Patient-related risk factors for late rectal bleeding after hypofractionated radiotherapy for localized prostate cancer: a single-center retrospective study.

BACKGROUND: Several studies have reported patient-related risk factors for late rectal bleeding following conventionally fractionated radiotherapy for prostate cancer. We investigated patient-related risk factors for late rectal bleeding after hypofractionated radiotherapy. METHODS: A total of 231 patients with local or locally advanced prostate cancer treated with hypofractionated radiotherapy (70 or 67.2 Gy in 28 fractions) were evaluated retrospectively. All patients received intensity-modulated radiotherapy with daily image guidance. The relationships between late rectal bleeding and risk factors like diabetes, hypertension, cirrhosis, and anticoagulant use were analyzed. RESULTS: During a median follow-up of 23 months, the crude rates of grade ≥ 1, grade ≥ 2, and grade ≥ 3 late rectal bleeding were 23.8%, 16.9%, and 9.5%, respectively. Cirrhosis and anticoagulant use predicted an increased risk of grade ≥ 3 rectal bleeding in multivariable analyses (hazard ratio [HR] 14.37, 95% confidence interval [CI] 3.09-66.87, P = 0.001, and HR 2.93, 95% CI 1.14-7.55, P = 0.026, respectively). The non-anticoagulant group had a significantly superior 5-year freedom from grade ≥ 3 bleeding compared to the anticoagulant group in a propensity-weighted log-rank analysis (88.0% vs. 76.7%, P = 0.041). A receiver operating characteristic curve analysis revealed that rectal bleeding was minimized in the anticoagulant group if the equivalent dose at fractionation of 2 Gy (EQD2) V77 Gy of the rectum was < 4.5% or if the EQD2 V8.2 Gy was < 71.0%. CONCLUSIONS: Patients taking anticoagulants or those with cirrhosis had a significantly higher risk of severe late rectal bleeding than other patients after hypofractionated radiotherapy for prostate cancer in the present study. The bleeding risk could be lowered by minimizing hotspots in patients taking anticoagulants.

Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review.

BACKGROUND: There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP. METHODS: A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers. RESULTS: We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012). CONCLUSION: The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Radical prostatectomy for clinically localized prostate cancer in patients aged 75 years or older: comparison with primary androgen deprivation therapy.

OBJECTIVE: To determine whether radical prostatetomy (RP) is suitable for prostate cancer patients with age ≥75 years in comparison to primary androgen deprivation therapy (PADT). PATIENTS AND METHODS: A cohort study was conducted in clinically localized prostate cancer patients with ≥75 years of age who underwent RP or PADT at six institutions from 2005 to 2013. Patients who had less than 12 months of follow-up, or received neoadjuvant or adjuvant therapy were excluded. We compared clinical characteristics, cancer-specific and overall survivals, and post-treatment complication rates between two groups. RESULTS: We included 92 and 99 patients in the RP and PADT groups, respectively. In survival analyses, there were no significant differences in cancer-specific and overall survivals (p = .302 and .995, respectively). The incidence of serious adverse events (cardio- or cerebrovascular event, or bone fracture) was higher in the PADT group (p = .001). Multivariable analysis showed that PADT had a worse effect on the serious adverse events (OR 10.12, p = .038). CONCLUSIONS: In selected elderly patients, RP was safe and effective for treatment of localized prostate cancer, as compared to PADT. Surgical treatment options should be considered in elderly patients with respect to life expectancy, rather than chronological age.

New Surgical Instruction Method for Homium Laser Enucleation of the Prostate, "Hand-Grab Navigated Technique," to Shorten the Learning Curve: The Results of Multicenter Analysis.

