Comparison of long-term results according to the primary mode of management and type of injury for posterior urethral injuries

BACKGROUND

We retrospectively reviewed the records of patients with traumatic posterior urethral injuries, analyzed postoperative findings to compare the results of the primary mode of management, and evaluated whether the Colapinto and McCallum classification system was valuable for predicting the complications.

METHODS

55 patients with traumatic posterior urethral injuries were included in the study. A total of 35 patients underwent immediate realignment over a Foley catheter including direct Foley catheter insertion (group 1) and 20 underwent initial suprapubic tube placement followed by delayed urethroplasty (group 2). Urethral injuries were interpreted using the Colapinto and McCallum classification based on the retrograde urethrographies.

RESULTS

44 (80.0%) of the patients were classified to type III in both groups (group 1, 29 [82.9%]; group 2, 15 [75.0%]). Of group 1, mild, moderate and severe urethral strictures developed in 7 (20.0%), 8 (22.9%) and 6 (17.1%), respectively, and developed in 6 (30.0%), 2 (10.0%) and 5 (25.0%), respectively, of group 2. Six (17.1%) and 2 (20.0%) had decreased potency and 4 (11.5%) and 1 (5.0%) were impotent in group 1 and 2, respectively. Of group 1, incontinence developed in 3 patients but 1 did not need treatment, and developed in 2 (10.0%) but 1 (5.0%) did not need treatment of group 2. The score test for trend demonstrated that there were no significant differences of these results.

CONCLUSIONS

Our findings suggest that complications in patients with posterior urethral injuries are not related to the primary mode of management. Because most injuries are type III, the evolution toward the classification system is needed.

Sexual activity in Korean male patients on clean intermittent catheterization with neurogenic bladder due to spinal cord injury

BACKGROUND

The aim of this study was to assess the sexual function and activity in male patients on clean intermittent catheterization with neurogenic bladder due to spinal cord injury.

METHODS

Eighty-nine patients (mean age 37.6 years with a range of 18-66) were included in the study. We requested all subjects to complete a questionnaire including the 5-item version of the International Index of Erectile Function (IIEF-5).

RESULTS

Of 89 patients, 60 (67.4%) reported having attempted no sexual intercourse over the past 6 months and 28 (31.5%) presented with IIEF-5 scores less than or equal to 21 points. When subjects were stratified according to the years since injury, 50.0% (16 of 32) with less than 2 years post-injury had no sexual activity, while 77.2 (44 of 57) with 2 years or more post-injury did (P = 0.027). Patients with sexual activity were 40.4% (23 of 57) and 18.8% (6 of 32) in patients who were able and unable to perform self-catheterization, respectively (P = 0.037). Patients with less than 2 years post-injury had 3.3-fold higher risk (odds ratio 3.33; 95% confidence interval 1.01-10.97; P = 0.048) of no sexual activity than those with 2 years or more post-injury on the multivariate model. The other parameters were not appreciably related to sexual activity.

CONCLUSION

Our results demonstrate that sexual activity as well as erectile function is poor in this population. In addition, our findings suggest that years since injury may influence sexual activity of patients with spinal cord injury.

Laparoscopic nephrectomy for renal diseases in children: is there a learning curve?

BACKGROUND/PURPOSE

We evaluated the impact of a surgeon's experience, divided our first 20 consecutive series that involved a single surgeon at the numerical midpoint of his experience, and compared outcomes regarding this midpoint.

METHODS

From August 1996 to August 2001, laparoscopic nephrectomy or nephroureterectomy was performed in 20 consecutive children, 12 girls and 8 boys aged between 1 and 15 years (median, 5.9 years). Disease was in the right side in 11 patients and in the left side in 9. The children were divided into 2 groups of 10. We retrospectively obtained data on all patients and compared pertinent perioperative information including operation time, blood loss, length of hospital stay, and postoperative complications.

RESULTS

The procedure was feasible in all cases and did not require conversion to open surgery or perioperative transfusion in any case. The operation time reduced from a median of 181 minutes over the first 10 patients to 125 minutes over the second 10, and this difference was significant (P = .02). Estimated blood loss and days to the first postoperative oral feeding for the second 10 patients were less than for those of the first 10 but there was no significant difference. The median hospital stay of the first 10 patients was 5.4 days (range, 2-10 days), significantly longer than the 2.5 days of the second 10 (range, 2-7 days) (P = .009).

CONCLUSIONS

Laparoscopic nephrectomy operation times in children reduced when the surgical experience level exceeded approximately 10 cases.

Impact of positive surgical margins and their locations after radical prostatectomy: comparison of biochemical recurrence according to risk stratification and surgical modality

PURPOSE

We investigated the influence of positive surgical margins (PSMs) and their locations on biochemical recurrence (BCR) according to risk stratification and surgical modality.

