Selection Criteria for Active Surveillance of Patients with Prostate Cancer in Korea: A Multicenter Analysis of Pathology after Radical Prostatectomy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Korean patients with prostate cancer (PC) typically present with a more aggressive disease than patients in Western populations. Consequently, it is unclear if the current criteria for active surveillance (AS) can safely be applied to Korean patients. Therefore, this study was conducted to define appropriate selection criteria for AS for patients with PC in Korea. MATERIALS AND METHODS: We conducted a multicenter retrospective study of 2,126 patients with low risk PC who actually underwent radical prostatectomy. The primary outcome was an unfavorable disease, which was defined by non-organ confined disease or an upgrading of the Gleason score to ≥ 7 (4+3). Predictive variables of an unfavorable outcome were identified by multivariate analysis using randomly selected training samples (n=1,623, 76.3%). We compared our selected criteria to various Western criteria for the primary outcome and validated our criteria using the remaining validation sample (n=503, 23.7%). RESULTS: A non-organ confined disease rate of 14.9% was identified, with an increase in Gleason score ≥ 7 (4+3) of 8.7% and a final unfavorable disease status of 20.8%. The following criteria were selected: Gleason score ≤ 6, clinical stage T1-T2a, prostate-specific antigen (PSA) ≤ 10 ng/mL, PSA density < 0.15 ng/mL/mL, number of positive cores ≤ 2, and maximum cancer involvement in any one core ≤ 20%. These criteria provided the lowest unfavorable disease rate (11.7%) when compared to Western criteria (13.3%-20.7%), and their validity was confirmed using the validation sample (5.9%). CONCLUSION: We developed AS criteria which are appropriate for Korean patients with PC. Prospective studies using these criteria are now warranted.

Partial versus Radical Nephrectomy for T1-T2 Renal Cell Carcinoma in Patients with Chronic Kidney Disease Stage III: a Multiinstitutional Analysis of Kidney Function and Survival Rate

BACKGROUND: To examine survival rates and renal function after partial nephrectomy (PN) and radical nephrectomy (RN) in patients with chronic kidney disease (CKD). METHODS: We studied 4,332 patients who underwent PN or RN for pathological T1a-T2N0M0 renal cell carcinoma from 1988 to 2014. Patients were divided into two subgroups of CKD stage I–II and stage III. Kidney function, and survival outcomes were compared between groups. RESULTS: We included 1,756 patients with CKD I–II and 276 patients with CKD III in the final pair-matched analysis. Kidney function was significantly better preserved in the PN than in the RN group among all patients. However, the beneficial effect of PN on kidney function gradually disappeared over time in CKD III patients. The 5-year overall survival (OS) rates after PN and RN differed in patients with CKD I–II disease (99.4% vs. 96.5%, respectively, P = 0.015). The 5-year OS rates after surgery were not affected by mode of nephrectomy in CKD III patients (97.8% vs. 93.5%, P = 0.103). The 5-year cancer-specific survival rates did not differ between treatment groups in all CKD stage. Cox hazard analysis showed that the operative method was a significant factor for OS in CKD I–II patients (hazard ratio [HR], 0.320; confidence interval [CI], 0.122–0.840; P = 0.021). However, PN was not beneficial in terms of OS in CKD III patients (HR, 0.395; CI, 0.086–1.172; P = 0.117). CONCLUSION: PN is associated with a higher OS rate and better kidney function in patients with preoperative CKD stage I and II, but not in those with CKD stage III.

An orthotopic nude mouse model of tongue carcinoma

INTRODUCTION: Development of carcinoma on oral tongue may cause bilateral cervical lymph node metastasis, rapid invasion and growth of the cancer cells due to rich blood supply in muscle tissues. It is not only difficult to develop an animal experimental model, but also to proceed follow-up research after the development of such model as the induction of cancer lead to difficulty in taking nutrition for the experimental animals that often causes early death. MATERIALS AND METHODS: IIn this study, author have transplanted YD-10Bmod cells into nude mouse oral tongues with different cells number (5x10(4), 5x10(5), 5x10(6) cells/mouse) and observed the development aspect of oral tongue cancers. RESULTS: The cancer developed from orthotopic transplantation of YD-10Bmod cells into nude mouse oral tongue show invasion and central necrosis of the tumor, similar to the cancers developed human oral tongue cancer. The difference in tumor size and the time of central necrosis development depending on the number of transplanted tumor cells shows the feasibility of extending the survival period of the nude mouse by limiting the transplanted tumor cells to <5x10(4) cells/mouse or under per nude mouse. CONCLUSION: This nude mouse model could be used effectively in developing effective chemotheray agent and establishing an animal experimental model that can be used to study the mechanism of cervical lymph node metastasis of the oral tongue cancer.