OBJECTIVES: To introduce a new surgical mentorship, the "hand-grab navigated technique," to shorten the learning curve for Holmium laser enucleation of the prostate. METHODS: Patients with benign prostatic hyperplasia were managed at six institutions with Holmium laser enucleation of the prostate. An analysis was done in the 200 of these patients (the set of first 20 patients treated with Holmium laser enucleation of the prostate by 10 surgeons) who were sorted into two groups depending on the surgeon's instructional group. Surgeons in group I learned Holmium laser enucleation of the prostate by self-study by using videos and written information, whereas those in group II were instructed by "the hand-grab navigated technique" along with the self-study. To evaluate the efficiency of hand-grab navigated technique, enucleation and morcellation efficiencies between the two groups were compared. RESULTS: The mean prostate volume was 49.5 ± 23.8 and 51.1 ± 25.2 g in group I and II, respectively, showing no significant difference. The enucleation efficiency was significantly greater (P = 0.01) in group II (0.35 ± 0.20 g/min) than in group I (0.21 ± 0.12 g/min). Morcellation efficiency was also significantly greater (P = 0.03) in group II (3.08 ± 3.27 g/min) than in group I (2.43 ± 2.68 g/min). CONCLUSION: The learning curve for Holmium laser enucleation of the prostate can be shortened with the "hand-grab navigated technique" when combined with the self-study.

Influence of Daytime or Nighttime Dosing with Solifenacin for Overactive Bladder with Nocturia: Impact on Nocturia and Sleep Quality.

We compared changes in nocturia and sleep-related parameters between daytime and nighttime solifenacin dosing in patents with overactive bladder (OAB) and nocturia. We comparatively analyzed the data of a 12-week prospective, open-label, multicenter, randomized study. All 127 patients who presented to 5 centers in Korea for the treatment of OAB with nocturia between January 2011 and December 2013 were enrolled in this study. The patients were divided into 2 groups by medication timing: group 1, daytime (n = 62); and group 2, nighttime (n = 65). The International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), and Athens Insomnia Scale (AIS) were used to assess OAB symptoms and sleep quality. We evaluated the parameter changes before and 12 weeks after daytime or nighttime solifenacin administration. Baseline data, which included sex, age, body mass index (BMI), total AIS, IPSS, and OABSS, did not differ between the 2 groups. Total IPSS, OABSS, and total AIS significantly improved after solifenacin administration regardless of timing (P < 0.001). After solifenacin administration, the number of nocturia episodes decreased in the group 1 and 2 (P < 0.001). There were no significant intergroup differences in changes in AIS, IPSS, OABSS, and number of nocturia episodes 12 weeks after solifenacin administration. Treating OAB with solifenacin may improve nocturia and sleep quality, but advantages did not differ significantly by medication timing.

Radical Prostatectomy in Korean Men Aged 75-Years or Older: Safety and Efficacy in Comparison with Patients Aged 65-69 Years.

Prostate cancer is the most common type of male cancer worldwide. Although radical prostatectomy (RP) is advised for prostate cancer in patients with a life expectancy of more than 10 years by various guidelines, most elderly men still do not undergo the procedure regardless of increasing life expectancy. This study aimed to determine whether RP is suitable for patients with prostate cancer aged 75 years or older. A retrospective study of patients who underwent RP at 6 institutions between 2005 and 2012 was conducted. Patients were divided into 2 groups at the time of surgery: 65-69 years (younger group) and 75 years or older (older group). We compared clinical characteristics, pathological results, complication rates, and recurrence-free survival between the two groups. Compared with the younger group, the older group had significantly higher preoperative serum prostate-specific antigen level, pre- and postoperative Eastern Cooperative Oncology Group (ECOG) performance status grade, hypertension prevalence, and Gleason score at biopsy and RP. However, except urinary incontinence, there were no statistically significant differences in the peri- and post-operative complications. After median follow-up periods of 36 months (younger group) and 40 months (older group), the biochemical recurrence-free survival rates were not significantly different (P = 0.581). Although the urinary incontinence rate was higher in the older group, RP was a suitable option for selected Korean men aged 75 years or older with limited complication rates and excellent outcomes similar to those for patients aged 65-69 years.

