The Significance of Simultaneous Transurethral Resection of Bladder Tumor and the Prostate in Patient who have Superficial Bladder Cancer with Bladder Outlet Obstruction / 대한비뇨기과학회지

PURPOSE: We evaluated the clinical significance of simultaneous transurethral resection of bladder tumor(TURB) and the prostate(TURP) in patients who have superficial bladder cancer with bladder outlet obstruction. MATERIALS AND METHODS: Between April 1997 to April 2006, 213 patients with superficial bladder cancer were included in this study. The patients were treated with TURB only(n=107, Group I) or TURB with TURP (n=106, Group II). Bladder cancer recurrence was observed by performing cystoscopy and urine cytology. Uroflowmetry was performed three months after surgery. RESULTS: There were no significant differences in age, the tumor size or the number of tumors between groups I and II. There was no evidence of cancer implantation where TURP was applied. The recurrence rate of group II was significantly lower than that of group I(p=0.044), and the time to recurrence was longer for group II than for group I(p=0.026). There was no significant difference in the progression rate between the two groups(p=0.788). Three months after surgery, the mean residual urine volume was lower for group II(7.9ml) than that for group I(21.7ml). CONCLUSIONS: For superficial bladder cancer patients with bladder outlet obstruction, simultaneous TURB and TURP may help reduce the bladder cancer recurrence rate and delay the time to recurrence without the risk of cancer implantation at the site where TURP is applied.

The Effect and Mechanism of Intravesical Electrical Stimulation in Spinal Cord Injured Rats / 대한비뇨기과학회지

PURPOSE: The objective of this study was to evaluate whether the effect on afferent c-fiber activity is the underlying mechanism of intravesical electrical stimulation (IVES) in spinal cord injured rats. MATERIALS AND METHODS: Thirty five female Sprague-Dawley rats weighting 200-300g each were divided into the normal and spinalized groups. For the spinalized rats, we observed the c-fos expression, and we compared this in the non-IVES group with that in the IVES group. Cystometrograms were performed for all the groups via a suprapubic catheter. RESULTS: After performing IVES in the normal and spinalized rats, the abnormal increases of the intercontraction interval (ICI) and the voiding pressure (VP) were reduced close to the normal range. In the spinalized rats, the number of c-fos positive cells in the dorsal commissure (DCM) decreased in the group that had IVES performed when compared with the non-IVES group. CONCLUSIONS: The IVES reduced the c-fos gene expression in the L6-S1 spinal cord segment and also the bladder hyperreflexia in the spinalized rats through the inhibition of afferent c-fiber activity, in addition to affecting the A delta mechanoreceptors.

When should Videourodynamic Study be Performed after Correcting the Defect in Patients with Myelodysplasia? / 대한비뇨기과학회지

PURPOSE: Because vesicourethral dysfunction in myelodysplasia patients is a major cause of upper urinary deterioration and urinary incontinence, urodynamic evaluation should be performed as early as possible. We attempted to establish the proper time when videourodynamic study should be performed and which patients require early interventional therapy. MATERIALS AND METHODS: Out of the 222 patients seen in the pediatric urology department, 22 patients underwent correction of myeloplasia defect from January 2001 to September 2004. Preoperatively, the patients were assessed with videourodynamic study, and the postoperative videourodynamic studies were repeated at 2 to 6 months intervals. Four urodynamic parameters (bladder volume, compliance, detrusor activity and detrusor sphincteric synergy) were identified, graded and then added to obtain the urodynamic score. RESULTS: There was no statically significant difference in all urodynamic parameters between the preoperative and postoperative 2 month videourodynamic studies, but a statistically significant difference was noted in compliance between the preoperative and postoperative 6 month videourodynamic studies. The compliance was more decreased in the patients who had received surgical correction in their older age and high detrusor activity was observed for these patients on the preoperative videourodynamic study. CONCLUSIONS: Postoperative videourodynamic study and early treatment are recommended for the patients who are at high risk for upper urinary tract deterioration. However, for the low risk patients, postoperative 2 month videourodynamic study can prevent unnecessary treatment.

