Update of the Diagnostic and Therapeutic Role of the Pelvic Lymph Node Dissection Boundaries During Radical Cystectomy in Muscle Invasive Bladder Cancer

Radical cystectomy (RC) is the gold standard treatment option for muscle invasive bladder cancer (MIBC). However, up to 25% of patients who undergo RC show metastatic lymph node deposits during the procedure. In such cases, the 5-year survival rate is reported to be 25%–30%. Pelvic lymph node dissection (PLND) can also provide useful prognostic information, including data regarding the disease burden, lymph node density, and extracapsular extension of metastatic lymph nodes. Accordingly, the National Comprehensive Cancer Network guidelines recommend that PLND that includes the common iliac lymph node should be performed at the time of RC to allow reliable staging of MIBC. In addition to its diagnostic role, many studies have reported the potential therapeutic role of PLND. Data from clinical trials indicate a substantial oncological advantage in PLND cohorts compared to non-PLND cohorts, regardless of pathological nodal status, as a result of removal of metastatic and micrometastatic tumor cells nested in lymph nodes. As such, despite the diagnostic and therapeutic role of PLND in MIBC, the optimal PLND template remains controversial. Currently, extended PLND (E-PLND) is recommended for diagnostic purposes, however, E-PLND did not show therapeutic effectiveness in some recent preliminary randomized controlled trials. In this review, we will discuss the appropriate range of PLND for RC in terms of its diagnostic and therapeutic importance, and propose an appropriate range of PLNDs based on the evidence and randomized trials so far.

Enhanced Recovery After Surgery Program for Radical Cystectomy

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) which remains the gold standard therapy for the treatment of muscle-invasive bladder cancer, yet is still associated with a high morbidity rate as well as a prolonged length of hospitalization (LOH). Recently, there has been a great deal of interest in developing multimodal and multidisciplinary strategies that might aid in the acceleration postoperative convalescence by decreasing variance in perioperative care for patients having complex operations. Many patient series have shown that Enhanced Recovery After Surgery (ERAS) protocols can improve outcomes in patients having RC by reducing the incidence of gastrointestinal complications and the LOH without increasing readmissions or overall morbidity. Many studies are going to evaluate and incorporate scientific data in ERAS program to modify as many of the variables leading to RC morbidity, as well as to enhance how patients are cared for before and after operation. In this review, we offer a summary of the preoperative, intraoperative, and postoperative key components of undergoing an ERAS protocol for patients undergoing RC, as well as future research prospects.

Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present / 대한배뇨장애요실금학회지

The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.

Lower Urinary Tract Symptoms in Prostate Cancer Patients Treated With Radiation Therapy: Past and Present / 대한배뇨장애요실금학회지

The incidence of prostate cancer (PCa) is increasing concomitantly with population aging. Accordingly, interest in radiation therapy (RT) and the frequency of RT are also increasing. The types of RT can be broadly divided into external beam RT (EBRT), brachytherapy (BT), and combination therapy (EBRT+BT). Lower urinary tract symptoms (LUTS) after RT for the treatment of PCa are common; however, there are few reviews on the relationship between RT and LUTS. Herein, we review the causes and incidence of LUTS, as well as the evaluation and treatment options. Because of the reported risks of RT, patients undergoing RT should be counseled regarding the challenges of treatment and informed that they may have higher failure rates than nonirradiated patients. Moreover, thorough evaluation and treatment strategies are needed to support treatment recommendations. With a review of the existing literature, this narrative article provides an overview to aid urologists in treating patients presenting with complications associated with RT for the treatment of PCa. Further research is required to provide evidence of the effectiveness and feasibility of the management approach to the care of patients with LUTS after RT for the treatment of PCa.

The Treatments for Low-Risk Prostate Cancer

Recently, the prevalence of prostate cancer has been increased with the screening of prostate-specific antigen and the increase in the elderly population. In particular, the diagnosis of the low-risk prostate cancer has increased greatly, and social interest for overtreatment has been heightened in Korea. Therefore, this review aimed to provide evidence-based treatment guidelines in low-risk prostate cancer based on Korean population. The literature provides evidence on treatment options, such as watchful waiting, active surveillance, radical prostatectomy, and radiation therapy according to the life expectancy of patients with low-risk prostate cancer. Furthermore, this review provides information on the efficacy of pelvic lymph node dissection and adjuvant radiation therapy during/after radical prostatectomy in low-risk prostate cancer.

