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.

Clinico-pathological Characteristics of Prostate Cancer in Korean Men and Nomograms for the Prediction of the Pathological Stage of the Clinically Localized Prostate Cancer: A Multi-institutional Update / 대한비뇨기과학회지

PURPOSE: In this multi institutional study, the data of 604 men with clinically localized prostate cancer, who underwent radical prostatectomy, with updated nomograms predicting the pathological stage, were analyzed. MATERIALS AND METHODS: Prostate biopsies and prostatectomy specimens from men treated with radical prostatectomy, obtained between 1990 and 2003, were included. The patient distribution with respect to clinical stage, serum prostate-specific antigen (PSA) and biopsy Gleason score, as well as final pathological findings, including organ-confined disease (OCD), extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph node metastasis (LNM), were analyzed for the construction of nomograms representing the percent probabilities of each respective pathological outcome. RESULTS: The median serum PSA at the time of surgery and biopsy Gleason score were 9.9ng/ml and 7, respectively. The preoperative serum PSA was 4ng/ml or less in 38 (6.3%) patients and the tumor was impalpable in 292 (48.2%) of patients. The biopsy Gleason scores were 7 and 8 or higher in 186 (30.7%) and 169 (27.9%), respectively. Throughout the clinical stages and PSA ranges, the Gleason score was 7 or higher in more than 50% of patients, but 8-10 in 20-30%. The overall OCD, ECE, SVI and LNM rates were 57.1, 27.8, 10.9 and 4.2%, respectively. CONCLISIONS: A significantly high proportion of prostate cancers arising in Korean men exhibited poor differentiation, with Gleason scores of 7 or higher, regardless of the clinical stage or initial serum PSA. Updated nomograms acknowledging such characteristics have been developed, which may aid in the treatment planning of these individuals.

The Anatomic Distribution and Pathological Characteristics of Prostate Cancer: A Mapping Analysis / 대한비뇨기과학회지

PURPOSE: We mapped the location of prostate cancer in Korean men, and investigated the volume and tumor distribution in relation to clinicopathological variables. MATERIALS AND METHODS: The volume of cancer and the anatomic location of each tumor foci were determined from 186 radical prostatectomy specimens, which were digitized to fit into a prototype prostate model. Using the computer-based digital images, the zonal cancer volume and distributional frequency were analyzed with respect to the clinical and pathological parameters, which were demonstrated in gray scales. RESULTS: The preoperative serum prostate-specific antigen (PSA) level ranged from 2.0 to 38.9ng/ml. The mean cancer volume of the 186 specimens was 4.5ml (median 1.9ml, range 0.01-37.7). The impalpable cancers were located more anteriorly and in the transition zone, and were also were smaller in volume (2.7ml vs. 5.5ml, p=0.004) than the palpable cancers. Cancers with seminal vesicle invasion were located more medially in the peripheral zone, and were larger in volume than organ-confined cancers or cancers with extracapsular extension (13.2ml vs. 3.0ml, p<0.001). For Gleason scores of 2-6, 7, and 8-10, the mean cancer volumes were 2.2, 3.7 and 8.2ml, respectively (p<0.001). High grade cancers were located more medially in the peripheral zone, especially when approaching the apex. CONCLUSIONS: T1c cancers are located more anteriorly and in the transition zone; therefore, inclusion of these areas for targeted biopsy may help to improve the detection of cancer in patients with elevated PSA levels and impalpable prostate cancer. A medial location of seminal vesicle invasive cancers may imply an ejaculatory ducts route of invasion rather than a direct extracapsular extension.

Initial Experiences of Complete Primary Exstrophy Repair in Cloacal and Bladder Exstrophy / 대한비뇨기과학회지

We report here the short-term results of 3 cases of cloacal and bladder exstrophy that underwent complete primary exstrophy repair. One case was diagnosed as bladder exstrophy and the others were diagnosed as cloacal exstrophy. Complete primary exstrophy repair for all 3 cases was carried out within 24 hours after birth. There was no wound dehiscence within the follow-up period of 12 months. The complete primary exstrophy repair with positioning the bladder neck and urethra in the deep pelvic cavity achieves a satisfactory short-term result.

