The Short- and Long-Term Anticipation of Prostate Cancer Incidence in Korea: Based on Social Aging Trends and Prostate-Specific Antigen Testing Rate during the Last Decade.

The current incidence of prostate-specific antigen (PSA) testing, which plays a crucial role in detecting prostate cancer (PCa) in an aged population, is low in Korea. Reflecting these epidemiologic characteristics, we estimated the short- and long-term incidences of PCa. A regression equation model was extracted based on two critical pieces of information: (1) the distribution of newly detected PCa cases in each age group of the 50s, 60s, 70s, and over 80s from a recent period (2006-2020), and (2) the PSA testing rate (PSAr) from the previous decade (2006-2016) for each age subgroup. The incidence increased fourfold (4533 in 2006 to 16,815 in 2020), with each age subgroup accounting for 7.9% (50s), 31.4% (60s), 43.0% (70s), and 17.1% (over 80s) of cases in 2020. PSAr increased by an average of 1.08% annually. If these trends are maintained, 28,822 new cases will be diagnosed in 2030 (expected PSAr: 14.4%) and 40,478 cases in 2040 (expected PSAr: 26.4%). If a public PSA screening were implemented for men only in their 60s (assuming a PSAr of 60% in the 60s) and 70s (assuming a PSAr of 80% in the 70s) in 2030, 37,503 cases in 2030 (expected PSAr: 23.1%) and 43,719 cases in 2040 (expected PSAr: 29.9%) would be estimated. According to the projection, the incidence of PCa will increase twofold by 2034 compared to 2020. If national screening were only conducted in the 60s and 70s, a higher detection of almost threefold would be expected by 2040.

The Long-Term Impact of 5-alpha Reductase Inhibitors on the Development of Bladder Cancer and the Need for Radical Cystectomy: A Nationwide Observational Study.

PURPOSE: To investigate the long-term effects of taking 5-alpha reductase inhibitors (5ARIs) on the development of bladder cancer (BC) and the implementation of radical cystectomy (RC), a standard procedure for advanced BC. MATERIALS AND METHODS: From the National Health Insurance Sharing Service database, males aged over 40 years who underwent serum prostate-specific antigen testing from 2006 through 2017 were identified, which is required for the prescription of 5ARIs. The association between the administration duration of 5ARIs and the practice for BC was analyzed. RESULTS: Of the 3,843,968 subjects, 1,514,713 (39.4%) took 5ARIs for an average of 1.53 years, remaining 2,329,255 (60.6%) as non-5ARI counterparts. The incidence of BC was higher in the non-5ARI than in the 5ARI group (1.25% vs. 0.87%, p<0.001), as was the implementation rate of RC (11.1% vs. 10.4%, p=0.037). In a multivariate analysis, the non-5ARI group had a significant risk of BC (hazard ratio [HR]=2.289, 95% confidence interval [CI]=2.241-2.338) and RC (HR=2.199, 95% CI=2.061-2.348) than the 5ARI group. Among the 5ARIs group, though the incidence of BC was maintained (slope=-0.002 per year, p=0.79) after an initial increase for two years, the rate of RC decreased (slope=-1.1, p<0.001) consistently for ten years during the administration. CONCLUSIONS: Compared to the untreated group, 5ARIs use was associated with lower rates of BC and RC. In contrast to the increase in BC seen with short-term use of less than two years, long-term use of 5ARIs decreased the rate of RC in a duration-dependent manner for ten years, suggesting a strategy to prevent disease progression.

Efficacy of Various Treatment in Premature Ejaculation: Systematic Review and Network Meta-Analysis.

