despite nerve-sparing prostatectomy.

OBJECTIVE

To set the protocol for intraoperative cavernous nerve monitoring and mapping during robot-assisted radical prostatectomy (RARP), and to evaluate its safety and clinical feasibility.

DESIGN, SETTING, AND PARTICIPANTS

A prospective phase I/II, feasibility study was performed. A total of 30 patients with prostate cancer who underwent RARP at a high-volume tertiary academic hospital were enrolled.

SURGICAL PROCEDURE

Pudendal somatosensory evoked potential, bulbocavernosus reflex, spontaneous corpus cavernosum electromyography (CC-EMG), median nerve stimulation evoked CC-EMG, and neurovascular bundle (NVB)-triggered CC-EMG with various stimulation protocols were assessed during conventional RARP under total intravenous anesthesia with controlled muscle relaxation.

MEASUREMENTS

The primary endpoint was the completion rate of planned surgery and assessment. Adverse events, and erectile and urinary functions were evaluated within 1 yr. CC-EMGs were graded and correlated with functional outcomes.

RESULTS AND LIMITATIONS

The completion rate was 100%. Only one patient experienced adverse events, which were not related to study intervention. Grades of CC-EMGs including NVB-triggered CC-EMG before prostate removal were associated with baseline five-item International Index of Erectile Function (IIEF-5) score (grades 0-1, 4.6±2.7; grade 2, 13.2±6.8; grades 3-4, 16.6±5.9; p=0.003). Furthermore, grades of CC-EMGs including NVB-triggered CC-EMG after prostate removal were significantly associated with potency recovery (grade 0, 12.5%; grade 1, 0%; grade 2, 33.3%; grades 3-4, 100% at 12 mo; p=0.005) and postoperative IIEF-5 scores at all evaluation time points (grades 0-1, 2.6±2.8; grade 2, 4.3±5.8; grades 3-4, 15.7±11.0 at 12 mo; p=0.003).

CONCLUSIONS

We successfully established the protocol for safe intraoperative cavernous nerve monitoring and mapping using CC-EMG during RARP. Its grades were well correlated with erectile function.

PATIENT SUMMARY

In this first-in-human feasibility study, we successfully established the protocol for safe intraoperative cavernous nerve monitoring and mapping method during robot-assisted radical prostatectomy. The results were significantly associated with erectile function. Evaluation of clinical efficacy to preserve potency seems worthy of further optimization and investigation in confirmatory clinical trials.

Comparison of intraoperative handling and wound healing between (NEOSORB® plus) and coated polyglactin 910 suture (NEOSORB®): a prospective, single-blind, randomized controlled trial

BACKGROUND

Coated polyglactin 910 suture with chlorhexidine (NEOSORB® Plus) has recently been developed to imbue the parent suture with antibacterial activity against organisms that commonly cause surgical site infections (SSI). This prospective, single-blinded, randomized trial, was performed to compare the intraoperative handling and wound healing characteristics of NEOSORB® Plus with those of the traditional polyglactin 910 suture (NEOSORB®) in urologic surgery patients.

METHODS

Patients (aged 19 to 80 years, n = 100) were randomized in a 1:1 ratio for treatment with either NEOSORB® Plus or NEOSORB®, and stratified into an open surgery or a minimally invasive surgery group. The primary endpoint was the assessment of overall intraoperative handling of the sutures. Secondary endpoints included specific intraoperative handling measures and wound healing characteristics. Wound healing was assessed at one and 11 days after surgery. Cumulative skin infection, seroma, and suture sinus events within 30 days after surgery were also evaluated.

RESULTS

A total of 96 patients were included, with 47 patients in the NEOSORB® Plus group and 49 patients in the NEOSORB® group. Scores for intraoperative handling were favorable and were not significantly different between the two suture groups. Wound healing characteristics were also comparable. The incidence of adverse events was 13.6%, although none were deemed attributable to the suture, and no difference was observed between the two groups.

