Robotic Simple Prostatectomy: Why and How? / 대한배뇨장애요실금학회지

Increasingly many studies have presented robotic simple prostatectomy (RSP) as a surgical treatment option for large benign prostatic hyperplasia (BPH) weighing 80–100 g or more. In this review, some frequently used RSP techniques are described, along with an analysis of the literature on the efficacy and complications of RSP and differences in treatment results compared with other surgical methods. RSP has the advantage of a short learning curve for surgeons with experience in robotic surgery. Severe complications are rare in patients who undergo RSP, and RSP facilitates the simultaneous treatment of important comorbid diseases such as bladder stones and bladder diverticula. In conclusion, RSP can be recommended as a safe and effective minimally invasive treatment for large BPH.

Estramustine Phosphate Monotherapy in Castration-Resistant Prostate Cancer Patients Who Cannot Receive Cytotoxic Chemotherapy

Purpose@#To investigate whether estramustine phosphate (EMP) monotherapy is applicable to castration-resistantprostate cancer (CRPC) patients who cannot receive cytotoxic chemotherapy. @*Materials and Methods@#This retrospective single-arm study was conducted in CRPC patients who had notexperienced cytotoxic chemotherapy and received EMP monotherapy (560 mg/day) at 2 institutions from 2008to 2017. We analyzed prostate-specific antigen (PSA) responses, overall survival, and adverse effects of EMPtreatment. @*Results@#A total of 28 patients were analyzed. A reduction in serum PSA was observed in 11 patients (39.3%).Seven cases (25.9%) achieved more than 25% reduction of PSA, and 5 of them (18.5%) experienced more than50% reduction. Median overall survival was 23 months (interquartile range, 10–60 months). Multivariable analysesdemonstrated that low level of PSA at diagnosis of CRPC and long duration of prior androgen deprivation therapywere independent favorable factors predicting long-term overall survival. Adverse effects were edema (n=2; grade2), nausea/vomiting (n=1; grade 2), gynecomastia (n=1; grade 2), and dyspnea (n=1; grade 1). Neither thromboembolicevent nor grade 3–5 toxicity was observed. There was no discontinuation caused by side effects ofEMP. @*Conclusions@#EMP monotherapy could be considered as a safe treatment option with some effectiveness for CRPCpatients who did not undergo cytotoxic chemotherapy. EMP is not generally recommended anticancer drug in thecurrent guidelines for CRPC, but EMP monotherapy is thought to have an alternative role when a standard treatmentcannot be selected due to patient's age, health condition, or comorbidity.

Silencing of Heat Shock Protein 27 Expression Accelerates Doxazosin-induced Apoptosis in Prostate Cancer Cell Line PC-3

PURPOSE: Heat shock proteins (HSPs) are highly expressed during stress responses and cellular adaptation to environmental changes. One such protein is HSP27, a 27kDa protein that prevents cell death induced by many pro-apoptotic agents. Therefore, the aim of this study was to investigate the correlation between HSP27 expression and apoptosis induced by doxazosin treatment in prostate cancer cell line PC-3. MATERIALS AND METHODS: RT-PCR, Western blotting, and immunocytochemical staining were performed to determine whether HSP27 mRNA and protein are expressed in PC-3 cells. Next, to investigate the effects of doxazosin on apoptosis and HSP27 protein expression in PC-3 cells, the cells were stained using a TUNEL kit (to detect apoptotic cells) and with HSP27 antibody (to assess HSP27 protein expression) 6, 12, 24, and 48h after treatment with 25microM doxazosin. In addition, to determine whether HSP27 mRNA interference accelerates doxazosin-induced apoptosis of PC-3, we knocked down HSP27 with siRNA and then evaluated the rate of apoptosis after doxazosin treatment. RESULTS: HSP27 mRNA and protein were expressed in PC-3 cells. Furthermore, HSP27 mRNA and protein levels increased until 12 hours after 25microM doxazosin treatment, whereas the rate of apoptosis did not increased dramatically. After 12 hours, HSP27 expression decreased and then apoptosis was accelerated. In addition, siRNA-mediated knockdown of HSP27 induce higher apoptosis rate of PC-3 cells even before 12hrs after doxazosin treatment. CONCLUSIONS: By inhibiting apoptosis, HSP27 expression might play an important role in inhibiting progression to castration-refractory prostate cancer and resistance to anti-cancer treatment.