METHODS

A total of 1,874 post-radical-prostatectomy (RP) patients of pT2-T3a between 2000 and 2010 at three tertiary centers, and who did not receive neoadjuvant/adjuvant therapy, were included in this study. Patients were stratified according to BCR risk: low risk (PSA <10, pT2a-b, and pGS ≤6), intermediate risk (PSA 10-20 and/or pT2c and/or pGS 7), and high risk (PSA >20 or pT3a or pGS 8-10). The median follow-up was 43 months.

RESULTS

PSMs were a significant predictor of BCR in both the intermediate- and high-risk-disease groups (P = .001, HR 2.1, 95 % CI 1.3-3.4; P < .001, HR 2.8, 95 % CI 2.0-4.1). Positive apical margin was a significant risk factor for BCR in high-risk disease (P = .003, HR 2.0, 95 % CI 1.2-3.3), but not in intermediate-risk disease (P = .06, HR 1.7, 95 % CI 0.9-3.1). Positive bladder neck margin was a significant risk factor for BCR in both intermediate- and high-risk disease (P < .001, HR 5.4, 95 % CI 2.1-13.8; P = .001, HR 4.5, 95 % CI 1.8-11.4). In subgroup analyses, robotic RP provided comparable BCR-free survival regardless of risk stratification. Patients with PSMs showed similar BCR-free survival between open and robotic RP (log-rank, P = .897).

CONCLUSIONS

Post-RP PSMs were a significantly independent predictor of disease progression in high-risk disease as well as intermediate-risk disease. Both positive apical and bladder neck margins are also significant risk factors of BCR in high-risk disease. Patients with PSMs showed similar BCR-free survival between open and robotic surgery.

Effect of Intraoperative Red Blood Cell Transfusion on Postoperative Complications After Open Radical Cystectomy: Old Versus Fresh Stored Blood

INTRODUCTION

Transfusion with red blood cells (RBCs) is associated with adverse clinical outcomes. We determined whether an intraoperative RBC transfusion is related to postoperative complications in patients undergoing open radical cystectomy. We also compared the effect of transfusion with fresh versus old blood on postoperative complications.

PATIENTS AND METHODS

A total of 261 patients undergoing open radical cystectomy were divided into no-transfusion or transfusion groups. Transfused patients were divided according to RBC storage duration (fresh, ≤ 14 days; old, > 14 days). Postoperative complications, such as infection, paralytic ileus, urinary tract obstruction, and anastomotic leak, were noted.

RESULTS

Infection (26.5%) was the most common postoperative complication, followed by procedural (17.6%), gastrointestinal (16.7%), renal (13.7%), and vascular (10.5%) problems. Age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.00-1.07; P = .029), urinary diversion with a neobladder (OR, 2.30; 95% CI, 1.29-4.11; P = .005), and intraoperative RBC transfusion (OR, 1.77; 95% CI, 1.02-3.07; P = .042) were independent predictors of postoperative complications in a binary logistic analysis. Patients (n = 172; old blood, n = 47; fresh blood, n = 116; mixed blood, n = 9) who received an intraoperative RBC transfusion had a higher incidence of postoperative complications than those (n = 89) who did not undergo intraoperative transfusion (65.1% vs. 49.4%, P < .05). No difference in the incidence of postoperative complications between transfusions with old blood and fresh blood was observed (63.8% vs. 65.5%).

CONCLUSION

Intraoperative RBC transfusion is associated with increased postoperative complications in patients undergoing open radical cystectomy. The RBC storage duration may not affect the incidence of postoperative complications in this study population.

Clinical Significance of Pre-treated Neutrophil-Lymphocyte Ratio in the Management of Urothelial Carcinoma: A Systemic Review and Meta-Analysis

Purpose: We performed a study-level meta-analysis to summarize the current evidence on the correlation between pretreatment neutrophil-to-lymphocyte ratios (NLR) and oncological outcomes in each type of management for urothelial carcinoma. Method: All articles published until February 2017 in PubMed, Scopus, and EMBASE database were collected and reviewed. The current evidence on correlations between pretreatment NLR and oncological outcomes in each type of management for urothelial carcinoma, including transurethral resection of bladder tumor (TURBT), radical cystectomy (RCx), chemotherapy (CTx), and nephroureterectomy (NUx), were summarized. Results: Thirty-eight studies containing clinical information on 16,379 patients were analyzed in this study. Pooled hazard ratios (HR) and odds ratios (OR) with 95% confidence intervals were calculated after weighing each study. Heterogeneity among the studies and publication bias were assessed. Pretreatment NLR was significantly associated with muscle invasiveness (OR: 4.27), recurrence free survival (RFS, HR: 2.32), and progression-free survival (PFS, HR: 2.45) in TURBT patients. In the RCx patients, high NLR was negatively associated with both disease status (extravesical extension and lymph-node positivity, OR: 1.14 and 1.43, respectively) and oncological outcomes [overall survival (OS), PFS], and cancer specific survival (CSS, HR: 1.18, 1.12, and 1.35, respectively). Pretreatment NLR was negatively correlated with pathologic downstaging (OR: 0.79) and positively correlated with PFS (HR: 1.30) and OS (HR: 1.44) in CTx patients. For patients who underwent NUx, pretreatment NLR was significantly associated with OS (HR: 1.72), PFS (HR: 1.63), and CSS (HR: 1.68). Conclusions: Pretreatment NLR is a useful biomarker for disease aggressiveness, oncological outcome, and treatment response in the management of patients with urothelial carcinoma. More evidence is needed to clarify these results.