CONCLUSIONS

NEOSORB® Plus is not inferior to traditional sutures in terms of intraoperative handling and wound healing, potentially making NEOSORB® Plus a beneficial alternative for patients at increased risk of SSI.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02431039 . Trial registration date 14 August 2015.

Geriatric assessment using the G8 to predict postoperative complications in patients undergoing major uro-oncologic surgery: Comparison with the Charlson Comorbidity Index

OBJECTIVE

To evaluate the ability of the G8 assessment to predict postoperative complications in older adults undergoing major uro-oncologic surgery in comparison with the Charlson Comorbidity Index (CCI).

MATERIALS AND METHODS

The study included patients ≥65 years old who underwent major uro-oncologic surgery between December 2017 and December 2019 and were enrolled in the Seoul National University Prospectively Enrolled Registry for Genitourinary Cancer (SUPER-GUC). Odds ratio (OR) smoothing was used to visualize risk according to G8 scores. Chi-square tests were used to compare postoperative complication rates according to G8 score or CCI category.

RESULTS

A total of 657 patients undergoing radical prostatectomies (n = 372, 56.6%), partial/radical nephrectomies (n = 149, 22.7%), radical cystectomies (n = 76, 11.6%), and nephroureterectomies (n = 60, 9.1%) were included. Complication rates did not significantly differ between patients with CCI scores ≥1 and those with CCI scores of 0 (15.0% vs. 12.4%, p = 0.34). However, the complication rate was significantly higher in patients with G8 scores ≤14 than in those with G8 scores >14 (18.1% vs. 10.5%, p = 0.005). When the OR smoothing curve was used to divide patients into three groups based on G8 scores of <10, 10-14, and > 14, we observed significant differences in complication rates among the groups (37.5% vs. 16.9%. vs. 10.5%; p = 0.001).

CONCLUSION

The G8 can aid in predicting postoperative complications in patients ≥65 years old. Comprehensive geriatric assessment is warranted in patients with G8 scores ≤14 prior to major uro-oncologic surgery. Older patients with G8 scores <10 should be counseled regarding the very high risk of surgery.

The Cancer of the Bladder Risk Assessment (COBRA) score for predicting cancer-specific survival after radical cystectomy for urothelial carcinoma of the bladder: External validation in a cohort of Korean patients

OBJECTIVES

To validate the Cancer of the Bladder Risk Assessment (COBRA) score for predicting cancer-specific survival (CSS) in comparison with the American Joint Committee on Cancer (AJCC) staging system using an external cohort of urothelial carcinoma of the bladder (UCB) from South Korea.

MATERIALS AND METHODS

The final validation cohort consisted of 855 patients who underwent radical cystectomy (RC) for UCB in a single institution. The impact of the COBRA score on CSS was estimated using Cox proportional hazard models. Discrimination accuracy was quantified with concordance index. Calibration plots were used to determine the relationship between model-predicted CSS and actual CSS at 2 years and 5 years after RC. Clinical usefulness of the COBRA score was assessed using decision curve analyses.

RESULTS

One-point increase in the COBRA score (range, 0-6) was closely related to a 1.50-fold increase (95% confidence interval [CI]: 1.39-1.62) in the risk of death from UCB. Discrimination accuracies of the COBRA score and AJCC staging system for CSS at 5 years were 70.6% (95% CI: 67.2-74.0) and 68.3% (95% CI: 65.0-71.6), respectively. Compared to the AJCC staging system, the COBRA score was generally well-calibrated for predicting CSS at 2 and 5 years after RC. On decision curve analyses, the use of the COBRA score showed more clinical net benefits across a wide range of threshold probabilities than the AJCC staging system.

CONCLUSIONS

Our external validation results suggest that although the COBRA score is not perfectly accurate, it shows a reasonable level of discriminative ability, adequate calibration, and meaningful net benefit gain for predicting CSS after RC in a Korean UCB cohort.

Novel Classification for Upper Tract Urothelial Carcinoma to Better Risk-stratify Patients Eligible for Kidney-sparing Strategies: An International Collaborative Study

BACKGROUND

The European Association of Urology risk stratification dichotomizes patients with upper tract urothelial carcinoma (UTUC) into two risk categories.

