Factors Affecting the Outcome of Extraperitoneal Laparoscopic Radical Prostatectomy: Pelvic Arch Interference and Depth of the Pelvic Cavity

PURPOSE: To determine the effect of pelvic arch interference and the depth of the pelvic cavity, as shown on preoperative magnetic resonance imaging (MRI), on the performance of extraperitoneal laparoscopic radical prostatectomy (ELRP). MATERIALS AND METHODS: In 115 patients, pelvic bone images were obtained at the time of prostate MRI before ELRP. In the reconstructed sagittal plane, we measured the true conjugate diameter, the obstetric conjugate diameter, the difference between the true and obstetric diameters, and the distance between the true conjugate and the prostate apex (pelvic depth). We analyzed which factors were associated with operative time (OT), estimated blood loss (EBL), and positive surgical margins (PSMs). RESULTS: The difference between the true and obstetric conjugate diameters was 12.7+/-3.7 mm, and the pelvic depth was 59.9+/-6.0 mm. The OT, EBL, and the rate of PSMs were 260.1+/-91.1 minutes, 633.3+/-524.7 ml, and 19% (22/115), respectively. According to multiple linear regression analysis, predictors of a higher EBL included pelvic depth (3.0% higher per 1 mm increase in diameter difference, p=0.01) and prostate volume (1.5% higher per 1 cc increase in prostate volume, p=0.002). Factors associated with a longer OT were pelvic depth (p=0.04), serum prostate-specific antigen (p=0.04), prostate volume (p=0.02), and Gleason score (p=0.001). For PSMs, only pT2 was an independent factor. CONCLUSIONS: Our results suggest that the depth of the pelvic cavity and prostate volume may increase surgical difficulty in patients undergoing ELRP.

Prostate Cancer with Solitary Metastases to the Bilateral Testis

We present the case of an 81-year-old patient with testicular metastasis from prostate carcinoma. After the initial diagnosis of prostate cancer, he had an 8-year course of hormonal therapy and showed no clinical evidence of metastasis to other organs. Asymptomatic metastasis of prostate carcinoma to the testis is a rare clinical condition. We diagnosed his condition, based on histopathology following a subcapsular orchiectomy and transurethral resection of the prostate.

Delayed Diagnosis of an Intraurethral Foreign Body Causing Urosepsis and Penile Necrosis

Cases of self-inserted foreign bodies in the male urethra and urinary bladder are unusual. In most cases, the type of foreign body can be identified by taking a history or from radiological findings; sometimes, however, it is difficult to identify the foreign body because of decreased mental capacity of the patient or unknown radiological characteristics of the foreign body. We experienced a chronic alcoholic patient with septicemia and penile necrosis in whom a fragment of mirror glass had passed through the urethra into the bladder. The glass, 2 cm in length and 0.7 cm in diameter, was detected by cystoscopy and was removed by using a resectosope.

Multiple, Bilateral Fibroepithelial Polyps Causing Acute Renal Failure in a Gastric Cancer Patient

We report a case of primary fibroepithelial polyps (FEPs) in the middle of both ureters in a patient with advanced gastric cancer and acute renal failure. Ureteral FEPs are rare benign lesions, and multiple, bilateral lesions are extremely rare. To our knowledge, this report is the seventh case of bilateral FEPs in the literature. Our case has clinical implications because FEPs should be considered as a cause of ureteral obstruction inducing acute renal failure in advanced gastric cancer.

Inflammatory Myofibroblastic Tumor of the Kidney Misdiagnosed as Renal Cell Carcinoma

The inflammatory myofibroblastic tumor (IMT), also knowns as inflammatory pseuduotumor, is a soft tissue lesion of unknown etiology. In the urogenital tract, IMT mainly affects the urinary bladder or prostate, but rarely the kidney. It has been considered as a nonneoplastic reactive inflammatory lesion, but nowadays, it is regarded as a neoplasm due to its high recurrence rate and metastasis. We describe a case of a 61-yr-old woman that had originally been misdiagnosed as renal cell carcinoma, which was pathologically revealed to be an IMT.

