Clinical guidelines for diagnosis of hematuria

Background: Hematuria is a common condition caused by various factors, including infections, inflammations, stone diseases, and anatomical abnormalities. While hematuria can be mistaken for other conditions, its significance should not be overlooked, as studies have shown that some patients with hematuria are diagnosed with urological cancers.Current Concepts: Experts agree on the need for specific diagnostic tests such as cystoscopy, upper urinary tract imaging, and urine cytology for visible hematuria. However, opinions differ when it comes to microscopic hematuria. Delays in diagnosing bladder cancer can significantly impact mortality rates. Therefore, objective diagnostic criteria, as well as guidelines to reduce excessive evaluations, costs, and side effects, are required. As of 2020, the American Urological Association has released new guidelines for the diagnosis and management of microscopic hematuria, that focus on assessing the risk of urological malignancies in individual patients and recommend tailored evaluations based on risk levels. This article provides an overview of these guidelines, discussing diagnostic criteria, initial evaluations, risk stratification, and recommended evaluations of the urinary tract.Discussion and Conclusion: Guidelines on hematuria aim to reduce unnecessary invasive procedures, provide appropriate follow-up strategies to patients with persistent or recurrent microscopic hematuria, and improve patient outcomes while minimizing unnecessary tests and procedures.

Preoperative smoking and robot-assisted radical cystectomy outcomes & complications in multicenter KORARC database

To investigate the influence of preoperative smoking history on the survival outcomes and complications in a cohort from a large multicenter database. Many patients who undergo radical cystectomy (RC) have a history of smoking; however, the direct association between preoperative smoking history and survival outcomes and complications in patients with muscle-invasive bladder cancer (MIBC) who undergo robot-assisted radical cystectomy (RARC) remains unexplored. We conducted a retrospective analysis using data from 749 patients in the Korean Robot-Assisted Radical Cystectomy Study Group (KORARC) database, with an average follow-up duration of 30.8 months. The cohort was divided into two groups: smokers (n = 351) and non-smokers (n = 398). Propensity score matching was employed to address differences in sample size and baseline demographics between the two groups (n = 274, each). Comparative analyses included assessments of oncological outcomes and complications. After matching, smoking did not significantly affect the overall complication rate (p = 0.121). Preoperative smoking did not significantly increase the occurrence of complications based on complication type (p = 0.322), nor did it increase the readmission rate (p = 0.076). There were no perioperative death in either group. Furthermore, preoperative smoking history showed no significant impact on overall survival (OS) [hazard ratio (HR) = 0.87, interquartile range (IQR): 0.54-1.42; p = 0.589] and recurrence-free survival (RFS) (HR = 1.12, IQR: 0.83-1.53; p = 0.458) following RARC for MIBC. The extent of preoperative smoking (≤ 10, 10-30, and ≥ 30 pack-years) had no significant influence on OS and RFS in any of the categories (all p > 0.05). Preoperative smoking history did not significantly affect OS, RFS, or complications in patients with MIBC undergoing RARC.

Comparison of functional and oncological outcomes between uterus-sparing radical cystectomy and standard radical cystectomy in females: A retrospective study

PURPOSE

This study aimed to compare the functional and oncological outcomes of females who underwent uterus-sparing radical cystectomy (USRC) and standard radical cystectomy (SRC).

MATERIALS AND METHODS

Between February 2009 and December 2020, 90 female patients who underwent radical cystectomy with urinary diversion were included in this study, comprising the USRC and SRC groups. Functional outcomes were assessed in 63 patients who only underwent radical cystectomy with neobladder formation. Questionnaire scores, clean intermittent catheterization (CIC) rate, and urinary continence rate were analyzed. Oncological outcomes were assessed in 86 patients, regardless of the urinary diversion type. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were compared.

RESULTS

CIC rate was significantly lower in the USRC group than in the SRC group (14.7% vs. 48.0%; p=0.005). The continence rate was significantly higher in the USRC group than in the SRC group (85.3% vs. 40.0%; p=0.001). There were no significant differences in OS (p=0.890), CSS (p=0.700), or RFS (p=0.270) between the two groups. In multivariate analysis, uterine preservation did not significantly increase the hazard ratio (HR) of OS (HR, 0.62; 95% CI, 0.18-2.11; p=0.450), CSS (HR, 0.99; 95% CI, 0.22-4.40; p=0.990), or RFS (HR, 0.46; 95% CI, 0.19-1.11; p=0.840).

