New Trends in Innovative Technologies Applying Artificial Intelligence to Urinary Diseases / 대한배뇨장애요실금학회지

Artificial intelligence (AI) is used in various fields of medicine, with applications encompassing all areas of medical services, such as the development of medical robots, the diagnosis and personalized treatment of diseases, and personalized healthcare. Medical AI research and development have been largely focused on diagnosis, prediction, treatment, and management as an auxiliary means of patient care. AI is mainly used in the fields of personal healthcare and diagnostic imaging. In urology, substantial investments are being made in the development of urination monitoring systems in the personal healthcare field and diagnostic solutions for ureteral stricture and urolithiasis in the diagnostic imaging field. This paper describes AI applications for urinary diseases and discusses current trends and future perspectives in AI research.

Enucleated Weight/Enucleation Time, Is It Appropriate for Estimating Enucleation Skills for Holmium Laser Enucleation of the Prostate? A Consideration of Energy Consumption

PURPOSE: To date, the parameters for evaluating enucleation efficiency have only considered enucleation time, although operators simultaneously consume both time and energy during holmium laser enucleation of the prostate. This study was undertaken to find a better way of assessing enucleation skills, considering both enucleation time and consumed energy. MATERIALS AND METHODS: One hundred (n=100) consecutive patients who underwent holmium laser enucleation of the prostate from April 2012 to April 2014 by a single surgeon were enrolled. Ten groups of 10 consecutive cases were used to analyze the parameters of enucleation efficiency. RESULTS: The mean enucleation time, consumed energy, and enucleated weight were 41.3±19.2 minutes, 66.2±36.0 kJ, and 26.6±21.8 g, respectively. Concerning learning curves, like enucleation time-efficacy (=enucleated weight/enucleation time), enucleation energy-efficacy (=enucleated weight/consumed energy) also had an increasing tendency. Enucleation ratio efficacy (=enucleated weight/transitional zone volume/enucleation time) plateaued after 30 cases. However, enucleation time-energy-efficacy (=enucleated weight/enucleation time/consumed energy) continued to increase after 30 cases and plateaued at 61 to 70 cases. Furthermore, one-way analysis of variance showed that group means for enucleation time-energy-efficacy (F=3.560, p=0.001) were significantly different, but that those of enucleation ratio efficacy (F=1.931, p=0.057) were not. CONCLUSIONS: When both time and energy were considered, enucleation skills continued to improve even after 30 cases and plateaued at 61 to 70 cases. Therefore, we propose that enucleation time-energy-efficacy should be used as a more appropriate parameter than enucleation ratio efficacy for evaluating enucleation skills.

Is Tubeless Percutaneous Nephrolithotomy a Feasible Technique for the Treatment of Staghorn Calculi?

PURPOSE: Tubeless percutaneous nephrolithotomy (PNL) remains a challenging technique for the surgical treatment of staghorn renal calculi. Our study was designed to compare surgical outcomes between conventional and tubeless PNL. MATERIALS AND METHODS: We retrospectively enrolled consecutive patients who underwent conventional or tubeless PNL under general anesthesia performed by a single surgeon (H.J.) for the treatment of staghorn calculi between 2003 and 2012. All patients were divided into two groups: group 1 included patients who underwent conventional PNL and group 2 included patients who were managed by tubeless PNL for the treatment of staghorn calculi. Preoperative and postoperative parameters were analyzed between the two groups, including age, stone burden, complications, any interventions, and duration of hospital stay. RESULTS: A total of 165 patients (group 1, 106; group 2, 59) were enrolled in the study. No significant differences in age, sex, body mass index, or stone laterality were observed between the two groups. The mean stone burdens (+/-standard deviation) of group 1 and group 2 were 633.6 (+/-667.4) and 529.9 (+/-362.8), respectively (p=0.271). The postoperative stone-free clearance rate was higher in group 2 (78.0%) than in group 1 (69.8%); however, the difference was not clinically significant (p=0.127). In addition, no significant differences in postoperative complications, including fever, bleeding, infection, or additional interventions, were observed between the two groups. CONCLUSIONS: Our results demonstrated that tubeless PNL has the same effectiveness and safety as conventional PNL in the treatment of staghorn calculi. Tubeless PNL may be feasible for managing renal staghorn calculi.

