Bong Hee Park

Efficacy and Safety of a Novel, Double-Layered, Coated, Self-Expandable Metallic Mesh Stent (Uventa™) in Malignant Ureteral Obstructions

BACKGROUND AND PURPOSE Malignant ureteral obstruction (MUO) is a common condition and an intractable situation for patients with advanced cancer. There is currently no ideal ureteral stent to release the obstruction. Our purpose was to evaluate the clinical efficacy and safety of a novel, double-layered, coated, self-expandable metallic mesh stent (Uventa(™)) in MUO. PATIENTS AND METHODS In a retrospective design, a total of 71 ureter units (54 patients) were included from December 2009 to March 2012. Indications were those who had MUO with a polymeric Double-J stent malfunction, severe polymeric stent irritation, or severe pain during periodic stent change. Patients underwent Uventa placement using a retrograde approach. RESULTS All stents were positioned at the proper site without procedure-related complications. The overall success (no obstruction and no additional intervention except supplementary Uventa placement) and primary success (no obstruction and no additional intervention) rates were 81.7% (58/71 ureter units) and 64.8% (46/71 ureter units) during the follow-up period, which had a median of 308 (35-802) days. The most common reason for primary failure was tumor progression beyond the stent segment (75.0%), followed by reactive hyperplasia at the stent tips (12.5%), bladder invasion of the primary tumor (8.0%), and stent-related pain (8.0%). Twelve patients had overall success after secondary Uventa placement. There were no severe complications. The complications included persistent flank pain (15.5%), lower urinary tract symptoms (7.0%), acute pyelonephritis (2.8%), stent migration (2.8%), and persistent hematuria (2.8%). CONCLUSIONS These data show that Uventa can be an effective and safe option for palliative treatment of patients with MUO in a large series of patients.

Curcumin potentiates antitumor activity of cisplatin in bladder cancer cell lines via ROS-mediated activation of ERK1/2.

Resistance of bladder cancer to cisplatin is a major obstacle to successful treatment. In the current study, we investigated the apoptotic effects of curcumin and cisplatin co-treatment in 253J-Bv(p53 wild-type) and T24(p53 mutant) bladder cancer. We found that curcumin and cisplatin co-treatment primarily targets reactive oxygen species(ROS) and extracellular regulated kinase(ERK) signaling during the apoptosis induction in bladder cancer. The apoptosis rate in 253J-Bv and T24 cells co-treated with curcumin and cisplatin was increased compared to that in cells exposed to single-agent treatment conditions. Also, caspase-3 activation and ROS production were observed in both cells treated with curcumin and cisplatin, together with upregulation of p-MEK and p-ERK1/2 signaling. NAC(ROS scavenger) and U0126(ERK inhibitor) inhibited apoptosis induced by curcumin and cisplatin. In addition, when 253J-Bv cells were co-treated with curcumin and cisplatin, p53 and p21 expression levels were markedly increased when compared to controls. Unlike 253J-Bv cells, T24 cells were co-treated with curcumin and cisplatin revealed an induction of apoptosis through decreased p-signal transducer and activator of transcription 3(STAT3) expression. Moreover, pretreatment with U0126 suppressed curcumin and cisplatin-induced upregulation of p53, p21, and p-STAT3 and downregulation of survival proteins in both cells. In conclusion, co-treatment with curcumin and cisplatin synergistically induced apoptosis through ROS-mediated activation of ERK1/2 in bladder cancer.

Midterm efficacy and complications of readjustable midurethral sling (Remeex system) in female stress urinary incontinence with recurrence or intrinsic sphincter deficiency.

OBJECTIVE To evaluate the efficacy, complications, and managements of the readjustable midurethral sling (Remeex system) for the treatment of recurrent stress urinary incontinence (SUI) after previous anti-incontinence surgeries or intrinsic sphincter deficiency (ISD). METHODS Between March 2008 and February 2012, 102 women, who presented with previous failed surgery or ISD, were treated with the Remeex system at 4 different institutions. We retrospectively reviewed medical history, physical examination, urodynamic study, postvoiding residual volume, and/or 1-hour pad test of the patients. Surgical outcomes were evaluated using the Severity Index for Urinary Incontinence. The degree of patient satisfaction was assessed, and all complications were classified according to the modified Clavien classification system. RESULTS After a mean follow-up of 27.6 months (range, 14-56 months), 91 patients (89.2%) were cured and 6 patients (5.9%) were improved. The patients satisfaction rate was 87.2% (89 of 102 patients). Overall, 41 patients (40.2%) experienced 53 complications; 15 patients (14.7%) presented de novo urgency, which was properly managed with anticholinergics, and 14 patients (13.7%) underwent delayed sling readjustment for recurrent SUI (n = 13) and urinary retention (n = 1) during follow-up. Among 6 patients (5.9%) with wound infection, 4 patients were successfully treated by daily dressing with antibiotics, and 2 patients underwent removal of the Remeex system owing to intractable infection. Most complications were classified as grade 1 (54.8%) or 2 (15.1%) and were successfully treated with minimal conservative measures. CONCLUSION The Remeex system is a valuable adjunct for recurrent SUI after previous anti-incontinence surgeries or ISD, considering most complications are Clavien grade I or II.