CONCLUSIONS

USRC resulted in higher continence rates and lower CIC rates than SRC without negatively affecting oncological outcomes. Hence, with thorough deliberation, USRC should be considered for females undergoing radical cystectomy.

Korean version of the functional assessment of cancer therapy (FACT)-vanderbilt cystectomy index (VCI): translation and linguistic

PURPOSE

To develop a Korean version of the Functional Assessment of Cancer Therapy (FACT)-Vanderbilt Cystectomy Index (VCI) from the original English version, with subsequent linguistic validation in Korean patients who underwent radical cystectomy with urinary diversion.

MATERIALS AND METHODS

Translation and linguistic validation were carried out between January and May of 2013, which consisted of the following stages:(1) permission for translation;(2) forward translation;(3) reconciliation;(4) backward translation;(5) cognitive debriefing and(6) final proof-reading.

RESULTS

During the forward translation phases,word as such as "bother","spend time", "support", "coping" and "concern" were adjusted to be more comprehensible to the target population. There conciled Korean version was accepted without certain objections because the original version and the backward translation were almost congruent except for minor differences in a subset of questions. The translation was tested using 5 Korean-speaking subjects. The subjects took an average of 8.2 minutes to complete the questionnaire, without difficulty and found the questionnaire clear and easy to understand. The panel discussed each of the issues raised by subjects and most terms were judged by the panel as to not require further changes because the overall comprehension levels were relatively high and because the translated terms were accurately rendered in the target languages.

CONCLUSION

This report has demonstrated that despite translation difficulties, the linguistic validation of the FACT-VCI in the Korean language was successful. The next step is to assess the psychometric properties of the Korean version of FACT-VCI.

Acidic Urine Is Associated With Poor Prognosis of Upper Tract Urothelial Carcinoma

PURPOSE

To assess the prognostic role of acidic urine (low urine pH) in upper tract urothelial cancer (UTUC).

MATERIALS AND METHODS

We reviewed patients enrolled in Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Upper Tract Urothelial Cancer (SUPER-UC-UTUC) who underwent surgical resection from March 2016 to December 2020 in Seoul National University Hospital (SNUH). Patients with non-urothelial cancer or those who are in condition at end-stage renal disease were excluded. Acidic urine was defined as urine pH ≤ 5.5.

RESULTS

A total of 293 patients with a mean age of 70.7 ± 9.5 years were enrolled in this study. Pre-operative laboratory results showed a mean estimated glomerular filtration rate (eGFR) of 64.1 ± 19.2 mL/min/1.73m2 and a mean urine pH of 5.86 ± 0.66. Patients were subdivided into low (pH ≤ 5.5) and high (pH > 5.5) urine pH for comparison. As a result, all variables were comparable except for the T stage, which was significantly higher in the low urine pH group (p = 0.017). Cox regression analysis was performed to assess the clinical impact of acidic urine on patient survival. Multivariate Cox regression analysis revealed that tumor multifocality (HR 2.07, p = 0.015), higher T stage (HR 1.54, p = 0.036), lymphovascular invasion (HR 1.69, p = 0.033), eGFR < 60 mL/min per 1.73 m2 (HR 1.56, p = 0.017), and acidic urine (HR 1.63, p < 0.01) independently decreased disease-free survival (DFS), while multifocality (HR 9.50, p < 0.01), higher T stage (HR 9.51, p = 0.001) and acidic urine (HR 10.36, p = 0.004) independently reduced the overall survival (OS).

CONCLUSIONS

Acidic urine is independently associated with reduced DFS and OS in UTUC. Acidic urine contributing to acidic environment may promote acquisition of agressive behavior of UTUC.

Evaluating the efficacy of secondary transurethral resection of the bladder for high-grade Ta tumors

PURPOSE

The need for secondary transurethral resection of the bladder (re-TURB) in patients with high-grade Ta tumors has not been assessed. This study aimed to compare the outcomes of patients with high-grade Ta tumors who did and did not undergo re-TURB.

MATERIALS AND METHODS

This study used data from the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Transurethral Bladder Tumor Resection (SUPER-UC-TURB). Patients with high-grade Ta tumors who underwent TURB between March 2016 and December 2019 were included. Following the initial TURB, if the pathology results showed a tumor grade higher than high-grade Ta, re-TURB was performed according to the surgeon's recommendation. The recurrence-free survival rate was assessed by Kaplan-Meier analysis and Cox regression analysis between patients who did and did not undergo re-TURB.

