Medical Travel among Non-Seoul Residents to Seek Prostate Cancer Treatment in Medical Facilities of Seoul / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study aims to investigate the trend in medical travel by non-Seoul residents to Seoul for treatment of prostate cancer and also to investigate the possible factors affecting the trend. MATERIALS AND METHODS: This study represents a retrospective cohort study using data from theKoreanNationalHealth Insurance System from 2002 to 2015. Annual trends were produced for proportions of patients who traveled according to the age group, economic status and types of treatment. Multiple logistic analysiswas used to determine factors affecting surgeries at medical facilities in Seoul among the non-Seoul residents. RESULTS: A total of 68,543 patients were defined as newly diagnosed prostate cancer cohorts from 2005 to 2014. The proportion of patients who traveled to Seoul for treatment, estimated from cases with prostate cancer-related claims, decreased slightly over 9 years (28.0 at 2005 and 27.0 at 2014, p=0.02). The average proportion of medical travelers seeking radical prostatectomy increased slightly but the increase was not statistically significant (43.1 at 2005 and 45.4 at 2014, p=0.26). Income level and performance ofrobot-assisted radical prostatectomy were significant positive factors for medical travel to medical facilities in Seoul. Combined comorbidity diseases and year undergoing surgery were significant negative factors for medical travel to medical facilities in Seoul. CONCLUSION: The general trend of patients travelling from outside Seoul for prostate cancer treatment decreased from 2005 to 2014. However, a large proportion of traveling remained irrespective of direct distance from Seoul.

A Prospective, Multicenter, Open-Label Study of Dose Escalation Therapy in Male Patients With Nocturia Refractory to 0.2-mg Tamsulosin Monotherapy / 대한배뇨장애요실금학회지

PURPOSE: To investigate the efficacy and safety of 0.4 mg of tamsulosin in patients with nocturia not responding to 0.2 mg.METHODS: Patients with intractable nocturia after treatment with 0.2 mg of tamsulosin for>1 month were included in a multicenter, prospective, observational, single-arm study. Patients were prescribed 0.4 mg of tamsulosin and followed up for 2 months to assess nocturnal voiding and nocturia-related bother. Changes in the mean number of nocturnal voids, the proportion of 50% responders, 3-day frequency-volume chart parameters, and questionnaire scores were assessed.RESULTS: Sixty-two patients were prescribed 0.2 mg of tamsulosin, of whom 56 were prescribed 0.4 mg of tamsulosin. Ten patients dropped out. A single case of orthostatic hypotension was reported. The mean age was 68 years. After 1 and 2 months of taking 0.4 mg of tamsulosin, 23.9% and 22.7% of patients demonstrated a>50% reduction of nocturia, and 16.1% and 19.4% of patients rated the treatment as “very effective,” respectively. Dose escalation to 0.4 mg of tamsulosin, compared to 0.2 mg, did not show an additional effect on reducing nocturnal urine volume. Multivariate logistic regression analysis showed that lower serum sodium levels (odds ratio [OR], 0.41, P=0.037) and the presence of urge incontinence (OR, 7.08, P=0.036) were predictors of a significant improvement of nocturia in response to 0.4 mg of tamsulosin.CONCLUSIONS: Dose escalation may yield a significant improvement of nocturia in>20% of patients, and may be especially helpful in patients with lower sodium levels and urge incontinence.

Feasibility of Polycaprolactone Scaffolds Fabricated by Three-Dimensional Printing for Tissue Engineering of Tunica Albuginea

PURPOSE: To investigate the feasibility of a polycaprolactone (PCL) scaffold fabricated by three-dimensional (3D) printing for tissue engineering applications for tunica albuginea. MATERIALS AND METHODS: PCL scaffolds were fabricated by use of a 3D printing system. Two scaffolds were fabricated that differed in the architecture of the lay-down pattern: a 90°PCL scaffold and a 45°PCL scaffold. Mechanical properties were measured to compare tensile strength between the two scaffold types. The scaffolds were characterized by scanning electron microscope (SEM) images. The scaffolds were seeded with fibroblast cells, and the ability of these scaffolds to support the cells was evaluated by immunofluorescence staining. RESULTS: The PCL scaffolds had well-structured shapes, regular arrays, and good interconnection in SEM images. The horizontal and vertical Young's modulus coefficients were 13 and 12 MPa for the 90°PCL scaffold and 19 and 21 MPa for the 45°PCL scaffold, respectively. Microscopy images revealed that human fibroblast cells covered the entire scaffold surface. Immunofluorescence staining of ER-TR7 confirmed that the fibroblast cells remained viable and proliferated throughout the time course of the culture. CONCLUSIONS: This preliminary study provides experimental evidence for the feasibility of 3D printing of PCL scaffolds for tissue engineering applications of tunica albuginea.