Animal Model of Interstitial Cystitis/Bladder Pain Syndrome / 대한배뇨장애요실금학회지

No abstract available.

Second Primary Cancer Risk among Kidney Cancer Patients in Korea: A Population-Based Cohort Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Secondary primary cancers (SPCs) commonly arise in patients with renal cell carcinoma (RCC). We designed the present study to estimate the SPC incidence in Korean patients with RCC. MATERIALS AND METHODS: The study cohort was population-based and consisted of 40,347 individuals from the Korean Central Cancer Registry who were diagnosed with primary renal cancer between 1993 and 2013. Standardized incidence ratios (SIRs) for SPCs were estimated for different ages at diagnosis, latencies, diagnostic periods, and treatments. RESULTS: For patients with primary RCC, the risk of developing a SPC was higher than the risk of developing cancer in the general population (SIR, 1.13; 95% confidence interval, 1.08 to 1.18). Most cancer types showed higher incidences in patients with RCC than in the general population. However, the relative incidence of gastric cancer as an SPC varied by age. Gastric cancer incidence was elevated in young patients (< 30 years) with RCC, but reduced in older (≥ 30) patients with RCC. Patients with advanced RCC died prematurely, regardless of SPC development. In contrast, those with early-stage RCC survived for longer periods, although SPC development affected their post-RCC survival. After SPC development, women had better survival than men. CONCLUSION: In Korean patients with primary RCC, the incidence of SPC was 13% higher than the incidence of cancer in the general population. These findings may play important roles in the conduct of follow-up evaluations and education for patients with RCC.

Lifestyle Risk Prediction Model for Prostate Cancer in a Korean Population / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The use of prostate-specific antigen as a biomarker for prostate cancer (PC) has been controversial and is, therefore, not used by many countries in their national health screening programs. The biological characteristics of PC in East Asians including Koreans and Japanese are different from those in the Western populations. Potential lifestyle risk factors for PC were evaluated with the aim of developing a risk prediction model. MATERIALS AND METHODS: A total of 1,179,172 Korean men who were cancer free from 1996 to 1997, had taken a physical examination, and completed a lifestyle questionnaire, were enrolled in our study to predict their risk for PC for the next eight years, using the Cox proportional hazards model. The model’s performance was evaluated using the C-statistic and Hosmer–Lemeshow type chi-square statistics. RESULTS: The risk prediction model studied age, height, body mass index, glucose levels, family history of cancer, the frequency of meat consumption, alcohol consumption, smoking status, and physical activity, which were all significant risk factors in a univariate analysis. The model performed very well (C statistic, 0.887; 95% confidence interval, 0.879 to 0.895) and estimated an elevated PC risk in patients who did not consume alcohol or smoke, compared to heavy alcohol consumers (hazard ratio [HR], 0.78) and current smokers (HR, 0.73) (p < 0.001). CONCLUSION: This model can be used for identifying Korean and other East Asian men who are at a high risk for developing PC, as well as for cancer screening and developing preventive health strategies.

Learning From Heart Failure: How Will We Lead Bladder Failure Into the Future? / 대한배뇨장애요실금학회지

No abstract available.

Treatment of MIBC - Neoadjuvant Chemotherapy: New Standard of Care

The standard management for patients with muscle invasive bladder cancer (MIBC) involves radical cystectomy and pelvic lymph node dissection. Although this treatment may be curative, a large proportion of patients will develop recurrence and will ultimately die of metastatic disease. Prospective, randomized clinical trial data demonstrate a survival advantage for those patients who receive neoadjuvant chemotherapy (NAC) prior to radical cystectomy and this concept was confirmed by meta-analysis. The administration of cisplatin-based combination NAC has consistently demonstrated a survival benefit of 5%. The pathologic downstaging is used as a surrogate end point. The efficacy of NAC for MIBC was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. Dose dense M-VAC (DDMAVC) is preferred over standard MVAC, and gemcitabine/cisplatin is a reasonable alternative to standard M-VAC for NAC. In Korea, while NAC use has slowly increased over time, it remains an underutilized therapeutic approach in Korean clinical practice.