Endoscopic Management of Upper Urinary Tract Urothelial Carcinoma

Upper urinary tract urothelial carcinoma (UTUC) is relatively uncommon. Radical nephroureterectomy with an ipsilateral bladder cuff excision has been the gold standard treatment for UTUC. However, recent advances in technology have made possible the increased use of endoscopic management for the treatment of UTUC. The definitive goal of endoscopic management of UTUC is cancer control while maintaining renal function and the integrity of the urinary tract. Endoscopic management includes both the retrograde ureteroscopic and antegrade percutaneous approaches. The endoscopic management of UTUC is a reasonable alternative for patients with renal insufficiency or a solitary functional kidney, bilateral disease, or a significant comorbidity that precludes radical surgery. Select patients with a functional contralateral kidney who have low-grade, low-stage tumors may also be candidates for endoscopic management. The careful selection of patients is the most important point for the successful endoscopic management of UTUC. It is crucial that patients are compliant and motivated, because a lifetime protocol of strict surveillance is necessary. Adjuvant topical therapy with Bacillus Calmette-Guerin or mitomycin C can be used after endoscopic management of UTUC in an attempt to reduce recurrence. In this article, we review current endoscopic techniques, indications for endoscopic treatment, clinical outcomes of endoscopic management, adjuvant topical therapy, and surveillance in patients with UTUC.

Initial Use of High-Dose Anticholinergics Combined with Alpha-Blockers for Male Lower Urinary Tract Symptoms with Overactive Bladder: A Prospective, Randomized Preliminary Study

To evaluate the clinical efficacy of initial combined treatment of alpha‐blocker plus dose‐dependent anticholinergic agent compared to the alpha‐blocker monotherapy in benign prostatic hyperplasia patients with overactive bladder.

Recent advances in robotic surgery in female urology

Pelvic organ prolapse and lower urinary tract fistulas are two disorders frequently managed in female urology. New techniques have been adapted and improved to decrease morbidity and improve clinical outcomes of these disorders. The adaptation of minimally‐invasive approaches for the management of pelvic organ prolapse and lower urinary tract fistulas began with laparoscopy. However, laparoscopic surgery has not gained widespread popularity as a result of the associated technical challenges, such as intracorporeal suturing and pelvic dissection. Robotic surgery has been widely carried out in urological oncology since 2001, and has been widely adapted because of its advantages over conventional laparoscopy for the management of pelvic organ prolapse and lower urinary tract fistulas. The current literature has shown the safety, feasibility and favorable clinical outcomes of robotic surgery for the treatment of these disorders. Robotic surgery in the management of pelvic organ prolapse and lower urinary tract fistula repairs might offer a promising advancement and benefits. However, further long‐term data should be followed to assess the durability of this newer, and minimally‐invasive approach.

MP59-13 A USEFUL METHOD FOR ASSESSING DIFFERENCES OF COMPENSATORY HYPERTROPHY IN THE CONTRALATERAL KIDNEY BEFORE AND AFTER RADICAL NEPHRECTOMY IN PATIENTS WITH RENAL CELL CARCINOMA: ELLIPSOID FORMULA ON COMPUTED TOMOGRAPHY

before and after partial nephrectomy, and compare the findings with 99mTc-DMSA renal scan. METHODS: The data of 51 patients with a unilateral renal tumor managed by partial nephrectomy were retrospectively analyzed. The RCV of tumor-bearing and contralateral kidneys was measured using ImageJ software. Split estimated glomerular filtration rate (eGFR) and SRV calculated using this RCV were compared with the split renal function (SRF) measured with 99mTc-DMSA renal scan. RESULTS: A strong correlation between SRF and SRV of the tumor-bearing kidney was observed before and after surgery (r 1⁄4 0.89, p < 0.001 and r 1⁄4 0.94, p < 0.001). The preoperative and postoperative split eGRF of the operated kidney showed moderate correlation with SRF (r 1⁄4 0.39, p 1⁄4 0.004 and r 1⁄4 0.49, p < 0.001). Correlation between reductions in SRF and SRV of the operated kidney (r 1⁄4 0.87, p < 0.001) was stronger than that between SRF and percent reduction in split eGFR (r 1⁄4 0.64, p < 0.001). CONCLUSIONS: Compared with split eGFR, the SRV calculated using CT-based renal volumetry has a strong correlation with the SRF measured using 99mTc-DMSA renal scan. CT-based SRV measurement before and after partial nephrectomy can be used as a single modality for anatomical and functional assessment of the tumor-bearing kidney.