PURPOSE: To investigate the various strategies used for the treatment of premature ejaculation (PE); these encompassed behavioral, drug and surgical interventions. MATERIALS AND METHODS: We retrieved data from electronic literature searches of PubMed and Cochrane library using the MeSH (Medical Subject Headings terms) and text keywords from the earliest available date of indexing through September 2022. The subject headings and text keywords included those related to the population (male patients with PE), interventions & comparisons (mono and combination treatment), and outcomes (ejaculation latency time, ELT). RESULTS: The initial search identified a total of 454 articles from electronic databases. Finally, a total of 10,474 patients from 59 direct comparison trials were included 143 effect sizes with 43 treatments. Of these, 9 of mono treatments and 4 of combination treatments were statistically significant. Pharmaceutical agents commonly used for patients with PE are prescribed off-label, except for dapoxetine. The surface under the cumulative ranking curve values of ranking probabilities for each treatment performance, which indicated that tramadol 100 mg ranked first in terms of ELT. CONCLUSIONS: Medications recommended by the American Urological Association and the Sexual Medicine Society of North America were all incorporated within the present review, together with additional management approaches that have been evaluated in randomized controlled trials. The findings indicated that in addition to SSRIs, tramadol, clomipramine, topical agents and PDE5 inhibitors could be used in the therapy of PE.

Medical Treatment for Peyronie's Disease: Systematic Review and Network Bayesian Meta-Analysis.

PURPOSE: To investigate the efficacy of medical treatment options for Peyronie's disease (PD) including oral drugs, intralesional treatment and mechanical treatment compared with placebo treatment using network meta-analysis (NMA). MATERIALS AND METHODS: We searched the randomized controlled trials (RCTs) of PD in PubMed, Cochrane library, and EMBASE up to October 2022. RCTs included medical treatment options: oral drugs, intralesional treatment and mechanical treatment. Studies reporting at least one of the outcome measures of interest including curvature degree, plaque size, and structured questionnaires (International Index of Erectile Function, IIEF) were included. RESULTS: Finally, 24 studies including 1,643 participants met our selection criteria for NMA. There was no statistically significant treatment compared to placebo of the curvature degree, plaque size, IIEF in Bayesian analysis. The SUCRA values of ranking probabilities for each treatment performance, which indicated that hyperthermia device ranked first in NMA. However, in frequentist analysis, 7 of mono treatments (coenzyme Q10 [CoQ10] 300 mg, hyperthermia device, interferon alpha 2b, pentoxifylline 400 mg, propionyl-L-carnitine 1 g, penile traction therapy [PTT], vitamin E 300 mg) and 2 of combination treatments ("PTT-extracorporeal shockwave treatment", "vitamin E 300 mg-propionyl-L-carnitine 1 g") were statistically significant for improvement of curvature degree, and 9 of mono treatments (CoQ10 300 mg, hyaluronic acid 16 mg, hyperthermia device, interferon alpha 2b, pentoxifylline 400 mg, propionyl-L-carnitine 1 g, verapamil 10 mg, vitamin E 300 mg, vitamin E 400 U) and 3 of combination treatments ("interferon alpha 2b-vitamin E 400 U", "verapamil 10 mg-antioxidants", "vitamin E 300 mg-propionyl-L-carnitine 1 g") were statistically significant in the improvement of plaque size. CONCLUSIONS: At present, there is no clinical treatment alternatives that have been demonstrated to be effective compared to placebo. Nonetheless, as the frequentist approach has shown that a number of agents are efficacious, further research is expected to develop more effective treatment options.

Urological complications after COVID 19 vaccine according to age, sex and manufacturer.

OBJECTIVES: To examine the effects of age, sex, and type of COVID-19 vaccine on urological complications after vaccination with COVID-19. MATERIALS AND METHODS: We used the Vaccine Adverse Event Reporting System (VAERS) data from December 2020 to August 2022 to analyze urological symptoms post-vaccination adverse events (AEs) associated with COVID-19 vaccines authorized for the U.S. POPULATION: We collected AEs after 1-2 dose vaccination in VAERS, but not those after an additional booster shot. Age was divided into three groups (< 18 years, 18-64 years, and > 64 years), and compared incidence of AEs after vaccination with either mRNA vaccine (mRNA-1273, Moderna; and BNT162b2, Pfizer-BioNTech) or a viral vector vaccine (JNJ-78436735, Janssen/Johnson and Johnson) as reported in VAERS data. RESULTS: Cumulative incidence rates (CIRs) of LUTS, voiding symptom, storage symptom, infection, and hematuria were 0.057, 0.282, 0.223, 1.245, and 0.214, respectively. By gender, CIRs OF LUTS, storage symptom, and infection were statistically significantly higher in women, whereas CIRs of voiding symptom and hematuria were statistically significantly higher in men. CIRs of AEs per 100,000 in age groups of < 18 years, 18-64 years, and > 64 years were 0.353, 1.403, and 4.067, respectively. All AE types except for voiding symptom displayed the highest CIRs in the Moderna vaccine group. CONCLUSIONS: Based on an updated analysis of available data, the prevalence of urologic complications following administration of COVID-19 vaccines is low. However, specific urologic complications such as gross hematuria are not low in incidence.

