Ureteral Injury in Gynecologic Surgery: A 5-Year Review in A Community Hospital

PURPOSE: We reviewed the cases of ureteral injury during gynecologic surgeries in a community hospital and attempted to find possible options for alleviating these distressing situations. MATERIALS AND METHODS: A total of 2,927 patients underwent gynecologic surgeries in the last 5 years at our hospital. We retrospectively analyzed the cases, particularly the possible risk factors and management according to the time of detection of the injury. Thirty-five cases (1.2%) were identified with ureteral injury in a total of 2,927 gynecologic surgeries. Risk factors included endometriosis, pelvic inflammatory disease, previous pelvic surgery, history of pelvic radiation, and congenital anomalies. Among 2,927 patients, 522 had predisposing factors for ureteral injuries. RESULTS: The incidence of ureteral injury in laparoscopic cases was 1.1%, similar to the cases of laparotomy (1.2%). The rate of ureteral injury was significantly higher in the group with risk factors (2.7%) than in the group without risk factors (0.9%; p=0.002). Prophylactic ureteral stenting was performed in 101 of 522 patients with risk factors according to the gynecologic surgeon's preference. The injury rate (1.0%) in the stenting group was lower than that in the non-stenting group (3.1%; p=0.324). Management of ureteral injuries was successful in all cases. Of the patients with postoperatively diagnosed injuries, two patients were managed with secondary procedures, such as retrograde balloon dilatation or ureteroneocystostomy. CONCLUSIONS: The incidence of ureteral injury was significantly higher in cases having risk factors than in cases without risk factors. Surgeons should be cautious to avoid ureteral injury during gynecologic surgery, especially in patients with risk factors.

Palliative Care of Malignant Ureteral Obstruction with Polytetrafluoroethylene Membrane-Covered Self-Expandable Metallic Stents: Initial Experience

PURPOSE: We assessed the efficacy and safety of insertion of a polytetrafluoroethylene membrane-covered self-expandable metallic stent (UVENTA stent) for palliation of malignant ureteral obstruction on the basis of our early results. MATERIALS AND METHODS: Eighteen patients underwent UVENTA stent insertion for extrinsic malignant ureteral obstructions of 20 ureters. The UVENTA stents were deployed retrogradely under cystoscopy and fluoroscopy. Candidates for the procedure had preexisting double-J stents that were nonfunctional or caused excessive bladder irritation. We recorded the success and patency rate in addition to any complications associated with the procedure. RESULTS: The mean length of obstruction was 10.6 cm (range, 2 to 20 cm). Two ureters were obstructed in the upper ureter, 9 in the lower ureter, and 9 in multiple levels of ureter. Simultaneous balloon dilation was performed in 12 ureters. UVENTA stents were successfully inserted in all patients. No obstruction of the UVENTA stents occurred during the mean follow-up period of 7.3 months (patency rate 100%), but de novo ureteral obstruction developed in 4 ureters. There were no instances of stone formation, hyperplastic reaction, encrustation, or migration. Abnormally elevated serum creatinine decreased to normal levels and hydronephrosis gradually resolved during the 4 weeks after UVENTA insertion. No significant complications developed except for transient and self-limiting hematuria and mild lower abdominal pain. CONCLUSIONS: UVENTA stents may relieve malignant ureteral obstruction safely and easily. Long-term follow-up is necessary to assess the role of this stent in the treatment of malignant ureteral obstruction.

Voiding and Sexual Function after Autonomic-Nerve-Preserving Surgery for Rectal Cancer in Disease-Free Male Patients

PURPOSE: We evaluated the effects of surgery for rectal cancer on postoperative voiding and sexual function over the course of time. MATERIALS AND METHODS: Data from 28 patients who underwent autonomic nerve preserving rectal cancer surgery were retrospectively analyzed. Operations were performed between October 2005 and July 2007 and all patients were followed-up for more than 3 years. Preoperatively, all patients underwent urodynamic studies including uroflowmetry, and filled out the International Prostate Symptom Score (IPSS). The evaluation of sexual function consisted of Erectile Function domain score in International Index of Erectile Function (IIEF-EFD) and Ejaculation domain score in Male Sexual Health Questionnaire (MSHQ-EjD). Data from uroflowmetry and questionnaires were examined. RESULTS: At 3 years postoperatively the prostate volume was similar to the preoperative value (P=0.727). There were no statistically significant postoperative changes in the average maximum flow rate (15.9 ml/s vs. 16.2 ml/s, p=0.637) and post-void residual urine volume (34.7 ml vs. 36.8 ml, p=0.809). No statistically significant differences were observed in the IPSS (13.2 vs. 12.2, p=0.374). However, although pelvic autonomic nerve preservation have been performed, a significant proportion of rectal cancer patients suffer from sexual dysfunction and the average of IIEF-EFD and MSHQ-EjD scores was decreased postoperatively until 3 years (25.1 vs. 16.1 and 28.3 vs. 14.2 respectively, p<0.001). CONCLUSIONS: Voiding function was not affected after autonomic nerve-preserving rectal cancer surgery, however sexual function was significantly aggravated. We recommend that the baseline genitourinary function should be evaluated before the treatment for male rectal cancer patients, and penile rehabilitation is necessary for their quality of life after treatment.