OBJECTIVE

To evaluate the predictive value of a new classification to better risk stratify patients eligible for kidney-sparing surgery (KSS).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective study including 1214 patients from 21 centers who underwent ureterorenoscopy (URS) with biopsy followed by radical nephroureterectomy (RNU) for nonmetastatic UTUC between 2000 and 2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A multivariate logistic regression analysis identified predictors of muscle invasion (≥pT2) at RNU. The Youden index was used to identify cutoff points.

RESULTS AND LIMITATIONS

A total of 811 patients (67%) were male and the median age was 71 yr (interquartile range 63-77). The presence of non-organ-confined disease on preoperative imaging (p < 0.0001), sessile tumor (p < 0.0001), hydronephrosis (p = 0.0003), high-grade cytology (p = 0.0043), or biopsy (p = 0.0174) and higher age at diagnosis (p = 0.029) were independently associated with ≥pT2 at RNU. Tumor size was significantly associated with ≥pT2 disease only in univariate analysis with a cutoff of 2 cm. Tumor size and all significant categorical variables defined the high-risk category. Tumor multifocality and a history of radical cystectomy help to dichotomize between low-risk and intermediate-risk categories. The odds ratio for muscle invasion were 5.5 (95% confidence interval [CI] 1.3-24.0; p = 0.023) for intermediate risk versus low risk, and 12.7 (95% CI 3.0-54.5; p = 0.0006) for high risk versus low risk. Limitations include the retrospective design and selection bias (all patients underwent RNU).

CONCLUSIONS

Patients with low-risk UTUC represent ideal candidates for KSS, while some patients with intermediate-risk UTUC may also be considered. This classification needs further prospective validation and may help stratification in clinical trial design.

PATIENT SUMMARY

We investigated factors predicting stage 2 or greater cancer of the upper urinary tract at the time of surgery for ureter and kidney removal and designed a new risk stratification. Patients with low or intermediate risk may be eligible for kidney-sparing surgery with close follow-up. Our classification scheme needs further validation based on cancer outcomes.

Prognostic value of impaired estimated glomerular filtration rate in intravesical BCG-treated non-muscle-invasive bladder cancer patients

To evaluate the influence of patient-associated parameters and comorbities, with a special focus on renal function after intravesical adjuvant bacillus Calmette-Gue´rin (BCG) immunotherapy in patients with non-muscle-invasive bladder cancer (NMIBC). We retrospectively reviewed the medical records of patients treated from October, 1991 to December, 2013 at Seoul National University who were diagnosed with NMIBC and treated with intravesical BCG. A total of 344 patients who were diagnosed with NMIBC and treated with intravesical BCG were enrolled in this study. Tumor recurrence was observed in 171 patients (49.3%); progression to higher pT category or grade was found in 68 patients (15.1%). Multivariate analysis demonstrated that recurrent tumors and the presence of multiple tumors increased the risk of recurrence. However, other factors also appeared to predict recurrence, such as impaired renal function (<60 ml/min), which was associated with recurrence in univariate and multivariate analyses (HR 1.879 p = 0.008). It is worthy of notice that impaired renal function was an independent predictor of tumor recurrence after BCG instillation in multivariate analysis. Therefore, we should consider not only the clinical or pathologic findings of a tumor but also renal function during decision-making for additional therapy.

The one year outcome after KTP laser vaporization of the prostate according to the calculated vaporized volume

The aim of this study was to develop a new simple method for measuring the vaporized volume and to evaluate the outcome of high-power potassium-titanyl-phosphate (KTP) photoselective laser vaporization. A total of 65 patients, with a mean age of 67.7 yr (range 53 to 85), were included in the primary analysis. The vaporized volume was calculated as the pre-operative volume minus the immediate post-operative volume plus the volume of the defect. For all patients, the subjective and objective parameters improved significantly after surgery. Six and 12 months after surgery, the group with a smaller vaporized volume (<15 g) had a lower reduction of the mean International Prostate Symptom Score (P=0.006 and P=0.004) and quality of life index (P=0.006 and P=0.004) when compared to the group with a greater vaporized volume (>or=15 g). There were no differences in the change of the maximum flow rate and post-void residual based on the vaporized volume. Our findings suggest that the subjective improvement, after a high-power KTP laser vaporization, may be dependent on the vaporized volume obtained after the procedure.