Modified Distal Urethral Polypropylene Sling (Canal Transobturator Tape) Procedure: Efficacy for Persistent Stress Urinary Incontinence After a Conventional Midurethral Sling Procedure / 대한배뇨장애요실금학회지

PURPOSE: Despite reports of persistent stress urinary incontinence (SUI) in patients after the midurethral sling (MUS) procedure, there is no widely accepted definition or cause of the condition. In many cases, the mesh implanted in the previous MUS procedure has been found to have migrated proximally. The aim of this study was to evaluate the efficacy of the modified distal urethral polypropylene sling, or canal transobturator tape (TOT), procedure for persistent SUI after a conventional MUS procedure on the assumption that persistent SUI after MUS is due to the location of the sling. METHODS: From January 2008 to April 2012, 31 female patients who underwent the canal TOT procedure presented with incontinence or lower urinary tract symptoms (LUTS) were included in this study. We identified patients who had been operated on by use of the conventional MUS procedure at other medical facilities, whose Valsalva leak pressure point was less than 120 cm-H2O by urodynamic study, and who were also diagnosed with persistent SUI. If vaginal or urethral mesh exposure was concomitant with persistent SUI, the mesh was removed completely or in part. Surgical procedures for canal TOT were identical to the original TOT procedures, except in the number and location of the vaginal incisions. Incontinence Impact Questionnaire-Short Form (IIQ-7) and Urogenital Distress Inventory-Short Form (UDI-6) scores were assessed preoperatively and at 3 months postoperatively. RESULTS: There were no intraoperative or postoperative complications. Twenty-eight patients (90.3%) showed improvement in incontinence or other LUTS. Postoperative scores of the IIQ-7 (0.65+/-0.48) and UDI-6 (3.48+/-2.28) were significantly improved compared with preoperative scores (1.26+/-0.58 and 7.52+/-4.30, respectively; P<0.05). CONCLUSIONS: Improper sling location is one of the major causes of persistent SUI after the conventional MUS procedure. Our results demonstrate that canal TOT may be an alternative method in the treatment of persistent SUI after the conventional MUS procedure.

Is Concomitant Bladder Neck Reconstruction Necessary in Neurogenic Incontinent Patients Who Undergo Augmentation Cystoplasty?

PURPOSE: In patients with neurogenic bladder due to spinal cord injury or disease who undergo augmentation cystoplasty (AC) for not only bladder dysfunction but also sphincteric incontinence, the need for concomitant bladder neck reconstruction at the time of AC has not yet been established. The aim of this study was to evaluate whether concomitant bladder neck reconstruction is necessary when performing AC. MATERIALS AND METHODS: We retrospectively investigated 35 patients who underwent AC from January 2006 to September 2010. Medical history, preoperative and postoperative fluoroscopic urodynamic study (FUDS) parameters, and responses to an incontinence questionnaire (ICIQ Korean version) were reviewed. RESULTS: A final analysis was performed on 17 patients (9 male, 8 female) who were diagnosed with sphincteric incontinence. Continence status, the number of pads used, and the bother score were significantly improved postoperatively in this subpopulation. Preoperatively, all patients used pads, and the average daily number was 2.2 (median; range 0 to 6). Postoperatively, the number of pads used decreased significantly to 0.9 (median; range 0 to 3) pads a day (p=0.002). Urodynamic parameters including bladder capacity, compliance, involuntary detrusor contraction, and bladder neck incompetence proven by FUDS were also significantly improved. CONCLUSIONS: Our study demonstrated that both objective urodynamic parameters and subjective incontinence symptoms improved significantly after the completion of AC as a single procedure in patients with sphincteric incompetence. This implies that anti-incontinence bladder outlet surgery does not have to be performed simultaneously and can be considered later as a staged operation.