Outcome and Prognostic Factors of Salvage Radiotherapy for Biochemical Failure after Radical Prostatectomy: A Single Institute Experience / 대한비뇨기과학회지

PURPOSE: To assess the prognostic factors for recurrence-free survival after salvage radiotherapy (RT). MATERIALS AND METHODS: Between 1990 and 2003, 20 patients underwent RT for biochemical failure after a radical prostatectomy (prostate-specific antigen; PSA>0.2ng/ml). The biochemical failure developed at a mean of 17.3 months (3-58) after the RP, and the mean PSA level at failure was 0.62ng/ml (0.4-1.0). All patients received curative radiation (mean dosage 64.5Gy); with a mean follow-up of 42.7 months after the RT. The pre-RT clinical and pathological parameters were evaluated to find prognostic factors affecting the biochemical recurrence-free survival (bRFS) after RT. RESULTS: The mean time to RT from biochemical failure was 5.1 months (1-21), with a mean PSA level at the commencement of RT of 1.39ng/ml (0.36-6.70). In 18 patients, the serum PSA declined to an undetectable level, at a mean of 4.9 months (1-12) after RT. Of these, 8 (44.4%) showed a biochemical relapse, at a mean of 19.3 months (1-38). The actuarial 1, 3 and 5-year bRFS were 75.0, 48.5 and 39.0%, respectively. The bRFS was significantly increased with an interval to RT after failure of within 3 months (p=0.002) and the PSA level at RT was below 0.7ng/ml (p=0.036). No other clinicopathological factors had a significant influence. CONCLUSIONS: Salvage RT for biochemical failure provides effective local tumor control, with a modest durable biochemical response. A more favorable outcome may be expected when the RT is instituted earlier, with a lower PSA level after failure.

Nomograms for the Prediction of Pathologic Stage of Clinically Localized Prostate Cancer in Korean Men

We analyzed the prostate cancer data of 317 Korean men with clinically localized prostate cancer who underwent radical prostatectomy at Asan Medical Center between June 1990 and November 2003 to construct nomograms predicting the pathologic stage of these tumors, and compared the outcome with preexisting nomograms. Multinomial log-linear regression was performed for the simultaneous prediction of organ-confined disease (OCD), extracapsular extension (ECE), seminal vesicle invasion (SVI) and lymph node metastasis (LNM) using serum prostate-specific antigen (PSA), Gleason score and clinical stage. Nomograms representing percent probabilities were constructed and compared with those presented by Partin et al. by calculating areas under the receiver operating characteristics (ROC) curves. Median serum PSA at surgery was 10.8 ng/mL, and median biopsy Gleason score was 7. Overall OCD, ECE, SVI and LNM rates were 59.6%, 20.5%, 11.7% and 8.2%, respectively, and areas under the curves were 0.724, 0.626, 0.662, and 0.794, respectively. Pathologic stage of localized prostate cancer in Korean men may be predicted using the Partin table, with acceptable accuracy for OCD and LNM, but less so for ECE and SVI.

Early Catheter Removal after Radical Retropubic Prostatectomy / 대한비뇨기과학회지

PURPOSE: There is a trend towards early catheter removal after radical retropubic prostatectomy (RRP). Therefore, the feasibility of early catheter removal after RRP was explored. MATERIALS AND METHODS: Twenty-four consecutive patients having undergone a RRP performed by one surgeon were divided into two groups. Groups A and B comprised the patients who had their cystography taken either 6 or 14 days after surgery, respectively. Voiding symptoms in the immediate (after catheter removal) and late postoperative (1 month after catheter removal) periods were assessed. The mean patient ages were 68.8, ranging from 59 to 76 and 66.8, ranging from 61 to 73 years in groups A and B (p=0.37), respectively. The Mean follow-up was 4.3 months (1-9). RESULTS: One patient in each group showed significant urine leakage on cystography, which required a further week of catheter indwelling. In group A, 8 patients (72.7%) needed pads for their incontinence immediately after catheter removal and 3 (27.3%) required pads continuously 1 month after catheter removal. In group B, incontinence that required pads developed in 9 patients (81.8%) immediately after catheter removal, and in 3 (27.3%) 1 month after catheter removal. One patient in group A required a 3-day Foley catheter indwelling for urinary retention. There were 4 (36.4%) and 2 (18.2%) patients in groups A and B, respectively, with weak urinary stream (Qmax<15ml/sec). CONCLUSIONS: A catheter can be safely removed, with caution, 6 days after a radical retropubic prostatectomy for the development of urinary retention and weak stream, which might be caused by anastomotic edema and transiently decreased bladder contractility.