Effect of Transurethral Resection of the Prostate Based on the Degree of Obstruction Seen in Urodynamic Study

PURPOSE: We retrospectively investigated the effect of transurethral resection of the prostate (TURP) on the basis of the degree of obstruction seen in preoperative urodynamic study in patients with benign prostatic hyperplasia (BPH) who complained of lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: The subjects of this study were 285 patients who were diagnosed with BPH with LUTS and who subsequently underwent TURP. The Abrams-Griffiths number was calculated from the urodynamic results to divide the patients into the following groups: unobstructed, equivocal, and obstructed. There were 26 patients (9.1%) in the unobstructed group, 98 patients (34.4%) in the equivocal group, and 161 patients (56.5%) in the obstructed group. The preoperative and postoperative uroflowmetry, residual urine, International Prostate Symptom Score (IPSS), and quality of life (QoL) score were compared between the three groups to evaluate the outcome of the treatment. RESULTS: The reduction in the IPSS was 14.4 in the obstructed group, which was higher than the reductions of 12.7 in the equivocal group and 9.5 in the unobstructed group, but this difference was not statistically significant (p=0.227). The QoL score was also not significantly different across the three groups (p=0.533). The postoperative maximum flow rate was significantly improved in all three groups. The obstructed group had an improvement of 7.8+/-7.2 mL/s, which was higher than the improvement of 3.7+/-6.2 mL/s in the unobstructed group (p=0.049) but was not significantly different from the improvement of 5.6+/-6.9 mL/s in the equivocal group (p=0.141). CONCLUSIONS: TURP led to an improvement in the maximum flow rate and LUTS even in BPH patients without BOO. Therefore, TURP can be expected to improve LUTS in BPH patients without definite urodynamic obstruction.

Experience With Robot-Assisted Laparoscopic Radical Prostatectomy at a Secondary Training Hospital: Operation Time, Treatment Outcomes, and Complications With the Accumulation of Experience

PURPOSE: To investigate the learning curve and outcomes of robot-assisted laparoscopic radical prostatectomy (RALP) performed by a relatively lower volume surgeon at a secondary training hospital. MATERIALS AND METHODS: The medical records and the surgery video recordings of 100 patients who underwent RALP by a single surgeon between March 2010 and January 2013 were reviewed. The first 10 cases were grouped into period 1, cases 11 to 40 into period 2, cases 41 to 70 into period 3, and cases 71 to 100 into period 4. The interval between the operations, the operative time for each step of the surgery, the total console time, and the operative outcomes were investigated. RESULTS: The mean interval between surgeries was 10.6+/-9.3 days. The console time decreased progressively after the first 10 cases and reached under 3 hours after 75 cases. The time taken to begin dissection of the dorsal vein complex, for the division of the bladder neck, for lateral dissection with neurovascular bundle preservation, and for apex dissection decreased significantly with experience, although the time for vesicourethral anastomosis did not. The margin-positive rate of stage T2 patients was 27.4% (20/73), and the transfusion rate was 50% in period 1 patients and 3.3% in period 4 patients. No major complications occurred. CONCLUSIONS: It is difficult to shorten the learning curve of surgeons in secondary training hospitals owing to the smaller number of cases and the irregular surgical intervals. Although the operation time was relatively longer, the surgical outcome and complication rates were comparable with those of surgeons at larger hospitals.

Efficacy of Alfuzosin After Shock Wave Lithotripsy for the Treatment of Ureteral Calculi

PURPOSE: We evaluated the efficacy of alfuzosin for the treatment of ureteral calculi less than 10 mm in diameter after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: A randomized, single-blind clinical trial was performed prospectively by one physician between June 2010 and August 2011. A total of 84 patients with ureteral calculi 5 to 10 mm in diameter were divided into two groups. Alfuzosin 10 mg (once daily) and loxoprofen sodium 68.1 mg (as needed) were prescribed to group 1 (n=41), and loxoprofen sodium 68.1 mg (as needed) only was prescribed to group 2 (n=44). The drug administration began immediately after ESWL and continued until stone expulsion was confirmed up to a maximum of 42 days after the procedure. RESULTS: Thirty-nine of 41 (95.1%) patients in group 1 and 40 of 43 (93.0%) patients in group 2 ultimately passed stones (p=0.96). The number of ESWL sessions was 1.34+/-0.65 and 1.41+/-0.85 in groups 1 and 2, respectively (p=0.33). The patients who required analgesics after ESWL were 8 (19.5%) in group 1 and 13 (30.2%) in group 2 (p=0.31). Visual analogue scale pain severity scores were 5.33+/-1.22 and 6.43+/-1.36 in groups 1 and 2, respectively (p=0.056). The time to stone expulsion in groups 1 and 2 was 9.5+/-4.8 days and 14.7+/-9.8 days, respectively (p=0.005). No significant adverse effects occurred. CONCLUSIONS: The use of alfuzosin in combination with ESWL seems to facilitate stone passage and to reduce the time of stone expulsion but does not affect the stone-free rate.