RESULTS

In total, 187 patients with high-grade Ta who underwent initial TURB were included, of whom 115 underwent re-TURB and 72 did not. Patients in the re-TURB group had a significantly higher 2-year recurrence-free survival rate than did those in the no re-TURB group (81.3% vs. 60.1%; p=0.005). Whether patients underwent re-TURB was a significant predictor of the risk of bladder cancer recurrence in both the univariate (HR, 0.52; 95% CI, 0.27-0.98; p=0.044) and multivariate (HR, 0.41; 95% CI, 0.19-0.97; p=0.041) analysis.

CONCLUSIONS

The risk for bladder cancer recurrence was increased, and the 2-year recurrence-free survival was significantly decreased, in patients with high-grade Ta tumors who did not undergo re-TURB. Thus, re-TURB is beneficial in patients with high-grade Ta bladder cancer.

Clinical determinants of recurrence in pTa bladder cancer following transurethral resection of bladder tumor

BACKGROUND

Non-muscle invasive bladder cancer can be controlled by transurethral resection of bladder (TURB), but suffers from frequent recurrences in 60-70% of cases. Although, recurrence interval after TURB influences treatment course and prognosis, its implication and risk factors have not been fully elucidated. We evaluated the risk factors of early (within 1 yr) and late (after 1 yr) recurrence of pTa bladder cancer and clinical significance of recurrence interval on disease progression and overall survival.

METHODS

In this study, pTa bladder cancer patients enrolled in prospective patient registry system of Seoul National University, SUPER-UC, were retrospectively examined to determine the clinical risk factors for recurrence and its significance regarding to recurrence interval. A total of 1067 bladder cancer patients who underwent TURB between March 20 and June 2021 were included and classified into three groups of no recurrence, early, or late recurrence to be comparatively analyzed.

RESULTS

Early recurrence was associated with poorer cystectomy-free survival and overall survival than late recurrence. Risk factors for early recurrence included a high number of previous TURB, tumor multiplicity, tumor location, tumor shape, incompleteness of TURB, and high tumor grade. Otherwise, late recurrence was associated with low-grade tumors with insufficient TURB depth.

CONCLUSION

Patients with risk factors for early recurrence should be closely followed up with special cautions.

Effect of Gleason scores of lymph node metastases on prognosis of patients with prostate cancer

The long-term mortality risk from prostate cancer increases in lymph node (LN) positive patients. This study was done to assess the effect of lymph node Gleason score (LNGS) on prognosis in patients with LN-positive prostate cancer. Among the 1,415 patients who received pelvic lymph node dissection (PLND), 117 (8.4%) patients had a positive LN. The PGS of the prostate specimens and the LNGS of the positive LNs were assessed by uropathologists. The median age of patients at surgery was 67 years (interquartile range [IQR], 62-71 years) and the median follow-up duration was 44.3 months (IQR, 27.0-78.5 months). Pathologic Gleason scores (PGS) of 6-9 included one (0.9%), 53 (49.5%), 22 (20.6%), and 31 (29.0%) patients. The median total number of retrieved LNs was 9.0 (IQR, 5.3-12.8). The median number of positive LNs was one (IQR, 1-2). Cancer architecture with a Gleason pattern and score were observed in LNs as in ordinary prostate specimens. LNGS 6-9 included nine (8.1%), 57 (51.4%), 31 (27.9%), and 14 (12.6%) patients. The speaman's analysis showed the meaningful correlation between PGS and LNGS (P = 0.249, P = 0.011). The univariate analysis showed that the number of positive LNs and LNGS were significantly associated with prostate cancer-specific survival (P = 0.028; P = 0.005). The same architecture that is seen in the prostate was seen in positive LNs, and LNGS may be a significant prognostic factor in patients with LN-positive prostate cancer.

Prognostic Significance of Blood Type A in Patients with Renal Cell Carcinoma

PURPOSE

In this study, we evaluated the prognostic significance of the ABO blood type in patients with renal cell carcinoma (RCC) who had undergone partial or radical nephrectomy.

MATERIALS AND METHODS

Information on the ABO blood type was obtained from 1750 patients with RCC. A total of 1243 men and 507 women (mean age, 55.41 ± 12.43 years) with RCC who had undergone partial or radical nephrectomy were enrolled in this study. The median follow-up duration was 35.0 months (interquartile range [IQR], 16.0-67.0). During the follow-up period, 271 patients experienced RCC recurrence, and 137 patients died from RCC.