Poor Preoperative Glycemic Control Is Associated with Dismal Prognosis after Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Korean Multicenter Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study is to evaluate the effect of diabetes mellitus (DM) and preoperative glycemic control on prognosis in Korean patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU). MATERIALS AND METHODS: A total of 566 patients who underwent RNU at six institutions between 2004 and 2014 were reviewed retrospectively. Kaplan-Meier and Cox regression analyses were performed to assess the association between DM, preoperative glycemic control, and recurrence-free, cancer-specific, and overall survival. RESULTS: The median follow-up period was 33.8 months (interquartile range, 41.4 months). A total of 135 patients (23.8%) had DM and 67 patients (11.8%) had poor preoperative glycemic control. Patients with poor preoperative glycemic control had significantly shorter median recurrence-free, cancer-specific, and overall survival than patients with good preoperative glycemic control and non-diabetics (all, p=0.001). In multivariable Cox regression analysis, DM with poor preoperative glycemic control showed association with worse recurrence-free survival (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.31 to 3.90; p=0.003), cancer-specific survival (HR, 2.96; 95% CI, 1.80 to 4.87; p=0.001), and overall survival (HR, 2.13; 95% CI, 1.40 to 3.22; p=0.001). CONCLUSION: Diabetic UTUC patients with poor preoperative glycemic control had significantly worse oncologic outcomes than diabetic UTUC patients with good preoperative glycemic control and non-diabetics. Further investigation is needed to elucidate the exact mechanism underlying the impact of glycemic control on UTUC treatment outcome.

Leukemoid Reaction, a Rare Paraneoplastic Syndrome in Urothelial Cell Carcinoma: Is It an Indicator of a Poor Prognosis?

A leukemoid reaction is usually associated with malignancies of the lung, stomach, and thyroid. In contrast, urothelial cell carcinoma is rarely associated with leukemoid reactions, with few cases reported over the past 30 years. Here, we describe a patient with urothelial cell carcinoma who exhibited a leukemoid reaction. The patient had an elevated white blood cell count and experienced a rapid and aggressive clinical course, terminating in death. For urothelial cell carcinoma patients exhibiting a leukemoid reaction, removal of the inciting tumor is the definitive treatment. However, considering the aggressive nature of these tumors, if the patient is unsuitable for radical surgical management, palliative chemotherapy should be considered.

Report of the Korean Journal of Urology Editorial Board Meeting 2014

No abstract available.

Transobturator Tape for Female Stress Urinary Incontinence: Preoperative Valsalva Leak Point Pressure Is Not Related to Cure Rate or Quality of Life Improvement

PURPOSE: We investigated whether the Valsalva leak point pressure (VLPP) is valuable for predicting postoperative outcome measurement after transobturator suburethral tape (TVT-O) implantation for treating stress urinary incontinence (SUI) in women. MATERIALS AND METHODS: A total of 204 female patients who underwent TVT-O placement for treatment of SUI from March 2008 to February 2012 were enrolled in this retrospective study. All patients completed the incontinence quality of Life questionnaire (I-QoL), a self-reported quality of life measure specific to urinary incontinence, and the cure rate of incontinence was measured before and 6 months after surgery. Cure was defined as no leakage of urine postoperatively both subjectively and objectively. We compared pre- and postoperative I-QoL scores according to preoperative VLPP and Stamey grade. RESULTS: The numbers of patients with Stamey grades I, II, and III were 99 (48.5%), 84 (41.2%), and 21 (10.3%), respectively. A total of 30 (14.7%), 87 (42.6%), and 87 patients (42.6%) showed VLPP90 cm H2O, respectively. Preoperative VLPP was not significantly different according to preoperative I-QoL or change in I-QoL after surgery. However, I-QoL after surgery improved in patients with a high preoperative Stamey grade (p=0.001). CONCLUSIONS: VLPP was not a factor related to surgical outcome from the midurethral sling procedure. Stamey grade rather than VLPP was important for predicting subjective quality of life and improved incontinence-related quality of life after surgery.