Laparoscopic Management of Complicated Urachal Remnants / 전남의대학술지

Managing persistent and symptomatic urachal anomalies requires wide surgical excision of all anomalous tissue with a cuff of bladder tissue via the open approach. We report 7 cases with complete laparoscopic removal of symptomatic urachal remnants with or without a cuff of bladder tissue. We expected that this technique would be less invasive and have lower morbidity. We report on the feasibility of this approach, including efficacy and outcomes. Eight patients with a mean age of 36.5 years who had symptomatic urachal diseases underwent laparoscopic excision between July 2004 and July 2012. With the use of four ports, the urachal remnant was dissected transperitoneally and then removed via the umbilicus port. The clinical results of laparoscopic urachal remnant excision as a minimally invasive surgery, the perioperative records, and pathologic results were evaluated. There were no intraoperative or postoperative complications. Mean surgery time was 2.7 hours. Mean hospital stay was 14.6 days. The patients with bladder cuff resection had a long admission and Foley catheterization period (mean, 14.4 and 11 days). Pathological evaluations were 6 cases of infected urachal cysts, 1 case of infected urachal sinus, and 1 case of urachal adenocarcinoma. We found no postoperative complications including any symptom recurrence or voiding difficulty during a mean follow-up of 46.3 months. The perioperative surgical outcomes achieved infection control and symptomatic relief and additionally good cosmesis. Complete laparoscopic removal of symptomatic urachal remnants with or without a cuff of bladder tissue seems to be a safe, effective, and better cosmetic alternative with the advantages of a minimally invasive approach.

Laparoscopic Management of Complicated Urachal Remnants / 전남의대학술지

Managing persistent and symptomatic urachal anomalies requires wide surgical excision of all anomalous tissue with a cuff of bladder tissue via the open approach. We report 7 cases with complete laparoscopic removal of symptomatic urachal remnants with or without a cuff of bladder tissue. We expected that this technique would be less invasive and have lower morbidity. We report on the feasibility of this approach, including efficacy and outcomes. Eight patients with a mean age of 36.5 years who had symptomatic urachal diseases underwent laparoscopic excision between July 2004 and July 2012. With the use of four ports, the urachal remnant was dissected transperitoneally and then removed via the umbilicus port. The clinical results of laparoscopic urachal remnant excision as a minimally invasive surgery, the perioperative records, and pathologic results were evaluated. There were no intraoperative or postoperative complications. Mean surgery time was 2.7 hours. Mean hospital stay was 14.6 days. The patients with bladder cuff resection had a long admission and Foley catheterization period (mean, 14.4 and 11 days). Pathological evaluations were 6 cases of infected urachal cysts, 1 case of infected urachal sinus, and 1 case of urachal adenocarcinoma. We found no postoperative complications including any symptom recurrence or voiding difficulty during a mean follow-up of 46.3 months. The perioperative surgical outcomes achieved infection control and symptomatic relief and additionally good cosmesis. Complete laparoscopic removal of symptomatic urachal remnants with or without a cuff of bladder tissue seems to be a safe, effective, and better cosmetic alternative with the advantages of a minimally invasive approach.

Effect of Low-Dose Triple Therapy Using Gabapentin, Amitriptyline, and a Nonsteroidal Anti-Inflammatory Drug for Overactive Bladder Symptoms in Patients With Bladder Pain Syndrome / 대한배뇨장애요실금학회지

PURPOSE: Patients with bladder pain syndrome/interstitial cystitis (BPS/IC) can have pain as a main symptom and overactive bladder (OAB) symptoms that are directly or indirectly related to a major mechanism that causes pain. The primary purpose of this study is firstly to identify the prevalence rate of OAB symptoms in patients with BPS/IC, secondly to identify changes in OAB symptoms after low-dose triple therapy, and thirdly to build a theoretical foundation to improve quality of life for patients. METHODS: Patients who met the inclusion criteria of BPS/IC through basic tests including the O'Leary-Sant symptom index, overactive bladder symptom score (OABSS), and visual analog scale (VAS) were identified. Treatment-based changes in OAB symptoms were identified using the IC Symptom Index and IC Problem Index (ICSI/ICPI), OABSS, and VAS before, and 4 and 12 weeks after low-dose triple therapy. RESULTS: The patients consisted of 3 men and 20 women, and their mean age was 61.9 years (41.0-83.2 years). Comparing values before treatment, and 4 and 12 weeks after treatment (baseline vs. 4 weeks to baseline vs. 12 weeks), the rates of improvement were as follows: ICSI, 44.2% to 63.7%; ICPI, 46.9% to 59.4%; OABSS, 34.3% to 58.2%; and VAS, 53.6% to 75.0%, which showed statistically significant differences (P0.05). CONCLUSIONS: Low-dose triple therapy in BPS/IC results in a clear decrease in OAB symptoms in the first 4 weeks after treatment, and additional treatment for 8 weeks had a partial effect with varied statistical significances depending on the questionnaires.