Comparative study of international prostate symptom scores and urodynamic parameters in men and women with lower urinary tract symptoms

BACKGROUND

We compared urinary symptoms and urodynamic parameters in men and women with lower urinary tract symptoms.

METHODS

A total of 164 individuals (76 men and 88 women) were rated according to the International Prostate Symptom Score and underwent a detailed urodynamic investigation. Patients were stratified by age into 2 groups, namely, those < 50 years (the younger group) and those > 50 years (the elderly group).

RESULTS

In the elderly group, scores of voiding symptoms for men were higher than those for women (p = 0.012). Maximum flow rates (Qmax) for women were higher than those for men (p = 0.025 for the younger groups, and p < 0.001 for the elderly groups). Detrusor pressure at Qmax (p < 0.001), opening pressure (p < 0.001) and closing pressure (p = 0.023) were elevated in elderly men vs. in elderly women. A multiple linear regression analysis identified straining (beta = 0.479, p < 0.05) and incomplete emptying (beta = 0.487, p < 0.05) as the only variables influencing quality of life (QOL) in younger men and women, respectively. In elderly men, nocturia (beta = 0.352, p < 0.05) and frequency (beta = 0.287, p < 0.05) were significantly associated with QOL. Frequency (beta = 0.452, p < 0.05) possibly explained a QOL reduction in elderly women.

CONCLUSIONS

Our findings suggest that in the elderly patients, storage symptoms are more associated with QOL than voiding symptoms. However, storage symptoms were not associated with QOL in younger men.

Metastasis of transitional cell carcinoma to the lower abdominal wall 20 years after cystectomy

Iatrogenic implantation has been the main cause in the majority of cases of transitional call carcinoma (TCC) with metastasis to the abdominal wall. A 66-year-old woman had undergone radical cystectomy 20 years prior to presenting. Radiological investigations revealed one mass in the left lower abdominal wall and one mass in the right inguinal area. She underwent wide excision of the lesions that revealed metastasis of TCC. This report describes this case of a woman with bladder carcinoma who developed a metastasis in the anterior abdominal wall following an apparent disease-free interval of 20 years.

Impact of prostate volume on the efficacy of high-power potassium-titanyl-phosphate photoselective vaporization of the prostate: a retrospective, short-term follow-up study on evaluating feasibility and safety

PURPOSE

We determined the impact of prostate volume on the efficacy of the high-power (80 W) potassium-titanyl-phosphate (KTP) photoselective laser vaporization of the prostate in men with lower urinary tract symptoms (LUTS).

MATERIALS AND METHODS

Patients were stratified into 3 groups according to prostate volume: '< 40 g' (n = 49) and '40-59 g' (n = 49) and '≥ 60 g' (n = 22). Median follow-up was 9 months (range 6 to 21).

RESULTS

No differences in age and follow-up duration were observed in the three groups. At baseline, no significant differences were noted in the three groups in terms of the International Prostate Symptom Score (IPSS) (21.4, 19.4 and 19.1; p = 0.412) as well as the maximum flow rate (Qmax) (10.2, 9.2, and 8.6 mL/s; p = 0.291) and post-void residual (PVR) (66.2, 80.4, and 71.5 mL; p = 0.856). The mean operative times were 30.9, 46.9, and 58.6 minutes (p< 0.001) and total median energy deliveries for each group were 62.3, 97.6, and 135.9 kJ, respectively (p< 0.001). No severe intraoperative complication was observed. At the last follow-up, these parameters improved significantly regardless of prostate volume, and the IPSS (11.1, 9.4, and 12.3; p = 0.286) as well as Qmax (15.9, 15.9, and 14.2 mL/s; p = 0.690) and PVR (33.7, 28.4, and 14.2 mL; p = 0.395) were not significantly different among the groups.