Corrigendum: The learning curve for robot-assisted radical cystectomy with total intracorporeal urinary diversion based on radical cystectomy pentafecta.

[This corrects the article DOI: 10.3389/fonc.2022.975444.].

A comparison between asymptomatic and symptomatic ureteral stones.

To investigate the characteristics and impact of asymptomatic (silent) ureteral stones on renal function and compare them with those of symptomatic stones. We retrospectively reviewed the medical records of 677 patients who underwent ureteroscopic lithotripsy or laparoscopic ureterolithotomy for ureteral stones between 2016 and 2020. Patients were divided into two groups according to the presence of recognizable symptoms. We investigated the characteristics and impact of silent stones on post-treatment renal function recovery and compared them with those of symptomatic stones. Among the 677 patients, 43 (6.4%) had asymptomatic ureteral stones, and 634 (93.6%) had symptomatic ureteral stones. Compared to symptomatic stones, asymptomatic stones were larger (11.4 mm vs. 9.6 mm, p = 0.003), more commonly present in the upper ureter (62.7% vs. 48.0%, p = 0.04), and more commonly associated with high-grade hydronephrosis (32.8% vs. 12.3%, p < 0.001); however, no difference in metabolite composition was observed between the two group of stone. In the asymptomatic stone group, the mean preoperative estimated glomerular filtration rate (eGFR) was 77.37 ± 23.54 mL/min/1.73 m2, and the mean postoperative eGFR indicated no significant improvement at 1 day, 7 days, 3 months, and 12 months (76.66 ± 21.45, 77.89 ± 20.87, 77.29 ± 22.22, and 76.71 ± 24.21 mL/min/1.73 m2, respectively; p = 0.567, p = 0.613, p = 0.924, and p = 0.202, respectively). In the symptomatic stone group, the mean preoperative eGFR was 78.17 ± 28.25 mL/min/1.73 m2; the mean postoperative eGFRs at 1 day, 7 days, 3 months, and 12 months were 81.24 ± 26.38, 86.16 ± 25.61, 89.11 ± 25.43, and 89.50 ± 26.01 mL/min/1.73 m2, respectively and demonstrated significant improvement (p = 0.002, p < 0.001, p < 0.001, and p < 0.001, respectively). Silent stones irreversibly impaired renal function, even after proper management. Therefore, active treatment strategies are required for all patients who are hesitant to receive treatment for silent stones because of their asymptomatic status to prevent permanent renal impairment.

The learning curve for robot-assisted radical cystectomy with total intracorporeal urinary diversion based on radical cystectomy pentafecta.

