Doh Yoon Cha

Detailed analysis of patients with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institutional study.

PURPOSE Lymph nodes in the prostatic anterior fat pad rarely harbor metastatic disease. Therefore, the characteristics of patients with prostatic anterior fat pad lymph node metastasis are not well described in the literature. We identified the perioperative characteristics and assessed the clinical outcomes of patients with prostatic anterior fat pad lymph node metastasis. MATERIALS AND METHODS At 8 tertiary care centers a total of 4,261 patients underwent complete removal and pathological analysis of the prostatic anterior fat pad. We describe preoperative and pathological characteristics, and clinical management and outcomes in patients with metastatic disease to the prostatic anterior fat pad. RESULTS Metastatic disease to the prostatic anterior fat pad lymph nodes was detected in 40 patients (0.94%), of whom 37 (92.5%) had intermediate or high risk features preoperatively. Most patients with prostatic anterior fat pad metastases underwent concomitant pelvic lymph node dissection, and adjuvant therapy with radiation, androgen ablation and/or chemotherapy. A total of 27 patients (67.5%) with prostatic anterior fat pad metastatic disease were up-staged as a result of prostatic anterior fat pad pathological analysis, of whom 14 (51.8%) remained free of biochemical recurrence with observation and/or definitive adjuvant/salvage therapy. CONCLUSIONS Most patients with prostatic anterior fat pad metastatic disease had intermediate to high risk features preoperatively. In some patients with such lymph node metastasis removing these lymph nodes resulted in prolonged biochemical recurrence-free survival. Therefore, we recommend that the prostatic anterior fat pad be removed in all patients undergoing radical prostatectomy. However, pathological analysis of the prostatic anterior fat pad may be limited to patients with intermediate to high risk oncological features preoperatively.

Comparison of 3 Upper Tract Anticarcinogenic Agent Delivery Techniques in an Ex Vivo Porcine Model

OBJECTIVE To evaluate the degree of urothelial exposure using 3 upper tract delivery techniques in an ex vivo porcine model, to determine the optimal modality to locally deliver topical anticarcinogenic agents in patients with upper tract urothelial carcinoma. MATERIALS AND METHODS An indigo carmine solution was infused into en bloc porcine urinary tracts to test the 3 techniques: antegrade infusion via nephrostomy tube, reflux via indwelling double-pigtail stent, and retrograde administration via a 5F open-ended ureteral catheter. Nine renal units (3 per delivery method) were used. After a 1-hour dwell time, the urinary tracts were bivalved and photographed. Each renal unit was evaluated by 3 blinded reviewers who estimated the total percentage of stained urothelial surface area using a computer-based area approximation system. In addition, as a surrogate for exposure adequacy, a validated equation was used to calculate the staining intensity at 6 predetermined locations in the upper tract, with lower values representing more efficient staining. RESULTS Mean percent of surface area stained for the nephrostomy tube, double-pigtail stent, and open-ended ureteral catheter groups was 65.2%, 66.2%, and 83.6%, respectively (P = .002). Mean staining intensities were 40.9, 33.4, and 20.4, respectively (P = .023). CONCLUSION Our results suggest that retrograde infusion via open-ended ureteral catheter is the most efficient method of upper tract therapy delivery. Larger studies using in vivo models should be performed to further validate these findings and potentially confirm this method as optimal for delivery of topical anticarcinogenic agents in upper tract urothelial carcinoma.

Outcomes of Intrarenal Bacillus Calmette-Guérin/Interferon-α2B for Biopsy-Proven Upper-Tract Carcinoma in Situ