RESULTS

Type A was the most common blood type (568, 32.5%), followed by type O (525, 30.0%), type B (464, 26.5%), and type AB (193, 11.0%). Generally, blood type was not associated with any clinicopathological factors. Unlike blood type O, the multivariate analysis of progression-free survival (PFS) showed that blood type non-O (A, B, and AB) was an independent prognostic factor for a worse outcome (95% confidence interval [CI]: 1.24- 2.37, hazard ratio [HR] = 1.71, P = .001; 95% CI: 1.08-2.13, HR = 1.51, P = .016; 95% CI: 1.03-2.43, HR = 1.58, P = .037, respectively). Cancer-specific survival (CSS) analysis showed that blood type A was an independent factor associated with a worse prognosis for CSS (95% CI: 1.05-2.64, HR 1.66, P = .031, respectively).

CONCLUSION

The ABO blood type is significantly associated with PFS and CSS in patients with RCC following partial or radical nephrectomy. Blood type non-O (A, B, and AB) is an independent prognostic factor for a worse PFS outcome, and blood type A is an independent factor associated with a worse CSS prognosis. .

Real-World Treatment Patterns and Outcomes in Patients With Bacillus Calmette-Guérin-Unresponsive High-Risk Non-Muscle-Invasive Bladder Cancer: A Multicountry Medical Chart Review

INTRODUCTION

Treatment patterns for patients with bacillus Calmette-Guérin (BCG)-unresponsive high-risk non-muscle-invasive bladder cancer (NMIBC) who are ineligible for or decline radical cystectomy (RC) are inconsistently reported. We retrospectively described demographic, clinical, and treatment characteristics for these patients and assessed their clinical outcomes.

PATIENTS AND METHODS

Medical charts of patients with BCG-unresponsive high-risk NMIBC (carcinoma in situ [cohort A] or T1/high-grade Ta [cohort B]) who were ineligible for or declined RC documented between January 1, 2011, and December 31, 2018, at 15 academic centers were reviewed. Primary objectives were to characterize demographic, clinical, and nonsurgical treatment characteristics. Secondary objectives included assessing real-world progression-free survival (rw-PFS) from muscle-invasive/metastatic disease, rw-PFS from worsening grade or stage, real-world complete response rate (rw-CRR) in cohort A, real-world event-free survival (rw-EFS) from high-risk NMIBC in cohort B, and overall survival.

RESULTS

The study included 129 patients (cohort A, n = 57; cohort B, n = 72). Median age was 72.0 years (interquartile range, 64.0-80.0). Most patients were male (72.1%) and current/former smokers (69.8%). Median follow-up was 32.1 months (interquartile range, 20.7-47.6). BCG rechallenge with or without interferon-α (63.6%) was the most commonly utilized first nonsurgical therapy, followed by intravesical mitomycin C with or without electromotive drug administration or thermochemotherapy (15.5%), and intravesical valrubicin (10.9%); among those who received BCG rechallenge alone, 54.8% later received a non-BCG therapy in ≥ 2 subsequent treatments. 36-month rate for rw-PFS from muscle-invasive/metastatic disease was 73.5%, 66.8% for rw-PFS from worsening grade/stage, and 82.5% for overall survival. In cohort A, 6-month rw-CRR was 22.2%. In cohort B, 36-month rw-EFS rate from high-risk NMIBC was 50.2%.

CONCLUSION

After BCG-unresponsive disease, most patients with high-risk NMIBC received BCG rechallenge with or without other therapies, and > 25% experienced disease progression within the first 3 years. Effective bladder-sparing options for BCG-unresponsive NMIBC are needed.

CLINICAL TRIAL REGISTRATION

N/A.

Prediction of Pathologic Findings with MRI-Based Clinical Staging Using the Bayesian Network Modeling in Prostate Cancer: A Radiation Oncologist Perspective

PURPOSE

This study aimed to develop a model for predicting pathologic extracapsular extension (ECE) and seminal vesicle invasion (SVI) while integrating magnetic resonance imaging-based T-staging (cTMRI, cT1c-cT3b).

MATERIALS AND METHODS

A total of 1,915 who underwent radical prostatectomy between 2006-2016 met the inclusion/exclusion criteria. We performed a multivariate logistic regression analysis as well as Bayesian network (BN) modeling based on possible confounding factors. The BN model was internally validated using 5-fold validation.