CONCLUSION

Although a larger prostate requires more time and energy delivery, photoselective laser vaporization of the prostate is safe and efficacious for patients with LUTS regardless of prostate volume.

External validation of a clinical scoring system for hematuria

BACKGROUND

The aim of this study was to evaluate the accuracy of a new scoring system in Korean patients with hematuria at high risk of bladder cancer.

MATERIALS AND METHODS

A total of 319 consecutive patients presenting with painless hematuria without a history of bladder cancer were analyzed, from the period of August 2012 to February 2014. All patients underwent clinical examination, and 22 patients with incomplete data were excluded from the final validation data set. The scoring system included four clinical parameters: age (≥50 = 2 vs. <50 =1), gender (male = 2 vs. female = 1), history of smoking (smoker/ex-smoker = 4 vs. non-smoker = 2) and nature of the hematuria (gross = 6 vs. microscopic = 2).

RESULTS

The area under the receiver-operating characteristic curve (95% confidence interval) of the scoring system was 0.718 (0.655-0.777). The calibration plot demonstrated a slight underestimation of bladder cancer probability, but the model had reasonable calibration. Decision curve analysis revealed that the use of model was associated with net benefit gains over the treat-all strategy. The scoring system performed well across a wide range of threshold probabilities (15%-45%).

CONCLUSIONS

The scoring system developed is a highly accurate predictive tool for patients with hematuria. Although further improvements are needed, utilization of this system may assist primary care physicians and other healthcare practitioners in determining a patient's risk of bladder cancer.

In vivo hepatocyte growth factor gene transfer to bladder smooth muscle after bladder outlet obstruction in the rat: a morphometric analysis

PURPOSE

We determined whether hepatocyte growth factor gene transfer after partial bladder outlet obstruction would prove effective for decreasing transforming growth factor-beta expression and consequently decreasing collagen deposition in partially obstructed rat bladders.

MATERIALS AND METHODS

Ten-week-old male Sprague-Dawley rats were divided into 3 groups of 10 each, including group 1--sham operation, group 2--bladder outlet obstruction for 4 weeks and group 3--hepatocyte growth factor gene transfer after bladder outlet obstruction. Two weeks after the onset of bladder outlet obstruction in group 3 hepatocyte growth factor-liposome complex (50 microg human hepatocyte growth factor cDNA) was injected into the smooth muscle of the rats.

RESULTS

We noted no difference between groups 2 and 3 with regard to the ratio of bladder weight to body weight. The ratio in groups 2 and 3 was significantly higher than in group 1 (p = 0.043). The mean percent of collagen area +/- SE was 36.32% +/- 1.83%, 27.90% +/- 2.66% and 8.97% +/- 3.35% in groups 1 to 3, respectively (p <0.05). Relative hepatocyte growth factor and c-met mRNA and protein expression were higher in group 3 than in groups 1 and 2. However, the expression of transforming growth factor-beta1 mRNA and protein was higher in group 2 than in groups 1 and 3.

CONCLUSIONS

These findings may imply a possible novel therapeutic strategy against bladder dysfunction arising in patients with bladder outlet obstruction.

Clinical and urodynamic features according to subjective symptom severity in female urinary incontinence

AIMS

The aim of this study was to determine the relationship between subjective symptom severity and clinical or urodynamic parameters and to compare these parameters according to subjective symptom severity.

METHODS

A total of 268 female patients with grade II (n = 94) and grade III (n = 174) according to the Ingelman-Sundberg scale were included in the study. Mean patient age was 55.9 years (range 28-80). Of 268 patients, 196 women (73.1%) complained of stress urinary incontinence (SUI) and 72 (26.9%) reported additional symptoms of urge urinary incontinence (UUI). Fifty-four (20.1%) women previously had hysterectomies and 12 (4.5%) underwent surgery for UI.