Predictors of Intravesical Recurrence After Radical Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma: An Inflammation-Based Prognostic Score

PURPOSE: Systemic inflammatory responses, which are defined in terms of the Glasgow prognostic score (GPS), have been reported to be independent predictors of unfavorable outcomes in various human cancers. We assessed the utility of the GPS as a predictor of intravesical recurrence after radical nephroureterectomy (RNU) in upper urinary tract carcinoma (UTUC). MATERIALS AND METHODS: We collected data for 147 UTUC patients with no previous history of bladder cancer who underwent RNU from 2004 to 2012. Associations between perioperative clinicopathological variables and intravesical recurrence were analyzed by using univariate and multivariate Cox regression models. RESULTS: Overall, 71 of 147 patients (48%) developed intravesical recurrence, including 21 patients (30%) diagnosed with synchronous bladder tumor. In the univariate analysis, performance status, diabetes mellitus (DM), serum albumin, C-reactive protein, GPS, and synchronous bladder tumor were associated with intravesical recurrence. In the multivariate analysis, performance status (hazard ratio [HR], 2.33; 95% confidence interval [CI], 1.41-3.85; p=0.001), DM (HR, 2.04; 95% CI, 1.21-3.41; p=0.007), cortical thinning (HR, 2.01; 95% CI, 1.08-3.71; p=0.026), and GPS (score of 1: HR, 6.86; 95% CI, 3.69-12.7; p=0.001; score of 2: HR, 5.96; 95% CI, 3.10-11.4; p=0.001) were independent predictors of intravesical recurrence. CONCLUSIONS: Our results suggest that the GPS as well as performance status, DM, and cortical thinning are associated with intravesical recurrence after RNU. Thus, more careful follow-up, coupled with postoperative intravesical therapy to avoid bladder recurrence, should be considered in these patients.

Small Renal Masses: Surgery or Surveillance

The incidence of kidney cancer has been rising over the past two decades, especially in cases in which the disease is localized and small in size (<4 cm). This rise is mainly due to the widespread use of routine abdominal imaging such as ultrasonography, computed tomography, and magnetic resonance imaging. Early detection was initially heralded as an opportunity to cure an otherwise lethal disease. However, despite increasing rates of renal surgery in parallel to this trend, mortality rates from renal cell carcinoma have remained relatively unchanged. Moreover, data suggest that a substantial proportion of small renal masses are benign. As a result, the management of small renal masses has continued to evolve along two basic themes: it has become less radical and less invasive. These shifts are in part a reflection of an improved understanding that the biology of incidentally discovered renal cell carcinoma may be more indolent than previously thought. However, not all small renal masses are indolent, and de novo metastatic disease can develop at the initial presentation. Therefore, it is with this background of clinical uncertainty and biological heterogeneity that clinicians must interpret the benefits and disadvantages of various clinical approaches to small renal masses.

Predicting Factors for Stent Failure-Free Survival in Patients With a Malignant Ureteral Obstruction Managed With Ureteral Stents