Predictive Factors for Upgrading or Upstaging in Biopsy Gleason Score 6 Prostate Cancer

PURPOSE: Although biopsy Gleason score (GS) 6 prostate cancers are expected to demonstrate a more indolent clinical course than those with GS 7 or higher cancers, substantial proportion reveal upgrading or upstaging on final pathology. We investigated predictive factors of upstaging or upgrading after radical prostatectomy (RP) in biopsy GS 6 prostate cancers. MATERIALS AND METHODS: A total of 133 patients with biopsy GS 6 prostate cancer who underwent radical prostatectomy between March 2004 and March 2008 were reviewed. Patients were divided into 4 groups according to the number of positive biopsy core: single positive core (group 1, n=53), 2 (group 2, n=29), 3-5 (group 3, n=39) and 6 or more cores (group 4, n=12). We investigated the value of preoperative variables (age, PSA, Clinical stage, number and laterality of positive core, maximal core length, maximal core percentage) in predicting GS upgrading or upstaging in final pathology. RESULTS: Among all subjects, 70 (52.6%) were upgraded to GS 7 or higher and 29 (21.8%) were upstaged to pT3 at final pathology. Upgrading rates were 39.6%, 55.2%, 56.4% and 91.7%, and upstaging rates were 13.2%, 13.8%, 28.2% and 58.3% for groups 1, 2, 3 and 4, respectively. The upgrading and upstaging rates were similar among groups 1, 2 and 3, but were significantly higher in group 4 compared to the others. In multivariate analysis, number of positive cores 6 or more was the only factor significantly predictive of upgrading or upstaging following RP. No preoperative variables were observed to predict upgrading or upstaging following RP in patients with 5 or less positive biopsy cores. CONCLUSIONS: Of patients with only one or 2 positive core GS 6 prostate cancers, substantial proportion of cancers upgraded or upstaged in RP specimens, but no predictive factor could be identified. We should keep in mind these when counseling patients.

Management of Urethral Fistulas and Strictures after Hypospadias Repair / 대한비뇨기과학회지

PURPOSE: Urethrocutaneous fistulas and urethral strictures are the most frequent complications after hypospadias repair. We reviewed outcomes after surgical repair of these complications to evaluate the factors determining successful outcome. MATERIALS AND METHODS: In 60 patients with fistula or stricture after hypospadias repair performed between September 1993 and January 2008, we reviewed incidences, clinical features, and outcome after repair with respect to initial hypospadias types. RESULTS: Fistulas were observed in 42 patients and were surgically repaired in 39 (92.8%). In 8 (19.0%) and 3 (7.1%) patients, concurrent meatal and urethral strictures were noted, respectively. The number of fistulas was single in 38 (90.5%) and 2 in 4 (9.5%) patients. Fistulas occurred most frequently from the penoscrotal type hypospadias (22/65, 33.8%) and had initially undergone transverse preputial island flap repair (13/26, 50%). Complete excision of the fistulous tract and multilayer advancement flap closure was the most common method for fistula repair (24), followed by cross-suture in 9 and repeat urethroplasty in 6. Initial management was successful in 35 (89.7%) patients. Urethral strictures were observed in 16 patients with equal incidences at the meatus and the other portion of the urethra. Successful outcome was achieved in all metal stenosis after repeat meatoplasty, whereas for urethral strictures, 4 (20%) patients who underwent visual urethrotomy experienced recurrent strictures. CONCLUSIONS: Urethrocutaneous fistulas can be successfully repaired by complete excision and cross-suture closure and multiple coverage with healthy tissues. In urethral strictures, reconstruction of ample neo-meatus is the key to achieving sufficient stream regardless of the stricture site.