RESULTS

Patients with severe incontinence (grade III) are older, have longer duration of symptoms, concomitant urgency or UUI, and low maximal urethral closure pressure and low Valsalva leak point pressure (VLPP). No difference in other characteristics including pad test loss and urethral mobility was observed in the two groups. In the multivariate logistic regression analysis, a longer duration of symptoms was associated with an increased likelihood of severe symptoms (P = 0.025). Patients with mixed incontinence were at five-fold increased risk of severe symptoms compared with those with SUI only (P = 0.011). In the same model, increasing VLPP was associated with a decreased likelihood of severe symptoms (P = 0.037).

CONCLUSIONS

Longer symptom duration, mixed incontinence and low VLPP have independent effects on the severity of incontinence. Our findings suggest that incontinent patients with sphincteric impairment or urge component may have and increased probability of severe symptoms.

Patients with Biopsy Gleason Score 3 + 4 Are Not Appropriate Candidates for Active Surveillance

OBJECTIVE

The aim of this study was to evaluate the feasibility of including patients with biopsy Gleason score (bGS) 3 + 4 prostate cancer in an active surveillance (AS) protocol.

METHODS

A total of 615 patients underwent a radical prostatectomy and satisfied the following requirements: prostate-specific antigen ≤10 ng/dL, clinical stage T1c or T2a, 2 or fewer positive biopsy cores, and bGS 6 or 3 + 4 prostate cancer. The patients were divided into two groups according to their bGS (bGS 6 group, n =534; bGS 3 + 4 group, n = 81).

RESULTS

The adverse pathological features were significantly higher in the bGS 3 + 4 group (16.7 vs. 49.4%, p< 0.001). Biochemical recurrence (BCR)-free survival was also significantly lower in this group (p < 0.001). In a multivariate analysis, clinical stage (odds ratio [OR] 2.026, p =0.007), maximum percentage of biopsy core involvement (OR 1.015, p = 0.014), and bGS (OR 1.913, p = 0.030) were independent risk factors for adverse pathological features. However, the bGS was the only variable to forecast BCR (hazard ratio 3.567, p < 0.001).

CONCLUSIONS

A bGS 3 + 4 was the leading risk factor for a worse postoperative prognosis. Therefore, patients with a bGS 3 + 4 are not appropriate candidates for AS.

External Validation of Models for Prediction of Lymph Node Metastasis in Urothelial Carcinoma of the Bladder

PURPOSE

To externally validate models to predict LN metastsis; Karakiewicz nomogram, clinical nodal staging score (cNSS), and pathologic nodal staging score (pNSS) using a different cohort.

MATERIALS AND METHODS

Clinicopathologic data from 500 patients who underwent radical cystectomy and pelvic lymphadenectomy were analyzed. The overall predictive values of models were compared with the criteria of overall performance, discrimination, calibration, and clinical usefulness.

RESULTS

Presence of pN+ stages was recorded in 117 patients (23.4%). Agreement between clinical and pathologic stage was noted in 174 (34.8%). Based on Nagelkerke's peudo-R2 and brier score, pNSS demonstrated best overall performance. Area under the receiver operating characteristics curve, showed that pNSS had the best discriminatory ability. In all models, calibration was on average correct (calibration-in-the-large coefficient = zero). On decision curve analysis, pNSS performed better than other models across a wide range of threshold probabilities.

CONCLUSIONS

When compared to pNSS, current precystectomy models such as the Karakiewicz nomogram and cNSS cannot predict the probability of LN metastases accurately. The findings suggest that the application of pNSS to Asian patients is feasible.