Perioperative Blood Transfusion as a Significant Predictor of Biochemical Recurrence and Survival after Radical Prostatectomy in Patients with Prostate Cancer

PURPOSE

There have been conflicting reports regarding the association of perioperative blood transfusion (PBT) with oncologic outcomes including recurrence rates and survival outcomes in prostate cancer. We aimed to evaluate whether perioperative blood transfusion (PBT) affects biochemical recurrence-free survival (BRFS), cancer-specific survival (CSS), and overall survival (OS) following radical prostatectomy (RP) for patients with prostate cancer.

MATERIALS AND METHODS

A total of 2,713 patients who underwent RP for clinically localized prostate cancer between 1993 and 2014 were retrospectively analyzed. We performed a comparative analysis based on receipt of transfusion (PBT group vs. no-PBT group) and transfusion type (autologous PBT vs. allogeneic PBT). Univariate and multivariate Cox-proportional hazard regression analysis were performed to evaluate variables associated with BRFS, CSS, and OS. The Kaplan-Meier method was used to calculate survival estimates for BRFS, CSS, and OS, and log-rank test was used to conduct comparisons between the groups.

RESULTS

The number of patients who received PBT was 440 (16.5%). Among these patients, 350 (79.5%) received allogeneic transfusion and the other 90 (20.5%) received autologous transfusion. In a multivariate analysis, allogeneic PBT was found to be statistically significant predictors of BRFS, CSS, and OS; conversely, autologous PBT was not. The Kaplan-Meier survival analysis showed significantly decreased 5-year BRFS (79.2% vs. 70.1%, log-rank, p = 0.001), CSS (98.5% vs. 96.7%, log-rank, p = 0.012), and OS (95.5% vs. 90.6%, log-rank, p < 0.001) in the allogeneic PBT group compared to the no-allogeneic PBT group. In the autologous PBT group, however, none of these were statistically significant compared to the no-autologous PBT group.

CONCLUSIONS

We found that allogeneic PBT was significantly associated with decreased BRFS, CSS, and OS. This provides further support for the immunomodulation hypothesis for allogeneic PBT.

The role of prolactin levels in the sexual activity of married men with erectile dysfunction

OBJECTIVE

To evaluate the effects of risk factors for erectile dysfunction (ED) including anthropometry, hormones, metabolic profiles and lifestyle, on sexual activity in married men with ED.

PATIENTS AND METHODS

The study included 261 men (mean age 53.7 years, range 23-80), who were evaluated for anthropometry, hormone levels, metabolic profiles and lifestyle factors. Erectile function was evaluated using the self-administered International Index of Erectile Function. Patients were classified into two groups based on the six-item erectile-function domain, as those with sexual activity and those without.

RESULTS

Of all patients, 62.5% (163 of 261) had no sexual activity (erectile-function domain score <6). There was a significant difference in mean (sem) prolactin level between patients with and with no sexual activity, at 4.8 (0.4) vs 6.8 (0.7) (P = 0.013). Of all patients, 73.7% (42 of 57) with diabetes had no sexual activity, while 59.3% (121 of 204) without diabetes had (P = 0.048). In a multivariate model, a higher prolactin level was associated with a greater likelihood of sexual inactivity (odds ratio 1.094; 95% confidence interval, 1.010-1.185; P = 0.028) but diabetes lost its statistical significance. The area under the receiver-operating characteristic curve for prolactin was 60.5% (95% confidence interval, 52.9-68.1%; P = 0.009) for sexual inactivity. No other factors were significant in this regard.

CONCLUSION

Our findings suggest that prolactin levels might play a role in sexual activity in men with ED.

Elevated Neutrophil to Lymphocyte Ratio Predicts Poor Prognosis in Non-muscle Invasive Bladder Cancer Patients: Initial Intravesical Bacillus Calmette-Guerin Treatment After Transurethral Resection of Bladder Tumor Setting

The objective of this study was to investigate pretreatment systemic inflammatory response (SIR) markers in patients who underwent initial intravesical treatment for high-risk non-muscle invasive bladder cancer (NMIBC). A total of 385 patients who underwent initial intravesical Bacillus Calmette-Guerin treatment after transurethral resection of bladder tumor (TURB) were included. We analyzed the relationship between oncological outcomes and ratios of SIR markers, including neutrophil-to-lymphocyte ratio (NLR), derived neutrophil-to-lymphocyte ratio (dNLR), and platelet-to-lymphocyte ratio (PLR). Each SIR marker was used for analysis. Their cut-off values were determined through receiver operation characteristics curves analysis. Patients were divided into two groups according to pretreatment NLR (<1.5 vs. ≥1.5), dNLR (<1.2 vs. ≥1.2), and PLR values (171< vs. ≥171). Patients with NLR ≥ 1.5 and dNLR ≥ 1.2 were associated with poor prognosis in terms of overall survival and cause-specific survival. However, no serum SIR marker was associated with prognosis in recurrence-free survival or progression-free survival. Cox multivariate analysis revealed that age, NLR, dNLR, hemoglobin, and pathologic T stage were significant factors predicting overall survival. Age, NLR, and pathologic T stage were significant factors predicting cancer-specific survival, NLR and tumor number were the most important predictors of bladder preserving survival. NLR before treatment was correlated with both oncological outcomes and survival outcome in NMIBC patients undergoing initial intravesical BCG treatment after TURB. Increased NLR reflects a poor prognosis of these outcomes.