A 12-Week, Open Label, Multi-Center Study to Evaluate the Clinical Efficacy and Safety of Silodosin on Voiding Dysfunction in Patients with Neurogenic Bladder.

OBJECTIVES: The purpose of this study is to evaluate clinical effect and safety of α1A -adrenoceptor blocker, silodosin, in patients with voiding dysfunction caused by neurogenic bladder. METHODS: From April 2011 to January 2012, patients who were diagnosed as potential voiding dysfunction associated with neurogenic bladder, aged ≥ 20 years were enrolled. Silodosin (8 mg/day) was administered once daily in the morning with food. The efficacy was assessed at the baseline and after 12 weeks of the treatment having following parameters of international prostate symptom score and other measures including the maximum flow rate and the postvoid residual urine volume. RESULTS: A total of 97 patients were screened and 95 were enrolled. Of these 95 patients, 82 patients were completed and included in analysis. After 12-weeks of treatment, mean total international prostate symptom score decreased significantly from 22.23 ± 6.80 to 14.98 ± 9.48 (P = 0.0002). Voiding symptoms and storage symptoms were also improved by decreasing in international prostate symptom score-QoL from 4.62 ± 0.92 to 3.48 ± 1.63 (P < 0.0001). Maximum flow rate increased significantly from 10.72 ± 2.66 to 15.14 ± 6.63 (P < 0.0001). The main adverse event was ejaculation disorder. No serious adverse events related to silodosin were noted. CONCLUSIONS: This study indicates that silodosin was significantly effective, well tolerated and safe in patients who have voiding dysfunction associated with neurogenic bladder.

Factors associated with continuing medical therapy after transurethral resection of prostate.

OBJECTIVE: To report the clinical characteristics of patients who have persistent lower urinary tract symptoms (LUTS) after surgery for benign prostatic hyperplasia (BPH) and continue their medical therapy postoperatively. MATERIALS AND METHODS: We retrospectively studied 372 patients who underwent transurethral resection of prostate for LUTS/BPH in 8 institutions to determine the differences between patients who continued LUTS/BPH medications for >3 months after surgery and those who did not. Preoperative, intraoperative, and postoperative clinical parameters were assessed. The Student t test and chi square test were used to compare each parameter between patient groups. Multivariate logistic regression analysis was performed to identify risk factors for persistent LUTS and continuing medical therapy after surgery. RESULTS: There were 205 patients (55.1%) who continued their LUTS/BPH medications for >3 months postoperatively. They reported poorer International Prostate Symptom Scores and uroflowmetry results after surgery. Multivariate analysis showed that age >70 years (odds ratio [OR], 2.474; P = .001), history of diabetes (OR, 1.949; P = .040), history of cerebrovascular accident (OR, 5.932; P = .001), any previous LUTS/BPH medication use (OR, 5.384; P = <0.001), and previous antimuscarinic drug use (OR, 2.962; P = .016) were significantly associated with symptom persistency and continuing medical therapy. CONCLUSION: Many patients have persistent voiding dysfunction after surgical treatment for LUTS/BPH. Older age, history of diabetes, history of cerebrovascular accidents, and preoperative antimuscarinic drug uses are possible risk factors.

Prevalence and risk factors of bladder neck contracture after radical prostatectomy.

