The Treatments for Intermediate Risk Prostate Cancer

The population of intermediate-risk prostate cancer patients is a large heterogeneous group with diverse prognoses and challenges the struggle to develop more meticulous and standardized treatment recommendations. Furthermore, there are no specific treatment guidelines based on Korean patients although the cancer nature of this patient group is known to be somewhat different from those of western patients. This review will examine the treatment options for intermediate-risk prostate cancer patients in specific clinical situations. The literature provides evidence that combining androgen deprivation therapy (ADT) for 6 months with radiation therapy (RT) may have superior survival than RT alone. Also, patients with adverse pathologic features and lymph node metastasis will benefit from adjuvant RT and ADT respectively after radical prostatectomy (RP). In addition, patients with life expectancy ≥10 years will benefit from lymphadenectomy during RP when lymph node metastasis is suspected as well as neurovascular bundle saving during RP is recommended because of its superior functional results.

Loupe-Assisted Vasovasostomy Using a Prolene Stent: A Simpler Vasectomy Reversal Technique

PURPOSE: Microsurgical vasovasostomy is associated with high patency and pregnancy rates, but is difficult and requires significant effort and time to learn. Therefore, we assessed a simplified loupe-assisted vasovasostomy method using a Prolene stent. MATERIALS AND METHODS: The medical records of 82 patients who underwent loupe-assisted vasovasostomy with a Prolene stent by a single surgeon between January 2004 and December 2015 were reviewed. The association between the vasal obstructive interval (VOI) and the success rate was evaluated. RESULTS: The average age at the time of vasovasostomy was 39.8 years (range, 29~57 years). The mean VOI was 6.6 years (range, 1~19 years). The mean operation time was 87.0 minutes (range, 55.0~140.0 minutes). The overall patency and natural pregnancy rates were 90.2% and 45.1%, respectively. The success rate decreased as time after vasectomy increased (odds ratio, 0.869; 95% confidence interval, 0.760~0.993; p=0.039). The cases were divided into 2 groups according to the mean VOI: group A (>7 years) and group B (≤7 years), with 31 cases (37.8%) and 51 cases (62.2%), respectively. The patency and pregnancy rates of group A were 80.6% and 51.6%, respectively, while those of group B were 96.1% and 41.2%, respectively. CONCLUSIONS: Loupe-assisted vasovasostomy using a Prolene stent is a safe and effective method.

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.

Efficacy of Holmium Laser Enucleation of the Prostate in Patients with a Small Prostate (≤30 mL)

PURPOSE: We investigated the effects of holmium laser enucleation of the prostate (HoLEP) in patients with a small prostate (≤30 mL) in whom medical treatment was ineffective. MATERIALS AND METHODS: Data from 132 patients who underwent HoLEP by a single surgeon between 2012 and 2015 were retrospectively analyzed. All patients received benign prostatic hyperplasia medication for at least 6 months before surgery. The patients were divided into 2 groups according to prostate size: group 1, ≤30 mL (n=30); and group 2, >30 mL (n=102). Clinical characteristics and the International Prostate Symptom Score (IPSS), including quality of life (QoL), peak urinary flow rate (Qmax), and postvoid residual urine (PVR), before surgery and 3 months postoperatively, were compared between the 2 groups. RESULTS: In group 1, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. The voiding subscore also significantly decreased 3 months after surgery (p < 0.001), but the storage subscore was not significantly different (p=0.055). In group 2, hemoglobin, the IPSS, QoL, and PVR significantly decreased and the Qmax significantly increased 3 months after surgery. In these patients, both the storage subscore and voiding subscore significantly decreased after surgery (both p < 0.001). There were no significant differences between the groups in hemoglobin, IPSS, QoL, Qmax, and PVR either before or 3 months after surgery. CONCLUSIONS: When other medical treatments are ineffective, HoLEP is an effective intervention for patients with a small prostate.