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.

Preoperative Nomograms for Predicting Extracapsular Extension in Korean Men with Localized Prostate Cancer: A Multi-institutional Clinicopathologic Study

We developed a nomogram to predict the probability of extracapsular extension (ECE) in localized prostate cancer and to determine when the neurovascular bundle (NVB) may be spared. Total 1,471 Korean men who underwent radical prostatectomy for prostate cancer between 1995 and 2008 were included. We drew nonrandom samples of 1,031 for nomogram development, leaving 440 samples for nomogram validation. With multivariate logistic regression analyses, we made a nomogram to predicts the ECE probability at radical prostatectomy. Receiver operating characteristic (ROC) analyses were also performed to assess the predictive value of each variable alone and in combination. The internal validation was performed from 200 bootstrap re-samples and the external validation was also performed from the another cohort. Overall, 314 patients (30.5%) had ECE. Age, Prostate specific antigen (PSA), biopsy Gleason score, positive core ratio, and maximum percentage of biopsy tumor were independent predictors of the presence of ECE (all P values <0.05). The nomogram predicted ECE with good discrimination (an area under the ROC curve of 0.777). Our nomogram allows for the preoperative identification of patients with an ECE and may prove useful in selecting patients to receive nerve sparing radical prostatectomy.

Laparoscopic Treatment of Appendicovesical Fistula

A 23-year-old man had a history of intermittent episodes of urinary tract infection with associated low abdominal pain for 15 years. Persistent bacteriuria even with prolonged antibiotics was the reason why he was referred to our hospital. Laboratory tests were normal except pyuria and growth of Escherichia coli in the urinary samples. Cystoscopy revealed a small slit-like opening on the right lateral wall of bladder dome. We found some air within the bladder and a suspicious communicating tract between the appendix and bladder on a CT scan. With a strong impression of appendicovesical fistula, a laparoscopy was performed to confirm a diagnosis and to remove the appendicovesical fistula resulting in a satisfactory result without any complication.

Radical Prostatectomy: Respective Roles and Comparisons of Robotic and Open Surgeries

Over the years, several surgical modifications have been incorporated into radical prostatectomy in order to improve the surgical outcome. Despite the rapid dissemination of robot-assisted laparoscopic prostatectomy (RALP) through the urologic community, comparative studies on the practicality of RALP compared to open radical prostatectomy (OP) are lacking. Thus, it remains difficult to draw any conclusions regarding cancer control and postoperative morbidity. This review will introduce the evolution of surgical technique and the current status of RALP in relation to OP in the management of localized prostate cancer focusing on the perioperative, oncological and functional outcomes. Based on the review of literatures, perioperative outcomes, such as blood loss, transfusion rates, hospitalization duration and complication rates, all favored RALP. The positive surgical margin rates of RALP were similar to those of OP with regard to the oncological outcomes. With regard to the functional outcomes, OP and RALP also showed similar continence and potency rates. However, refinements in technique employed during RALP have improved the early return of continence postoperatively. Although OP remains the gold standard treatment in localized prostate cancer, robotic surgery and continued technical advancements will ultimately improve patient outcomes. However, further prospective randomized comparative clinical trials with a long-term follow-up utilizing validated questionnaire are needed to prove the superiority of either surgical approach in terms of functional and oncological outcomes. In addition, RALP technique will need a substantial decrease in the cost of the robotic system to achieve wider global acceptance and application.