Effect of dutasteride on the expression of hypoxia-inducible factor-1alpha, vascular endothelial growth factor and microvessel density in rat and human prostate tissue

OBJECTIVE

To evaluate the effects of dutasteride on the expression of angiogenesis markers in rat and human prostates.

MATERIAL AND METHODS

Eight-week-old male Sprague-Dawley rats were divided into three groups of six each according to dutasteride dose, including the control group (regular diet), 2.5 mg group (2.5 mg/kg dutasteride) and 5.0 mg group (5.0 mg/kg dutasteride). A total of 41 patients awaiting transurethral resection of the prostate (TURP) were divided into two groups: 20 patients received no medication and 21 received 0.5 mg dutasteride daily for 2-4 weeks until TURP.

RESULTS

At 2 weeks, dutasteride effected a significant decrease in body weight and prostate weight compared with the control rat group. Analysis by reverse transcription-polymerase chain reaction and Western blot revealed that hypoxia-inducible factor-1alpha (HIF-1alpha) and vascular endothelial growth factor (VEGF) expression was lower in the dutasteride-treated groups than in the control group, except for HIF-1alpha protein. HIF-1alpha and VEGF expression was similar in the 2.5 mg and 5.0 mg groups. Human prostate tissues demonstrated homogeneous staining of HIF-1alpha and VEGF with regard to extent, intensity and intracellular location in both groups. There was no significant difference in microvessel density between the two groups.

CONCLUSIONS

The expression of HIF-1alpha and VEGF in rat prostates is suppressed by dutasteride. However, less than 4 weeks of dutasteride administration does not suppress the expression of HIF-1alpha, VEGF and microvessel density in human prostate tissue. Further clinical investigation with dutasteride including a larger, placebo-controlled study is warranted to establish the mechanism and duration of dutasteride.

Patients' experience with ambulatory urodynamics. A prospective study

OBJECTIVE

To assess emotional variables in patients who underwent ambulatory urodynamic monitoring (AUM).

MATERIAL AND METHODS

A total of 33 females and 7 males aged 23-72 years with an overactive bladder who had undergone three consecutive AUM sessions were included in the study on a prospective basis. Patients completed a self-administered questionnaire before and immediately after each procedure. Answers were given using a visual analog scale.

RESULTS

The pre-procedural level of anxiety did not differ significantly with respect to sex, age, education level or income. The degree of bother experienced by patients aged > or = 50 years was higher than for those aged < 50 years: 5 vs 2.5 (p = 0.030). As income increased, the degrees of pain (p = 0.016), bother (p = 0.013) and boredom (p = 0.010) decreased. Other emotional aspects did not differ significantly according to age or income (p > 0.05). Only the subjective bother score influenced the examiner-rated degree of intolerance during AUM (p = 0.007). A total of 34 patients (85.0%) indicated that they would be willing to return for a further session of AUM. The degree of intolerance decreased at the second (p = 0.006) and third (p = 0.049) AUM sessions, whereas other parameters were not significantly different.

CONCLUSION

Our results demonstrate that AUM is acceptable and well tolerated by patients with bladder dysfunction.

Adjuvant chemotherapy for locally advanced upper tract urothelial carcinoma: updated results of the Seoul National University Hospital experience

OBJECTIVES

The objective of this study was to update the long-term outcome in the treatment of locally advanced upper tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU) regarding the role of adjuvant chemotherapy.

MATERIALS AND METHODS

Clinical data from 138 patients who underwent RNU for locally advanced UTUC (pT3/4 or pN+) were analyzed.

RESULTS

The adjuvant chemotherapy group comprised 66 patients, and other 72 patients did not receive adjuvant chemotherapy. Cisplatin-based chemotherapy was the most common regimen, depending on the patient's eligibility and renal function. The median follow-up period was 48.7 months (interquartile range: 29.2-96.9 months). The 3-and 5-year disease-specific survival (DSS) rates were 76.0% and 69.9% for the non- -adjuvant chemotherapy group versus 74.6% and 54.5% for the adjuvant chemotherapy group (p=0.301, log-rank test). Overall survival (OS) rates for the same time period were 70.1% and 62.9% for the non-adjuvant chemotherapy group versus 73.8% and 53.2% for the adjuvant chemotherapy group (p=0.931, log-rank test). On multivariate analysis, adjuvant chemotherapy could not predict DSS and OS after surgery. When patients who received cisplatin-based adjuvant chemotherapy (n=59) were compared to those who did not receive adjuvant chemotherapy, similar results were found.