Short-term Effect of Radical Hysterectomy with or without Adjuvant Radiation Therapy on Urodynamic Parameters in Patients with Uterine Cervical Cancer / 대한배뇨장애요실금학회지

PURPOSE: Lower urinary tract dysfunction is the most common complication after radical pelvic surgery. The aims of this study were to assess the effect of radical hysterectomy (RH) on the storage function of the lower urinary tract and to evaluate the impact of radiation therapy (RT) on postoperative urodynamic parameters. METHODS: This was a retrospective review of preoperative and postoperative urodynamic variables, which were prospectively collected. All women from 2006 to 2008, who underwent RH for uterine cervical cancer with a stage of 1A to 2B with or without adjuvant RT were enrolled. All patients were divided into two groups: group 1, without RT, and group 2, with adjuvant RT. Urodynamic studies were performed before, 10 days after, and 6 months after RH. RESULTS: A total of 42 patients with a mean (+/-standard error) age of 51.9 (+/-12.3) years were analyzed. There were no significant differences in age, body mass index or clinical stage between the two groups. On the 10th postoperative day, all parameters were decreased except postvoid residual volume. In comparison with group 2 (n=14), group 1 (n=28) showed a significant increase in bladder compliance. At 6 months postoperatively, bladder compliance in group 1 had increased four times or more compared with that on postoperative 10 days. However, it had increased only 2.5 times in group 2 at the same time point (P<0.001). CONCLUSIONS: The results of our study suggest that adjuvant RT after RH might result in a deterioration of bladder compliance. It is highly suggested that practitioners pay attention to low bladder compliance, especially in patients who have adjuvant RT after RH.

Holmium Laser Enucleation of Prostate for Benign Prostatic Hyperplasia: Seoul National University Hospital Experience / 대한배뇨장애요실금학회지

PURPOSE: The objective of this study was to report the experience acquired at the Seoul National University Hospital with Holmium Laser Enucleation of Prostate (HoLEP), combined with mechanical morcellation for symptomatic benign prostatic hyperplasia (BPH). METHODS: A retrospective review was performed on the clinical data of 309 consecutive patients who underwent HoLEP at our institution between July 2008 and June 2010. All patients were evaluated preoperatively for prostate volume by transrectal ultrasound, maximum urinary flow rate (Qmax), International Prostate Symptoms Score (IPSS) and quality of life (QoL) score. Peri- and postoperative parameters were evaluated and patients were followed-up at 1-, 3-, 6-, and 12- months with the aforementioned investigations. RESULTS: The patients' mean age was 68.3 (+/-6.5) years and mean prostate volume was 55.6 (+/-23.6) mL. Mean enucleation time was 56.2 (+/-25.1) minutes, mean morcellation time was 11.3 (+/-9.5) minutes, and the mean resected weight of the prostate was 20.8 (+/-16.9) g. The mean catheter indwelling period was 1.9 (+/-1.7) days and mean hospital stay was 2.9 (+/-1.5) days. Significant improvement was noted in Qmax, IPSS, and QoL at the 1-year follow-up compared with baseline (P<0.01). At 1 month 17.2% of patients complained of irritative urinary symptoms, which were typically self-limiting within 3 months. Transient stress incontinence was reported in 15.2% of patients. No patient experienced persistent obstructive symptoms that required reoperation. CONCLUSIONS: Our study showed that HoLEP is a safe and effective therapeutic modality for BPH.

Clinicopathological Significance of the Lymphovascular Invasion Detected in Specimens from Radical Retropubic Prostatectomies / 대한비뇨기과학회지

PURPOSE: We tried to determine the clinicopathological significance of lymphovascular invasion (LVI) in patients who were treated for prostate cancer with radical retropubic prostatectomy. MATERIALS AND METHODS: From November 2003 to June 2005, 165 patients underwent radical retropubic prostatectomy for clinically-localized prostate cancer at our institution. The results of the final pathologic analyses were reviewed. RESULTS: Of the 165 total patients, foci of LVI were identified in 46 patients. LVI was associated with a higher preoperative serum level of prostate-specific antigen (p=0.006), the Gleason score (p<0.0001), a higher weight of tumor volume (p<0.0001), a higher rate of capsular penetration (p<0.0001), a higher rate of seminal vesicle involvement (p<0.0001), and a higher rate of a positive margin (p<0.0001). CONCLUSIONS: Since the pathological features of LVI appear to be associated with the other established features of more advanced prostate cancers, they may prove to be useful markers for predicting the prognosis of patients who undergo radical prostatectomy. Our findings support performing routine evaluation for LVI in radical prostatectomy specimens and its inclusion in the models for predicting the clinical outcome.