Comparison of Renal Function between Robot-Assisted and Open Partial Nephrectomy as Determined by Tc 99m-DTPA Renal Scintigraphy

We compared postoperative renal function impairment between patients undergoing robot-assisted partial nephrectomy (RAPN) and those undergoing open partial nephrectomy (OPN) by using Tc-99m diethylenetriaminepentaacetic acid (DTPA) renal scintigraphy. Patients who underwent partial nephrectomy by a single surgeon between 2007 and 2013 were eligible and were matched by propensity score, based on age, tumor size, exophytic properties of tumor, and location relative to the polar lines. Of the 403 patients who underwent partial nephrectomy, 114 (28%) underwent RAPN and 289 (72%) underwent OPN. Mean follow-up duration was 35.2 months. Following propensity matching, there were no significant differences between the two groups in tumor exophytic properties (P = 0.818) or nephrometry score (P = 0.527). Renal ischemic time (24.4 minutes vs. 17.8 minutes, P < 0.001) was significantly longer in the RAPN group than in the OPN group, while the other characteristics were similar. Multivariate analysis showed that greater preoperative renal unit function (P = 0.011) and nephrometry score (P = 0.041) were independently correlated with a reduction in glomerular filtration rate. The operative method did not correlate with renal function impairment (P = 0.704). Postoperative renal function impairment was similar between patients who underwent OPN and those who underwent RAPN, despite RAPN having a longer ischemic time.

Multiple Human Papillomavirus Infection Is Associated with High-Risk Infection in Male Genital Warts in Ulsan, Korea

Further understanding of male human papillomavirus (HPV) infection is necessary to prevent infection in men, as well as transmission to women. In our current study, we investigated patterns of HPV infection and genotype distributions in male genital warts using the Anyplex II HPV28 Detection kit. We reviewed the medical records of 80 male patients who presented to 5 neighborhood clinics in Ulsan, Korea, for the treatment of genital warts between April 2014 and January 2015. All patients underwent HPV genotyping. The prevalence and characteristics of HPV infection were analyzed, and the patterns of HPV infection according to age were assessed. Among the study patients, 13 (16.3%) were negative for HPV infection, 46 (57.3%) were infected with low-risk HPV, and 21 (26.3%) were infected with high-risk HPV. Patients with multiple HPV infection were more likely to have high-risk HPV infection (P = 0.001). The prevalence of HPV infection was much higher in samples obtained by tissue excision due to a definite lesion (P = 0.001). There were no differences in high-risk HPV infection (P = 0.459), multiple HPV infection (P = 0.185), and recurrence at diagnosis (P = 0.178) according to age. HPV-6 and HPV-11 were the most common type overall (39.7% and 13.8%, respectively). HPV-16 and HPV-18 were the most common high-risk infections (both 3.4%). HPV infection is not only commonly encountered in male genital warts, but is also accompanied by high-risk HPV and multiple infections.

Prevalence and clinical significance of incidental 18F-fluoro-2-deoxyglucose uptake in prostate

PURPOSE: To investigate the prevalence and clinical significance of incidental prostate fluoro-2-deoxyglucose (FDG) uptake and to evaluate its impact on patient management. MATERIALS AND METHODS: Of 47,109 men who underwent FDG positron emission tomography between 2004 and 2014, 1,335 (2.83%) demonstrated incidental FDG uptake in the prostate, with 99 of the latter undergoing prostate biopsy. The primary end point was the histological presence of prostate adenocarcinoma in the biopsy specimen. Outcomes, including treatment methods, survival, and causes of death, were also assessed. Factors associated with the diagnosis of prostate cancer were evaluated by using logistic regression analysis. RESULTS: Patients with prostate cancer were more likely to have higher serum prostate-specific antigen (PSA) (p=0.001) and focal FDG uptake (p=0.036) than were those without. Prostate cancer occurred in 1 of 26 patients (3.8%) with serum PSA or =2.5 ng/mL. Multivariable analysis showed that focal lesions (odds ratio [OR], 5.50; p=0.038), age (OR, 1.06; p=0.031), and serum PSA (OR, 1.28; p=0.001) were independent predictors of prostate cancer diagnosis. Most patients with prostate cancer had organ-confined tumors. Of these, 12 (29.3%) underwent radical prostatectomy and 25 (60.9%) received hormone therapy. Of the 11 patients who died, 9 died of primary cancer progression, with only 1 patient dying from prostate cancer. CONCLUSIONS: The prevalence of incidental FDG uptake in the prostate was not high, although patients with elevated serum PSA had a higher incidence of prostate cancer. Patients with FDG uptake in the prostate should be secondarily evaluated by measuring serum PSA, with those having high serum PSA undergoing prostate biopsy.