Objective: To analyze the learning curve for robot- assisted radical cystectomy (RARC) with total intracorporeal urinary diversion (ICUD) in terms of both time efficiency and quality of surgery based on radical cystectomy (RC)-pentafecta. Patients and methods: We identified 203 consecutive patients who underwent RARC with ICUD of the ileal conduit (IC, 85) and orthotopic neobladder (ONB, 118) performed by a single surgeon between 2011 and 2021. We grouped ten consecutive patients into time-associated blocks according to the operation order. Process efficiency and operation quality were measured based on the surgeon's console time and attainment/score sum of RC-pentafecta. The overcoming point of the learning curve was defined graphically and statistically. Results: The mean follow-up period was 44.5 ± 30.7 months. Of the 203 patients, 109 (53.7%) attained the five criteria of RC-pentafecta (ONB vs IC, 50.6% vs. 55.9%, p = 0.35). The attainment rate and sum of the RC-pentafecta score of the third group were not significantly different from those of all patients (40.0% vs. 53.7%, p = 0.369, 4.00 ± 1.05 vs. 4.41 ± 0.75, p = 0.137, respectively), and the proficiency in operation quality was satisfactory in the third group. The console times continually improved and stabilized after the 140th case (IC, 60; ONB, 80), and the attainment rate and sum of the RC-pentafecta were significantly different between before and after the 140th case (p<0.001). Conclusion: A single surgeon's learning curve for RARC with ICUD and pelvic lymph node dissection (PLND) showed an acceptable level of proficiency after 30 consecutive cases in terms of the operation quality. However, for an expert surgeon, 140 cases were required to reach a plateau in time efficiency and second leap with the RC-pentafecta. RARC with ICUD and PLND can be performed safely without compromising functional outcomes and complications through sharing and transmission of standardized techniques.

Preclinical evaluation of a regenerative immiscible bioglue for vesico-vaginal fistula.

Currently, there are no clinically available tissue adhesives that work effectively in the fluid-rich and highly dynamic environments of the human body, such as the urinary system. This is especially relevant to the management of vesico-vaginal fistula, and developing a high-performance tissue adhesive for this purpose could vastly expand urologists' surgical repertoire and dramatically reduce patient discomfort. Herein, we developed a water-immiscible mussel protein-based bioadhesive (imWIMBA) with significantly improved properties in all clinical respects, allowing it to achieve rapid and strong underwater adhesion with tunable rheological properties. We evaluated in vivo potential of imWIMBA for sealing thermally injured fistula tracts between the bladder and vagina. Importantly, the use of imWIMBA in the presence of prolonged bladder drainage resulted in perfect closure of the vesico-vaginal fistula in operated pigs. Thus, imWIMBA could be successfully used for many surgical applications and improve treatment efficacy when combined with conventional surgical methods. STATEMENT OF SIGNIFICANCE: Vesico-vaginal fistula (VVF) is an abnormal opening between the bladder and the vagina, which is a stigmatized disease in many developing countries. Leakage of urine into internal organs can induce serious complications and delay wound repair. Conventional VVF treatment requires skillful suturing to provide a tension-free and watertight closure. In addition, there is no clinically approved surgical glue that works in wet and highly dynamic environments such as the urinary system. In this work, for potential clinical VVF closure and regeneration, we developed an advanced immiscible mussel protein-based bioglue with fast, strong, wet adhesion and tunable rheological properties. This regenerative immiscible bioglue could be successfully used for sealing fistulas and further diverse surgical applications as an adjuvant for conventional suture methods.

Do patients benefit from total intracorporeal robotic radical cystectomy?: A comparative analysis with extracorporeal robotic radical cystectomy from a Korean multicenter study.

Purpose: This study aimed to compare complications, perioperative parameters, and oncologic outcomes between robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion (ECUD) and RARC with intracorporeal urinary diversion (ICUD). Materials and Methods: Between 2007 and 2017, 362 patients who underwent RARC with ECUD or ICUD at multiple tertiary referral institutions were assessed. The primary endpoints were complication rates. The secondary outcomes were perioperative recovery parameters and oncological outcomes including estimated recurrence-free survival (RFS) and recurrence pattern between the 2 groups. Additionally, the complication rates of 2 expert surgeons with experience of >100 RARCs were analyzed. Results: The ICUD group showed lower overall, gastrointestinal, and genitourinary complications (p=0.001, p=0.036, and p=0.036, respectively) than the ECUD group. Concerning perioperative outcomes, the ICUD group had a significantly longer operation time (p=0.002), although recovery parameters such as time to flatus passage, oral intake, and length of hospital stay were significantly shorter in this group (p=0.001, p<0.001, and p<0.001, respectively). There was no difference in oncologic outcomes such as positive margin rate (p=0.944) and 2-year RFS (p=0.496), and in the recurrence pattern between groups. In the comparison of the expert surgeons' complication rates, the major and total complication rates did not show differences (p=0.814 and p=0.102, respectively) while the minor complication rates were lower in the ICUD group (p=0.058). Conclusions: This multi-institutional cohort study demonstrated the benefits of the ICUD approach, as indicated by lower complication rates and better recovery parameters, although the oncological results were similar to those of ECUD.