Age-Specific Reference Ranges for Serum Prostate-Specific Antigen in Korean Men / 대한비뇨기과학회지

PURPOSE: The level of serum prostate-specific antigen (PSA) varies according to both age and race. It is known that the level of PSA increases with age, and that Asians have a lower incidence of prostate cancer and levels of PSA than Caucasians. In this study, the variation in the serum PSA level in samples collected from general populations were used to find an actual standard age-specific PSA reference range for Koreans. MATERIALS AND METHODS: Patients who received serum PSA level check-ups, between November 1998 and July 2005, at 8 domestic hospitals, were selected for the investigation. The PSA levels of 120,439 adult males, aged between 30 and 80 years, were measured, and those lower than 10ng/ml were analyzed. To estimate the increase in the level of serum PSA according to age, a simple linear regression analysis was carried out. RESULTS: The mean PSA level reference ranges according to age were 1.88, 1.92, 2.37, 3.56 and 5.19ng/ml for those in their thirties, forties, fifties, sixties and seventies, respectively. The rates of PSA change were 0.0023, 0.0175 and 0.0499 for those in their forties, fifties and sixties, respectively, indicating the rates of PSA level change increase steady with age, but these increases are greater for those in their fifties and most severe after their sixties. The level of age-specific PSA reference in Korean men was lower than that of men from Western countries. CONCLUSIONS: The age-specific PSA reference levels, as found in pre-existing literature, showed differences between races, with the overall reference levels being low for domestic data. The standard reference level of age-specific PSA for the screening of prostate cancer may be lower in Korean men than those from Western countries.

Intravesical Electrical Stimulation in Infrequent Voider Syndrome / 대한비뇨기과학회지

PURPOSE: Intravesical electrical stimulation (IVES) has been performed at the Severance Hospital for various purposes in children with voiding difficulty due to neurogenic or non-neurogenic causes. The effect of IVES in children with infrequent voider syndrome is controversial. The aim of this study was to investigate the effect of IVES in children with infrequent voider syndrome. MATERIALS AND METHODS: Between September 1999 and August 2001, 12 children diagnosed with infrequent voider syndrome, who received IVES at the Severance Hospital, were retrospectively analyzed. We investigated the changes in abdominal straining voiding, a voiding interval more than 8 hours, urgency and overflow incontinence after IVES. We also compared the uroflowmetry curve, maximal urine flow rate, maximal detrusor contraction pressure and residual urine volume after IVES. RESULTS: Abdominal straining voiding, a voiding interval more than 8 hours, urgency and overflow incontinence were decreased from 83.3 to 25.0%, 50.0 to 16.7%, 25.0 to 0% and 58.3 to 25.0%, respectively. After IVES, fractionated voiding and flat-shape voiding were decreased from 66.7 to 16.7% and 33.3 to 8.3%, respectively. Whereas, bell-shape voiding was increased from 0 to 75.0%. The maximal urine flow rate was increased significantly, from 5.6 3.7 to 11.2 4.2m/s (p=0.002), but the residual urine volume was decreased significantly, from 71.7 47.5 to 9.2 13.8ml (p=0.0001). The maximal detrusor contraction pressure was increased in some children. CONCLUSIONS: The maximal urine flow rate was significantly increased after IVES in children with infrequent voider syndrome, but the residual urine volume was decreased significantly. There was a significant treatment effect in flat-voiding children, leading to the conclusion that IVES can be particularly effective in this specific group of children with infrequent voider syndrome.

The Clinical Experience of the Ureterocystoplasty in Neurogenic Bladder / 대한비뇨기과학회지

PURPOSE: The ureter can be a very effective tissue for bladder augmentation, but the indications for ureterocystoplasty are still evolving, with the main problem being the limited number of patients with a nonfunctioning or poor functioning kidney. Recently, ureterocystoplasty, with preservation of ipsilateral renal function, has been reported by several authors. We reported our experience and follow-up results of ureterocystoplasty. MATERIALS AND METHODS: Between December 2000 and February 2003, 4 girls, aged 3 to 13 (mean age 7.2), with a low capacity, poorly compliant bladder underwent ureterocystoplasty using a single dilated ureter. Three patients had a dilated ureter due to high grade VUR (vesicoureteric reflux) and the other due to bilateral reflux. An urodynamic study showed an areflexic neurogenic bladder, with low compliance, in all patients. The technique was performed intraperitoneally using a midline abdominal incision. The distal parts of both detubularized magaureters were used for augmentation. The dilated proximal ureter was anastomosed to the longitudinally incised contralateral ureter, in an end to side fashion. RESULTS: The mean follow-up was 21 months (6-41). In a video-urodynamic study, the mean preoperative bladder capacity and post operative volume were 140cc (67-23) and 223cc (140-320), respectively, with an average increase of 17 to 113% (mean 71). The postoperative bladder compliance was normalized in all cases. Postoperative cystography showed excellent bladder configuration, with no vesicoureteral reflux. There were no surgical complications, such as bladder perforation, stone formation and bowel problem. The serum creatinine levels remained stable in all cases (0.3 to 0.6mg/dl). CONCLUSIONS: Although an increase in bladder capacity is not always optimal with the use of a distal ureter, it is good enough to ensure a good clinical outcome and allow an adequate catheterization interval, with a low complication rate.