RESULTS

According to the multivariate logistic regression analysis, initial prostate-specific antigen (iPSA) (β=0.050, p < 0.001), percentage of positive biopsy cores (PPC) (β=0.033, p < 0.001), both lobe involvement on biopsy (β=0.359, p=0.009), Gleason score (β=0.358, p < 0.001), and cTMRI (β=0.259, p < 0.001) were significant factors for ECE. For SVI, iPSA (β=0.037, p < 0.001), PPC (β=0.024, p < 0.001), Gleason score (β=0.753, p < 0.001), and cTMRI (β=0.507, p < 0.001) showed statistical significance. BN models to predict ECE and SVI were also successfully established. The overall area under the receiver operating characteristic curve (AUC)/accuracy of the BN models were 0.76/73.0% and 0.88/89.6% for ECE and SVI, respectively. According to internal comparison between the BN model and Roach formula, BN model had improved AUC values for predicting ECE (0.76 vs. 0.74, p=0.060) and SVI (0.88 vs. 0.84, p < 0.001).

CONCLUSION

Two models to predict pathologic ECE and SVI integrating cTMRI were established and installed on a separate website for public access to guide radiation oncologists.

Weekly versus 2-weekly versus 3-weekly docetaxel to treat metastatic castration-resistant prostate cancer

BACKGROUND

To compare the efficacy and toxicity of docetaxel treatment regimens in metastatic castration-resistant prostate cancer (mCRPC).

METHODS

We retrospectively analyzed 162 patients diagnosed with mCRPC who underwent docetaxel chemotherapy between 2009 and 2020. The patients were divided into three groups according to the dosage and interval of docetaxel (DCT) chemotherapy regimen: 30 mL/m2 weekly, 50 mL/m2 biweekly (every 2 weeks), and 75 mL/m2 triweekly (every 3 weeks).

RESULTS

There were no significant differences in the prostate-specific antigen (PSA) response rates (P = 0.709). The median time to progression was 3.0 [interquartile range (IQR 2.0-5.3)] months, 5.0 (IQR 2.0-13.0) months, and 5.0 (IQR 3.0-12.0) months in the weekly, biweekly, and triweekly groups, respectively (P = 0.062). The median overall survival (OS) was 12.5 (IQR 6.0-14.0) months, 18.8 (IQR 5.5-23.5) months, and 22.9 (IQR 11.0-33.0) months in the weekly, biweekly, and triweekly groups, respectively (P < 0.001). There were no differences in all toxicity and Grade 3 or higher toxicity. In Cox multivariate regression analysis, the Eastern Cooperative Oncology Group performance status (ECOG-PS), response to chemotherapy, and chemotherapy cycle also affected the PFS. Age, ECOG-PS, and chemotherapy cycle affected the OS.

CONCLUSIONS

The various options for optimal chemotherapy are indicated depending on the patient's conditions during the diagnosis of mCRPC. Treatment with DCT at 2-week or even 1-week intervals appears to be well tolerated in men diagnosed with mCRPC and represents a useful option when the conventional triweekly regimen is not tolerated due to poor patient condition.

Beta-human chorionic gonadotropin, carbohydrate antigen 19-9, cancer antigen 125, and carcinoembryonic antigen as prognostic and predictive biological markers in bladder cancer

INTRODUCTION

We evaluated the prognostic potential of the Beta-human chorionic gonadotropin (β-hCG), Carbohydrate Antigen 19-9 (CA19-9), Cancer Antigen 125 (CA125), and Carcinoembryonic Antigen (CEA) tumor markers for bladder cancer.

METHODS

We analyzed the records of 369 patients who underwent radical cystectomy for urothelial cancer (UC) between October 2012 until December 2019. Levels of CA19-9, CA125, CEA, and β-hCG before radical cystectomy were measured in all patient samples, and serum biomarker cutoff values were used as normal and elevated values.

RESULTS AND DISCUSSION

The proportion of abnormal β-hCG (P<0.001), CA19-9 (P<0.001), and CA125 (P=0.033) was significantly higher in locally advanced bladder UC than in organ-confined bladder UC. In patients with preoperative β-hCG and CA125 abnormality, there was poor prognosis of recurrence-free survival (RFS)(P=0.003, P=0.042) and overall survival (OS) (P=0.003, P=0.002). Using the Cox multivariate regression analysis, both β-hCG (HR: 3.88, 95% CI: 1.43-10.25) and CA125 (HR: 6.21, 95% CI: 1.34-32.16) were found to be significant independent factors for predicting OS and RFS. In addition, patients with a high number of increased tumor markers showed significantly worse OS ((P<0.001) and RFS (P=0.002) than patients with a low number of increased tumor markers. In conclusion, serum β-hCG and CA125 levels could potentially be used for UC prognosis in patients undergoing radical cystectomy. To assess their usefulness in evaluating long-term recurrence and survival, further treatment responses and large-scale additional studies are needed.