Clinical features and prognosis of prostate cancer with high-grade prostatic intraepithelial neoplasia

PURPOSE: To evaluate the clinical features and biochemical recurrence (BCR) in prostate cancer (PCa) with high-grade prostatic intraepithelial neoplasia (HGPIN). MATERIALS AND METHODS: We retrospectively analyzed the medical records of 893 patients who underwent a radical prostatectomy for PCa between 2011 and 2012 at Asan Medical Center; 752 of these patients who did not receive neoadjuvant or adjuvant therapy and were followed up for more than 1 year were included. The cohort was divided into two groups-patients with and without HGPIN-and their characteristics were compared. The Cox proportional hazards model was used to analyze factors affecting BCR. RESULTS: In total, 652 study patients (86.7%) had HGPIN. There were no significant differences in preoperative factors between the two groups, including age (p=0.369) and preoperative prostate-specific antigen concentration (p=0.234). Patients with HGPIN had a higher Gleason score (p=0.012), more frequent multiple tumor (p=0.013), and more perineural invasion (p=0.012), but no other postoperative pathologic characteristics were significantly different between the two groups. There were no significant differences in BCR (13.0% vs. 11.5%, p=0.665) and HGPIN was not associated with BCR (p=0.745). In multivariate analysis, only the T stage (p<0.001) was associated with BCR. CONCLUSIONS: PCa patients with HGPIN have a higher Gleason score, more frequent multiple tumors, and more perineural invasion than those without HGPIN. The presence of HGPIN is not an independent predictor of BCR.

Effects of statin use on the response duration to androgen deprivation therapy in metastatic prostate cancer

PURPOSE: To determine whether statin use delays the development of castration-resistant prostate cancer (CRPC) in patients with metastatic prostate cancer treated with androgen deprivation therapy (ADT). MATERIALS AND METHODS: A total of 171 patients with metastatic prostate cancer at the time of diagnosis who were treated with ADT between January 1997 and December 2013 were retrospectively analyzed. The patients were classified into two groups: the nonstatin use group (A group) and the statin use group (B group). Multivariate analysis was performed on statin use and other factors considered likely to have an effect on the time to progression to CRPC. RESULTS: The mean patient age was 67.1+/-9.1 years, and the mean follow-up period was 52 months. The mean initial prostate-specific antigen (PSA) level was 537 ng/mL. Of the 171 patients, 125 (73%) were in group A and 46 (27%) were in group B. The time to progression to CRPC was 22.7 months in group A and 30.5 months in group B, and this difference was significant (p=0.032). Blood cholesterol and initial PSA levels did not differ significantly according to the time to progression to CRPC (p=0.288, p=0.198). Multivariate analysis using the Cox regression method showed that not having diabetes (p=0.037) and using a statin (p=0.045) significantly increased the odds ratio of a longer progression to CRPC. CONCLUSIONS: Statin use in metastatic prostate cancer patients appears to delay the progression to CRPC. Large-scale, long-term follow-up studies are needed to validate this finding.

Clinicopathological features of Xp11.2 translocation renal cell carcinoma

PURPOSE: Xp11.2 translocation renal cell carcinoma (RCC) is characterized by various translocations of the TFE3 transcription factor gene. These rare cancers occur predominantly in children and young adults. Here, we review the clinicopathological features of Xp11.2 translocation RCC. MATERIALS AND METHODS: We identified 21 patients with Xp11.2 translocation RCC. We retrospectively analyzed patient characteristics, clinical manifestations, and specific pathological features to assess definitive diagnosis, surgical and systemic treatments, and clinical outcomes. RESULTS: The mean age at diagnosis was 43.4+/-20.0 years (range, 8-80 years; 8 males and 13 females). Eleven patients were incidentally diagnosed, nine patients presented with local symptoms, and one patient presented with systemic symptoms. The mean tumor size was 6.2+/-3.8 cm (range, 1.9-14 cm). At the time of diagnosis, 11, 1, and 5 patients showed stage I, II, and III, respectively. Four patients showed distant metastasis. At analysis, 15 patients were disease-free after a median follow-up period of 30.0 months. Four patients received target therapy but not effectively. CONCLUSIONS: Xp11 translocation RCC tends to develop in young patients with lymph node metastasis. Targeted therapy did not effectively treat our patients. Surgery is the only effective therapy for Xp11 translocation RCC, and further studies are needed to assess systemic therapy and long-term prognosis.