The Different Effects of Testicular Torsion on the Contralateral Testis between Pubertal and Adult Rats

PURPOSE: Our study aimed to determine whether the severity of damage to the contralateral testis by ipsilateral testicular torsion/detorsion in pubertal rats, which have an incomplete blood-testis barrier, is different from that in adult rats. MATERIALS AND METHODS: We divided pubertal (6 weeks, n=17) and adult (10 weeks, n=17) Sprague-Dawley (SD) rats into group S (sham; n=5), group O (orchiectomy; n=6), and group D (detorsion; n=6). After 4 hours' torsion of the ipsilateral testis, we applied orchiectomy (group O) and detorsion (group D) depending on the group and compared the histopathologic changes and germ cell apoptosis of the contralateral testis at the age of 13 weeks. RESULTS: In each age group, increased interstitial area, edema, and germ cell sloughing were observed in group D. The mean seminiferous tubule diameter decreased more in group D than in group S or O in each age group (p<0.05). The mean germ cell layer thickness and number of spermatids per tubule decreased more in group D than in group S or O in each age group; additionally, in group D, values decreased more in pubertal rats than in adult ones (p<0.05, respectively). The mean numbers of terminal deoxyuridine nick-end labeling (TUNEL)-positive cells were less than 1.0 in groups S and O, which was smaller than in group D (p<0.05); additionally, in group D, this value tended to be higher in pubertal rats than in adult ones (p=0.057). CONCLUSIONS: SD rats with a detorsioned testis had more severe damage to the contralateral testis than did those undergoing orchiectomy of the torsioned testis. Also, when comparing the severity of damage to the contralateral testis after ipsilateral torsion/detorsion between pubertal and adult rats, rats at a pubertal age, when most testicular torsions occur in clinical situations, had more severe damage than did those at an adult age.

Clinical Trial with Tamsulosin and Doxazosin for the Treatment of Premature Ejaculation in Patients with Co-morbid LUTS: a Comparative Study / 대한남성과학회지

PURPOSE: We wanted to evaluate the therapeutic potential of a low dose of tamsulosin, as compared with doxazosin, for the treatment of premature ejaculation in men with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Ninety-six patients (mean age: 55 years) who had LUTS with premature ejaculation were randomly assigned to receive 0.2 mg of tamsulosin and 4 mg of doxazosin daily for a period of 3 months. Patients were evaluated by taking the medical history, the International Prostatic Symptom Score (IPSS) and the Male Sexual Health Questionnaire (MSHQ) for ejaculatory function. The intravaginal ejaculatory latency time (IELT) measured by the patient's estimation and the sexual satisfaction ratio of both the partner and patient were investigated twice during the screening period and after treatment. At 3 months later, we assessed the differences in the IPSS score, the MSHQ score, the IELT and the sexual satisfaction ratio between the two groups. RESULTS: The two alpha 1-adrenoceptor antagonists had significant effects on the IPSS (p<0.05). However, we failed to find a statistically significant difference for each medication and the total MSHQ ejaculatory function score after medication in each group. The IELT was prolonged from 2.7+/-1.6 to 3.5+/-1.5 minutes and from 2.9+/-1.8 to 3.5+/-1.9 minutes in the tamsulosin and doxazosin groups, respectively. However, there was also no statistically significant difference of the IELT and the sexual satisfaction ratio in either group. CONCLUSIONS: For patients with premature ejaculation and LUTS, 0.2mg of tamsulosin improved the voiding symptoms, as assessed with the IPSS, as 4mg of doxazosin did, but neither medication seemed to be effective for the treatment of premature ejaculation.

Pathologic Outcome of Unilateral Low Risk Prostate Cancers on Multicore Prostate Biopsy after Radical Prostatectomy / 대한비뇨기과학회지

PURPOSE: To investigate clinicopathologic characteristics of unilateral, low risk prostate cancers detected via multi(>or=12)-core prostate biopsy. MATERIALS AND METHODS: One hundred four patients who underwent radical retropubic prostatectomy(RRP) for unilateral, low risk prostate cancer (clinical stage or=12)-core prostate biopsy were enrolled. In this retrospective study, we reviewed the patients' preoperative and pathologic data to assess potential predictors of pT2c or greater disease at the time of RRP, as well as characteristics of such disease. RESULTS: Of the 104 subjects, only 34(32.7%) were pathologically-proven to have unilateral disease, while the others showed pathologically-bilateral or worse disease from analysis of the RRP specimens. Subjects pathologically found to have uni- and bi-lateral disease showed no significant differences regarding age, prostate-specific antigen(PSA), free-to-total PSA ratio, prostate volume, clinical stage, number of positive cores, biopsy Gleason score, number of total biopsy sites, and highest percentage of tumor at any biopsy site. Multivariate logistic regression analysis revealed no significant preoperative predictors of pT2c or greater disease at RRP. CONCLUSIONS: Most patients with unilateral, low risk prostate cancer detected on multi(>or=12)-core prostate biopsy actually had pathologically- worse disease. For clinically-localized prostate cancer, a more accurate method to identify appropriate candidates for unilateral or focal ablative therapy should be developed.

