Experience with Laparoscopic Pyeloplasty, Including Robot-Assisted Laparoscopic Surgery, for Ureteropelvic Junction Obstruction

PURPOSE: Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction (UPJ) obstruction. We present our experience with the first 30 consecutive cases of laparoscopic pyeloplasty performed at our institution. MATERIALS AND METHODS: We studied 30 patients with ureteropelvic junction obstructions who underwent laparoscopic pyeloplasty between March 2004 and March 2009. Of the 30 patients, 5 patients underwent robot-assisted laparoscopic pyeloplasty (RALP) since April 2008. Patients were divided into 4 groups according to operative procedure: group 1, early laparoscopic pyeloplasty-dismembered (E/LP-D, n=9); group 2, late laparoscopic pyeloplasty-dismembered (L/LP-D, n=9); group 3, laparoscopic pyeloplasty-Fenger's method (LP-F, n=7); and group 4, RALP (n=5). RESULTS: The mean age of the patients was 34.0+/-12.8 years (range, 17-61 years). A crossing vessel was present in 37.9% of cases. Mean follow-up was 30+/-14 months (range, 11-62 months). Mean operative time was 267.3+/-78.7 minutes (range, 154-460 minutes), and the average length of the postoperative hospital stay was 4.6+/-1.6 days (range, 3-10 days). There were no intraoperative complications or transfusion. The success rate was 73.3%. The success rates of E/LP-D, L/LP-D, LP-F, and RALP were 6/9 (66.7%), 7/9 (77.8%), 5/7 (71.4%), and 4/5 (80%), respectively, without significant difference (p>0.05). Operation time and length of hospital stay were shorter in the L/LP-D group than in the E/LP-D group. CONCLUSIONS: Laparoscopic pyeloplasty may be an alternative treatment for an ureteropelvic junction obstruction, but the technical complexity of the procedure has made it difficult for many surgeons to adopt. RALP is a technically feasible management option for UPJ obstruction.

The Efficacy of Retrograde Intrarenal Surgery (RIRS) in the Management of Renal Stone Disease

PURPOSE: With recent technological advances, the indications for retrograde intrarenal surgery (RIRS) have gradually increased. We evaluated the efficacy and treatment outcomes of RIRS for the treatment of renal stones. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 23 patients with renal stones (7 in the renal pelvis, 9 in the renal calyx, and 7 in the renal diverticulum) treated with RIRS from January 2001 to July 2008. Mean stone burden was 110 mm2 (range, 9.42-428.6 mm2), and all operations were performed under general anesthesia using a semi-rigid ureteroscope in 9 cases, a flexible ureteroscope in 11 cases, and both types simultaneously in 3 cases. The holmium:yttrium-aluminum-garnet (Ho: YAG) laser and the nitinol basket were used for stone fragmentation and retrieval. The patients were followed up postoperatively with KUB (21 cases) or nonenhanced computed tomography (CT; 2 cases). Success was defined as no visible stones on KUB or nonenhanced CT. RESULTS: The mean operating time was 93 minutes (range, 30-205 minutes) and the mean hospital stay was 3.7 days (range, 1-9 days). Of 23 patients, 16 (70%) experienced complete elimination of the stone after only a single intervention. After ancillary extracorporeal shock wave lithotripsy (ESWL), the success rate was increased to 74% (17/23). In the remaining 6 patients, residual stone findings were less than 3 mm and were followed up with X-ray. CONCLUSIONS: RIRS is a feasible procedure for treating renal stone disease with minimal complications. The results of our study suggest that RIRS can be recommended as a primary modality in the management of renal stone disease in selected patients such as those with ESWL failure and renal diverticular stones.