Oncological and functional outcomes of robot-assisted radical cystectomy in bladder cancer patients in a single tertiary center: Can these be preserved throughout the learning curve?

Purpose: To evaluate the overall and segmental oncological and functional outcome of robot-assisted radical cystectomy (RARC) during the learning curve. Materials and Methods: From August 2007 to November 2017, a total of 120 bladder cancer patients were treated with RARC in a single-tertiary hospital. These were divided into three groups of 40 consecutive cases. Overall and subgroup analysis of each group was used to evaluate oncological and functional outcomes throughout the learning curve. Results: Among the 120 RARC cases, 42, 73, and 5 patients received extracorporeal urinary diversion (ECUD), intracorporeal urinary diversion (ICUD), and ureterocutaneostomy, respectively. There was a transition from ECUD to ICUD during the learning curve. The positive surgical margin rate was 0.8%. The mean lymph node yield for the standard and extended pelvic lymph node dissection was 12.5 and 30.1, respectively, and increased to 19.8 and 31.2 and further to 20.0 and 37.9, respectively, with each additional series of 40 cases. The 5-year overall survival and 3-year recurrence-free survival rates were 86.6% and 81.4%, respectively. The 1-year daytime continence rate was 75.7%, while the nighttime continence rate was 51.4%. The potency preservation rate was 66.7% (n=8) with or without phosphodiesterase-5 inhibitors (PDE5-I) at 1 year and 33.3% without PDE5-I (n=4). Conclusions: RARC results in comparable oncological and functional outcomes to open radical cystectomy. In addition, the oncological and functional outcomes were well maintained throughout the learning curve. ECUD transition to ICUD was safe and did not compromise oncological or functional outcome.

Comparison of effective teaching methods to achieve skill acquisition using a robotic virtual reality simulator: Expert proctoring versus an educational video versus independent training.

BACKGROUND: To compare the superiority of teaching methods for acquiring a proficient level of surgical skill in a robotic surgery-naïve individual using a robotic virtual reality simulator. METHODS: This study employed a prospective, randomized study design to assess student's learning curve. We divided 45 subjects into 3 groups: those with expert proctoring (group I), those who watched only an educational video (group II), and those with independent training (group III; n = 15 per group). The task used in this study was the Tube 2 and it imitates a vesicourethral anastomosis in robotic prostatectomy. The effects were analyzed by the time to end the task after overcoming the learning curve which is determined by several performance parameters. RESULTS: The number of task repetitions required to reach the learning curve plateau was 45, 42, and 37 repetitions in groups I, II, and III, which means that there was continuous improvement in performing the task after 40 repetitions only in groups I and II. The mean time for completing the task during the stabilization period was significantly different between group I and group III and group II and group III, which means that the independent training method was inferior to the other methods (group I vs. group II vs. group III: 187.38 vs. 187.07 vs. 253.47 seconds, P < .001). CONCLUSIONS: This study's findings showed that an educational video can be as beneficial as expert proctoring, which implies that the development of a standardized educational video would be worthwhile.

Predictive Validation of a Robotic Virtual Reality Simulator: The Tube 3 module for Practicing Vesicourethral Anastomosis in Robot-Assisted Radical Prostatectomy.