BACKGROUND AND PURPOSE While nephroureterectomy (NU) remains the gold-standard treatment for upper-tract carcinoma in situ (UT-CIS), it may be unnecessarily aggressive in comparison with the treatment of bladder CIS. Upper-tract administration of bacillus Calmette-Guérin (BCG) has shown promise for UT-CIS, but with limited reports and varied results. Furthermore, all previous reports included patients with positive cytology results without biopsy-proven CIS, or combined BCG with other topical therapies that are used for bladder CIS. We report our experience using a novel technique to directly instill BCG with interferon-α2B (BCG/IFN) into the upper-tract in patients with biopsy-proven UT-CIS. PATIENTS AND METHODS Patients who received a diagnosis of isolated, biopsy-proven UT-CIS from September 2003 to January 2012 were included. After biopsy, all patients received a 6-week induction course of BCG/IFN, administered via an open-ended ureteral catheter. Initial follow-up was scheduled 1 month after the completion of the intrarenal therapy and consisted of flexible ureteroscopy, selective urinary cytology, retrograde pyelography, and rebiopsy of the upper tract. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology results, and absence of clinical progression. Absence of visualized lesions with persistently positive cytology results or persistence of lesions after induction was considered no response (NR). New upper-tract lesions after an initial CR were considered recurrences. Patients with a CR were placed on maintenance therapy for 2 years. Surveillance was performed every 3 months with ureteroscopy, selective cytology, and imaging. RESULTS Eleven patients (mean age=73 years) were followed for a median of 13.5 months (3.7-103.3 mos). Eight patients had an initial CR, while three initially had NR. Two of the NR patients had negative biopsy results but persistently positive cytology results; both of these patients underwent a second induction course and achieved a CR. The third NR patient had persistence of lesions after induction and was offered a nephroureterctomy. Total kidney preservation rate was 91% (10/11). There were no treatment-related adverse events. CONCLUSION This study demonstrates the safety and efficacy of intrarenal BCG/IFN maintenance therapy for patients with UT-CIS. Unlike other mechanisms of delivery, including percutaneous administration or reflux via double pigtail stents, this office-based technique spares the morbidity of a chronically indwelling nephrostomy tube or ureteral stent.

How Do Urodynamics Findings Influence the Treatment of the Typical Patient With Overactive Bladder

Overactive bladder (OAB) is a clinical symptom complex whose hallmark is the symptom of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence. Historically, urodynamics (UDS) evaluation has not been recommended in the initial evaluation of OAB, since it is defined primarily by clinical symptoms. As the pathophysiology of the OAB complex has become more clearly elucidated from recent studies, the role of UDS has again become a topic of discussion as a tool that can provide objective data to reflect these new findings. The utility of UDS in the diagnosis and treatment of OAB is still evolving, but in certain clinical scenarios, especially when empiric treatment has failed, it can provide definitive information that can identify associated pathologies and/or alter the treatment course. Herein, we will discuss the current literature regarding use of UDS in OAB patients and offer our own opinions as to its use.

Modified-PCNL Without Modified Instruments: A Description of Technique

BACKGROUND AND PURPOSE Mini-PCNL was developed to reduce the morbidity of PCNL by using smaller tract sizes. Most mini-techniques, however, require specialized instruments and use ureteroscopes as surrogates for nephroscopes, resulting in decreased visualization, poor irrigation, and difficult fragment extraction. We describe our modified technique (mPCNL) that allows for the use of standard PCNL equipment through a tract that is smaller than standard PCNL (sPCNL) but larger than previously reported for mini-PCNL. TECHNIQUE After ureteral access with a coaxial anti-retropulsion device, the patient is placed in the prone position. After percutaneous access under fluoroscopic guidance, a 24F balloon dilating catheter is used to place a 24F Amplatz sheath. A standard 26F rigid nephroscope is used to complete the entire procedure, with the modification of selectively removing the outer sheath to allow the scope to fit in the smaller tract. Standard lithotripters and graspers are used, as necessary. ROLE IN PRACTICE: We have performed this technique on 52 patients with a mean stone burden of 19.4 mm. Overall stone-free rate was 100%, even for stones >2 cm. This technique allows for improved visualization and irrigation compared with other mini-PCNL procedures and obviates the need to purchase specialized equipment.

Stones in Exceptional Situations

Calculi in kidneys with complex or anomalous anatomy present unique challenges for the medical as well as surgical aspects of stone treatment. These anomalous conditions include but are not limited to horseshoe, pelvic, ectopic, transplant, and polycystic kidneys. Despite aberrant anatomy, treatments in these situations should follow the same principles applied for treatment for stones in normal kidneys. Medical dissolution therapy should be employed whenever possible, especially because of the increased difficulty of surgical intervention in this patient population. Surgical treatments of stones for these patients include open surgery, extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, percutaneous nephrolithotomy (PCNL), and laparoscopy. This chapter focuses on the efficacy and the rationale behind most recent stone treatments, in the hopes of guiding urologists in formulating a more effective, individualized treatment for this patient population.