The Effectiveness of Non-contrast Computerized Tomography (CT) in Evaluation Ofresidual Stones after Percutaneous Nephrolithotomy / 대한비뇨기과학회지

PURPOSE: The sensitivity of antegrade pyelogram (AGP), plain film radiography (KUB) and non-contrast, thin cut abdomen computerized tomography (CT) were prospectively compared for the detection of residual stones following a percutaneous nephrolithotomy. MATERIALS AND METHODS: Fifty patients (53 renal units), who had undergone a percutaneous nephrolithotomy for radiopaque renal pelvis stone, as well as a non-contrast abdomen CT 1 month postoperatively, were prospectively evaluated. The number and size of residual fragments, as determined by immediate postoperative AGP, postoperative 1 month KUB and abdomen CT, were compared. RESULTS: The stone-free rates according to the AGP, KUB and non-contrast CT were 73.6 (39/53), 62.3 (33/53) and 20.8% (11/53), respectively. In terms of clinically insignificant residual fragments (CIRFs), the success rates were 84.9 (45/53), 83.0 (44/53) and 41.5% (22/53), respectively. With respect to the residual stones (22 cases), which were detected by CT, but not by KUB, 45.5% (10 cases) were more than 4mm in size on CT, with a mean size of 7.4mm. The sensitivity for the detection of residual fragments was 47.6% for KUB compared to 100% for non-contrast CT. Seven patients received additional extracorporeal shock wave lithotripsy (ESWL) for residual stones following CT. CONCLUSIONS: Non-contrast, thin cut abdomen CT is the most accurate imaging modality for determination of the stone-free rate following a PCNL. Non-contrast abdomen CT gives accurate information for the selection of patients who may benefit from additional ESWL treatment and for follow-up planning.

Stress-Activated Protein Kinase/c-Jun NH2 Terminal Kinase (SAPK/JNK) Expression in Transitional Cell Carcinoma of the Urinary Bladder / 대한비뇨기과학회지

PURPOSE: The SAPK/JNK group of MAP (mitogen-activated protein) kinases is known to regulate cellular proliferation, apoptosis and tissue morphogenesis. This study was performed to assess the clinical usefulness of the SAPK/JNK for a bladder tumor. MATERIALS AND METHODS: Ninety-five bladder tumors and 23 normal bladder mucosa were included in this study. Expression of the phosphorylated and unphosphorylated forms of JNK1 and 2 were examined using western blot analysis. The relationship between JNK expression and the bladder tumor stage, grade, recurrence, survival and P53 expression level were analyzed. RESULTS: The unphosphorylated JNK1 level was higher in bladder tumors than in normal bladder mucosa. With respect to the stage, the absolute and relative values of the phosphorylated JNK1 were higher in superficial tumors than in invasive tumors, while those of unphosphorylated JNK1 were higher in invasive tumors. The phosphorylated JNK1 level also had a negative correlation with the tumor grade and recurrence. A positive correlation existed between the p53 expression level and the absolute values of unphosphorylated JNK1 and 2. CONCLUSIONS: Among the 3 isoforms, JNK1 plays a role in the development of a bladder tumor. Higher expressions of the inactive forms in a bladder tumor than in a normal control and the active forms in a low stage and grade tumor might support the hypothesis that the loss of JNK1 activation may contribute to tumorigenesis.

Comparison of Transverse Preputial Island Flap, Onlay Island Flap and Tubularized Incised Plate Urethroplasty for Proximal Hypospadias / 대한비뇨기과학회지

PURPOSE: Numerous operative techniques have been developed to correct proximal hypospadias. Transverse preputial island flap urethroplasty have provided reliable results for the repair of proximal hypospadias, and the versatility of the preputial flap led to its adaptation as an onlay flap that could be sewn onto an intact or preserved urethral plate. Recently, tubularized incised plate urethroplasty(Snodgrass procedure) have been reported with good results. We retrospectively analyzed our experiences with these three techniques to know which procedure is recommendable for repair of proximal hypospadias. MATERIALS AND METHODS: Between January, 1994 and June, 1998, 44 patients underwent repair for the proximal hypospadias by a single surgeon using an transverse preputial island flap(21), onlay flap(16) and tubularized incised plate(7) procedure. We analysed the surgical outcome such as surgical complications according to each procedures. RESULTS: Postoperative complication rate was 57% for transverse preputial island flap, 13% for onlay flap and 14% for tubularized incised plate procedure. The rate of fistula formation were 42%, 13% and 14%, respectively. One diverticulum and two strictures were developed in three patients who underwent transverse preputial island flap procedure, whereas no diverticulum or stricture was developed after onlay or tubularized incised plate procedure. Cosmetic results were excellent in tubularized incised plate urethroplasty. CONCLUSIONS: Onlay or tubularized incised plate urethroplasty using an preserved urethral plate had better outcomes compared to the transverse preputial island flap procedure. The technique using urethral plate could be recommendable as first choice for proximal hypospadias although transverse preputial island flap procedure is worthy to be considered for more complicated cases.