Clinicopathological Features of Prostate Ductal Carcinoma: Matching Analysis and Comparison with Prostate Acinar Carcinoma

We evaluated the clinicopathological features and prognosis of 29 cases of prostate ductal carcinoma was considered to be an aggressive subtype of prostate acinar carcinoma. We selected 29 cases who were diagnosed prostate ductal carcinoma and had a radical prostatectomy (RP). The acinar group (n = 116) was selected among 3,980 patients who underwent a prostatectomy. The acinar group was matched to the ductal group for prostate specific antigen (PSA), clinical stage, Gleason score, and age. The mean (range) of the follow-up periods for the ductal and acinar group was 23.8 +/- 20.6 and 58 +/- 10.5 months, respectively. The mean age of the prostate ductal and acinar carcinoma patients was 67.3 and 67.0 yr and the mean PSA level was 14.7 and 16.2 ng/mL, respectively. No statistical differences were evident between groups in terms of the final pathologic stage or positive resection margin rate other than the postoperative Gleason score. A greater proportion of the ductal group demonstrated a postoperative Gleason score > or = 8 in comparison with the acinar group (P = 0.024). Additionally, we observed significant prognostic difference in our patient series in biochemical recurrence. The ductal group showed a poorer prognosis than the acinar group (P = 0.016). There were no differences significantly in terms of final pathology and rate of positive resection margin, but a greater proportion of the ductal group demonstrated a Gleason score > or = 8 than the acinar group after matching for PSA, Gleason score in biopsy and clinical stage. The ductal group also showed a poorer prognosis.

The Type of Nephrectomy Has Little Effect on Overall Survival or Cardiac Events in Patients of 70 Years and Older With Localized Clinical T1 Stage Renal Masses

PURPOSE: To compare the outcomes of nephron-sparing options (e.g., partial nephrectomy [PN]) and low-surgical-morbidity options (e.g., radical nephrectomy [RN]) in elderly patients with limited life expectancy. MATERIALS AND METHODS: We retrospectively reviewed 135 patients aged 70 years or older who underwent RN (n=82) or PN (n=53) for clinical T1 stage renal masses between January 2000 and December 2012. Clinicopathologic data were thoroughly analyzed and compared between the RN and PN groups. The modification of diet in renal disease equation was used to estimate glomerular filtration. Overall survival and cardiac events were assessed by using Kaplan-Meier survival analysis and Cox proportional-hazards regression modeling. RESULTS: Over a median follow-up period of 59.72 months, 17 patients (20.7%) in the RN group and 3 patients (5.7%) in the PN group died. Chronic kidney disease (<60 mL/min/1.73 m2) developed more frequently in RN patients than in PN patients (75.6% vs. 41.5%, p<0.001). The 5-year overall survival rate did not differ significantly between the RN and PN groups (90.7% vs. 93.8%; p=0.158). According to the multivariate analysis, the Charlson comorbidity index score was an independent predictor of overall survival (hazard ratio [HR], 2.679, p=0.037). Type of nephrectomy was not significantly associated with overall survival (HR, 2.447; p=0.167) or cardiac events (HR, 1.147; p=0.718). CONCLUSIONS: Although chronic kidney disease was lower after PN, overall survival and cardiac events were similar regardless of type of nephrectomy.

