Han Yong Choi

Renal Damage Caused by Warm Ischaemia During Laparoscopic and Robot-Assisted Partial Nephrectomy: An Assessment Using Tc 99m-DTPA Glomerular Filtration Rate

BACKGROUND Few studies assessing the functional change of each kidney following warm ischaemia after partial nephrectomy are available. OBJECTIVES Our aim was to identify the effects of the warm ischaemic time (WIT) on renal function after partial nephrectomy under the pneumoperitoneum. DESIGN, SETTING, AND PARTICIPANTS Forty-four consecutive patients who underwent laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RAPN) from June 2008 to May 2009 for a single cT1 renal tumour were included in this prospective protocol. MEASUREMENTS Technetium Tc 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scintigraphy was used to determine the glomerular filtration rate (GFR) of both kidneys and each kidney individually. Tc 99m-DTPA GFR was performed preoperatively and 3 mo postoperatively. In addition, we analysed Tc 99m-DTPA scintigraphy GFR regionally in the healthy areas of the affected kidney. RESULTS AND LIMITATIONS Patients with WIT > 28 min had a significantly greater decrease in the GFR of the affected kidney (p = 0.031). The GFR of the affected kidney showed a significant decrease perioperatively (46.4 ± 14.3 to 37.9 ± 11.9 ml/min per 1.73 m²; p = 0.003). The functional change of the nonaffected kidney showed an increasing trend (47.5 ± 13.8 to 51.4 ± 14.3 ml/min per 1.73 m²), although it was not statistically significant (p=0.103). Regional Tc 99m-DTPA GFR of both affected kidney and nonaffected kidney showed no significant differences perioperatively (6.3 ± 1.8 to 6.1 ± 1.9 ml/min per 1.73 m²; p = 0.641; 6.6 ± 1.9 to 7.1 ± 2.0 ml/min per 1.73 m² ; p = 0.200). On multivariate analysis, preoperative GFR, resected volume of marginal healthy tissue, and WIT were independent predictors for functional reduction of the affected kidney (p < 0.05). The study was limited by small numbers and short follow-up periods. CONCLUSIONS Stationary overall renal function after LPN or RAPN is masked possibly by functional compensation of the contralateral healthy kidney. The damage of the affected kidney estimated by scintigraphy occurs when WIT exceeds 28 min during partial nephrectomy under the pneumoperitoneum.

Comparison of percutaneous radiofrequency ablation and open partial nephrectomy for the treatment of size- and location-matched renal masses

Purpose: To compare percutaneous radiofrequency ablation (RFA) and open partial nephrectomy (OPN) for the treatment of renal cell carcinoma (RCC) with respect to renal function and mid-term oncological outcome. Materials and methods: From January 2006 to December 2008, 40 (RFA group) and 110 (OPN group) patients underwent RFA and OPN for sporadic RCC, respectively. The sizes and locations of RCCs were matched between the two groups. To determine the lesion size, the maximum transverse diameter was measured. Estimated glomerular filtration rates (eGFR) before and after treatment and overall three-year recurrence-free survival rates were calculated and compared. Results: Tumours in the RFA and OPN groups ranged from 9–76 mm (24.4 ± 13.1 mm) and from 6–60 mm (22.3 ± 10.2 mm), respectively (p = 0.962). The locations of RCCs were not significantly different (p = 0.101–0.508). The mean reductions of eGFR in the RFA and OPN groups were 2.3 ± 8.6 mL/min/1.73 m2 (range, −23 to +17.5 mL/min/1.73 m2) and 7.4 ± 10.9 mL/min/1.73 m2 (−23.6 to +42.8 mL/min/1.73 m2, respectively (p = 0.013). Overall three-year recurrence-free survival rates in the RFA and OPN groups were 94.7% and 98.9%, respectively (p = 0.266). Conclusion: For treating size- and location-matched RCCs, RFA is superior to OPN with respect to the preservation of renal function. Furthermore, RFA can achieve excellent mid-term outcomes that are equivalent to those of OPN.