CONCLUSIONS

There does not appear to be a significant DSS or OS benefit associated with adjuvant chemotherapy. Prospective randomized clinical trials are necessary to verify the effect of adjuvant chemotherapy on locally advanced UTUC.

Predicting biochemical recurrence in patients with high-risk prostate cancer using the apparent diffusion coefficient of magnetic resonance imaging

PURPOSE

We aimed to investigate whether the apparent diffusion coefficient (ADC) value in diffusion-weighted magnetic resonance imaging predicts the prognoses of patients with high-risk prostate cancer.

MATERIALS AND METHODS

A total of 157 patients with high-risk prostate cancer (based on D'Amico's criteria) were included in the analysis. Patients underwent preoperative 3.0 Tesla magnetic resonance imaging within 2 months before radical prostatectomy. Those who received neoadjuvant hormone therapy (33 persons) or radiation therapy (18 persons) were excluded. The ADC of the tumor calculated from 2 b-values (0 and 1,000 s/mm2) was measured. Areas under receiver operating characteristics curves were calculated to maximize the accuracy of the ADC value. Based on the obtained cutoff value, the patients were stratified into 2 groups: Group A consisted of patients with ADC values <746×10-6 mm2/s and group B comprised those with ADC values ≥746×10-6 mm2/s.

RESULTS

Group A showed higher rate of lymph positive and biochemical recurrence (BCR) rates than group B. Kaplan-Meier analysis showed that the BCR-free survival rate of group A was much lower than that of group B (p<0.001). On Cox proportional regression analyses, ADC group A (hazard ratio [HR], 3.238, p=0.002) and pathologic lymph node positive (HR, 2.242; p=0.009) were independent predictors of BCR.

CONCLUSIONS

In patients with high-risk prostate cancer, ADC value is significantly associated with BCR-free survival. Therefore, the ADC value is a useful tool for predicting the prognoses of these high-risk patients.

Serum prostate-specific antigen as a predictor of prostate volume in Korean men with lower urinary tract symptoms

The aim of the study was to assess the utility of prostate-specific antigen (PSA) as a predictor of prostate volume indexes (total prostate volume (TPV), transition zone volume and transition zone index) in Korean men with lower urinary tract symptoms (LUTS). From September 2003 to April 2006, 3431 patients with LUTS were included in the study; they had a median age of 63.8 years, a median prostate volume of 22.6 ml and a median serum PSA of 1.04 ng/ml. Men with a baseline PSA of >10 ng/ml were excluded, to reduce the likelihood of including occult prostate cancer. Prostate volume indexes and serum PSA levels had an age-dependent log-linear relationship. Receiver operating characteristic curve analysis showed that PSA had good predictive value for various prostate volume indexes thresholds. The approximate age-specific criteria for detecting men with a TPV of >40 ml are PSA levels of 1.20, 1.44 and 1.72 ng/ml for men with LUTS in their sixth, seventh and eighth decades, respectively. The results show that serum PSA identifies Korean men with large prostates reasonably well. Korean men may produce and/or release more PSA per unit prostate volume than white men. The cutoffs for PSA and prostate volume to response to LUTS therapy should be determined in this population.

Pre- and post-operative nomograms to predict recurrence-free probability in korean men with clinically localized prostate cancer

OBJECTIVES

Although the incidence of prostate cancer (PCa) is rapidly increasing in Korea, there are few suitable prediction models for disease recurrence after radical prostatectomy (RP). We established pre- and post-operative nomograms estimating biochemical recurrence (BCR)-free probability after RP in Korean men with clinically localized PCa.

PATIENTS AND METHODS

Our sampling frame included 3,034 consecutive men with clinically localized PCa who underwent RP at our tertiary centers from June 2004 through July 2011. After inappropriate data exclusion, we evaluated 2,867 patients for the development of nomograms. The Cox proportional hazards regression model was used to develop pre- and post-operative nomograms that predict BCR-free probability. Finally, we resampled from our study cohort 200 times to determine the accuracy of our nomograms on internal validation, which were designated with concordance index (c-index) and further represented by calibration plots.

RESULTS

Over a median of 47 months of follow-up, the estimated BCR-free rate was 87.8% (1 year), 83.8% (2 year), and 72.5% (5 year). In the pre-operative model, Prostate-Specific Antigen (PSA), the proportion of positive biopsy cores, clinical T3a and biopsy Gleason score (GS) were independent predictive factors for BCR, while all relevant predictive factors (PSA, extra-prostatic extension, seminal vesicle invasion, lymph node metastasis, surgical margin, and pathologic GS) were associated with BCR in the post-operative model. The c-index representing predictive accuracy was 0.792 (pre-) and 0.821 (post-operative), showing good fit in the calibration plots.