Long-Term Oncologic Outcomes after Radical Cystectomy for Bladder Cancer at a Single Institution

The aim of this study was to evaluate our experience using radical cystectomy to treat patients with bladder cancer and to describe the associations between pathologic features and clinical outcomes. All 701 patients who underwent radical cystectomy for bladder cancer were evaluated. The patient population consisted of 623 men and 78 women. The overall 5 and 10 yr recurrence-free survival (RFS) rates were 61.8% and 57.7%, respectively, and the 5 and 10 yr cancer-specific survival (CSS) rates were 70.8% and 65.1%, respectively. Multivariate analysis showed that factors significantly predictive of RFS and CSS included extravesical extension (P = 0.001), lymph node metastasis (P = 0.001), and lymphovascular invasion (P < 0.001 and P = 0.007). The 5 and 10 yr RFS rates for patients with lymph node metastasis were 25.6% and 20.8%, respectively, and the 5 and 10 yr CSS rates were 38.6% and 30.9%, respectively. Adjuvant chemotherapy significantly improved RFS (P = 0.002) and CSS (P = 0.001) in patients with lymph node metastasis. Radical cystectomy provides good survival results in patients with invasive bladder cancer. Pathologic features significantly associated with prognosis include extravesical extension, node metastasis, and lymphovascular invasion. Adjuvant chemotherapy improves survival in patients with advanced stage disease.

Histologic Variability and Diverse Oncologic Outcomes of Prostate Sarcomas

PURPOSE: Primary prostate sarcomas are a rare type of prostate cancer that account for less than 0.1% of primary prostate malignancies. We analyzed the experience of a single institution with prostate sarcoma over 20 years. MATERIALS AND METHODS: In this case series, the medical records of 20 patients with prostate sarcoma were reviewed from June 1990 to December 2013 to identify symptoms at presentation, diagnostic procedures, metastasis presence and development, histologic subtype, French Federation Nationale des Centres de Lutte Contre le Cancer grade, primary tumor grade and size, and treatment sequence, including surgery and preoperative and postoperative therapies. The average follow-up period was 23.6 months (range, 1.4-83.3 months). RESULTS: The average patient age was 46.3+/-16.7 years. Most patients presented with lower urinary tract symptoms (55%). The histologic subtype was spindle cell sarcoma in five patients (25%), rhabdomyosarcoma in three patients (15%), synovial sarcoma in three patients (15%), liposarcoma in three patients (15%), stromal sarcoma in three patients (15%), and Ewing sarcoma, nerve sheath tumor, and adenocarcinoma with sarcomatoid component (5% each). For liposarcoma, two patients were alive after complete surgical resection and had a good prognosis. At last follow-up, 15 patients had died of sarcoma. The 2- and 5-year actuarial survival rates for all 20 patients were 53% and 12%, respectively (medial survival, 20 months). CONCLUSIONS: The disease-specific survival rate of prostate sarcoma is poor. However, sarcoma that is detected early shows a better result with proper management including surgical intervention with radio-chemotherapy than with no treatment. Early diagnosis and complete surgical resection offer patients the best curative chance.

Retropubic Versus Robot-Assisted Laparoscopic Prostatectomy for Prostate Cancer: A Comparative Study of Postoperative Complications

PURPOSE: To compare the complications of radical retropubic prostatectomy (RRP) with those of robot-assisted laparoscopic prostatectomy (RALP) performed by a single surgeon for the treatment of prostate cancer. MATERIALS AND METHODS: The postoperative complications of 341 patients who underwent RRP and 524 patients who underwent RALP for prostate cancer at the Asan Medical Center between July 2007 and August 2012 were retrospectively reviewed and compared. Complications were classified according to the modified Clavien classification system. RESULTS: RALP was associated with a shorter length of hospital stay (mean, 7.9 days vs. 10.1 days, p<0.001) and duration of urethral catheterization (6.2 days vs. 7.5 days, p<0.001) than RRP. Major complications (Clavien grade III-IV) were less common in the RALP group than in the RRP group (3.4% vs. 7.6%, p=0.006). There were no significant differences in medical complications between procedures. Considering surgical complications, urinary retention (7.0% vs. 2.7%, p=0.002) and wound repair (4.1% vs. 0.2%, p<0.001) were more common after RRP than after RALP. Extravasation of contrast medium during cystography was more common in the RRP group than in the RALP group (10.0% vs. 2.1%, p<0.001). CONCLUSIONS: RALP is associated with a lower complication rate than RRP.