MP77-10 THE EFFECT OF ULTRASOUND-GUIDED COMPRESSION PERFORMED IMMEDIATELY AFTER TRANSRECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY ON POSTBIOPSY BLEEDING

INTRODUCTION AND OBJECTIVES: The diagnostic work-up of prostate cancer has experienced a rapid shift worldwide in recent years. This study aims to provide a current appraisal of the practice of prostate biopsy in Australia and New Zealand in the emerging era of transperineal template biopsy (TPB) and multiparametric MRI (mpMRI). METHODS: A 36-question online survey was distributed to 545 members of the Urological Society of Australia & New Zealand (USANZ), including consultant urologists and trainees. This was an updated survey, based on a similar questionnaire distributed to USANZ members in 2012, addressing patterns of prostate biopsy practice in 4 domains: transrectal ultrasound-guided (TRUS) biopsy; TPB; mpMRI and peri-operative antibiotic and analgesia use. Survey results were collated and statistical analysis was performed using descriptive statistics and chi-squared test. RESULTS: 155 participants completed the survey, with a response rate of 21.1%. 81.9% of respondents were consultant urologists and 66.5% worked in a metropolitan setting. 92.3% perform TRUS biopsy and 91.3% sample between 10-16 cores. 66.9% of respondents perform TPB, increased from 38.4% in 2012 (p<0.001). 59.4% perform mpMRI prior to initial biopsy, increased from 19.6% (p<0.001). 90.1% perform MRI prior to repeat biopsy after an initial negative biopsy. 97.2% use prophylactic oral antibiotics prior to TRUS biopsy, most commonly quinolones. 55.7% use parenteral antibiotics, compared to 69.4% previously (p1⁄40.013). 27.7% routinely use carbapenem prophylaxis in settings of recent overseas travel or quinolone exposure, compared to 27.9% in 2012 (p1⁄40.965). General anaesthetic/IV sedation is used for 60.6% of TRUS biopsies and 97.9% of TPB. CONCLUSIONS: Our survey demonstrates a shift in practice of biopsy for the diagnosis of prostate cancer among urologists in Australia & New Zealand, when compared with results of our initial study in 2012. More urologists are performing TPB now, and there has been a corresponding increase in the use of pre-initial biopsy mpMRI despite no current guidelines recommending this practice yet. There has been a reduction in the use of parenteral antibiotics overall, prior to TRUS biopsy, however, rates of carbapenem use have remained stable, suggesting ongoing concerns regarding the risk of sepsis due to antibiotic resistance.

Laparoscopic Hand-Assisted Adrenal-Sparing Surgery for a Giant Adrenal Myelolipoma: A Case Report

INTRODUCTION Adrenal myelolipoma is a rare, benign tumor. Surgical resection is advocated in case of symptomatic, large size (> 4cm), increase of size on follow-up and atypical appearance on imaging. Laparoscopic adrenalectomy is currently the gold standard operation for managing benign adrenal mass. However, to date, laparoscopic entire resection of ipsilateral adrenal gland with the tumor have been mainly reported in the literature. Under clinical circumstances, adrenal sparing surgery underused as first-line therapy for adrenal tumors. CASE PRESENTATION We present a case of adrenal myelolipoma involving the right adrenal gland of a 45-year-old woman who presented with right-sided flank pain. On radiologic and endocrine evaluation, she was diagnosed with a giant adrenal myelolipoma (> 8cm). Right hand-assisted laparoscopic partial adrenalectomy was performed, and postoperative recovery was uneventful. Finally, histological examination confirmed adrenal myelolipoma. On follow-up computed tomography, there was no residual tumor and the remaining right adrenal gland. CONCLUSION Our report suggests that hand-assisted laparoscopic partial adrenalectomy could be considered for appropriate removal of adrenal myelolipoma, even in giant adrenal myelolipoma.

V867 LAPAROSCOPIC ADRENALECTOMY STEP-BY-STEP SURGICAL SKILLS

Abstract Introduction and Objective: To introduce step-by-step skills and to show the learning curve of pure laparoscopic adrenalectomy performed by a single surgeon. Materials and Methods: From October 2008 to September 2011, 74 patients out of 112 who were diagnosed as adrenal mass received pure laparoscopic adrenalectomy. Eight cases were bilateral, and 66 cases were unilateral. After placing the patient in the flank position, a 12-mm camera port is inserted near umbilicus. Two 5-mm working ports are placed at the cross-sections of the midclavicle line, anterior axillary line, and subcostal margin. About 2-mm port for liver retraction is placed just below the xiphoid process if the mass is on the right side. When performing a right adrenalectomy, an avascular triangle formed by the vena cava, liver, and renal vein is identified. The adrenal gland is lifted up using a pair of forceps or suction, and adrenal vein is ligated. Inferior phrenic vascular supply at the liver margin and renal hilum vascular su...