PURPOSE: To determine predictive factors for stent failure-free survival in patients treated with a retrograde ureteral stent for a malignant ureteral obstruction. MATERIALS AND METHODS: We retrospectively reviewed 71 patients who underwent insertion of a cystoscopic ureteral stent due to a malignant ureteral obstruction between May 2004 and June 2011. Performance status, type of cancer, hydronephrosis grade, location of the obstruction, presence of bladder invasion, C-reactive protein (CRP), serum albumin, and inflammation-based prognostic score (Glasgow prognostic score, GPS) were assessed using a Cox proportional regression hazard model as predicting factors for stent failure. RESULTS: A univariate analysis indicted that hypoalbuminemia ( or =1 mg/dL; HR, 4.79; 95% CI, 2.0 to 11.1; p=0.001), and presence of a distal ureter obstruction (HR, 3.27; 95% CI, 1.19 to 8.95; p=0.021) were associated with stent failure-free survival. A multivariate analysis revealed that the presence of a mid and lower ureteral obstruction (HR, 3.27; 95% CI, 1.19 to 8.95; p=0.007), GPS > or =1 (HR, 7.22; 95% CI, 2.89 to 18.0; p=0.001), and elevated serum creatinine before ureteral stent placement (>1.2 mg/dL; HR, 2.16; 95% CI, 1.02 to 4.57; p=0.044) were associated with stent failure-free survival. CONCLUSIONS: A mid or lower ureteral obstruction, GPS > or =1, and serum creatinine before ureteral stent insertion >1.2 mg/dL were unfavorable predictors of stent failure-free survival. These factors may help urologists predict survival time.

A Comparative Study of Laparoendoscopic Single-Site Surgery Versus Conventional Laparoscopy for Upper Urinary Tract Malignancies

PURPOSE: The proper indication for laparoendoscopic single-site surgery (LESS) in urology is still under debate, especially for malignant diseases. We compared the perioperative outcomes between LESS and conventional laparoscopy (CL) for upper urinary tract malignancies. MATERIALS AND METHODS: We reviewed the records of 75 patients who underwent radical nephrectomy, nephroureterectomy with bladder cuff excision, or partial nephrectomy with the LESS or CL approach between December 2008 and December 2010. We compared characteristics and perioperative outcomes between patients who underwent LESS or CL. All operations were performed by three surgeons using the transperitoneal approach. RESULTS: For all three surgery types, no differences in patient characteristics, estimated blood losses, transfusion rates, or durations of hospital stay were found between the two groups. No complications were found between the two groups in those who underwent nephroureterectomy with bladder cuff excision; however, significantly more complications were found in the LESS group than in the CL group in those who underwent radical nephrectomy or partial nephrectomy. Most of the complications with LESS radical nephrectomy occurred in the early introduction period of the technique. CONCLUSIONS: No significant differences in perioperative outcomes were found between the LESS and CL groups in those who underwent radical nephrectomy or nephroureterectomy with bladder cuff excision. Therefore, the use of LESS in these cases is expected to expand as surgeons gain more experience with this technique and as other technical advances in laparoscopic instruments occur. However, partial nephrectomy with LESS should be performed restrictively considering the current level of surgical skill.

Fibroepithelial Polyp Mimicking a Renal Pelvis Tumor

No abstract available.

Expression of Caveolin-1 in Rat Urinary Bladder with Cyclophosphamide-Induced Cystitis / 대한배뇨장애요실금학회지

PURPOSE: The purposes of this study were to investigate the effect of cyclophosphamide (CYP)-induced inflammatory cystitis on caveolin 1 in rat urinary bladder and to determine the role of these molecules in the bladder dysfunction that occurs in inflammatory change in rat urinary bladder. METHODS: Female Sprague-Dawley rats were divided into control (n=30) and experimental (n=30) groups. Cystitis in experimental group was induced by intraperitoneal injection of CYP (200 mg/kg). The control group underwent an intraperitoneal saline injection. After 3 days, urodynamic studies were done to measure the contraction interval and contraction pressure. The expression and cellular localization of caveolin 1 were determined by Western blot and immunofluorescent study in rat urinary bladder. RESULTS: In cystometrograms, the contraction interval (minute) was significantly increased in the CYP-induced cystitis rats (15.8+/-1.5) than in the control group (6.3+/-0.5) (P<0.05). Conversely, the average contraction pressure (mmHg) was significantly higher in the CYP-induced cystitis rats (15.6+/-1.7) than in the control group (11.3+/-0.5) (P<0.05). Caveolin 1 was expressed in the capillaries, arteriols and venules. The protein expression of caveolin 1 was significantly decreased in the CYP-induced cystitis rats (P<0.05). CONCLUSIONS: Inflammatory change of urinary bladder maybe causes a significant change in the expression of caveolin 1. These findings suggest that caveolin 1 might have a functional role in the bladder dysfunction related with cystitis in rat urinary bladder.