The Subdivision of the Spinal Neurons for Detrusor Function / 대한비뇨기과학회지

Purpose: No ideal method for subdividing and assessing changes in neurons of the spinal cord during specific conditions has been established. We attempted to develop a method for subdividing spinal neurons using immunohistochemical and fluorescent staining, which is an important key towards understanding the mechanism of reflex voiding. Materials and Methods: Thirty Sprague-Dawley rats, weighting 200-300g, were divided into five groups. A cystometrogram was performed during saline or acetic acid instillation. We identified the neuronal pathway associated with the detrusor by injecting a pseudorabies virus (PRV) into the detrusor muscle and inspecting the changes in relation to different time sequences. An immunohistochemical staining method was used to stain the fos-protein encoded by the c-fos gene. Immunofluorescent staining was performed to evaluate changes in the neurons in relation to the voiding reflex, and the neurons then subdivided. Results: We confirmed pseudorabies virus (PRV) infection of the cells in the sacral parasympathetic nucleus through immunohistochemical staining two days after injection. On detection of an increase in c-fos positive cells after dividing the c-fos positive area of the L6 and S1 spinal cord into 4 sections, significant increases were observed in the sacral parasympathetic nucleus (SPN) and dorsal commissure (DCM). Double staining was performed to detect the neurons associated with the voiding reflex in the SPN and DCM areas showing overexpression of c-fos. Conclusions: The establishment of a method for detecting morphological changes, and subdividing neurons by immunohistochemical and fluorescent staining, may provide an important key towards understanding the mechanism of various neuromodulations of clinically applied treatments. (Korean J Urol 2005;46:487-494)

Voiding Dysfunction after Bilateral Detrusorrhaphy to Correct Vesicoureteral Reflux in Children / 대한비뇨기과학회지

PURPOSE: We evaluated the incidence and duration of voiding dysfunction following bilateral detrusorrhaphy to correct vesicoureteral reflux (VUR), and we also evaluated the factors that influence the development of voiding dysfunction and recovery from voiding function. MATERIALS AND METHODS: We performed a retrospective review on 36 children, 27 boys and 9 girls, who showed normal voiding function on preoperative video-urodynamic study and for whom data on post-void residual urine volume (PVR) were available postoperatively. The mean age and duration of follow-up were 3.1 2.6 years and 17.5 10.4 months, respectively. Postoperative voiding dysfunction included urinary retention and incomplete bladder emptying. RESULTS: The overall success rate was 97.2%. The urethral catheter was kept in for a mean period of 4.0 3.6 days. After urethral catheter removal, postoperative voiding dysfunction developed in 24 children and urinary retention developed in 5 children. The differences in age, grade of VUR or sex did not have significant influence on the development of voiding dysfunction. 35 children achieved normal PVR during the postoperative follow-up. The mean time to recovery of voiding function was 34.1 37.9 days. The differences in age, sex or grade of VUR did not have any significant influence on the recovery rate of voiding function. The time to recovery of the voiding function was significantly longer in the patients aged less than 2 years or those patients with bilateral high-grade VUR. However, sex did not significantly influence the time to recovery of voiding function. CONCLUSIONS: The development of postoperative voiding dysfunction is frequent, but temporary. However, it is necessary to consider a longer period of catheterization for the group of patients aged less than 2 years or those patients with bilateral high grade VUR.