OBJECTIVE: To predict actual performance in real surgery when vesicourethral anastomosis (VUA) is performed in patients after Tube 3 module training of robot-naive surgeons. METHODS: Forty-five patients were enrolled and divided into 3 groups according to chronological trends (each containing 15 patients). Three robot-naive surgeons in a single center completed VUA in robot-assisted radical prostatectomy (RARP) following robotic virtual reality simulator (RVRS) training. The practicing tool used in robotic virtual reality simulator was Tube 3, which was invented for the dV-Trainer that imitates a VUA in RARP. The effects of performance were investigated by analyzing the number of repetitions and the time required to complete the task until achieving the predetermined proficiency level. RESULTS: The targeted time (predetermined proficiency level) for completing tasks of Tube 3 and the number of required task repetitions to achieve the proficiency level were 283.1 s and 36 times, respectively, whereas in actual VUA procedures, the number of required attempts was 24, with an average time of 14.9 minutes. The mean time for completing VUA in real surgery significantly decreased with serial cases among all surgeons (1-15 vs 16-30 vs 31-45 cases, P <.001), as well as comparisons between groups (P <.001). CONCLUSION: The Tube 3 module can represent a valuable educational tool for procedure-specific robotic training by bridging the gap between safe acquisition of surgical skills and effective performance during actual VUA in RARP.

Efficacy of holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction (BOO) and non-neurogenic bladder dysfunction.

We aimed to compare the short-term outcomes of men who had urodynamic evidence of detrusor underactivity (DU) or detrusor overactivity (DO) of a non-neurogenic etiology as well as bladder outlet obstruction (BOO) and who underwent Holmium Laser Enucleation of the prostate (HoLEP). A database of 322 patients who underwent HoLEP between 2010 and 2014 was analyzed. Patients were classified into three groups according to the results of a preoperative urodynamic study. Preoperative parameters such as International Prostate Symptom Score (IPSS), Quality of Life (QoL) index, IPSS grade, uroflowmetry were compared with postoperative parameters measured at 6 months. There were 138 patients with BOO-only and 89 patients with BOO and detrusor dysfunction including 56 with DO and 33 with DU. The degree of improvement in IPSS-total (BOO: 10.7, DO: 8.3, DU: 7.0; p = 0.023) was greater in the BOO-only group than in the DU group. There were more patients whose IPSS grade improved in the BOO-only group (71%) than in the detrusor dysfunction group (DO: 53.6% and DU: 45.5%). Postoperative IPSS-voiding (4.5 vs 7.0), and Qmax (18 vs 13.7) in the BOO-only group were significantly better than those in the DU group. Additionally, postoperative IPSS-storage (4.7 vs 6.7), and IPSS-total (9.1 vs 12.3) in the BOO-only group were significantly better than in the DO group (all p < 0.05). In conclusion, early surgical management for men with severe LUTS and associated BPH before secondary degeneration occurs may be beneficial for preserving detrusor function and yield better treatment outcomes.

Oncologic Outcomes and Predictive Factors for Recurrence Following Robot-Assisted Radical Cystectomy for Urothelial Carcinoma: Multicenter Study from Korea.

The aim of our study was to evaluate intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns in a multicenter series of patients treated with robot-assisted radical cystectomy (RARC) for urothelial carcinoma (UC) of the bladder. Between 2007 and 2015, 346 patients underwent RARC at multiple tertiary referral centers in Korea. Descriptive statistics were used for demographics and perioperative variables. Survival and recurrence were estimated with Kaplan-Meier analysis. Logistic regression models were used to determine predictors of recurrence. Median follow-up was 33 months (interquartile range [IQR], 7-50). The numbers of patients with organ-confined and lymph node (LN)-positive disease were 237 (68.4%) and 68 (19.7%), respectively. LN density (1-20 vs. > 20) was 13.6% and 6.1%, with a median of 17 nodes removed (IQR, 9-23). In logistic regression analysis, type of LN dissection, and pathologic tumor stage were significant predictors of cancer recurrence and death from cancer. Local, distal recurrence and secondary UC occurred in 7 (2.0%), 53 (15.3%), and 4 (1.2%) patients, respectively. The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were 78%, 84%, and 73%, respectively. At last follow-up, RFS for extended pelvic LN dissection vs. standard pelvic LN dissection was 70% and 47% (P = 0.038). In addition, at last follow-up, LN density (0 vs. 1-20 vs. over 20) was 67%, 41%, and 29%, respectively (P < 0.001). Patients undergoing RARC in this multi-institutional cohort demonstrated intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns that were not unusual.