Changes in Serum Prostate-Specific Antigen Levels after Potassium-Titanyl-Phosphate (KTP) Laser Vaporization of the Prostate

PURPOSE: The prostate-specific antigen (PSA) level decreases after transurethral resection of the prostate (TURP). However, changes in the PSA level after potassium-titanyl-phosphate (KTP) laser vaporization of the prostate are not well known. The aim of this study was to investigate the effect of KTP laser vaporization of the prostate on PSA levels in patients with benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Serum PSA levels were checked before and 1, 3, 6, and 12 months after the procedure in patients who underwent KTP laser vaporization between October 2004 and August 2008. Patients with prostate cancer, a history of urinary retention, or prostatitis during the follow-up period were excluded. The results for 278 patients were studied. RESULTS: The mean age of the patients was 69.0+/-6.7 years (range, 50-91 years) and the mean preoperative PSA level was 2.72+/-2.93 ng/ml. The PSA level tended to be increased at 1 month after the operation (3.18+/-3.23 ng/ml, p=0.032) but decreased within 3 months and became stabilized after 6 months at 1.79+/-1.82 ng/ml (p<0.001). CONCLUSIONS: PSA levels may increase after KTP laser vaporization for a certain period of time, but eventually decrease and become stabilized after 6 months. Therefore, it may be appropriate to wait up to 3 months if the PSA level rises after the procedure, and further investigation should be considered if the PSA level still remains high after 6 months.

Management of Urethral Fistulas and Strictures after Hypospadias Repair / 대한비뇨기과학회지

PURPOSE: Urethrocutaneous fistulas and urethral strictures are the most frequent complications after hypospadias repair. We reviewed outcomes after surgical repair of these complications to evaluate the factors determining successful outcome. MATERIALS AND METHODS: In 60 patients with fistula or stricture after hypospadias repair performed between September 1993 and January 2008, we reviewed incidences, clinical features, and outcome after repair with respect to initial hypospadias types. RESULTS: Fistulas were observed in 42 patients and were surgically repaired in 39 (92.8%). In 8 (19.0%) and 3 (7.1%) patients, concurrent meatal and urethral strictures were noted, respectively. The number of fistulas was single in 38 (90.5%) and 2 in 4 (9.5%) patients. Fistulas occurred most frequently from the penoscrotal type hypospadias (22/65, 33.8%) and had initially undergone transverse preputial island flap repair (13/26, 50%). Complete excision of the fistulous tract and multilayer advancement flap closure was the most common method for fistula repair (24), followed by cross-suture in 9 and repeat urethroplasty in 6. Initial management was successful in 35 (89.7%) patients. Urethral strictures were observed in 16 patients with equal incidences at the meatus and the other portion of the urethra. Successful outcome was achieved in all metal stenosis after repeat meatoplasty, whereas for urethral strictures, 4 (20%) patients who underwent visual urethrotomy experienced recurrent strictures. CONCLUSIONS: Urethrocutaneous fistulas can be successfully repaired by complete excision and cross-suture closure and multiple coverage with healthy tissues. In urethral strictures, reconstruction of ample neo-meatus is the key to achieving sufficient stream regardless of the stricture site.