Comparison of an Indwelling Period Following Ureteroscopic Removal of Stones between Double-J Stents and Open-Ended Catheters: A Prospective, Pilot, Randomized, Multicenter Study

PURPOSE: The aim of this study was to evaluate whether long-term, postoperative ureteral stenting is necessary after ureteroscopic removal of stones (URS) during an uncomplicated surgical procedure. MATERIALS AND METHODS: We prospectively examined 54 patients who underwent URS for lower ureteral stones from February 2010 to October 2010. Inclusion criteria were a stone less than 10 mm in diameter, absence of ureteral stricture, and absence of ureteral injury during surgery. We randomly placed 5 Fr. open-tip ureteral catheters in 26 patients and removed the Foley catheter at postoperative day 1. The remaining 28 patients received double-J stents that were removed at postoperative day 14 by cystoscopy under local anesthesia. All patients provided visual analogue scale (VAS) pain scores at postoperative days 1, 7, and 14 and completed the storage categories of the International Prostate Symptom Score (IPSS) at postoperative day 7. RESULTS: The VAS scores were not significantly different on postoperative day 1 but were significantly smaller in the 1-day ureteral catheter group at postoperative days 7 and 14 (p<0.01). All of the storage categories of the IPSS were significantly lower in the 1-day ureteral stent group (p<0.01). The ratio of patients who needed intravenous analgesics because of severe postoperative flank pain was not significantly different between the two groups (p=0.81). No patients experienced severe flank pain after postoperative day 2, and no patients in either group had any other complications. CONCLUSIONS: One-day ureteral catheter placement after URS can reduce postoperative pain and did not cause specific complications compared with conventional double-J stent placement.

Analysis of Prescriptions of Alpha-Blockers and Phosphodiesterase 5 Inhibitors from the Urology Department and Other Departments / 대한배뇨장애요실금학회지

PURPOSE: We analyzed the prescriptions of alpha-blockers and phosphodiesterase 5 inhibitors (PDE5Is) in the urology department as well as in other departments of the general hospital. METHODS: We investigated the frequency of prescription of alpha-blockers and PDE5Is from 3 general hospitals from January 1, 2007 to December 31, 2009. For alpha-blockers, data were collected from patients to whom alpha-blockers were prescribed from among patients recorded as having benign prostatic hyperplasia according to the 5th Korean Standard Classification of Diseases. For PDE5Is, data were collected from patients to whom PDE5Is were prescribed by the urology department and by other departments. Alpha-blockers were classified into tamsulosin, alfuzosin, doxazosin, and terazosin, whereas PDE5Is were classified into sildenafil, tadalafil, vardenafil, udenafil, and mirodenafil. RESULTS: Alpha-blockers were prescribed to 11,436 patients in total over 3 years, and the total frequency of prescriptions was 68,565. Among other departments, the nephrology department had the highest frequency of prescription of 3,225 (4.7%), followed by the cardiology (3,101, 4.5%), neurology (2,576, 3.8%), endocrinology (2,400, 3.5%), pulmonology (1,102, 1.6%), and family medicine (915, 1.3%) departments in order. PDE5Is were prescribed to 2,854 patients in total over 3 years, and the total frequency of prescriptions was 10,558. The prescription frequency from the urology department was 4,900 (46.4%). Among other departments, the endocrinology department showed the highest prescription frequency of 3,488 (33.0%), followed by the neurology (542, 5.1%), cardiology (467, 4.4%), and family medicine (407, 3.9%) departments in order. CONCLUSIONS: A high percentage of prescriptions of alpha-blockers and PDE5Is were from other departments. For more specialized medical care by urologists is required in the treatment of lower urinary tract symptoms and erectile dysfunction.