A prospective, multicenter analysis of pseudocapsule characteristics: Do all stages of renal cell carcinoma have complete pseudocapsules?

OBJECTIVES: To assess the characteristics of pseudocapsule (PC) in localized renal cell carcinoma (RCC) by analyzing the rates of completeness of PC and pseudocapsular invasion and clinical and pathological risk factors of it. MATERIALS AND METHODS: Between February 2013 and September 2015, data were gathered prospectively from 180 consecutive patients who underwent partial nephrectomy or radical nephrectomy at 3 institutions, and 161 were enrolled. Evaluated factors included age and sex; histologic factors such as tumor diameter, stage, tumor subtype, necrosis, and Fuhrman grade; and clinical factors such as RENAL score; and completeness of PC. RESULTS: Only 94 tumors (58.4%) were surrounded by a continuous PC completely, 62 (38.5%) were partially surrounded, and 5 (3.1%) had no PC. Overall, 56 PCs (34.8%) were free from invasion, 58 PCs (36.0%) had partial invasion of PC without parenchymal invasion, and 47 PCs (29.2%) had parenchymal invasion. Defining parenchymal invasion as true pseudocapsular invasion, histologic diameter, RCC subtype, and completeness of PC were significant predictors for parenchymal invasion on multivariate analysis (P = 0.006, 0.046, and 0.002, respectively). CONCLUSIONS: Rate of complete PC in RCC is relatively low in this study. The risk factors for pseudocapsular invasion were a histologic diameter greater than 4cm, non-clear cell histology, and an incomplete PC. Surgeons must prepare for the possibility of a positive surgical margin if a tumor has at least one of these risk factors.

Robot-Assisted Radical Cystectomy with Total Intracorporeal Urinary Diversion: Comparative Analysis with Extracorporeal Urinary Diversion.

PURPOSE: To compare the perioperative outcomes, postoperative complications, and early oncologic outcomes of intracorporeal urinary diversion (ICUD) with those of extracorporeal urinary diversion (ECUD) following robot-assisted radical cystectomy (RARC) performed by a single surgeon at a tertiary referral hospital. MATERIALS AND METHODS: We reviewed a prospectively maintained, institutional review board-approved database of 70 patients treated with RARC and pelvic lymph node (LN) dissection for bladder cancer performed from 2007 through 2014. Data were collected for 64 patients who underwent either ICUD or ECUD. RESULTS: Thirty-eight patients underwent ECUD, and the remaining 26 underwent ICUD. Urinary diversion was performed extracorporeally in the first 37 cases and performed intracorporeally thereafter. There were no significant differences in patient characteristics between the ECUD and ICUD groups. Mean total operative time was 468 minutes for ECUD and 581 minutes for ICUD (P < .05). Mean estimated blood loss was 265 and 148 mL, respectively (P < .05). Minor and total complication rates for patients with the ECUD were higher than in patients with the ICUD (minor: 47.4% vs. 15.4%; total: 57.9% vs. 30.8%; P < .05). All patients showed negative surgical margin, while 21% in the ECUD group and 26.9% in the ICUD group had pathologic stage T3 or T4 (P > .05). The mean LN yield was 23.2 and 31.8, respectively (P < .05). CONCLUSIONS: From our experience, the results show that ICUD after RARC can be successful, with the benefits of decreased blood loss and lower transfusion and complication rates than ECUD. A larger series and long-term follow-up data will be necessary to support our results.

Concurrent and predictive validation of robotic simulator Tube 3 module.