Is a Decreased Serum Testosterone Level a Risk Factor for Prostate Cancer? A Cohort Study of Korean Men

PURPOSE: To investigate patients who had transrectal ultrasonography (TRUS)-guided prostate biopsy to define the role of the serum testosterone level in predicting prostate cancer risk and its association with a high Gleason score. MATERIALS AND METHODS: A total of 568 patients who underwent prostate biopsy were entered in this study. We divided the patients into two groups according to serum testosterone level (median level, 3.85 ng/ml): the high-testosterone group (n=285) and the low-testosterone group (n=283). Multivariate regression analysis was used to define the effect of age, prostate volume, serum prostate-specific antigen (PSA) level and PSA density, and serum testosterone level on the risk of prostate cancer and a high Gleason score. RESULTS: Baseline characteristics did not differ significantly between the two groups. Compared with the high-testosterone group, the low-testosterone group had a significantly higher prostate cancer incidence (38.9% vs. 29.5%, p=0.018). Factors associated with an increased risk of prostate cancer were increased age (odds ratio [OR]=1.08, 95% confidence interval [CI]=1.25-3.16, p=0.001), a high serum PSA level (OR=3.35, 95% CI=2.63-4.25, p=0.001), a low prostate volume (OR=0.183, 95% CI=0.11-0.30, p=0.001), and a low serum testosterone level (OR=1.99, 95% CI=1.25-3.16, p=0.001). Among these, only the serum PSA level was a strong predictor of high-grade prostate cancer (Gleason score > or =7) (OR=2.19, 95% CI=1.57-2.95, p=0.001). CONCLUSIONS: Patients with lower levels of serum testosterone had a higher risk of prostate cancer than did patients with high serum testosterone. Even though a lower serum testosterone level was a predictor of prostate cancer risk, it was not associated with an increased risk of high-grade prostate cancer.

Anterior Urethral Recurrence from an Upper Urinary Tract Urothelial Tumor

We report a case of a metachronous transitional cell carcinoma (TCC) of the penile urethra in an elderly male after nephroureterectomy. The patient had a history of right nephroureterectomy 18 months previously due to TCC of the upper urinary tract. A solitary urethral recurrence from a TCC of the upper urinary tract is rare. An anterior urethral recurrence of a TCC of the upper urinary tract has not been previously reported in the literature. The prognosis of a metachronous anterior urethral recurrence of an upper-tract TCC is poor.

The Functional Effect of Palliative Transurethral Resection of the Prostate on Lower Urinary Tract Symptoms in Patients with Prostate Cancer

PURPOSE: Voiding dysfunction occurs frequently in patients with prostate cancer. We investigated the functional effect of palliative transurethral resection of the prostate (pTURP) on lower urinary tract symptoms in patients with prostate cancer. MATERIALS AND METHODS: We retrospectively assessed all patients who had a pTURP at our institution between 1999 and 2006. Patients with incidental prostate cancer were excluded. In all, 64 patients were enrolled in the study. The International Prostate Symptom Score (IPSS), the quality of life (QoL), the maximal flow rate (Qmax), and the postvoid residual urine volume (PVR) were evaluated before and after 3 months of pTURP. A positive functional outcome was defined as PVR below 100 ml, no additional catheterization, no repeat pTURP, and no development of urinary incontinence. RESULTS: The patients' mean age was 76.32+/-6.8 years, and their mean prostate volume was 46.38+/-19.43 g. After pTURP, the mean IPSS improved from 25.83+/-6.71 to 18.63+/-5.96, the mean QoL score improved from 4.33+/-0.87 to 3.02+/-0.83, the mean maximal flow rate increased from 6.11+/-3.68 ml/sec to 14.20+/-6.30 ml/sec, and the PVR decreased from 153.69+/-32.03 ml to 41.89+/-25.35 ml. All voiding parameters showed significant improvement (p<0.001). Of the 64 patients, 12 had poor functional outcome after pTURP. The functional improvement rate of pTURP was 81.25%. CONCLUSIONS: The pTURP performed in patients with prostate cancer showed a favorable effect and resulted in significant improvement in voiding dysfunction. In patients with high-stage metastatic prostate cancer or cancer unsuitable for curative therapy, pTURP could be considered as a safe treatment method to improve lower urinary tract symptoms.