Two-year Experiences of Ureteral Stones: SWL Versus Ureteroscopic Manipulation / 대한비뇨기과학회지

PURPOSE: Shockwave lithotripsy(SWL) and ureteroscopic manipulation became the standard treatments for ureteral stones in recent years. There still exists significant debate as to the most appropriate treatment modality for ureteral stone management. MATERIALS AND METHODS: From January 1994 to December 1995, 651 patients of ureteral stones were treated and 589 patients were retrospectively reviewed excluding 62 patients for incomplete follow ups. Four hundred and forty-two patients were treated with SWL using MPL 9000 with ultrasonic guidance, 115 patients with ureteroscopic manipulation using 7.9 to 11.5Fr rigid and semirigid ureteroscopes. RESULTS: In SWL treatments, overall stone free rate was 74.7% with one session, Stone free rate was significantly affected by the size of stones. Stone free rate was 83.6% when the stone was smaller than 1.0cm and 42.1% when the stone was larger than 1.0cm Stone free rate after second SWL session was 84.4% and 90.3% after third session. The stone free rates according to the site of stones were 72.4(proximal), 70.0(mid), 80.2(distal), respectively. In ureteroscopic manipulation, overall stone free rate of 87.8% was obtained regardless of the size of stones. The success rates according to the location of stones were 75.0(proximal), 94.6(mid), 86.4%(distal), respectively. Open ureterolithotomy was performed in 32 patients with 100% success rate. CONCLUSIONS: In our study, the size of stones was the most important factor influencing the success rate of SWL treatment for ureteral stones. We consider ureteroscopic manipulation as the first line treatment modality when the stone is larger than 1.0cm, especially in distal ureter, Proper selection of patients for in situ SWL or ureteroscopy would improve the results of initial treatment.

Use of Serum PSA in Comparison of Biopsy Gleason Score with Radical Prostatectomy Gleason Score / 대한비뇨기과학회지

PURPOSE: The Gleason score of needle biopsies of the prostate and preoperative serum level of prostate-specific antigen(PSA) are two useful factors in predicting the final pathological staging of patients with prostate cancer treated by radical prostatectomy. Unfortunately, the Gleason score of the biopsy cores often differs from the Gleason score of radical prostatectomy specimen. We evaluated the role of Gleason scores of biopsy cores and the influence of PSA in predicting the Gleason scores of prostatectomy specimens and final pathological staging. MATERIALS AND METHODS: The records of 52 patients with prostate cancer treated by radical prostatectomy from June 1990 to June 1997 were reviewed. The patients were divided into three groups according to the sum of the Gleason scores, i.e. well differentiated(Gleason score 2-4), intermediate(5-7) and poorly differentiated tumors(8-10). The concordance between Gleason score of biopsy and prostatectomy specimen was analysed according to the Gleason score of tumor in biopsy specimen. Furthermore, we evaluated the different level of PSA could affect the concordance rate between Gleason scoreofbiopsyandprostatectomyspecimen. RESULTS: In well-differentiated tumors(Gleason score 2-4) in biopsy specimen, the concordance rate was 55.6%, In intermediate(5-7) differentiated cancers the Gleason score remained the same in 68%. In poorly differentiated tumors, the concordance rate was 72.2%. When PSA was less than 10ng/m1, concordance rate of well differentiated tumors and poorly differentiated tumors was 75%, 40%, respectively. Whereas the concordance rate of well differentiated tumors was 50% and that of poorly differentiated tumors was 90% when the PSA was higher than 20ng/m1. Using linear regression analysis, the preoperative PSA highly correlated with radical prostatectomy Gleason score(correlation coefficient(r)=0.38, p =0.005). CONCLUSIONS: The Gleason score of prostatectomy specimen was upgraded in 44.4% when the biopsy Gleason score was well differentiated, especially when preoperative PSA was higher than 20ng/m1. Therefore, the significance of biopsy Gleason score in the clinical application must be used cautiously when it is used to predict the pathological stage or biological potential of the cancer especially when it is low Gleason score with high PSA( > 20ng/m1). In the meantime, the level of PSA plays an significant role in determining organ confined disease, while high Gleason scone reflect the Iymph node positive disease.