The Impact of Voiding Dysfunction on Vesicoureteral Reflux and Renal Scars / 대한비뇨기과학회지

PURPOSE: To report the relationship between voiding dysfunction and reflux, renal scars and the common findings related to voiding dysfunction in patients with vesico-ureteral reflux (VUR). MATERIALS AND METHODS: Between March 2002 and February 2004, 56 children underwent a video-urodynamic study (video-UDS) for evaluation of VUR. The grade of VUR, various findings of voiding dysfunction and the maximal intravesical pressure (maxPves) were assessed during voiding, and severity of renal scars were assessed via video-UDS and DMSA scans, respectively. RESULTS: Voiding dysfunction was diagnosed in 30 patients (53.6%). The findings of voiding dysfunction were uninhibited contraction (14 patients), detrusor sphincter dyssynergia (15 patients) and bladder neck opening during the filling phase (17 patients). Urethrovaginal reflux and after contraction were noted in 6 and 8 patients, respectively. In the voiding dysfunction group, the mean VUR grade was 3.4, while this was 2.6 in 42 renal units of the normal voiding group (p=0.023). The mean maxPves values during voiding in the voiding dysfunction and normal voiding groups were 107.7 and 77cmH2O, respectively (p=0.002). On evaluation of the relationship between voiding dysfunction and the extent of renal scarring [no scar, single scar, multiple scars, reduced size], the existence of voiding dysfunction resulted in more severe forms of renal scarring (p=0.034). CONCLUSIONS: Voiding dysfunction can cause or aggravate VUR or urinary tract infection due to an increased intravesical pressure during voiding, which can ultimately cause permanent renal damage. Therefore, treatments, such as anticholinergic drugs or biofeedback, must be performed in patients with combined VUR and voiding dysfunction for a better treatment outcome.

The Natural Course in Children with Unilateral Multicystic Dysplastic Kidney / 대한비뇨기과학회지

PURPOSE: Advances in modern ultrasonography combined with a dimercaptosuccinic acid (DMSA) renal scan have permitted the diagnosis of a multicystic dysplastic kidney (MCDK) with a high degree of certainty. Most multicystic dysplastic kidneys undergo spontaneous involution during follow-up, as demonstrated by serial ultrasonography. The purpose of this study was to contribute to a better understanding of the natural history of a MCDK, and suggest guidelines for follow-up of a MCDK. MATERIALS AND METHODS: Between November 1988 and May 2004, 142 children with a MCDK were diagnosed at our institute. A retrospective data analysis was carried out on 38 patients who were conservatively managed and followed for more than 6 months. Follow up ultrasonography examinations were performed every 6 months until patients were 5 years old, and annually thereafter. Patients were divided into simple and complex MCDK based on postnatal physical examination and renal ultrasonography. A simple MCDK was defined as unilateral renal dysplasia without genitourinary abnormalities. Complex MCDK included patients with unilateral renal dysplasia, but with other genitourinary abnormalities. RESULTS: The follow-up periods ranged from 6 to 76 months, with a median of 21.5 months. Partial and complete involution of the affected kidney was observed in 6 (15.8%) and 8 (21.1%) patients, respectively. There was no significant difference in the median involution time between the groups. The median time to involution in all patients was 36 months. CONCLUSIONS: Conservative management for a MCDK appears to be a safe option. Because of a complex MCDK has a high incidence of UTI, prophylactic antibiotics may be required. We recommend the long-term follow-up of a MCDK using ultrasonography monitoring.

Histo-pathologic Characteristics of Cystic Renal Cell Carcinoma / 대한비뇨기과학회지

PURPOSE: No consistent histo-pathological characteristics of cystic renal cell carcinomas have previously been determined. In this study, attempts were made at our hospital to evaluate the histopathological characteristics of this cancer. MATERIALS AND METHODS: The medical records of 451 patients with renal cell carcinomas, having undergone a radical nephrectomy, between January 1995 and April 2002, were retrospectively reviewed. The renal cell carcinomas were classified, according to the criteria of the World Health Organization, as a cystic renal cell carcinoma in 31 of these patients (6.8%). The tumor size, nuclear grade and pathological stage were investigated. RESULTS: The mean age of the patients was 52 years, ranging from 35 to 75. Cancer stages were T1, T2 and T3 in 26 (84%), 3 (10%) and 2 (6%) patients, respectively. The nuclear grade and pathological stage were lower in patients with a cystic renal cell carcinoma. CONCLUSIONS: 81% of the cystic renal cell carcinoma cases were diagnosed incidentally. The cystic renal cell carcinomas were usually detected at lower stages and grades, and therefore were associated with a better prognosis than the renal cell carcinomas.