CyberKnife(TM) for the Treatment of Non-Metastatic Prostate Cancer

PURPOSE: The radiobiology of prostate cancer favors a hypofractionated dose regimen. We report here our experience with the CyberKnife(TM), demonstrating its efficacy, safety, and feasibility as a treatment modality for non-metastatic prostate cancer. MATERIALS AND METHODS: Between October 2002 and April 2006, 20 patients with biopsy-proven prostate cancer were treated with the CyberKnife(TM). The distribution of clinical risks, as assessed by using D'Amico's definition for risk grouping, was as follows: low (4), intermediate (5), and high (11). Three patients received 32 Gy, 7 patients received 34 Gy, and 10 patients received 36 Gy. All patients received the radiation doses in 4 fractions. The rectal and bladder toxicities were graded by using the criteria set forth by the Radiation Therapy Oncology Group (RTOG). RESULTS: The mean patient age was 71.4 years (range, 52-79 years), and the mean follow-up period was 35.5 months (range, 8-74 months). There were 2 acute and 1 late grade 2 gastrointestinal toxicities, and 1 acute and 2 late grade 2 urinary toxicities. The 5-year overall survival rate was 100%, respectively. The 5-year biochemical failure-free rate of the low-risk, intermediate-risk, and high-risk patients was 100%, 100%, and 90.9%, respectively. CONCLUSIONS: CyberKnife(TM) is a safe, well-tolerated, and rather effective treatment for non-metastatic prostate cancer. We obtained a 100% 5-year biochemical failure-free rate in low-risk and intermediate-risk patients. CyberKnife(TM) is a viable option for the treatment of non-metastatic prostate cancer.

Recovery of the Spontaneous Erections after Radical Prostatectomy with Early Tadalafil Treatment / 대한남성과학회지

PURPOSE: We evaluated the efficacy of tadalafil for the treatment of erectile dysfunction after nerve-sparing radical prostatectomy. MATERIALS AND METHODS: From April 2004 to February 2005, 28 patients who underwent nerve-sparing radical prostatectomy agreed this study and were enrolled. The subjects were divided into 2 groups: tadalafil group(n=15) and control group(n=13). The tadalafil group started medication(20 mg, 2 or 3 times a week) when daily pad requirement was less than 1(pad-free point, mean 74th day postoperatively). Efficacy assessments included the score on the International Index of Erectile Function(IIEF), erectile function domain(EF domain) and Sexual Encounter Profile questions 2(SEP2), and 3(SEP3). Questions were administered in the preoperative phase, pretreatment, and 6 months post-treatment. RESULTS: The preoperative score for the IIEF and EF domain were 46.0 and 18.5 in the tadalafil group and 44.8 and 17.9 in the control group, respectively(p>0.05, p>0.05). At pad-free point, the IIEF and EF domain scores in the tadalafil group were 9.8+/-7.5, 2.7+/-2.7 and in the control group 10.0+/-6.8, 3.1+/-2.5. The scores were reduced significantly at the pad-free point compared to the preoperative phase, but there was no significant difference between the 2 groups. At 6 months after treatment, the scores for the tadalafil group were 26.6+/-18.2, 10.3+/-7.3 and had increased significantly(p<0.05, p<0.05). There was a borderline difference in the EF domain score between the 2 groups(p=0.085). Four patients in the tadalafil group(26.7%) and 1 patient in the control group(7.7%) could penetrate successfully. CONCLUSIONS: Although there was no statistical significance between the 2 groups, early tadalafil treatment after nerve-sparing radical prostatectomy may enhance the early recovery of erectile function.

Continuing Trends of the Clinical Parameter Migration in Patients with Prostate Cancer in Korea / 대한비뇨기과학회지