Diagnostic Efficacy of Biochemical Studies and MIBG Scan in Pheochromocytoma / 대한비뇨기과학회지

We evaluated the role of clinical symptoms, biochemical studies and metaiodobenzylguanidine (MIBG) scan in the diagnosis of pheochromocytoma. From August 1991 to June 1997, 42 patients with complaints of hypertension or adrenal mass were evaluated with MIBG scan, 24 hour urinary vanillylmandelic acid (VMA), serum and 24 hour urinary catecholamine and radiologic studies such as CT, MRI or ultrasonography. Initial 9 patients were evaluated with 131 I-MIBG scan and the rest 33 patients with 123 I-MIBG scan. Of 42 patients, histologic diagnosis was obtained in 32 patients including 23 patients with pheochromocytoma or paraganglioma and 9 patients with other adrenal or extra-adrenal tumors. Remaining 10 patients had no evidence of adrenal disease on radiologic studies. Paroxysmal symptoms or hypertension was noted in 14 patients with pheochromocytoma or paraganglioma, while it was also found in 12 out of 19 patients without pheochromocytoma or paraganglioma. Sensitivity, specificity and positive predictive value (PPV) of each diagnostic modality were 60.9%, 92.9% and 93.3% in 24 hour urinary VMA, 61.9%, 75.0%, and 81.3% in 24 hour urinary catecholamine, 82.6%, 94.7%, and 95.0% in MIBG scan, respectively. Sensitivity and specificity were improved to 86.9% and 100% when 24 hour urinary VMA and MIBG scan were combined. In conclusion, MIBG scan was the most useful single screening method for the diagnosis of pheochromocytoma, and combination of MIBG scan and 24 hour urinary VMA would enhance the diagnostic accuracy.

Role of Clinical Stage, PSA and Gleason`s Score in Predicting Pathologic Outcome in Prostate Cancer / 대한비뇨기과학회지

Preoperative clinical staging in the prostate cancer does not always accurately predict the surgical-pathological outcome. We evaluated how the clinical staging, and other clinical parameters including preoperative PSA and Gleason`s score could reflect on the surgicopathological findings in 30 patients with prostate cancer, who underwent radical prostatectomy. Twelve of 24 patients with clinical T1 or T2 disease were understaged by clinical staging determined by digital rectal examination, bone scan, and radiologic studies including CT and MRI with endorectal coil. MRI with endorectal coil accurately reflected the extracapsular disease only in 59.1% of 22 patients studied. At the same time, it also showed low sensitivity (50%) with high specificity (100%) in detecting lymph node metastasis. Preoperative levels of PSA in patients with P2, P3, and N+ disease were 17.8 +/- 4.5, 47.9 +/- 11.3, 93.5 +/- 20.5ng/ml, respectively. The level of PSA was less than 20ng/ml in 9 of 12 patients with P2 disease, while they were greater than 20ng/ml in 9 of 12 patients with P3 disease. PSA may have a role to rule out lymph node metastasis when its level is less than 10ng/ml, although it did not reach the statistical significance because of small sample size. Gleason`s scores in patients with P2 disease were quite similar to those in patients with P3 disease (5.92 +/- 0.69 vs 5.67 +/- 0.56), whereas Gleason`s scores in all 6 patients with N+ disease were 9 or greater. Neoadjuvant hormonal therapy with LH-RH analogue and androgen receptor blocker for 1.5 to 3 months had no impact on the reduction of margin positivity or downstaging in 10 patients. PSA failure rate in patients with P2 and P3 disease was 25% at 1 year after operation. PSA is a good marker for differentiating between P2 and P3 disease (,p=0.0214) and can safely rule out N+ disease if its level is below 10ng/ml, while Gleason`s score may reflect the lymph node metastasis when it is 9 or greater (p=0.0012). Among the candidates for radical prostatectomy, selection of the patients on the basis of PSA and Gleason`s score might improve the surgical-pathological outcome.