Prognostic Significance of the Tumor Volume and Tumor Percentage for Localized Prostate Cancer / 대한비뇨기과학회지

PURPOSE: Tumor volume has been thought to be an important predictive factor for significant prostate cancer. We assessed the impact of the tumor volume(TV) and the tumor percentage(TP) of radical prostatectomy specimens on the pathological variables and the oncological outcome. MARERIALS AND METHODS: The tumor percentage and tumor volume were calculated for 525 cases by a single pathologist who determined the volume based on the surface area of the slides involved by tumor of the prostate. Univariate and multivariate logistic regression analyses were used to characterize the association of TP categories(20%) and TV(7.5cc) with the clinicopathological variables. Biochemical recurrence(BCR) was estimated using Kaplan-Meier analysis and Cox's hazard regression model. RESULTS: The mean prostate cancer volume was 6.5+/-8.5cc(median: 3.8, range: 0.04-73.8) and the mean percent tumor composition was 0.17+/-0.19 (median: 0.1, range: 0.01-0.95). A higher tumor volume and a higher tumor percentage were associated with extra-capsular extension(ECE), a positive surgical margin(PSM), a higher pT stage and a higher prostate-specific antigen(PSA) Gleason score(all p<0.05). In addition, TP was the independent predictor of ECE(adjusted odds ratio(OR): 22.66, 95% confidence interval(CI): 1.801-285.079, p=0.016), but the tumor volume was not associated with ECE on the multivariate logistic analyses. On the Kaplan-Meier analysis, but not on the Cox-hazard analyses, the TP did demonstrate a significant association with biochemical recurrence(p=0.035), yet the TV did not reach statistical significance(p=0.190). CONCLUSIONS: Our data indicates that the tumor percentage had a significant effect on the BCR on the Kaplan-Meier analysis. The tumor percentage rather than the tumor volume might be more useful to predict the prognosis of prostate cancer.

Prognostic Significance of Multifocal Tumor in Radical Prostatectomy / 대한비뇨기과학회지

PURPOSE: We investigate the impact of tumor multifocality on the biochemical recurrence rate after radical prostatectomy. MATERIALS AND METHODS: Data was collected from 525 patients who underwent radical prostatectomy for clinically localized prostate cancer from 2003 to 2007. We evaluated the potential associations of multifocality with various clinical and pathologic factors. The ability to predict extra-capsular extension(ECE) was tested by logistic regression models, whereas biochemical recurrence(BCR) was assessed via Kaplan-Meier analyses and Cox-hazard regression models. The BCR was defined as a level of serum prostate-specific antigen(PSA) of 0.2ng/ml or greater on consecutive evaluations. RESULTS: Multifocality was observed to be significantly associated with the presence of a high grade Gleason pattern(p=0.014), the pT stage(p< 0.001), ECE(p=0.005) and a positive surgical margin(PSM)(p=0.019). Moreover, it was the independent predictor of ECE on multivariate logistic regression analyses(p=0.039). However, although multifocality had a significant influence on biochemical recurrence on the Kaplan-Meier analyses (log rank test, p=0.019), only the PSA level and the Gleason score were significant predictors of BCR on the multivariated Cox-hazard analyses. CONCLUSIONS: Although multifocality was associated with adverse pathologic features, it had no significant effect on biochemical recurrence on the multivariated cox-hazard analyses.

Bilateral Neonatal Torsion of Testis / 대한비뇨기과학회지

Extravaginal neonatal testicular torsion, although it is rare, is being recognized with increasing frequency. Furthermore, bilateral neonatal torsion is very uncommon. Because of the seriousness of the outcome due to the risk of future anorchia, this condition that requires prompt recognition and careful decision making. We experienced a case in which the patient had bilateral neonatal testicular torsion and the patient showed bilateral necrotized testes during operation. However, the histopathologic findings during operation showed a small intact portion only in the left testis. Right orchiectomy and left orchiopexy were performed, and the left testis was saved. We report here on this case with a review of the literature.