Safety and Efficacy of Combined Transrectal Ultrasound-Guided Prostate Needle Biopsy and Transurethral Resection of the Prostate

PURPOSE: This study was conducted to examine whether simultaneous transrectal prostate needle biopsy (TPNB) owing to an increase in prostate-specific antigen (PSA) levels is safe and effective in patients who are scheduled for transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Combined TPNB and TURP was performed in a total of 42 patients aged 60 years and older who had gray-zone PSA values (4-10 ng/ml) and PSA density (PSAD) values of 0.12 and less. The frequencies of fever, sepsis, and epididymitis were assessed after surgery. The diagnostic accuracy was assessed, and the results of histologic examination were evaluated in terms of TPNB or TURP. In addition, the diagnostic accuracy was assessed according to age. RESULTS: Prostate cancer was diagnosed in 6 (14.3%) of the 42 patients: 2 patients were diagnosed with prostate cancer by TPNB only, 3 patients by TURP only, and 1 patient by combined TPNB and TURP. Four (25%) of the 16 patients aged under 70 years and 2 (7.8%) of the 26 patients aged 70 years and older were diagnosed with prostate cancer. Fever was observed in 9 patients (21.4%), 4 (9.5%) of whom had a fever of higher than 38degrees C. The fever normalized the day after surgery in all 9 patients. No septicemia was noted. There were no serious complications related to combined TPNB and TURP. CONCLUSIONS: The results of this study suggest that combined TPNB and TURP may be safe and effective in patients who require TURP.

Clinical and Urodynamic Significance of Morphological Differences in Intravesical Prostatic Protrusion

PURPOSE: The objectives of this study were to evaluate whether morphologic differences correlated with urodynamic and clinical characteristics in patients with benign prostatic hyperplasia (BPH) with intravesical prostatic protrusion (IPP) of trilobar or bilobar adenoma. MATERIALS AND METHODS: Between January 2008 and June 2009, 72 male patients who had undergone transurethral resection (TUR) owing to BPH with IPP were included in this study. They underwent preoperative urodynamic studies, the International Prostate Symptom Score (IPSS)/quality of life (QoL), maximal flow rate (Qmax), post-voiding residual urine volume (PVR), transrectal ultrasonography (TRUS), and serum prostate-specific antigen (PSA) measurement. The patients were classified into 2 groups (the trilobar and bilobar adenoma groups) on the basis of video findings during the TUR operation. RESULTS: The trilobar and bilobar adenoma groups consisted of 37 patients and 35 patients, respectively. The Mean+/-SD IPP, prostate volume (PV), and transition zone volume of the trilobar and bilobar adenoma groups were 11.8+/-5.2 mm and 9.0+/-3.8 mm (p=0.014), 81.1+/-25.8 g and 59.3+/-22.5 g (p<0.001), and 49.6+/-20.6 g and 34.8+/-19.4 g (p=0.003), respectively. The Mean+/-SD PSA, bladder contractility index (BCI), and bladder outlet obstruction index (BOOI) were 4.6+/-2.5 ng/ml and 3.5+/-1.7 ng/ml (p=0.042), 119.8+/-33.4 and 87.7+/-24.4 (p<0.001), and 62.6+/-29.5 and 44.6+/-20.4 (p=0.005), respectively. There were no significant differences in IPSS/QoL, Qmax, PVR, acute urinary retention, or detrusor overactivity in the 2 groups. CONCLUSIONS: IPP has two morphologic types of trilobar or bilobar enlargement. The PV, BOOI, and BCI were significantly smaller in the bilobar adenoma group than in the trilobar adenoma group.

Relationships between Relative Proportion of Tissue Components, Urodynamic Parameters, and Low Urinary Tract Symptoms in Patients with Benign Prostatic Hyperplasia

PURPOSE: This study was designed to investigate the relationship between the histological composition of the prostate, preoperative clinical parameters, and the results of transurethral resection of prostate (TURP). MATERIALS AND METHODS: A total of 61 patients with benign prostatic hyperplasia (BPH) who had undergone TURP were enrolled retrospectively. Slides were surveyed for relative areas (%) of glandular epithelium (GE), stroma (ST), and smooth muscle (SM) in stroma by performing immunohistochemistry, and the mean outcomes were calculated with a computer-assisted image analyzer (x200). RESULTS: Total prostate volume was less than 40 ml in 19 patients (group 1), 40 to 80 ml in 23 patients (group 2), and more than 80 ml in 19 patients (group 3). The percentage of SM was significantly greater in group 1 (29.5+/-4.2%) than in group 3 (23.7+/-3.2%), but GE and ST did not differ significantly. AG number was significantly higher in group 3 than in the other groups but did not correlate with SM. Improvements in International Prostate Symptom Score, which were similar in each group, were positively correlated with SM. CONCLUSIONS: SM in prostate adenoma is increased in men with a small prostate and may play an important role in lower urinary tract symptoms in small BPH