Gender-related outcomes in robot-assisted radical cystectomy: A multi-institutional study

PURPOSE

Robot-assisted radical cystectomy (RARC) optimizes patient recovery and has outcomes comparable with those of open surgery. This study aimed to compare the perioperative and oncologic outcomes of RARC in female and male patients.

MATERIALS AND METHODS

A retrospective cohort study of the Korean Robot-Assisted Radical Cystectomy Study Group database from 2007 to 2019 identified 749 patients (111 females and 638 males). Female were matched 1:1 to male by propensity score matching using a logistic regression. We compared perioperative outcomes, oncologic outcomes, and complications between the two groups.

RESULTS

The female group had comparable perioperative outcomes to the male group in terms of operation time, lymph node yield, positive surgical margin, blood transfusion rate, and hospitalization days. Complication rate and grade were not significantly different between the two groups. The most common complication was infection in female and gastrointestinal complications in male. We compared the 5-year overall, disease-specific, and recurrence-free survival of female and male: 58.2% vs. 68.0% (p=0.495), 75.7% vs. 79.3% (p=0.645), and 40.8% vs. 53.5% (p=0.913), respectively. On multivariable analysis, T stage (>T2), postoperative complications, and positive surgical margin were prognostic factors of poor outcome. Sex was not an independent predictor of the three survivals.

CONCLUSIONS

The current study suggests that RARC in female has comparable perioperative and oncologic outcomes to those in male. The complication rate of RARC in female was comparable to that in male, but the type of complications differed by sex.

High Carbohydrate Antigen 19-9 Levels Indicate Poor Prognosis of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) occurs in urothelial cells from the kidney and the ureters. Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker for pancreatic and gastrointestinal cancers, and its high levels are associated with poor prognosis in bladder cancer. In this study, prospective patients enrolled in the registry of Seoul National University were retrospectively examined to determine the clinical significance of CA 19-9 in UTUC. In 227 patients, high serum CA 19-9 levels reflected a high tumor burden represented by high T and N stages, leading to adverse prognosis in metastasis-free or overall survival. Subsequently, propensity score matching analysis showed that the CA 19-9 level is an independent prognostic factor of UTUC.

Safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy for extremely severe autosomal dominant polycystic kidney disease: Techniques and outcome

PURPOSE

To demonstrate the safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy in extremely severe autosomal dominant polycystic kidney disease (ADPKD), which corresponds to the Mayo imaging classification classes 1D and 1E.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent unilateral nephrectomy and contralateral heminephrectomy at the Seoul National University Hospital (Seoul, Korea) between May 1, 2016 and August 1, 2021. The preoperative kidney volume was calculated using the ellipsoid equation (length×width×thickness×π/6). The Mayo imaging classification was determined by height-adjusted total kidney volume and age. Using a midline vertical incision, heminephrectomy was performed first by horizontal transection, followed by contralateral nephrectomy. Hilar vessel clamping or resection-bed suturing was not required.

RESULTS

In all, nine patients with ADPKD of the highest severity (Mayo class 1D/1E) underwent unilateral heminephrectomy and contralateral nephrectomy for the most common cause of severe abdominal discomfort and malnutrition. All nine patients had end-stage renal disease with hypertension and anemia. The median preoperative total kidney volume was 10,905.8 mL (interquartile range [IQR], 8,170.4-16,227.6 mL). The median operation time was 140 minutes (IQR, 125-185 min) and the median estimated blood loss was 250 mL (IQR, 200-425 mL). Eight of the nine patients were discharged without ICU care or any complications. Delayed pseudoaneurysm occurred in one case and was successfully managed by embolization. All patients were symptom-free for a median follow-up period of 2 years.

CONCLUSIONS

Synchronous unilateral nephrectomy and contralateral heminephrectomy are safe and feasible treatment options for severe bilateral ADPKD.

Prognostic impact of postoperative neutrophil-to-lymphocyte ratio on survival outcomes of patients treated with radical nephroureterectomy for upper urinary tract urothelial carcinoma: a single institution retrospective analysis using propensity score matching