PURPOSE: To evaluate the prevalence of bladder neck contracture (BNC) and its risk factors in patients undergoing radical prostatectomy in Korea. MATERIALS AND METHODS: We analyzed data from 488 patients with prostatic cancer who underwent radical prostatectomy performed by seven surgeons in seven hospitals, including 365 open radical prostatectomies (ORPs), 99 laparoscopic radical prostatectomies (LRPs), and 24 robot-assisted laparoscopic radical prostatectomies (RARPs). Patients with BNCs were compared with those without BNCs to identify the risk factors for BNC occurrence. RESULTS: Overall, BNCs occurred in 21 of 488 patients (4.3%): 17 patients (4.7%) who underwent ORP, 4 patients (4%) who underwent LRP, and no patients who underwent RARP. In the univariate analysis, men with BNCs had a longer length of time before drain removal (12 days vs. 6.8 days, p<0.001), which reflected urinary leakage through the vesicourethral anastomosis. In the multivariate analysis, the length of time before drain removal was the only predictor of BNC (odds ratio, 1.12; p=0.001). Intraoperative blood loss was higher in patients with BNC, but the difference was not statistically significant. CONCLUSIONS: The most significant factor related to BNC occurrence after radical prostatectomy in our study was the length of time before drain removal, which reflects urinary leakage from the vesicourethral anastomosis. The proper formation of a watertight anastomosis to decrease urinary leakage may help to reduce the occurrence of BNC.

Current status of laparoendoscopic single-site surgery in urologic surgery.

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.

A case of laparoscopic radical prostatectomy for a prostatic stromal tumor of uncertain malignant potential.

Prostatic stromal tumor of uncertain malignant potential (STUMP) is a rare neoplasm with distinctive clinical and pathological characteristics. Here we report a case of laparoscopic radical prostatectomy performed in a patient with prostatic STUMP.

Comparison of oncological outcomes of transperitoneal and retroperitoneal laparoscopic radical nephrectomy for the management of clear-cell renal cell carcinoma: a multi-institutional study.

OBJECTIVE: • To investigate the oncological efficacy of retroperitoneal laparoscopic radical nephrectomy (RLRN) compared with transperitoneal laparoscopic radical nephrectomy (TLRN) for the management of clear-cell renal cell carcinoma (RCC). PATIENTS AND METHODS: • With emphasis on survival and disease recurrence, a retrospective analysis was made of 580 patients who underwent TLRN (472 patients) or RLRN (108 patients) at 23 institutions between January 1997 and December 2007. • Inclusion criteria were clear-cell RCC, stage pT1 to pT2 without any nodal involvement, and metastasis. • Overall survival and recurrence-free survival curves were estimated using the Kaplan-Meier method. • To assess the association between the surgical approach and survival outcomes, Cox proportional hazard models were constructed. RESULTS: • The median follow-up was 30 months in the TLRN group and 35.6 months in the RLRN group. Both groups were comparable regarding age, gender, body mass index (BMI), Fuhrman's grade, size of tumours and stage. • Kaplan-Meier curves and the log-rank test showed no significant difference between the TLRN and RLRN groups in 5-year overall (92.6% vs 94.5%; P = 0.669) and recurrence-free survival (92.0% vs 96.2%; P = 0.244). • In a Cox regression model with age, gender, Eastern Cooperative Oncology Group performance status, BMI, nuclear grade and T-stage adjusted variables, no significant difference was found between the two surgical approaches. CONCLUSION: • The present study is the largest oncological analysis for laparoscopic radical nephrectomy (LRN) comparing transperitoneal and retroperitoneal approaches. The data from it provide the objective evidence to suggest similar oncological outcomes for both approaches to LRN.

Outcomes of transurethral removal of intravesical or intraurethral mesh following midurethral sling surgery.

PURPOSE: To present outcomes of transurethral removal (TUR) of intravesical or intraurethral mesh after midurethral slings. MATERIALS AND METHODS: This was a retrospective chart review of 23 consecutive women: 20 with intravesical mesh and 3 with intraurethral mesh. RESULTS: To remove the mesh, transurethral resection with an electrode loop (TUR-E) was used in 16 women and transurethral resection with a holmium laser (TUR-H) was used in 7. The median follow-up was 2.1 months. Twenty-six percent of the women (6/23) had a mesh remnant: 6.2% (1/16) of the women treated with TUR-E and 71.4% (5/7) of the women treated with TUR-H. Of the 5 women treated with TUR-H, 3 underwent concomitant transvaginal removal. On the follow-up cystoscopic exam, a mesh remnant was observed in 3 women (1 treated with TUR-E and 2 treated with TUR-H). Vesico-vaginal fistulas were found in 2 women during and after TUR-E, respectively. Stress urinary incontinence recurred in 1 woman. CONCLUSIONS: TUR-E has a high success rate but carries a risk of bladder perforation. Complete resection using TUR-H depends on the location of the mesh and the range of motion of the instrument.