Safety and Efficacy of Percutaneous Nephrolithotomy for Staghorn Calculi in Patients 70 Years and Older

BACKGROUND: The aim of this study was to analyze the safety and efficacy of percutaneous nephrolithotomy (PNL) for staghorn calculi in patients 70 years and older. METHODS: From March 1990 to December 2011, 76 patients with staghorn calculi underwent PNL. They divided into two groups according to age: 70 years and older (group I, n=32) and younger than 70 years (group II, n=46). Preoperative parameters (stone type, stone volume, concomitant diseases, and preoperative urine culture results) and perioperative parameters (operative time, complication rate, transfusion rate, and success rate) were evaluated. Additionally, we analyzed the composition of the urinary stones using the chemical analysis method. RESULTS: There were no significant differences between the groups for stone size, urine culture rate, operative time, success rate, and complication rate. But comorbidity, American Society of Anaesthesiology score, postoperative hemoglobin level, and transfusion rate were different (p<0.05). There were no serious complications or deaths. Magnesium ammonium phosphate component was found in 53.1% of group I and 60.9% of group II. CONCLUSION: Outcomes of PNL for staghorn calculi in patients 70 years and older were comparable to those seen in younger patients. PNL for this condition can be considered a safe and effective surgical option for appropriately selected elderly patients.

Diagnostic Role of Prostate Resection in the Elderly Patients Who Experience Significant Co-Morbidity with a High Clinical Suspicion of Prostate Cancer

The necessity of routine prostate biopsy prior to transurethral resection of the prostate (TURP) in elderly comorbid patients with a high prostate specific antigen (PSA) level remains controversial. We assessed the role of TURP in prostate cancer diagnosis in these individuals. A total of 197 patients underwent TURP in conjunction with prostatic needle biopsy. Pathologic reviews of specimens of TUR chips and biopsy cores were analyzed. Overall, prostate cancer (CaP) was detected in 114 patients (57.6%). Ninety-eight cancers (86%) were detected with TURP and biopsy, and seven cancers (6.1%) with only TURP. The Gleason score of a TUR-specimen was identical to that of the biopsy-core in 43.9% of cases. Variables associated with diagnostic accuracy in the TUR-specimens included the prebiopsy PSA level, prostate specific antigen density (PSAD), and the Gleason score in biopsy cores. In patients with a PSA level and a PSAD that was greater than 15.4 ng/mL and 0.69 ng/mL/g, respectively, 100% of the cancers were detected in the TUR-specimens. Our results suggest that a prostatic biopsy might be omitted prior to TURP in elderly patients with significant co-morbidity and levels for PSA of >15.4 ng/mL.

Prostate Volume has Prognostic Value Only in Pathologic T2 Radical Prostatectomy Specimens

The objective of this study was to evaluate the prognostic roles of the prostate volume, tumor volume, and tumor percentage as a function of the pathologic T stage in radical prostatectomy specimens. This study included 259 patients who underwent radical prostatectomy between 2005 and 2010. The mean follow-up period was 41.2 months. In all of the specimens, prostate volume (P = 0.021), the Gleason score (P = 0.035), and seminal vesicle invasion (P = 0.012) were independent predictors of biochemical recurrence (BCR). In the T2 group, multivariate analysis showed that the BCR was significantly associated with prostate specific antigen (PSA) (P = 0.028), a lower prostate volume (P = 0.004), and the Gleason score (P = 0.040). The Kaplan-Meier survival curve showed that a smaller prostate volume was significantly associated with a greater risk of BCR ( or = 30 mL; P = 0.010). In the T3 group, patients with seminal vesicle invasion had a significantly shorter mean BCR-free survival (P = 0.030). In this study, tumor volume and tumor percentage did not predict BCR. Notably, a lower prostate volume is an independent predictor for BCR only in the organ-confined radical prostatectomy specimens. But, prostate volume could not predict BCR in most locally advanced tumors.