Percutaneous Nephrolithotomy: A Single Center Experience of 610 Cases

PURPOSE: We performed this study to evaluate the outcomes and complications of percutaneous nephrolithotomy (PCNL) at a single institute with a large series. MATERIALS AND METHODS: We reviewed the medical records of 610 patients who underwent PCNL between March 1995 and June 2008 for staghorn calculi in 139 (22.8%), partial staghorn calculi in 104 (17.0%), renal pelvis stone in 222 (36.4%), proximal ureter calculi in 60 (9.8%), and calculi within a caliceal diverticulum in 85 (13.9%) patients. Stone-free status was defined as no visible residual calcification or remnant calcification smaller than 4 mm in diameter (clinically insignificant residual fragment) on a plain KUB (X-ray examination of the kidney, ureter, and bladder) image. Characteristics of the stones, operation time, stone-free rate, and complications were evaluated. RESULTS: Initial stone burden was 665.9+/-600.6 mm2. Average operation time was 103.2+/-58.6 minutes. The mean hospital stay was 7.9 days. The stone-free rate was 84.9%, and ancillary procedures were required in 66 patients (10.8%), including 34 (5.6%) second-look PCNL and 26 (4.3%) ureteroscopic procedures. In the univariate analysis for prediction of stone-free rate, hydronephrosis, stone type, stone composition, and stone burden were significant prognostic factors. In the multivariate analysis, initial stone burden was the only independent factor affecting the stone-free rate. Complications were found in 95 patients (16.1%), 5 (0.8%) of whom needed embolization due to bleeding and 23 (3.8%) of whom showed pleural complications. CONCLUSIONS: PCNL is an effective method for the treatment of staghorn, large calyceal, and some upper ureteral stones with acceptable complication rates.

Risk Factors for Upper Urinary Tract Deterioration in Children with Neurogenic Bladder

PURPOSE: We evaluated the risk factors for upper urinary tract deterioration in children with neurogenic bladder. MATERIALS AND METHODS: The study population consisted of 60 children (36 boys, 24 girls) with neurogenic bladder confirmed by urodynamic study between January 1994 and June 2007. The average follow-up period was 48 months. The patients' medical records were assessed concerning gender, presence of vesicoureteral reflux (VUR), hydronephrosis, type of spinal dysraphism, level of spinal dysraphism, practice of clean intermittent catheterization (CIC), type of neurogenic bladder, bladder capacity, compliance, detrusor sphincter dyssynergia, recurrent urinary tract infection (UTI), and timing of primary neurosurgical repair. Upper urinary tract deterioration was diagnosed by 99m technetium-dimercaptosuccinic acid renal scan (DMSA) and aggravation of hydronephrosis and VUR. RESULTS: Upper urinary tract deterioration was detected in 15 patients (25%). Hydronephrosis, VUR, and UTI were associated with upper urinary tract deterioration in the univariate analyses. In the multivariate analyses, hydronephrosis [odds ratio (OR)=2.181, 95% confidence interval (CI)=1.191-11.941, p=0.036] and recurrent UTI [OR=5.810, 95% CI=1.200-28.192, p=0.029] were independent risk factors for upper urinary tract deterioration. CONCLUSIONS: Hydronephrosis and recurrent UTI increase the risk of upper urinary tract deterioration in children and adolescents with neurogenic bladder. Therefore, intensive observation and prompt intervention may be recommended for such cases.

Transperitoneal Laparoscopic Upper Pole Heminephrectomy in Pediatric Patients with Duplex Kidneys: Comparison with an Age-Matched Cohort of Open Surgery

PURPOSE: We evaluated the safety and feasibility of transperitoneal laparoscopic upper pole heminephrectomy (TLUHN) in pediatric patients by comparing an age-matched cohort undergoing open upper pole heminephrectomy (OUHN) by a single surgeon. MATERIALS AND METHODS: A total of 10 OUHNs were performed between 1995 and 2003 and 10 TLUHNs between 2003 and 2008. The 10 patients in each group were matched by age (p=0.94), gender (p=1.0), and body weight (p=0.91). RESULTS: There was no open conversion in the TLUHN group. The median operative time in the TLUHN and OUHN groups was 174 minutes (range, 98-205) and 190 minutes (range, 120-258), respectively (p=0.19). In the TLUHN and OUHN groups, the median blood loss was 25 ml (range, 20-30) and 35 ml (range, 20-100) (p=0.74), the median analgesic requirement was 0 hours (range, 0-42) and 0 hours (range, 0-87) (p=0.16), and the median hospital stay was 5.5 days (range, 3-7) and 7 days (range, 3-19) (p=0.01), respectively. There were no intraoperative complications in either group. Postoperative atelectasis occurred in two and five patients in the TLUHN and OUHN groups, respectively. Similar results were found in the subanalysis of patients younger than 24 months. CONCLUSIONS: TLUHN is safe and feasible even in small children and infants. Furthermore, decreased hospital stay is the main advantage of the laparoscopic approach compared with open surgery.