Retrovesical Multilocular Prostatic Cystadenoma Mimicking a Pelvic Cavity Tumor

We report the case of a 58-year-old man with a multilocular prostatic cystadenoma in the retrovesical space that mimicked a pelvic cavity tumor. Multilocular prostatic cystadenoma is a rare form of benign prostatic hyperplasia that originates from the prostate with extensive spread into the pelvis. Histologically, the tumor consisted of glands and cysts lined by prostatic-type epithelium lying in a hypocellular fibrous stroma. For a cystic tumor adjacent to the urinary tract, ectopic prostatic cystadenoma is needed to be considered in the differential diagnosis of pelvic cavity tumors.

The Adverse Effects of Cardiovascular Risk Factors on Lower Urinary Tract Symptoms and Erectile Function / 대한남성과학회지

PURPOSE: There are several reports about relationships between cardiovascular risk factors and lower urinary tract symptoms (LUTS). We investigated the effects of risk factors for vascular disease on LUTS and erectile function (ED). MATERIALS AND METHODS: We prospectively analyzed 273 patients who had LUTS or ED. A self administered questionnaire of International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) were given to patients. Cardiovascular risk factors including hypertension, smoking status, diabetes and dyslipidemia were determined in each patients. RESULTS: Mean age was 60.5+/-9.4 years. Mean IPSS, IIEF and IIEF-EF score were 15.9+/-5.9, 30.1+/-15.4 and 17.35+/-9.0, respectively. There are statistically significant differences in the IPSS (p=0.047), IIEF (p=0.024) and IIEF-EF domain score (p=0.044) between men with no risk factors and men with one or more risk factors. IPSS, IIEF and IIEF-EF score were 11.5+/-6.4, 39.8+/-11.9 and 19.6+/-8.7 in men with no risk factor (n=94), 16.6+/-5.6, 28.4+/-15.0 and 15.1+/-9.3 in men with at least one risk factor (n=179). In men with one to four risk factors, the mean IPSS was 14.5+/-5.1 (n=63), 16.3+/-4.4 (n=45), 21.2+/-5.5 (n=43) and 26.5+/-3.5 (n=28)(p=0.001); the mean IIEF score was 31.4+/-14.2, 27.8+/-16.8, 22.5+/-14.1 and 19.0+/-9.9 (p=0.037); the mean IIEF-EF score was 17.1+/-8.9, 14.7+/-9.0, 10.9+/-9.7 and 8.8+/-4.5 (p=0.023), respectively. CONCLUSIONS: Men with risk factors for vascular disease are more likely to have a higher IPSS and a lower IIEF and IIEF-EF score than men without risk factors. These results suggests that vascular disease of men is significantly related with the progression of LUTS and ED.

The Factor Affecting Radical Retropubic Prostatectomy: The Bony Pelvic Shape Imaged by Magnetic Resonance Imaging / 대한비뇨기과학회지