A Comparison of Surgical Morbidity and Postoperative Voiding Function in Infants and 1-2 year-old Children after Ureteral Reimplantation / 대한비뇨기과학회지

PURPOSE: The advisability of early ureteral reimplantation in infants is controversial, and to our knowledge no long-term results are available. Whether early ureteral reimplantation in infants increases surgical morbidity, compared to ureteral reimplantation after the age of 1 year, was investigated, and the long-term voiding function after ureteral reimplantation evaluated. MATERIALS AND METHODS: Between 1993 and 1999, 130 children underwent ureteral reimplantation at our institution. The diagnosis was a primary vesicoureteral reflux, obstructed megaureter and an ectopic ureter. Two groups of 64 children that underwent ureteral reimplantation were compared. Group 1 included children younger than 12 months at surgery and group 2 children those between 1 and 2 years. The long term results were evaluated with regard to surgical outcome, voiding function and urinary tract infection. An analysis of the voiding function included family interviews, uroflowmetry and post-void residual urine measurements. RESULTS: Complete long-term data were available for 47 boys and 17 girls. In Group 1, there were no complications in 50 renal units(96%), while two had postoperative reflux, and underwent macroplastique injection. In Group 2, there were no complications in 35 renal units(97.1%), while one patient had postoperative reflux, which resolved spontaneously. No significant difference was noted in the postoperative post-void residual urine volumes between the two groups. CONCLUSIONS: In our samples, early ureteral reimplantation resulted in a technical success rate of greater than 95% and low postoperative morbidity, with the exception of urinary tract infection. Our data show satisfactory bladder emptying and normal uroflowmetry. When indicated, ureteral reimplantation can be performed safely in young children, without fear of damaging bladder function.

The Effect of Biofeedback in Urge Syndrome and Dysfunctional Voiding / 대한비뇨기과학회지

PURPOSE: We wished to introduce the curative effect of biofeedback in children with urge syndrome and dysfunctional voiding, and examine the durability of effect and the difference in response to medication before and after biofeedback. MATERIALS AND METHODS: There were 15 patients with urge syndrome and 8 with dysfunctional voiding. Average age was 8.2 years old(range, 4-16 years). Pelvic floor relaxation biofeedback, voiding biofeedback, and intravesical biofeedback were enforced with 4-18 sessions(average, 7.4). We defined the patient with disappearance of more than 90% of symptoms as 'improved', disappearance of 50 to 90% as 'partially improved', and the rest as 'not improved'. We assessed the degree of improvement between groups, and changes in uroflowmetry, functional bladder capacity and response to medication after biofeedback. RESULTS: Nine(60%) of the 15 patients with urge syndrome and 4(50%) of the 8 patients with dysfunctional voiding showed improvement, and the overall response rate was 56%(13 of 23 patients). The mean follow-up period was 7.6 months, and the therapeutic effect lasted for 5.1 months. Among the 13 patients who were refractory to medical treatment, 8(61%) improved and 3 with partial improvement responded well to medication after biofeedback. There were significant improvements in uroflowmetry findings; the numbers of bell shape and discordant shape(fractionated, staccato) before and after biofeedback were 7, 14 and 19, 4, respectively. Functional bladder capacity was also improved significantly from 177ml to 236ml(p=0.014). CONCLUSIONS: Biofeedback is an effective and safe treatment modality in most patients with urge syndrome and dysfunctional voiding.

Renal Tuberculous Granuloma after Intravesical Bacillus Calmette-Guerin Instillation for Bladder Tumor / 대한비뇨기과학회지

We report a case of a clinically asymptomatic granulomatous renal mass during intravesical Bacillus Calmette-Guerin (BCG) immunotherapy for superficial bladder cancer. BCG is the most effective agent currently available for the treatment of superficial bladder cancer. The side effects, during or shortly after treatment, were minor and self-limiting in the large majority of patients (fever, bladder irritability and hematuria). We emphasize the rarity of such extravesical complications, and discussed the possible routes of renal inoculation. Treatment consisted of partial nephrectomy and anti tubercular agents.