The Effect of Ventilation with Individualized Positive End-Expiratory Pressure on Postoperative Atelectasis in Patients Undergoing Robot-Assisted Radical Prostatectomy: A Randomized Controlled Trial

For patients undergoing robot-assisted radical prostatectomy, the pneumoperitoneum with a steep Trendelenburg position could worsen intraoperative respiratory mechanics and result in postoperative atelectasis. We investigated the effects of individualized positive end-expiratory pressure (PEEP) on postoperative atelectasis, evaluated using lung ultrasonography. Sixty patients undergoing robot-assisted radical prostatectomy were randomly allocated into two groups. Individualized groups (n = 30) received individualized PEEP determined by a decremental PEEP trial using 20 to 7 cm H2O, aiming at maximizing respiratory compliance, whereas standardized groups (n = 30) received a standardized PEEP of 7 cm H2O during the pneumoperitoneum. Ultrasound examination was performed on 12 sections of thorax, and the lung ultrasound score was measured as 0-3 by considering the number of B lines and the degree of subpleural consolidation. The primary outcome was the difference between the lung ultrasound scores measured before anesthesia induction and just after extubation in the operating room. An increase in the difference means the development of atelectasis. The optimal PEEP in the individualized group was determined as the median (interquartile range) 14 (12-18) cm H2O. Compared with the standardized group, the difference in the lung ultrasound scores was significantly smaller in the individualized group (-0.5 ± 2.7 vs. 6.0 ± 2.9, mean difference -6.53, 95% confidence interval (-8.00 to -5.07), p < 0.001), which means that individualized PEEP was effective to reduce atelectasis. The lung ultrasound score measured after surgery was significantly lower in the individualized group than the standardized group (8.1 ± 5.7 vs. 12.2 ± 4.2, mean difference -4.13, 95% confidence interval (-6.74 to -1.53), p = 0.002). However, the arterial partial pressure of the oxygen/fraction of inspired oxygen levels during the surgery showed no significant time-group interaction between the two groups in repeated-measures analysis of variance (p = 0.145). The incidence of a composite of postoperative respiratory complications was comparable between the two groups. Individualized PEEP determined by maximal respiratory compliance during the pneumoperitoneum and steep Trendelenburg position significantly reduced postoperative atelectasis, as evaluated using lung ultrasonography. However, the clinical significance of this finding should be evaluated by a larger clinical trial.

Translation and Linguistic Validation of Korean Version of the Expanded Prostate Cancer Index Composite for Clinical Practice for Patients With Prostate Cancer

PURPOSE

Advances in the diagnosis and treatment of prostate cancer have increased the patients' stress level and decreased the quality of life. A variety of instruments are currently available to evaluate patients with prostate cancer. However, only a few tools are available to assess Korean patients, and therefore we demonstrated a linguistic validation of Korean Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP).

METHODS

EPIC-CP was translated into Korean and the linguistic validation was evaluated. The evaluation process includes permission for translation, forward translation, reconciliation, backward translation, cognitive debriefing, and proofreading. Two bilingual translators independently translated the original questionnaire, discussed the feasibility and naturalness of initial translation, followed by revision to the reconciled version. Another translator then performed a backward translation into English. Ten patients with prostate cancer completed the translated questionnaire and performed cognitive debriefing.

RESULTS

The original EPIC-CP was translated into 2 Korean versions. The different wording in both versions and the ordinary words in the initial translations were changed considering the nuances and meanings of medical terms. During the backward translation, the panels made slight changes to clarify the meaning and nuances of the translated questionnaire. During cognitive debriefing, 10 patients answered the questionnaire and offered their opinions regarding comprehensibility and naturalness. Most patients agreed that the translation was comprehensible in general.

CONCLUSION

Our study provides a successful linguistic validation of the EPIC-CP questionnaire. The translation is a helpful diagnostic tool to ensure the quality of life of patients with prostate cancer attending crowded clinics.

Stratifying risk for multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors in non-muscle-invasive bladder cancer

PURPOSE

The current stratification of risk groups regarding recurrence and progression of non-muscle-invasive bladder cancer (NMIBC) is problematic. We aimed to assess the long-term outcome and risk of multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors after transurethral resection of the bladder tumor (TURBT).

MATERIALS AND METHODS

We categorized 1,621 patients with NMIBC who underwent TURBT into four risk groups according to the European Association of Urology (EAU) guidelines as follows: low-risk, intermediate-risk, high-risk, and study group. The overall, cancer-specific, disease recurrence-free, and disease progression-free survival rates were estimated by using the Kaplan-Meier method. Then, the impact of risk group was assessed by using a multivariable Cox regression model.