PURPOSE: We investigated how the bony pelvic shape, as imaged by preoperative magnetic resonance imaging(MRI), affects radical retropubic prostatectomy(RRP). MATERIALS AND METHODS: We investigated 27 patients who underwent radical prostatectomy between January 2004 and December 2006 in our hospital. We obtained images of their pelvic bone size on the sagittal plane by performing pelvic MRI. We measured the true conjugate diameter, the obstetric conjugate diameter and the difference between the former and the latter. In addition, we examined the age, body mass index(BMI), prostate-specific antigen(PSA), prostate volume, Gleason's score, pathologic stage, operative time, the estimated blood loss and the surgical margin involvement. We analyzed the factors that affected the estimated blood loss, operative time and surgical margin involvement by multiple linear regression analysis and multiple logistic regression analysis. RESULTS: The mean age of the patients was 66.7+/-5.3 years, the true conjugate diameter and obsteric conjugate diameter were 105+/-8.9mm and 94.5+/-9.2 mm respectively, the difference of the diameters was 10.7+/-4.3mm, the BMI was 24.1+/-2.6kg/m(2), the PSA was 22.9+/-34.2ng/ml and the prostate volume was 33.7+/-14g. The estimated blood loss was 1,152.2+/-356.4cc, the operation time was 144.4+/-28.6 minutes and 8 patients had positive surgical margins. On the multiple linear regression analysis, the estimated blood loss increased 66cc in proportion to a 1mm difference between the true conjugate diameter and the obstetric conjugate diameter(p<0.001). The BMI was associated with the operative time on the multiple linear regression analysis(p=0.048). CONCLUSIONS: For patients with RRP, the BMI was associated with the operative time. The estimated blood loss increased in proportion to the difference between the true conjugate diameter and the obstetric conjugate diameter, as measured by pelvic MRI before operation. We suggest that the symphyseal surface variability can be the one of the factors that affects the degree of operative difficulty.

Lower Urinary Tract Symptoms after RadicalRetropubic Prostatectomy: Preliminary Study / 대한비뇨기과학회지

PURPOSE: The primary objective of this study was to evaluate the impact of radical retropubic prostatectomy(RRP) on lower urinary tract symptoms(LUTS) in patients with clinically localized prostate cancer. MATERIALS AND METHODS: Between 2000 and 2006, 82 men with clinically localized prostate cancer underwent RRP. The International Prostate Symptom Score(IPSS) and the IPSS quality of life(QoL) score, and uroflowmetry were administered both prior to and 1 year after RRP. RESULTS: The overall mean total IPSS, maximal flow rate, and postvoid residual volume did not change over time after RRP. Prior to and after RRP, the mean maximal flow rate and residual urine changed from 17.6ml/sec to 17.9ml/sec(p=0.566) and 16.9ml to 15.8ml(p=0.777), respectively. Total IPSS also changed after RRP, from 12.8 to 12.5(p=0.731). The reduction of the IPSS was more prominent in patients with severe symptoms(IPSS> or =20), whereas in those with moderate symptoms(8< or =IPSS<20), the score did not change significantly after RRP. Furthermore, in those patients with no or mild symptoms(IPSS<8), the score increased after RRP. CONCLUSIONS: RRP was not shown to improve uroflowmetric parameters, including maximal flow rate, postvoid residual urine, and IPSS, in cases of moderate LUTS. However, RRP may exert a beneficial effect in those patients with severe LUTS, and may also have adverse effects on some individuals with no or mild symptoms. We believe that these results might be utilized when counseling patients about treatment options for localized prostate cancer.

Solitary Metastatic Renal Tumor from Breast Cancer / 대한비뇨기과학회지

We report a case of a metastatic renal tumor secondary to breast cancer 9 years postmastectomy. This is the first case report of solitary renal metastasis from breast cancer with no other evidence of metastasis. A 47-year-old woman underwent a modified radical mastectomy and 6 cycles of CEF chemotherapy (Cyclophosphamide, Epirubicin, 5-FU) for cancer of the left breast. She was followed closely, but no recurrence or metastases were detected on either a physical or radiological examination. 9 years later, on a routine follow-up examination for metastatic breast cancer, abdomen ultrasound revealed a solid mass (4cm in diameter) in the upper portion of the right kidney. Computed tomography (CT) was used to further evaluate the solitary renal mass, which had become moderately enhanced. No regional lymph node, visceral or pulmonary metastases were found. A radionuclide bone scan confirmed no bony involvement. A laparoscopic radical nephrectomy was performed for a right renal tumor. The histopathological features were identical to those for cancer of the right breast. The patient was treated with adjuvant combination chemotherapy (docetaxel and adriamycin), and is still alive 9 months after a right radical nephrectomy, with no evidence of recurrence.