PURPOSE: We previously described a new procedure specific module (Tube 3) to allow the practice of vesicourethral anastomosis after robot-assisted radical prostatectomy. Herein, we report a predetermined proficiency level of Tube 3 and preliminary validation to explore whether this new module can lead to performance improvement in the da Vinci system. MATERIALS AND METHODS: Eight urology residents and three urology fellows performed the Tube 3 module 1 hour daily for 7 days. The learning curve was depicted through a scatterplot and the stable point was identified through the cumulative sum chart. Concurrent and predictive validations were performed with the da Vinci system. The mean time to complete the task and end product rating score between Tube 3 training group and no Tube 3 training group were compared. RESULTS: Concerning the learning curve, about 41 repetitions comprising about 5 hours were needed to achieve this stable point when the mean time to complete Tube of 384 seconds was set as a target. With regarding to the concurrent and predictive validation, there significant differences were evident in the mean time to complete 16 needle passages and the vesicourethral anastomosis and the end product rating score. CONCLUSIONS: The virtual reality (VR) simulator can yield sufficient improvement in technical performance in Tube 3 within 5 hours. The acquired proficiency can be transferable to the vesicourethral anastomosis using the da Vinci system.

Renal cryoablation of small renal masses: a Korea University experience.

PURPOSE: To evaluate the perioperative, functional, and oncological outcomes of renal cryoablation (RC) of small renal masses (SRMs) performed in Korea University Hospital. MATERIALS AND METHODS: We reviewed an Institutional Review Board-approved database of 70 patients who underwent RC and were followed up for a minimum of 3 months by a single surgeon in Korea University Hospital from August 2007 to May 2014. Among these patients, 68 patients (79 renal masses) were enrolled in our research. We evaluated perioperative, functional, and oncologic outcomes of RC. RESULTS: A total of 68 patients (79 renal masses) underwent RC in our institution. The mean age of the patients was 62.0 years. The mean tumor size was 2.25 cm. Among the 59 patients who underwent laparoscopic surgery, only 1 patient (1.47%) was converted to open surgery. No other perioperative complications occurred. The mean preoperative and 1-month postoperative estimated glomerular filtration ratio (eGFR) were 71.8 and 68.3 mL/min/1.73 m(2), respectively (p=0.19). The mean 1-year postoperative eGFR was 65.0 mL/min/1.73 m(2) (p=0.25). The mean follow-up period was 59.76 months (range, 3-119 months). Local tumor recurrence occurred in eight tumors (15.4%; a total of 52 renal cell carcinomas). Concerning treatment in the patients with recurrence, five patients underwent re-treatment and three patients are under active surveillance. None of the eight patients who experienced local recurrence had additional recurrence or tumor progression during the follow-up period. In our study, the recurrence-free rate was 83.0% and the cancer-specific survival rate was 100%. Moreover, the 5- and 10-year overall survival rates were both 100%. CONCLUSIONS: Long-term experience with RC in our institution demonstrates that RC is a safe and effective treatment for patients with SRMs.

Standardized analysis of complications after robot-assisted radical cystectomy: Korea University Hospital experience.

PURPOSE: To analyze the complications after robot-assisted radical cystectomy (RARC) by use of a standardized reporting methodology by a single surgeon. MATERIALS AND METHODS: We prospectively reviewed a maintained institutional database of 52 patients who underwent RARC to manage bladder cancer and were followed up in 3 months by a single surgeon at Korea University Medical Center from 2007 through 2014. All complications within 90 days of surgery were defined and categorized into 5 grades according to the Clavien-Dindo classification. Logistic regression analysis was used to identify predictors of complications. RESULTS: Fifty percent of patients (26 of 52) experienced a complication of any grade <90 days after surgery, and 11 patients (21.2%) experienced a major complication. Complications were grouped in systems-based categories. Fifty complications occurred in 52 patients and hematologic complication (transfusion) was the most common (13 of 52). Wound dehiscence, anastomotic leakage, urinary tract obstruction, mechanical obstruction, and thromboembolism occurred as major complications. Mean estimated blood loss (EBL) was 247 mL and mean total operative time was 496 minutes. The mean number of lymph nodes harvested was 24.6, with 30.5 for extended dissection. EBL (over 300 mL), operative time, and method of urinary diversion were significant negative predictors of minor complications, whereas EBL (over 300 mL) was a significant negative predictor of major complications (p<0.05). CONCLUSIONS: The present results show that the complication rate reported by use of a standardized methodology after robotic radical cystectomy is still considerable although comparable to that of contemporary robot series. EBL, operative time, and diversion methods were predictors of complications.