PURPOSE: With the widespread use of screening for prostate-specific antigen (PSA), T1c prostate cancer has shown a marked increase in Western countries. We reviewed the trends in clinical stage migration and the changes in the clinical characteristics for patients with prostate cancer in Korea, and we compared these values with those of Western men. MATERIALS AND METHODS: Between 1997 and 2006, 758 men (mean age: 68.6 years) were diagnosed with prostate cancer at our institution. According to the diagnostic period, the patients were divided into 3 groups (the 1997-2000, 2001-2003 and 2004-2006 groups) for comparative analysis of the clinical stage, the serum PSA level and the biopsy Gleason score. RESULTS: The proportion of clinically localized prostate cancer significantly increased by the period (56.8%, 62.5% and 75.4%, respectively; p<0.001) with that of metastatic disease showing a decreasing according to groups (40.0%, 27.5% and 17.6%, respectively; p<0.001). For localized disease, T1c cancers also increased from 26.4% to 19.2% to 31.6% (p=0.002), respectively. The median serum PSA level at diagnosis decreased from 34.5 ng/ml to 16.6ng/ml to 10.8ng/ml (p<0.001), respectively, with the proportion of patients with a PSA level< or =10ng/ml increasing significantly (19.2%, 33.3% and 47.7%, respectively; p<0.001). Although the proportion of biopsy Gleason scores that were 8-10 decreased from 71.2% to 50.2% to 38.3%, respectively, it still comprised 20.8% of the T1c cancers and 22.8% of the cancers with a PSA< or =10ng/ml in the last period, and these values were significantly higher than those in the Western reports. CONCLUSIONS: Downward migration of the clinical stage along with decreases for the serum PSA level and biopsy Gleason score were evident in Korean men. However, the proportion of T1c cancer was still lower than that in the Western series and the fraction of Gleason score 8-10 cancer was distinctively high. We believe this mandates establishing PSA screening programs and administering vigorous management.

The Effect of Neoadjuvant Hormonal Treatment in Prostate Cancer on Biochemical Recurrence / 대한비뇨기과학회지

PURPOSE: When combined with surgery, neoadjuvant hormonal therapy (NHT) has not demonstrated a significant benefit for meaningful clinical endpoints such as progression-free survival or overall survival. We evaluated the effect of NHT on prostate cancer. MATERIALS AND METHODS: From 1995 to 2004, 519 patients underwent radical retropubic prostatectomy(RRP). One-hundred thirty of them were included in this retrospective case-control study and they were assessed for age, the preoperative prostate-specific antigen(PSA) level, the clinical stage and the biopsy Gleason score(GS). The subjects were divided into two groups: the RRP only group(n=65) and the NHT group(n=65), and these were matched for the 3 above mentioned parameters. The protocols for NHT were maximal androgen blockade(n=40), antiandrogen only(n=8), and LHRH analogue only(n=17). Biochemical recurrence was defined as a level of serum PSA of 0.2ng/ml or greater on 2 consecutive evaluations. RESULTS: The mean age of the RRP only group and the NHT group was 64.2 and 63.5, respectively(p>0.05). The rates of a positive surgical margin and biochemical recurrence in the NHT group were 49.2% and 42.5%, respectively, and they were 46.2% and 46.2%, respectively, in RRP only group, and there was no statistical difference between the two groups. In high risk patients(clinical stage> or =T3, biopsy GS> or =8, serum PSA>20ng/ml), NHT group was not differences compared with the RRP group. Neither the duration (3 months vs. 6 months) of NHT nor the regimens of NHT improved the clinical and surgical outcome. CONCLUSIONS: NHT did not improve biochemical recurrence and the positive surgical margin.

The Serum Selenium Level in Korean Men and Its Association with Age and Prostate Cancer / 대한비뇨기과학회지

PURPOSE: It has been suggested that selenium is protective against prostate cancer. We examined serum level of selenium in Korean men and we investigated the association of the serum selenium level with age and prostate cancer. MATERIALS AND METHODS: The study included 390 Korean men (112 cases that were pathologically diagnosed as prostate cancer and 278 controls with normal digital rectal examination and a prostate-specific antigen (PSA) level less than 4.0ng/ml). The serum selenium concentration was compared between the prostate cancer patients and the control group, and the association with the age range and cancer stage was investigated. RESULTS: The mean serum selenium level of the prostate cancer patients was 110.2ng/ml and mean serum selenium level of control group was 116.8ng/ml. The selenium level of the prostate cancer patients was lower than that of the control group, but there was no significant difference (p= 0.250). There was no association between the selenium level and age (fifth decade: 116.5ng/ml, sixth decade: 113.9ng/ml, seventh decade: 118.5ng/ ml, eighth decade: 111.4ng/ml, p=0.589). In addition, selenium concentration was not associated with stage of prostate cancer (localized: 102.8ng/ ml, locally advanced: 118.0ng/ml, metastatic: 109.0ng/ml, p=0.578). CONCLUSIONS: The mean serum selenium level of Korean men is lower than that of western men (126-136ng/ml). This result may be associated with the lower selenium content in Korean soil and food. There was no consistent change in the serum selenium level according to age. The association between the serum selenium and the risk of prostate cancer needs further investigation.