Nerve Regeneration and Detrusor Contractility after Muscle Precursor Cells Implantation in Unilateral Pelvic Nerve Transected Rat / 대한비뇨기과학회지

Purpose: Preliminary data suggest that muscle precursor cells (MPCs) play a role in the repair of injured tissues by responding to the release of unknown growth factors, which subsequently induce their differentiation toward a given lineage, such as a nerve cell. The author explored the potential use of these cells for facilitating the regeneration of the peripheral pelvic autonomic nerve. Materials and Methods: MPCs were isolated from the gastrocnemius muscle of normal rats, which were purified via the preplate technique. In this study, 15 male Sprague-Dawley rats weighting 250 to 300 grams were used. Three experimental groups were included: a control group (C, n=5), a unilateral pelvic nerve transected group, with a sham (Hank's balanced salt Solution) injection (S, n=5), and a unilateral pelvic nerve transected group, with MPCs injections (3x10(5)cells) at the site of transection (M, n=5). Two weeks after surgery, a polyethylene tube-50 connected to a pressure transducer was inserted into the dome of the bladder, and the intravesical pressures measured during electrical stimulation (20Hz, 0.05ms, 10v) of the proximal part of the transection of preganglionic pelvic nerve. Then, the rats were sacrificed, and the major pelvic ganglia (MPG) removed for immunohistochemistry of enkephalin. Results: The maximal intravesical pressures for the C, M and S groups were 28.5cmH2O, 13.5cmH2O and 8.6cmH2O, respectively (p<0.001). The pressure difference between the maximal pressure after electrical stimulation and the basal pressure before electrical stimulation for the C, M and S groups were 23.8cmH2O, 8.9cmH2O and 4.6cmH2O, respectively (p< 0.001). The intensity of pericellular immunoreactivity for enkephalin from the removed MPG was more markedly decreased in the S than C group, but was more markedly increased in the M than S group. Conclusions: MPCs can promote peripheral autonomic nerve regeneration, with good correlations between the functional and immunohistochemical results of neurorecovery effect of MPCs.

Effect of Delayed Estrogen Replacement on Vaginal Histologic Composition in Rabbit / 대한비뇨기과학회지

PURPOSE: A decline in the circulating levels of estrogen impairs vaginal engorgement, which leads to histopathological changes in the vaginal tissues. The aim of this study was to evaluate the effect of delayed estrogen replacement on the vagina structure in castrated rabbits. Materials and Methods: New Zealand White female rabbits were randomly divided into three groups; two groups (the castration and castration estrogen replacement groups) were castrated: the control group underwent sham operations. Nine weeks after surgery, the estrogen replacement group received subcutaneous injections of estrogen (50microgram/kg/day) for 4 weeks. Vaginal tissue was processed for histology with Masson's trichome stain. The expressions of e-NOS and n-NOS were examined by immunohistochemistry and Western blot. RESULTS: From the histology, marked thinning of the vaginal epithelial layers, and decreased smooth muscle content and submucosal microvasculatures were evident, but with no increase in the collagen fibers in the castrated group was noted. The vaginal tissue of the estrogen replaced animal showed similar morphological features to those in the control rabbits. From the histomorphometry, the percentage of vaginal smooth muscle in the castrated group was significantly decreased compared to those in the control and estrogen replaced groups. The expression and signal intensity of e-NOS were decreased in the vagina of the castrated animals compare to those in the control group. In the estrogen replaced group, the expression of e-NOS was normalized. CONCLUSIONS: Delayed estrogen replacement showed structural restoration of vaginal tissues. These results suggest that delayed estrogen replacement therapy could improve the sexual function in menopausal women.