The Relationship between RUNX3 Inactivation and Its Pathological Features in Renal Cell Carcinoma

PURPOSE: DNA methylation is a key regulator of gene transcription and genomic stability, and alterations in DNA methylation are frequently detected in human tumors. Recent study has suggested that inactivation of runt-related transcription factor 3 (RUNX3), primarily epigenetic alterations in DNA methylation, is closely associated with bladder tumor stage, grade, and prognosis. The aim of this study was to evaluate the association between RUNX3 inactivation and renal cell carcinoma (RCC). MATERIALS AND METHODS: RCC tissues (n=56) were obtained from patients who underwent radical nephrectomy. The methylation pattern of RUNX3 was determined by using methylation specific-polymerase chain reaction (MS-PCR) and direct DNA sequencing. RESULTS: Methylation of the RUNX3 promoter was observed in 75.0% of the samples (42/56). The tumor stage and grade were significantly associated with the methylation status (p0.05, respectively). CONCLUSIONS: This study demonstrated that promoter methylation of RUNX3 is frequently observed in RCC. In addition, RUNX3 methylation is closely associated with aggressive pathologic features.

Changes in Voiding Patterns after Transobturator Tape Operation in Female Patients with Stress Urinary Incontinence / 대한비뇨기과학회지

PURPOSE: A lot of patients with stress urinary incontinence(SUI) have lower urinary tract symptoms. So we evaluated the changes of voiding pattern following transobturator tape(TOT) operation, and investigated the factors for predicting persistent urinary frequency after operation. MATERIALS AND METHODS: The items of preoperative evaluations consisted of history taking, physical examination, cystometrography, 3 day frequency-volume chart and symptoms questionnaire. Patients with anticholinergics or any neurologic diseases that affect the voiding pattern were excluded. Between January to November 2006, 46 patients with TOT operation were enrolled, and were reevaluated with physical examination, 3 day frequency-volume chart and symptom questionnaires, postoperatively. RESULTS: The patients who voided 8 or more times per day had shorter symptom duration and higher body mass index(BMI) than those who voided under 8 times per day(each p<0.05). In 30 patients who void 8 or moretimes per day preoperatively, 17(56.7%) patients became void under 8 times, postoperatively. In each patient who had urgency or urge incontinence symptoms preoperatively, respective 72.7 and 82.8% resolved their symptoms, postoperatively. No one complained de novo urgency or urge incontinence, postoperatively. In a multivariate analysis, the patient with a history of previous pelvic surgery or moderate to severe urge incontinence was tightly associated with an increased likelihood of persistent urinary frequency after TOT operation (odd ratio[OR] 24.8, 95% confidence interval[CI] 2.044-301.284, p=0.012 and OR 31.9, 95% CI 1.662- 613.619, p=0.022, respectively). CONCLUSIONS: The TOT operation can improve the symptoms of urinary frequency, urgency and urge incontinence in patients with SUI. However, the patients who had previous pelvic surgeriesor moderate to severe urge incontinence should be fully advised for the risk of sustaining frequency, postoperatively

A Primary Large Cell Neuroendocrine Carcinoma of the Urinary Bladder in a 19-year-old Man / 대한비뇨기과학회지

Primary large cell neuroendocrine carcinomas of the urinary bladder are extremely rare. To date, only six cases of large cell neuroendocrine carcinoma have been reported. We present a case of a 19-year-old man who presented with gross hematuria and who was subsequently found to have a solitary tumor on the dome of the urinary bladder. The patient underwent transurethral resection of the bladder tumor for histological confirmation. A diagnosis of large cell neuroendocrine carcinoma was made based upon immunohistochemical reactivity for synaptophysin and CD56. Based on the pathologic diagnosis, he subsequently had a partial cystectomy. Histologically, the tumor penetrated the perivesical fat. It has now been 6 months since the surgery, and the patient is preparing to receive his 5th cycle of chemotherapy. There is no evidence of tumor recurrence or metastasis.

A Large Stone in the Dilated Left Seminal Vesicle: Laparoscopic Removal and Partial Seminal Vesiculectomy / 대한비뇨기과학회지

Stones in the seminal vesicle are extremely rare. We report a case with a large stone in a dilated seminal vesicle. A 20-year-old man presented with a large calcified density in the pelvic cavity on plain films. A 6.0 cm cone shaped stone was noted in the dilated left seminal vesicle diagnosed by radiological examination. We treated the patient by transperitoneal laparoscopic stone removal and partial seminal vesiculectomy. The composition of stone was carbonate apatite. This approach to the treatment of such pathological conditions of the seminal vesicles provides an additional option.