Comparison of laparoscopic and open partial nephrectomies in t1a renal cell carcinoma: a korean multicenter experience.

PURPOSE: We analyzed a series of patients who had undergone laparoscopic partial nephrectomies (LPNs) and open partial nephrectomies (OPNs) to compare outcomes of the two procedures in patients with pathologic T1a renal cell carcinomas (RCCs). MATERIALS AND METHODS: From January 1998 to May 2009, 417 LPNs and 345 OPNs were performed on patients with small renal tumors in 15 institutions in Korea. Of the patients, 273 and 279 patients, respectively, were confirmed to have pT1a RCC. The cohorts were compared with respect to demographics, peri-operative data, and oncologic and functional outcomes. RESULTS: The demographic data were similar between the groups. Although the tumor location was more exophytic (51% vs. 44%, p=0.047) and smaller (2.1 cm vs. 2.3 cm, p=0.026) in the LPN cohort, the OPN cohort demonstrated shorter ischemia times (23.4 min vs. 33.3 min, p<0.001). The LPN cohort was associated with less blood loss than the OPN cohort (293 ml vs. 418 ml, p<0.001). Of note, two patients who underwent LPNs had open conversions and nephrectomies were performed because of intra-operative hemorrhage. The decline in the glomerular filtration rate at the last available follow-up (LPN, 10.9%; and OPN, 10.6%) was similar in both groups (p=0.8). Kaplan-Meier estimates of 5-year local recurrence-free survival (RFS) were 96% after LPN and 94% after OPN (p=0.8). CONCLUSIONS: The LPN group demonstrated similar rates of recurrence-free survival, complications, and postoperative GFR change compared with OPN group. The LPN may be an acceptable surgical option in patients with small RCC in Korea.

Retroperitoneal laparoendoscopic single-site surgery in urology: initial experience.

PURPOSE: To present our initial experience with single-port laparoscopic urologic surgery via the retroperitoneal approach using the Alexis wound retractor with flexible laparoscopic instrumentation. PATIENTS AND METHODS: Since December 2008, 14 patients have undergone single-port laparoscopic surgery for various urological diseases, including renal cyst decortication in 5 patients, adrenalectomy in 2 patients, nephroureterectomy in 2 patients, nephrectomy in 3 patients, and ureterolithotomy in 2 patients. For the retroperitoneal approach, the Alexis wound retractor with a single port was used. RESULTS: All cases were completed without conversion to standard laparoscopic or open surgery. The mean operative time and mean estimated blood loss for decortication of the renal cysts were 56 minutes (range 45-70 minutes) and 179 mL (range 22-398 mL), respectively; the mean operative time and mean estimated blood loss for extirpative or reconstructive surgery were 156 minutes (range 115-21 minutes) and 403 mL (range 35-1324 mL), respectively. The mean hospital stay was 6.5 days (range 4-14 days). There were no major intraoperative complications, but wound dehiscence and bleeding were noted in two patients. CONCLUSION: Retroperitoneal single-port laparoscopic urologic surgery, particularly in patients requiring free-hand suturing, is technically feasible. The initial clinical experience of organ-ablative, extirpative, and reconstructive surgery with this approach is reported.

Laparoscopic decortication of large renal cysts: a comparison between the transperitoneal and retroperitoneal approaches.