Purpose: To investigate the prognostic impact of postoperative neutrophil to lymphocyte ratio (NLR) on survival outcomes in upper urinary tract urothelial carcinoma (UTUC). Materials and methods: Data from 397 patients with UTUC who underwent radical nephroureterectomy (RNU) without a history of neoadjuvant chemotherapy between 2002 and 2017 were retrospectively analyzed. Based on a postoperative NLR cut-off of 3, patients were divided into low NLR (<3) or high NLR (≥ 3) groups. After 2:1 propensity score matching, a Kaplan-Meier with log-rank test was used to compare survival outcomes between the two groups. Univariate and multivariate Cox proportional hazard models were used to investigate the impact of the postoperative NLR on survival outcomes. Results: The matched cohort (n=176) consisted of 116 low NLR and 60 high NLR patients. The Kaplan-Meier curves showed significant differences in the 3- and 5-year overall and cancer-specific survival rates between the two groups (each p = 0.03). Multivariate Cox regression analysis revealed that a postoperative high NLR was an independent predictor of worse overall survival (hazard ratio [HR]:2.13; 95% confidence interval [CI]:1.18-3.85, p = 0.012) and cancer-specific survival (HR:2.16; 95% CI 1.11-4.21, p = 0.024). Conclusions: Propensity score matching analysis revealed postoperative high NLR can be considered a potential inflammatory biomarker for predicting survival outcomes of UTUC patients treated with RNU.

Association between decreased ipsilateral renal function and aggressive behavior in renal cell carcinoma

BACKGROUND

To assess prognostic value of pre-operative ipsilateral split renal function (SRF) on disease-free survival (DFS) and its association with aggressive pathological features in renal cell carcinoma (RCC) patients.  METHODS: We examined patients registered in SNUG-RCC-Nx who underwent partial or radical nephrectomy at Seoul National University Hospital between January 1, 2010 and December 31, 2020. Patients with the following criteria were excluded from the study. 1) non-kidney origin cancer or benign renal tumor, 2) no pre-operative Tc 99 m-DTPA renal scan, 3) single kidney status or previous partial or radical nephrectomy, and 4) bilateral renal mass. Finally, 1,078 patients were included.

RESULTS

Among 1,078 patients, 899 (83.4%) showed maintained ipsilateral SRF on DTPA renal scan; 179 patients (16.6%) showed decreased SRF. The decreased SRF group showed significantly large tumor size (maintained vs. decreased SRF; 3.31 ± 2.15 vs. 6.85 ± 3.25, p < 0.001), high Fuhrman grade (grade 3-4) (41.7% vs. 55.6%, p < 0.001), and high T stage (T stage 3-4) (9.0% vs. 20.1%, p < 0.001). Pathological invasive features, including invasion of the renal capsule, perirenal fat, renal sinus fat, vein, and collecting duct system, were associated with low SRF of the ipsilateral kidney. Univariate Cox regression analysis identified higher SSIGN (The stage, size, grade, and necrosis) score and decreased ipsilateral SRF as significant risk factors, while multivariate analysis showed SSIGN (5-7) (hazard ratio [HR] 11.9, p < 0.001) and SSIGN (8-10) (HR 69.2, p < 0.001) were significantly associated with shortened DFS, while decreased ipsilateral SRF (HR 1.75, p = 0.065) showed borderline significance. Kaplan-Meier analysis showed that decreased ipsilateral SRF (< 45%) group had shorter DFS than the other group (median DFS: 90.3 months vs. not reached, p < 0.001).

CONCLUSIONS

Among unilateral RCC patients, those with low ipsilateral SRF showed poor prognosis with pathologically invasive features. Our novel approach may facilitate risk stratification in RCC patients, helping formulate a treatment strategy.

Role of lymphatic invasion in predicting biochemical recurrence after radical prostatectomy

OBJECTIVE

Lymphatic invasion in prostate cancer is associated with poor prognosis. However, there is no consensus regarding the clinical and prognostic value of lymphatic invasion. This study aimed to investigate the prognostic value of lymphatic invasion in biochemical recurrence (BCR) and compare the recurrence rates between patients with lymphatic invasion and lymph node metastasis.

METHODS

We retrospectively analyzed 2,207 patients who underwent radical prostatectomy (RP) without pelvic lymph node dissection (PLND) and 742 patients who underwent RP with PLND for clinically localized or locally advanced prostate cancer, between 1993 and 2020, at Seoul National University Hospital. Kaplan-Meier analysis was performed to estimate BCR-free survival (BCRFS) using the log-rank test. The Cox proportional hazards model was used to identify the significant factors for BCR. Propensity score matching was performed with a 1:2 ratio to match age, initial PSA level, pathological T stage, and Gleason score to exclude confounding effects.