CONCLUSIONS

In summary, we developed pre- and post-operative nomograms predicting BCR-free probability after RP in a large Korean cohort with clinically localized PCa. These nomograms will be provided as the mobile application-based SNUH Prostate Cancer Calculator. Our nomograms can determine patients at high risk of disease recurrence after RP who will benefit from adjuvant therapy.

External validation of online predictive models for prediction of cancer-specific mortality and all-cause mortality in patients with urothelial carcinoma of the urinary bladder

PURPOSE

The objective of the study was to validate the previously reported lookup Table and Bladder Cancer Research Consortium (BCRC) nomogram in predicting cancer-specific mortality (CSM) and all-cause mortality (ACM) after radical cystectomy using an external cohort from South Korea.

METHODS

The study comprised 409 patients. Discrimination was quantified with the concordance index. The relationship between the model-derived and actual CSM and ACM was graphically explored within calibration plots. Clinical net benefit was evaluated by decision curve analysis.

RESULTS

Of the 409 patients, 147 (35.9 %) had died from various causes. One hundred two deaths were attributable to bladder cancer. For CSM at 5 years, the bootstrap-corrected concordance indices of the American Joint Committee on Cancer (AJCC) staging system, lookup Table, and BCRC nomogram were 71.8 % (95 % confidence interval [CI] 66.9-76.5), 73.0 % (95 % CI 67.9-78.0), and 76.2 % (95 % CI 71.6-80.9), respectively. For ACM at the same time point, the discrimination accuracies of these models were 70.7 % (95 % CI 66.7-74.6), 72.8 % (95 % CI 68.5-76.9), and 76.2 % (95 % CI 72.3-80.2), respectively. The calibration plots tended to exaggerate both survival outcomes in all models. When compared to the lookup Table as well as the AJCC staging system, the BCRC nomogram performed well across a wide range of threshold probabilities using decision curve analysis.

CONCLUSIONS

The BCRC nomogram was characterized by higher accuracy and larger potential clinical benefit compared to the lookup Table. However, there is a great need for additional models that consider outcomes of patients for whom the existing models do not apply.

Prostate activity and prostate cancer in spinal cord injury

In addition to androgen, autonomic nerves may be involved in prostatic function. As patients with spinal cord injury (SCI) have impaired innervation of the prostate, the prostate volume and prostate-specific antigen (PSA) level in patients with SCI may be different from those of healthy men. Experiments in rats with SCI indicate that neurogenic factors play an important role in prostate growth and function but the same phenomena may not occur in men with SCI because the current animal models differ from clinical results in humans in several respects. Although many of studies indicate the importance of intact peripheral innervation on the secretory function of the prostate, the effect of more central denervation such as occurs in complete SCI at the cervical, thoracic, or lumbar levels on prostatic function is unclear. In addition, the impact of central nervous system injury on prostatic secretory activity, and consequently on serum PSA levels, is also not clear. Furthermore, the impact of hormonal changes on prostate cancer development and prognosis observed in patients with SCI may also be affected by the level of injury and patient age at the time of injury, which have not been studied. In this article, we review prostate activity and prostate cancer in SCI and discuss how they may relate to neurogenic factors.

Effects of Variant Histology on the Oncologic Outcomes of Patients With Upper Urinary Tract Carcinoma After Radical Nephroureterectomy: A Propensity Score-Matched Analysis

PURPOSE

To determine the prognostic effect of upper tract urothelial carcinoma (UTUC) with variant histology (VH) after radical nephroureterectomy (RNU).

PATIENTS AND METHODS

The data of 1173 patients who received RNU for UTUC without neoadjuvant chemotherapy in 11 institutions between 2002 and 2016 were retrospectively reviewed. A matched propensity score analysis was performed. Clinicopathologic variables, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were compared between patients with pure UTUC and patients with UTUC and VH. Univariate and multivariate Cox proportional regression models were used to determine the independent variables associated with oncologic outcomes.

RESULTS

UTUC with VH was observed in 93 patients (7.9%). After propensity score matching, UTUC with VH showed no difference in clinicopathologic features compared to pure UTUC; however, it was associated with shorter RFS, CSS, and OS (log rank, P = .011, P = .002, P = .006, respectively). Additionally, the multivariate analysis revealed that VH was independently associated with a poor RFS [hazard ratio (HR) = 1.92; 95% confidence interval (CI), 1.27-2.89; P = .002], CSS (HR = 4.47; 95% CI, 1.99-10.1; P = .001), and OS (HR = 3.00; 95% CI, 1.55-5.78; P = .001). However, the Kaplan-Meier method revealed that differences in RFS, CSS, and OS were not significant in patients who received adjuvant chemotherapy (log rank, P = .562, P = .060, P = .153, respectively).

CONCLUSION

UTUC with VH was independently associated with poor oncologic outcomes in patients with UTUC after RNU. Although patients with UTUC and VH had a poor prognosis compared to patients with pure UTUC, adjuvant chemotherapy would be helpful in improving the survival rates of these patients.