BACKGROUND: We compared the operative outcomes and follow-up results of laparoscopic decortication of large, simple renal cysts, performed by the transperitoneal (TP) and retroperitoneal (RP) approaches, and identified selection criteria for each approach. MATERIALS AND METHODS: Between 2000 and 2007, 53 patients with renal cysts underwent laparoscopic decortication via the TP (n = 25) and RP approaches (n = 28), according to the location of the cysts. Operative and follow-up data were collected retrospectively, and the approaches were compared with regard to intra- and postoperative parameters, complications, and success rate. RESULTS: Among the 53 patients, 48 (90.5%) had their cysts completely removed, and in 5 (9.5%), the cyst size was reduced to less than one half of the initial cyst volume. Thirty-three patients (84.6%) had their symptoms completely relieved within 3 months, while 6 patients (15.3%) had continued mild pain. There were no significant differences in the symptomatic response and radiologic findings between the two approaches. The RP approach had the advantages of reduced operation time, time to oral intake and ambulation, as well as analgesic use. One patient in the RP group required laparoscopy to control postoperative bleeding. CONCLUSIONS: Based on the cyst location, as the major selection criteria, both approaches were comparable with regard to symptomatic improvement and radiologic findings. The retroperitoneal approach had the advantages of reduced operation time, time to oral intake and ambulation, as well as analgesic use. Therefore, we prefer to perform laparoscopic decortication by the retroperitoneal approach without mobilization of the bowel.

Transurethral resection of intravesical mesh after midurethral sling procedures.

PURPOSE: We evaluated the efficacy of the transurethral resection (TUR) for the management of intravesically exposed polypropylene mesh after midurethral sling (MUS) procedures. PATIENTS AND METHODS: Fourteen patients had a TUR for intravesical mesh after MUS procedures (tension-free vaginal tape, 11; transobturator tape, 3). In six patients with large stones, cystoscopic division and cystolitholapaxy were needed before the TUR. RESULTS: Patients presented with dysuria (9), hematuria (7), urgency incontinence (5), urinary frequency (2), and pelvic pain (2). Thirteen of 14 (92.9%) patients had the mesh completely removed during a mean follow-up of 18 months; one patient had a recurrent bladder stone. Complications included de novo mixed incontinence, pelvic hematoma, and vesicovaginal fistula among three patients. CONCLUSION: Urologists should suspect intravesical mesh erosion or stone formation in patients with persistent pain, hematuria, or bladder irritation symptoms after MUS procedures. The TUR was a useful treatment modality for patients with intravesical complications after MUS procedures.

The clinical significance of bone mineral density and testosterone levels in Korean men with non-mosaic Klinefelter's syndrome.

OBJECTIVE: To measure bone mineral density (BMD) and testosterone levels in patients with non-mosaic Klinefelter's syndrome (KS), as a low BMD is common in hypogonadal men, but little is known about the relationship between BMD and serum testosterone levels in men with KS. PATIENTS, SUBJECTS AND METHODS: The study included 40 patients with KS and 20 healthy fertile men recruited as controls. Serum testosterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels were measured by radioimmunoassay. The BMD was obtained at the lumbar spine (L2-4), femoral neck and Ward's triangle, by dual-energy X-ray absorptiometry. RESULTS: The serum testosterone level was lower, while FSH and LH were higher, in patients with KS than in the control group (P < 0.001). Patients with KS had a significantly lower mean (sd) BMD at the lumbar spine, femoral neck and Ward's triangle, than the controls, at 0.88 (0.13) vs 1.09 (0.10) (P < 0.001), 0.78 (0.12) vs 0.87 (0.10) (P = 0.006) and 0.65 (0.12) vs 0.76 (0.11) g/cm(2) = 0.001), respectively. There was a linear correlation between all BMD values and serum testosterone levels in men with KS who had a low serum testosterone level. CONCLUSIONS: There was a relationship between a lower BMD and testosterone levels in patients with KS. These findings suggest that low testosterone levels cause inadequate bone development and a low BMD in men with KS; therefore, testosterone replacement might be necessary to prevent bone mineral deficiency and future risk of fractures in men with KS who also have low serum testosterone levels.