Efficacy and Safety of Intravenous Propofol Anesthesia during Transrectal Ultrasound-Guided Prostate Biopsy

PURPOSE: Transrectal ultrasonography (TRUS)-guided prostate biopsy causes fear and pain in 65% to 90% of patients. This study was designed to evaluated the use of intravenous propofol anesthesia during TRUS-guided prostate biopsy. MATERIALS AND METHODS: Between January 2006 and June 2008, 195 men undergoing a transrectal prostate biopsy were divided into 2 groups according to anesthetic technique. Group A consisted of 99 patients who received intravenous propofol infusion through an 18 gauge needle during TRUS-guided prostate biopsy. Group B consisted of 96 patients who intrarectally received 10 ml of 2% lidocaine gel 10 minutes before TRUS-guided prostate biopsy. Pain scores were assessed on a visual analogue scale immediately after prostate biopsy. RESULTS: The pain score was significantly reduced in group A compared with group B. There was a significant difference in the mean pain score between the 2 groups (1.0+/-1.3 in group A versus 2.9+/-2.0 in group B; p<0.01). Also, there was a significant difference in the willingness to undergo rebiopsy between the 2 groups (83.8% in group A versus 17.7% in group B; p<0.01). However, the complication rates were not significantly different between the 2 groups. Gross hematuria was found in 14% of group A patients and 18% of group B patients. CONCLUSIONS: Our results proved the advantage of intravenous propofol anesthesia during TRUS-guided prostate biopsy. Intravenous propofol infusion can be a safe and simple technique that significantly reduces pain during TRUS-guided prostate biopsy.

Intratesticular Varicocele Associated with Ipsilateral Extratesticular Varicocele

Intratesticular varicocele is a rare entity and refers to a dilated intratesticular vein radiating from the mediastinum testis into the testicular parenchyma. A 22-year-old man was admitted to our hospital with left testicular pain. On physical examination, a grade III varicocele was noted on the left side. Gray-scale ultrasound and color Doppler ultrasound examinations revealed intratesticular and extratesticular varicocele. The patient underwent spermatic vein ligation by open modified Palomo varicocelectomy.

Is the 3-day Stenting Sufficient for Ureteroscopic Lithotripsy? / 대한비뇨기과학회지

PURPOSE: There has been great demand for indwelling stents for preventing pain, obstructive symptoms and other complications after endoscopic procedures. However, there is no consensus on the placement of a ureteral stent after an ureteroscopy. Inherent stent related problems warrant the minimum possible stenting duration without compromising the results of an ureteroscopy. A prospective randomized trial was performed to evaluate whether 3-day stenting is sufficient for ureteroscopic lithotripsy. MATERIALS AND METHODS: A total of 38 patients underwent an ureteroscopic lithotripsy. There were no severe operative complications. The patients were randomized into 2 groups; Group A: 18 patients who had an internal stent for 3 days after the ureteroscopic lithotripsy, and group B: 20 patients with a stent for 2 weeks. The ureteroscopic lithotripsies were performed with an 8Fr. or 10Fr. ureteroscope, under intravenous propofol anesthesia. Postoperative symptom questionnaires were acquired from each patient. A radiological follow-up was performed at least 4 weeks after the stent removal in all patients. RESULTS: There were no significant differences in the age, sex, stone size or usage of the instrument between the 2 groups. Of the 38 patients, 32 (84%) had discomfort associated with the indwelling stent. The most common symptom was irritative voiding symptom. There were no significant differences in the flank pain and ureteral stricture between the 2 groups. CONCLUSIONS: There was no difference between the 3-days and 2-weeks indwelling stented groups with respect to complications. Therefore, 3 days seems to be a more adequate duration for the decrease stent related complications and symptoms after an ureteroscopic lithotripsy, with no serious intraoperative complications.

High Flow Priapism Treated by Repeated Embolization / 대한남성과학회지

We describe a case of priapism after perineal blunt trauma in a 32-year old man who complained of painless and persistent erection. We confirmed high-flow priapism by cavernosal blood gas analysis, Doppler ultrasonography, and arteriography. A pseudoaneurysm was blocked by selective carvernosal artery embolization with autologous clot. Penile tumescence did not completely disappear during the following 4 weeks, and the patient complained of penile discomfort. Reembolization of the cavernosal artery with autologous clot was successful in reversing the erection. The patient has normal erectile status and no complaints during 30 months follow-up.