RESULTS

The study group comprised 52 patients (3.2%) within a mean follow-up of 64.8 months. The disease recurred and progressed in 41 (78.8%) and 7 (13.5%) patients, respectively. Among the four groups, the study group showed the highest risk for 10-year recurrence after TURBT. The disease progression risk in the study group was between that of the intermediate- and high-risk groups. Cancer-specific and all-cause deaths occurred in one and four patients in the study group, respectively. The study group had a higher risk for disease recurrence than did the high-risk group; however, it did not have a higher risk for disease progression than in the high-risk group.

CONCLUSIONS

Multiple, recurrent, and large (≥3 cm) Ta, G1/G2 tumors carry a higher risk for disease recurrence, but not progression, than in the EAU high-risk group of NMIBC.

The Effect of Remote Ischemic Preconditioning on Serum Creatinine in Patients Undergoing Partial Nephrectomy: A Randomized Controlled Trial

Renal function declines after partial nephrectomy due to ischemic reperfusion injury induced by surgical insult or renal artery clamping. The effect of remote ischemic preconditioning (RIPC) on reducing renal injury after partial nephrectomy has not been studied regarding urinary biomarkers. Eighty-one patients undergoing partial nephrectomy were randomly assigned to either RIPC or the control group. RIPC protocol consisted of four cycles of five-min inflation and deflation of a blood pressure cuff to 250 mmHg. Serum creatinine levels were compared at the following time points: preoperative baseline, immediate postoperative, on the first and third days after surgery, and two weeks after surgery. The incidence of acute kidney injury, other surgical complication rates, and urinary biomarkers, including urine creatinine, β-2 microglobulin, microalbumin, and N-acetyl-beta-D-glucosaminidase were compared. Split renal functions measured by renal scan were compared up to 18 months after surgery. There was no significant difference in the serum creatinine level on the first postoperative day (median (interquartile range) 0.87 mg/dL (0.72-1.03) in the RIPC group vs. 0.92 mg/dL (0.71-1.12) in the control group, p = 0.728), nor at any other time point. There was no significant difference in the incidence of acute kidney injury. Secondary outcomes, including urinary biomarkers, were not significantly different between the groups. RIPC showed no significant effect on the postoperative serum creatinine level of the first postoperative day. We could not reveal any significant difference in the urinary biomarkers and clinical outcomes. However, further larger randomized trials are required, because our study was not sufficiently powered for the secondary outcomes.

Value and Safety of Midazolam Anesthesia during Transrectal Ultrasound-Guided Prostate Biopsy

PURPOSE

Although transrectal ultrasound-guided prostate biopsy is useful for diagnosing prostate cancer, it is a painful procedure. There are many methods for providing pain relief and for treating discomfort during the procedure, but occasionally these are reported to be of limited use. We aimed to evaluate the value and safety of midazolam-induced anesthetic transrectal ultrasound-guided prostate biopsy.

MATERIALS AND METHODS

From August 2008 to December 2009, 104 male patients, who were examined with transrectal ultrasound-guided prostate 12-core biopsy, were randomly assigned to two groups. Group 1 (n=51) received ketorolac (Tarasyn®) 30 mg. Group 2 (n=53) was treated with midazolam (Dormicum®) 3 mg, which was increased to 5 mg if necessary. Immediately after the procedure, the patients were asked to rate their comfort level by using a 10-point visual analog self-assessment pain scale.

RESULTS

The pain scale in group 2 was significantly lower than that in group 1 (p<0.05). The patients assigned to group 2 experienced no side-effects from midazolam and were more satisfied than the patients in group 1 (p<0.05).

CONCLUSIONS

Midazolam anesthesia relieves pain effectively, and the patient's satisfaction is better than with conventional transrectal ultrasound-guided prostate biopsy. Midazolam-induced anesthetic transrectal ultrasound-guided prostate biopsy is useful and safe.