Extramammary Paget Disease of External Genitalia: Surgical Excision and Follow-up Experiences With 19 Patients

PURPOSE

There are only a few reports of extramammary Paget disease (EMPD) of the external genitalia because it is a rare malignancy. We investigated patients with EMPD of the penis and scrotum and report the outcome of surgical management.

MATERIALS AND METHODS

From 2000 to 2012, a total of 19 patients diagnosed as having penile and scrotal EMPD underwent wide local excision with or without intraoperative frozen biopsy or preoperative mapping biopsy. The medical charts of these patients were reviewed and analyzed retrospectively. Mean follow-up was 22.5 months (range, 1 to 60 months).

RESULTS

The mean age of the patients was 68 years (range, 57 to 82 years). In some patients, the lesions were misdiagnosed as either eczema or some other benign skin lesion at outside institutions, with a mean delay in diagnosis of 43.5 months (range, 1 to 198 months). Intraoperative frozen biopsy or preoperative mapping biopsy was performed in 18 patients. The resection margin was negative in 9 patients (47.4%) and positive in 10 patients (57.6%). Intraepithelial EMPD without dermis invasion was observed in 5 patients (26.3%), whereas diseases with dermis invasion were noted in 14 patients (73.7%). During the follow-up period, recurrences occurred in four patients, and two patients with dermis invasion and recurrence died from the disease.

CONCLUSIONS

Diagnosis of EMPD should not be delayed to allow for prompt management. Our findings suggest that intraoperative frozen biopsy or preoperative mapping biopsy cannot guarantee negative margins on final pathology. However, preoperative mapping biopsy and wide local excision with intraoperative frozen biopsy demonstrates good prognosis of EMPD, especially in those cases without dermal invasion.

Are urothelial carcinomas of the upper urinary tract a distinct entity from urothelial carcinomas of the urinary bladder? Behavior of urothelial carcinoma after radical surgery with respect to anatomical location: a case control study

BACKGROUND

To compare the prognosis of upper urinary tract (UUT)-urothelial carcinoma (UC) and UC of the bladder (UCB) by pathological staging in patients treated with radical surgeries.

METHODS

The study population comprised 335 and 302 consecutive radical surgery cases performed between 1991 and 2010 for UUT-UC and UCB, respectively. Five-year recurrence-free survival (RFS) and cancer-specific survival (CSS) rates were analyzed. The median follow-up period of all subjects was 59.3 months (range, 0.1-261.0 months).

RESULTS

No difference was observed in median patient age, distribution of pathologic T stage, or rates of positive surgical margin between the two groups. The UUT-UC group had significantly more frequent hydronephrosis than the USB group (48.1% vs. 20.2%, p < 0.001). However, the UUT-UC group showed significantly less frequent grade III tumors (28.1% vs. 58.6%, p < 0.001), lymphovascular invasion (18.8% vs. 35.8%, p < 0.001), and associated carcinoma in situ (9.0% vs. 21.9%, p < 0.001) than the UCB group. Five year RFS rates in the UUT-UC and UCB groups were 77.0% and 75.9%, respectively (p = 0.546). No significant difference in RFS rate was observed between pathological T stage subgroups. Five year CSS rates in the UUT-UC and UCB groups were 76.1% and 76.2%, respectively (p = 0.462). No significant difference was observed in CSS rate between the pathologic T stage subgroups.

CONCLUSIONS

UUT-UC and UCB showed comparable prognosis at identical stages. However, our results should be verified in a prospective study due to the retrospective study design in this study.

Age is not a limiting factor for midurethral sling procedures in the elderly with urinary incontinence

OBJECTIVE

The object was to evaluate clinical outcome of the midurethral sling procedures in the elderly compared with middle-aged women.

METHODS

A total of 266 women who underwent midurethral sling procedures with at least follow-up greater than 6 months were included in the study. Patients were divided as the elderly group (65 years old or older, n = 60) and the middle-aged group (45-64 years old, n = 206).

RESULTS

Although postoperative urge symptoms were more prevalent in the elderly group (25.0%) than in the middle-aged group (6.3%), there were no significant differences between the two groups for the rates of postoperative urge incontinence (p = 0.159). Stress incontinence was cured by 91.3% in the middle-aged group and 85.0% in the elderly group, respectively (p = 0.158).

CONCLUSIONS

Age does not seem to be a significant risk factor for failure of midurethral sling procedures.

Use of inkjet-printed single cells to quantify intratumoral heterogeneity

Quantification of intratumoral heterogeneity is essential for designing effective therapeutic strategies in the age of personalized medicine. In this study, we used a piezoelectric inkjet printer to enable analysis of intratumoral heterogeneity in a bladder cancer for the first time. Patient-derived tumor organoids were dissociated into single cell suspension and used as a bioink. The individual cells were precisely allocated into a microwell plate by drop-on-demand inkjet printing without any additive or treatment, followed by culturing into organoids for further analysis. The sizes and morphologies of the organoids were observed, so as the expression of proliferation and apoptotic markers. The tumor organoids also showed heterogeneous responses against chemotherapeutic agent. Further, we quantified mRNA expression levels of representative luminal and basal genes in both type of tumor organoids. These results verify the heterogeneous expression of various genes among individual organoids. This study demonstrates that the fully automated inkjet printing technique can be used as an effective tool to sort cells for evaluating intratumoral heterogeneity.