Clinical Outcomes of Bosniak Category IIF Complex Renal Cysts in Korean Patients

PURPOSE: To assess the clinical reliability of the Bosniak IIF category and to determine the proper radiologic follow-up duration and intervals for category IIF complex renal cysts. MATERIALS AND METHODS: We studied 201 patients with category IIF renal cysts from January 1996 to January 2011. Renal cyst progression to category III was defined as an increase in complexity of the cyst in follow-up radiologic studies. We monitored radiologic changes and progression of renal cysts during the follow-up period and analyzed the pathologic results of those patients who were treated surgically. RESULTS: At a mean follow-up of 20 months, only 14 cases (7%) showed evidence of progression to stage III, with a mean time to progression of 11 months (range, 3 to 65 months). There were no significant differences in age, gender, cyst size, or change in cyst size between the progressive and non-progressive groups. Of 12 cases treated surgically, 10 cases (83.3%) showed renal cell carcinoma with pT1 stage, and there was no recurrence during postoperative follow-up of 23 months. Of the 187 patients without radiologic progression, 23 cases were treated surgically, and all of them showed benign cysts. CONCLUSIONS: The IIF category showed significant clinical reliability by a low rate of radiologic progression and a high rate of malignancy in the radiologic progressive group but a low rate of malignancy in the non-progressive group. Although it is hard to decide on a proper follow-up duration because of the variable time to progression, too frequent follow-up study seems to be unnecessary considering that most malignant cases were of a low stage.

Small (<4 cm), Unclassified Renal Cell Carcinoma Presenting with Initial Bone Metastasis: A Case of a Metastatic Lesion Missed at the Initial Diagnosis

A 49-year-old man presented with an incidentally detected right renal mass on a health examination. The abdominal computed tomography and magnetic resonance imaging showed a 3-cm right renal mass suspected of being a hypovascular tumor, such as papillary renal cell carcinoma, and an osteoblastic metastatic lesion on the right iliac bone. However, we missed a bone lesion at the time of diagnosis. A laparoscopic radical nephrectomy was performed and the final pathology confirmed unclassified renal cell carcinoma. The follow-up imaging studies showed several neck lymph nodes and multiple bone metastases at the lumbar spine, right iliac bone, and left femur. Thirteen cycles of temsirolimus were administered to the patient, but follow-up positron emission tomography showed newly developed liver and left adrenal metastasis and increased bone metastasis. It is important to note that T1a renal cell carcinoma can present with distant metastasis and thus demands scrupulous examination even though the tumor size may be small.

Retroperitoneoscopic Partial Nephrectomy in a Horseshoe Kidney

A 21-year-old woman with a 4 cm enhancing cystic renal mass in the left moiety of a horseshoe kidney was treated through a retroperitoneal laparoscopic approach. The tumor was excised completely with cold scissors, and renal parenchyma suturing with a surgical bolster was done with Vicryl 2-0 sutures. Choosing the proper approach according to the location of the lesion and the surgeon's experience with both approaches are of importance in laparoscopic surgery in horseshoe kidney cases. A preoperative kidney computed tomography angiography was helpful for understanding the complex renal vasculature.

Clinical Experiences of Pheochromocytoma in Korea

PURPOSE: We report herein 119 patients with pheochromocytoma at our institute over the last 23 years. MATERIALS AND METHODS: Between 1986 and 2009, 119 patients were diagnosed with pheochromocytoma at our institute. We reviewed the medical records of these patients. RESULTS: Of 119 patients, 45 were male and 74 were female, and mean age was 43.83 +/- 13.49 years. Forty-three patients (36.1%) were diagnosed incidentally, and 8 patients (6.7%) were found to have familial pheochromocytoma. The mean dimension of the tumors was 5.89 +/- 3.18 cm. 4 patients had bilateral tumors; three of these patients were found to have familial pheochromocytoma and 1 patient was diagnosed with malignant pheochromocytoma. A total of eight patients (6.7%) were found to have malignant pheochromocytoma. In 1 patient, metastasis to a lymph node was found at the time of diagnosis. Metastases were found at a mean of 49 +/- 25.83 (6-75) months after surgery in the other seven patients. 6 patients died of malignant pheochromocytoma at a mean of 31 +/- 28.71 months (1-81) after diagnosis, and the other 2 patients survived for 15 and 24 months, respectively. CONCLUSION: Approximately 35% of patients with pheochromocytoma are diagnosed incidentally, and the number of detected cases is increasing. Although familial pheochromocytoma was found only in 6.7% of the patients, genetic testing should be considered in all patients, especially in patients with a family history, young age, or multifocal, bilateral, extra-adrenal, or malignant tumors. Given that malignant pheochromocytomas are frequently diagnosed during the follow-up period, long-term follow-up is necessary to confirm the absence of recurrence or metastasis.