RESULTS

Of the 2,207 patients who underwent RP without PLND, lymphatic invasion (L1Nx) was observed in 79 (3.5%) individuals. Among the 742 patients who underwent RP with PLND, lymph node metastases were found in 105 patients (14.2%). In patients with lymph node metastasis, lymphatic invasion was observed in 50 patients (47.6%), whereas lymphatic invasion was observed in 53 patients (8.3%) among those without lymph node metastasis. In patients who underwent RP without PLND, Kaplan-Meier analysis showed significantly poorer BCR-free survival in the L1Nx group than in the L0Nx group (p < 0.001). In patients who underwent RP with PLND, the L1N0, L0N1, and L1N1 groups showed significantly worse prognoses than the L0N0 group (p < 0.001). However, there was no significant difference in BCRFS between the L1N0 and lymph node metastasis groups, including the L0N1 and L1N1 groups. After propensity score matching at a 1:2 ratio, the L1Nx group showed significantly poorer outcomes in terms of BCRFS than the L0Nx group (p = 0.05). In addition, the L1N0 group showed a significantly worse prognosis than the L0N0 group after propensity score matching.

CONCLUSION

Lymphatic invasion in radical prostatectomy specimens is an independent prognostic factor, which can complement lymph node status for predicting biochemical recurrence. Considering lymphatic invasion as an adverse pathological finding, similar to lymph node metastasis, adjuvant therapy could be considered in patients with lymphatic invasion.

Combined treatment with anticancer vaccine using genetically modified endothelial cells and imatinib in bladder cancer

PURPOSE

We sought to maximize the antitumor effect of an anticancer vaccine based on genetically modified endothelial cells by combining it with the platelet-derived growth factor receptor inhibitor imatinib.

MATERIALS AND METHODS

Human umbilical vein endothelial cells (HUVECs) were infected with 10 MOI of Ad-CMV-mGMCSF to make anticancer vaccines. One million mouse bladder cancer cells (MBT-2) were subcutaneously inoculated in C3H mice. The experimental groups included the following: Group 1 (phosphate-buffered saline), Group 2 (anticancer vaccine and GM-CSF), Group 3 (imatinib), and Group 4 (anticancer vaccine, GM-CSF, and imatinib). Tumor growth and body weight were measured weekly. At 4 weeks, the tumors were immunostained with anti-CD31, and microvessel density (MVD) was measured. To evaluate the immunological mechanism of each treatment, flow cytometry analysis of activated CD4 and CD8 cells was performed.

RESULTS

At 4 weeks, the mean body weight of each group, excluding the extracted tumor weight, was not significantly different. Since week 3, the mean tumor volume in Group 4 was the smallest among the treatment groups (p<0.05), and a synergistic suppressive effect on tumor volume was observed in Group 4. The MVD in Group 4 was the most suppressed among the treatment groups (p<0.05), and a synergistic anti-angiogenic effect was observed. Flow cytometry analysis revealed that activated CD4+ and CD8+ cells increased in Group 2 and decreased in Group 3 compared with the other groups.

CONCLUSIONS

The combination of genetically modified endothelial cell vaccines and imatinib showed a synergistic antiangiogenic effect in bladder cancer.

External validation of an international multicenter study to predict survival in Korean patients with pT2N0M0 renal cell carcinoma

OBJECTIVES

To determine whether a tumor size cut-off can improve the prognostic accuracy of the current tumor-node-metastasis staging system in Korean patients with pT2 renal cell carcinoma (RCC).

METHODS

We identified 819 patients treated with radical nephrectomy for clinical RCC between 1995 and 2005. The study included 102 patients of pT2N0M0 RCC.

RESULTS

When 5-year survival rates were calculated using 0.5-cm increments between 7.5 and 12.5 cm, none of the cut-offs provided a significant difference in 5-year overall and cancer-specific survival. Cut-offs of 9.5 and 10.0 cm provided significant difference in 5-year progression-free survival (log-rank score 4.37, P = .037; log-rank score 6.75, P = .009, respectively). However, a 10.5-cm cut-off provided the greatest difference in 5-year progression-free survival (log-rank score 7.19; P = .007). Multivariate Cox proportional hazards model analysis using the variables of age, sex, American Society of Anesthesiologists score, tumor side, histologic type, tumor grade, and tumor diameters showed that tumor diameter was an independent predictor of progression-free survival when 10.0 cm (hazard ratio [HR], 2.72; 95% confidence interval [CI] 1.19-6.22; P = .018), and 10.5 cm (HR, 2.77; 95% CI 1.21-6.33; P = .016) were chosen as the cut-offs.

CONCLUSIONS

In our study, only size-related recurrence or metastatic potential was found, and a 10.5-cm cut-off best stratified this difference. However, size-related cancer-specific and overall survival differences were not found among patients.