Fluoxetine as a Treatment for Premature Ejaculation: A Double-Blind, Randomized, Placebo-Controlled Study / 대한비뇨기과학회지

Premature ejaculation is the most common male sexual dysfunction and defined as persistent or recurrent occurrences of ejaculation before or shortly after penetration. But there has never been any effective oral agents for the patients with premature ejaculation. Recently, fluoxetine, a potent serotonin reuptake inhibitor, being used as antidepressant, has been suggested to be helpful for the patients with premature ejaculation. Twenty three male outpatients with premature ejaculation were randomly divided into fluoxetine (n=12) and placebo (n=11) group. In the fluoxetine group, the dose of fluoxetine was 20 mg/day for the first one week and 40 mg/day for the remaining 5 weeks. Patient and his female partner were interviewed separately before starting medication, three weeks and six weeks after medication. The mean intravaginal ejaculation latency time increased to 187.5 seconds after 3 weeks and 254.2 seconds after 6 weeks front 46.7 seconds before treatment (p<0.05). Only 1 out of 12 patients in the fluoxetine group was able to have thrusts over 30 times before treatment. After 3 weeks of Treatment, 8of 12 patients and after 6 weeks of treatment, 7 patients were able to have thrusts over 30 times. There was no significant improvement of intravaginal ejaculation latency time and number of thrusts in the placebo group. Symptomatic improvement was noticed in 75% with fluoxetine group and 18.2% with placebo group. Side reactions of fluoxetine, fatigue and yawning, were noticed in 41% of the patients, but they did not interfere with their daily activities. These findings suggest that fluoxetine can be safely used as a good pharmacotherapeutic treatment for the patients with premature ejaculation.

Role of Prostate Specific Antigen, Digital Rectal Examination and Transrectal Ultrasound in the Diagnosis of Prostate Cancer / 대한비뇨기과학회지

We evaluated the role of prostate specific antigen(PSA), digital rectal examination(DRE) and transrectal ultrasound(TRUS) in the diagnosis of prostate cancer. Of 93 patients with pathologically proven diagnosis, 19 patients had prostate cancer and 68 patients had BPH, while remaining 6 patients had other benign prostatic disease. Among the patients with prostate cancer, 17 patients had elevated PSA level(89%) and most of their PSA levels elevated above 10ng/ml(79%), while 2 patients with stage A disease had normal PSA level. Of 26 patients whose PSA levels were between 4 and 10microgram/ml, only 2 patients had prostate cancer(7.7%). However, these patients had significantly elevated PSA density compared to others. The positive predictive value of PSA, DRE and TRUS was 27%, 44% and 40% respectively. DRE and TRUS had 56% and 58% positive predictive value in patients with elevated PSA level in contrast to 0% positive predictive value of DRE and TRUS in patients with normal PSA level. When all three methods were combined, the positive predictive value rose to 67%. Although positive predictive value of DRE and TRUS was 44 and 40 % respectively, these methods appeared to be valuable when PSA level elevated concomitantly. Our data suggest that prostate biopsy should be performed in patients with elevated PSA level above 10ng/ml and PSA density might be valuable in patients with marginal PSA level (4-10ng/ml).