Is proximal urethral mobility important for transobturator tape procedure in management of female patients with stress urinary incontinence?

OBJECTIVES

To assess the change in urethral mobility (UM) after the transobturator tape (TOT) procedure and to evaluate the effect of UM on the outcome of the TOT procedure in women with stress urinary incontinence.

METHODS

A total of 159 women 33 to 77 years old (mean 55.3) was included in this study. UM was quantified using the Q-tip angle. Patients were stratified into the urethral hypermobility (UH) group (Q-tip test angle 30 degrees or greater, n = 96) and the non-UH group (Q-tip test angle less than 30 degrees, n = 63). The mean follow-up time was 6.5 +/- 0.4 months.

RESULTS

In the UH group, the Q-tip test values decreased significantly compared with the baseline data (41.2 degrees +/- 1.1 degrees versus 31.0 degrees +/- 1.4 degrees, P <0.001). No difference was evident in the non-UH group (17.0 degrees +/- 0.9 degrees versus 17.0 degrees +/- 1.1 degrees, P = 965). The overall cure rate was not significantly different in either group (91.7% versus 84.1%, P = 0.142). After the TOT procedure, 66 had a Q-tip test result of 30 degrees or greater. The overall cure rate was not significantly different in the postoperative UH and non-UH groups (92.4% versus 86.0%, P = 0.209).

CONCLUSIONS

The results of our study have shown that UM decreases after the TOT procedure in the UH group but not in the non-UH group. The cure rate was not lower in the non-UH group compared with that in the UH group. Our findings suggest that the lack of UM should not be considered a factor indicating a high risk of failure after the TOT procedure.

Beneficial effects of microsurgical varicocelectomy on semen parameters in patients who underwent surgery for causes other than infertility

OBJECTIVES

To evaluate whether clinical varicoceles are associated with abnormal semen parameters and whether varicocelectomy could improve the parameters in patients with causes other than infertility.

METHODS

A total of 268 adult men with clinical varicocele underwent microsurgical varicocelectomy resulting from causes other than infertility. A retrospective analysis of total sperm count, total motile sperm count, sperm concentration, motility, and morphology were performed.

RESULTS

Of 268 patients, at least 1 abnormal parameter (concentration, motility, or morphology) was found on preoperative semen analysis in 169 (63.1%) patients for whom 121 postoperative analyses were available. Abnormal sperm concentration was observed in 49 (40.5%) patients, motility in 112 (92.6%) patients, and morphology in 82 (67.8%) patients. Total sperm count, total motile sperm count, sperm concentration, and motility showed statistically significant improvement after microsurgical varicocelectomy, however, sperm morphology did not. Subgroup analysis of patients with oligospermia, asthenospermia, or teratospermia showed significant improvement in all semen parameters after varicocelectomy. The highest improvement rate was observed in sperm concentration of patients with oligospermia when a greater than 20% change in preoperative value was defined as improvement or deterioration in semen parameters. Overall, 92 (76.0%) patients showed improvement in at least 1 semen parameter.

CONCLUSIONS

The majority of varicocele patients with causes other than infertility had abnormal semen parameters, and most semen parameters showed significant improvement after microsurgical varicocelectomy. Therefore, regardless of the chief complaint, semen analysis should be performed in men with clinical varicocele.

Nocturia in patients with lower urinary tract symptoms: association with diurnal voiding patterns

OBJECTIVE

To determine whether diurnal voiding patterns predict nocturia in patients with lower urinary tract symptoms (LUTS), as few studies have evaluated the association between diurnal and nocturnal voiding patterns.

PATIENTS AND METHODS

We prospectively analysed the frequency-volume charts (FVCs) of consecutive patients with LUTS. At the initial visit patients had a detailed clinical evaluation and subsequently were requested to complete a 72-h FVC. In all, 104 (41 men and 63 women, mean age 63 years, range 50-83) were included in the primary analyses. Associations between daytime variables and nocturia were described using maximum likelihood estimates of the relative risk and by 95% confidence intervals (CIs) based on logistic regression models.

RESULTS

When at least one night-time void was used to define nocturia the multivariate logistic model showed a negative association of mean daytime voided volume with nocturia (P = 0.001). The odds ratio for nocturia decreased with this variable to 0.98 (95% CI 0.96-0.99). When 'voiding at least twice per night' was used to define nocturia only the number of daytime voids was positively related to nocturia (odds ratio 1.22; 95% CI 1.01-1.48; P= 0.040).

CONCLUSION

Nocturia may be associated with diurnal voiding patterns; these results also suggest that the causes of nocturia of one or of two or more voids may differ. This highlights the role of bladder function in more severe forms of nocturia.