Extramedullary Plasmacytoma of the Retroperitoneum / 대한비뇨기과학회지

Extramedullary plasmacytoma is an uncommon neoplasm and it occurs most frequently in the upper respiratory tract. Among the extramedullary plasmacytomas, retroperitoneal plasmacytoma is an extremely rare tumor with only about 10 cases having been reported in the world. Herein, we reported on a extramedullary plasmacytoma in the retroperitoneum. A 68-year-old man presented with left flank pain. The initial clinical diagnosis was retroperitoneal tumor. Retroperitoneal tumor mass excision along with left nephrectomy was performed and the histopathology showed plasmacytoma. There was no evidence of multiple myeloma. After the operation, he was treated with radiotherapy and the out-patient department follow-up is going on.

Urethral Dysfunction in a Non-Insulin Dependent Diabetes Mellitus Rat Model / 대한비뇨기과학회지

Purpose: We assessed whether urethral dysfunction related to nitric oxide (NO) is responsible for voiding dysfunction in rats with non-insulin dependent diabetes mellitus. Materials and Methods: A total of 27 male Sprague-Dawley rats (14 diabetic rats and 13 control rats) were included. Diabetes mellitus was induced by intraperitoneal administration of streptozotocin (90mg/kg) on the second day after birth. Cystometry with determining the detrusor leak point pressure (LPP) was performed in the diabetic and control rats at the age of 12 and 24 weeks. The effect of intravenous injection with L- nitro-arginine-methyl ester (L-NAME) as a NO inhibitor and sodium nitroprusside (SNP) as a NO donor were also evaluated. Results: Diabetic rats showed an increased bladder capacity and a higher detrusor LPP than the controls at both ages. After intravenous injection of L-NAME, the control rats showed an increased detrusor LPP, but no change was observed in the diabetic rats. With administering SNP, the detrusor LPP was decreased in both the diabetic and control rats. Conclusions: Urethral resistance was more increased in the diabetic rats than the controls, which may be the result of dysfunction of the urethral nerve containing NO. The urethral factor, in addition to cystopathy, also plays an important role for the pathogenesis of voiding dysfunction in diabetic patients.

Xanthogranulomatous Epididymitis / 대한비뇨기과학회지

Xanthogranulomatous epididymitis is extremely uncommon inflammatory disease of the epididymis that may result in massive destruction of the organ. It's clinical manifestation mimics epididymal tumor or abscess, which does not allow easy discrimination between theses diseases. We report here on a case of xanthogranulomatous epididymitis in a 69 years old man that, did not respond to antibiotic therapy.

The Relationship between Inflammation or Bacterial Infection according to the Traditional 4-glass Tests or Tc-99m Ciprofloxacin Imaging and the Scores of the National Institute of Health-Chronic Prostatitis Symptom Index in Men with Chronic Prostatitis / 대한비뇨기과학회지

PURPOSE: We wanted to determine whether inflammation and bacterial infection, as tested for by the traditional 4-glass test or Tc-99m ciprofloxacin imaging, correlate with the symptom severity in men with chronic prostatitis. MATERIALS AND METHODS: The study included 256 patients with symptoms of prostatitis. The Korean version of the National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) was used to measure the symptoms of each patient. To diagnose bacterial infection, four-glass tests were performed that included culture for general bacteria, Mycoplasma hominis and Ureaplasma urealyticum, and polymerase chain reaction was performed for Chlamydia trachomatis. The patients with established uropathogens localized to the expressed prostatic secretion or the voided urine 3 were classified as having chronic bacterial prostatitis (CBP). To further localize the infection, the single photon emission computerized tomography images were obtained 3 hours after intravenous injection of Tc-99m ciprofloxacin. Associations between the symptoms and the inflammation and infection were evaluated. RESULTS: Based on the 4-glass tests, the patients were classified as CBP (n=16) or as chronic pelvis pain syndrome (CCPS) (the inflammatory type, n=94; non-inflammatory type, n=146). The CBP patients had a higher pain score than did the CPPS patients and there were no significant differences in the subscores for voiding symptoms and the quality of life between the groups. No significant differences were found in the total score or the subscores of the NIH-CPSI based on the presence or location of infection on the Tc-99m ciprofloxacin imaging. CONCLUSIONS: These findings suggest that bacterial infection, not inflammation, as determined by traditional laboratory tests contribute to the symptoms, especially pain, in men with chronic prostatitis.