Nomogram to Predict Insignificant Prostate Cancer at Radical Prostatectomy in Korean Men: A Multi-Center Study

PURPOSE: Due to the availability of serum prostate specific antigen (PSA) testing, the detection rate of insignificant prostate cancer (IPC) is increasing. To ensure better treatment decisions, we developed a nomogram to predict the probability of IPC. MATERIALS AND METHODS: The study population consisted of 1,471 patients who were treated at multiple institutions by radical prostatectomy without neoadjuvant therapy from 1995 to 2008. We obtained nonrandom samples of n = 1,031 for nomogram development, leaving n = 440 for nomogram validation. IPC was defined as pathologic organ-confined disease and a tumor volume of 0.5 cc or less without Gleason grade 4 or 5. Multivariate logistic regression model (MLRM) coefficients were used to construct a nomogram to predict IPC from five variables, including serum prostate specific antigen, clinical stage, biopsy Gleason score, positive cores ratio and maximum % of tumor in any core. The performance characteristics were internally validated from 200 bootstrap resamples to reduce overfit bias. External validation was also performed in another cohort. RESULTS: Overall, 67 (6.5%) patients had a so-called "insignificant" tumor in nomogram development cohort. PSA, clinical stage, biopsy Gleason score, positive core ratio and maximum % of biopsy tumor represented significant predictors of the presence of IPC. The resulting nomogram had excellent discrimination accuracy, with a bootstrapped concordance index of 0.827. CONCLUSION: Our current nomogram provides sufficiently accurate information in clinical practice that may be useful to patients and clinicians when various treatment options for screen-detected prostate cancer are considered.

Renal Cell Carcinoma in Patients on Dialysis for End-Stage Renal Disease / 대한신장학회지

No abstract available.

Laparoendoscopic Single-Site Nephrectomy Using a Modified Umbilical Incision and a Home-Made Transumbilical Port

PURPOSE: To assess the clinical utility of laparoendoscopic single-site surgery (LESS) nephrectomy using a modified umbilical incision and home-made transumbilical port in cases requiring extirpative surgery. MATERIALS AND METHODS: Initial consecutive 18 patients underwent LESS nephrectomies that were performed by a single surgeon. A home-made port was placed through a modified umbilical incision, the length of which had preoperatively been determined. The laparoscopic transperitoneal nephrectomy procedures were performed with various combinations of standard and articulating laparoscopic instruments. Patient characteristics and perioperative outcomes, including pathologic results, were recorded prospectively. RESULTS: All 18 extirpative surgeries, including simple nephrectomy (eight cases), radical nephrectomy (nine cases), and nephroureterectomy (one case), were completed successfully. The median operation time was 167 min (range 82-220), and the median blood loss was 250 mL (range 0-1050). All specimens were extracted intact through a modified umbilical incision (median length 2.5 cm, range 1.5-6.0). Final pathological analysis revealed a nonfunctioning kidney in five cases, a dysplastic kidney in three cases, a mixed epithelial and stromal tumor in one case, renal cell carcinoma in eight cases (T1: five cases, T3: three cases), and Ta ureter transitional cell carcinoma in one case. CONCLUSION: LESS nephrectomy using a home-made port and modified umbilical incision is feasible with both minimal incision and cost-effective. Our technique may be more useful for extirpative procedures in which a specimen needs to be removed intact, because incision length can be freely adjusted. Prospective comparisons are warranted to more clearly elucidate the utility of this surgical technique.