Post-operative acute kidney injury in patients with renal cell carcinoma is a potent risk factor for new-onset chronic kidney disease after radical nephrectomy

BACKGROUND Radical nephrectomy is a significant risk factor for chronic kidney disease (CKD). There are few reports on the renal outcome of acute kidney injury (AKI) after radical nephrectomy. The aim of this study was to determine the incidence of AKI and whether post-operative AKI is associated with new-onset CKD after radical nephrectomy for renal cell cancer (RCC). METHODS We conducted a retrospective study of 519 adult patients (>40 years old) with normal renal function who underwent unilateral radical nephrectomy for a solitary renal cortical tumour and were pathologically diagnosed with RCC between January 2000 and February 2007. Post-operative AKI was classed using risk, injury, failure, loss and end-stage kidney disease (RIFLE) criteria. CKD was defined as a decrease in estimated glomerular filtration rate (GFR) to <60 mL/min/1.73 m(2). RESULTS According to the RIFLE criteria, 165 of 175 patients fell into the AKI risk category, 8 patients fell into the AKI injury category and 2 patients fell into the AKI failure category. Multivariate analysis revealed that older age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.00-1.05], male gender (OR 3.13, 95% CI 1.91-5.12), higher body mass index (OR 1.08, 95% CI 1.01-1.15), smaller RCC size (OR 0.87, 95% CI 0.81-0.93) and higher preoperative GFR (OR 1.04, 95% CI 1.03-1.06) were independent risk factors for post-operative AKI. CKD was more prevalent in the AKI risk group than in patients without AKI 1 year after surgery (54.7% versus 43.9%, respectively; P = 0.006) and 3 years after surgery (50% versus 32%, respectively; P = 0.003). Patients who experienced post-operative AKI had a 4.24-fold higher risk of new-onset CKD after multiple adjustments were made to the data (95% CI 2.28-7.89, P < 0.001). CONCLUSION AKI after radical nephrectomy in patients with RCC is a potent risk factor for new-onset CKD. Prevention of post-operative AKI is essential for reducing the incidence of CKD after nephrectomy.

Does Prolonged Warm Ischemia After Partial Nephrectomy Under Pneumoperitoneum Cause Irreversible Damage to the Affected Kidney

PURPOSE We determined the effects of warm ischemia time on the recovery of renal function after partial nephrectomy under pneumoperitoneum. MATERIALS AND METHODS In this prospective study 37 consecutive patients who underwent laparoscopic partial nephrectomy or robot-assisted partial nephrectomy between June 2008 and May 2009 to remove a single cT1 renal tumor were evaluated using (99m)Tc-diethylenetriamine pentaacetic acid renal scintigraphy preoperatively, and at 3 and 12 months postoperatively. RESULTS The most significant reduction in the glomerular filtration rate of the affected kidney at 3 and 12 months after surgery (p = 0.018, p = 0.036, respectively) was seen for a warm ischemia time cutoff of 28 minutes. The glomerular filtration rate of the affected kidney was consistently and significantly reduced at 3 and 12 months postoperatively (-22.4% to -30.6%, p <0.001) in patients with a warm ischemia time greater than 28 minutes. In contrast, no significant glomerular filtration rate change was seen in patients with a warm ischemia time of 28 minutes or less. In terms of the contributional change of the affected kidney to total renal function, there is a trend toward a recovery after an initial decrease in both groups with a warm ischemia time greater than 28 minutes vs 28 minutes or less. On multivariate analysis warm ischemia time was a strong independent predictor of glomerular filtration rate reduction even 12 months after surgery (β = -1.3; 95% CI -1.8, -0.7; p <0.001). CONCLUSIONS If the warm ischemia time is greater than 28 minutes during laparoscopic partial nephrectomy or robot-assisted partial nephrectomy, the functional damage to the affected kidney progresses even up to 1 year after surgery.

Mass Screening for Prostate Cancer in Korea: A Population Based Study

PURPOSE We investigated the detection rate of prostate cancer in Korean men through a population based mass screening test. MATERIALS AND METHODS In June 2007 serum prostate specific antigen was examined in 3,943 residents in the Gangneung (1,429), Daegu (1,396) and Jeonju (1,118) areas who were 55 years or older with prostate specific antigen 3.0 ng/ml or greater considered the criterion for 12-site transrectal biopsy recommendation. The serum prostate specific antigen distribution and the cancer detection rate were analyzed according to participant regions and age groups. RESULTS Mean +/- SD serum prostate specific antigen in the entire cohort was 2.4 +/- 8.6 ng/ml. It significantly increased with increasing age, that is 1.2, 2.2, 3.4 and 4.7 ng/ml in the groups 55 to 64, 65 to 74, 75 to 84 and 85 years or older, respectively (p <0.0001). However, no regional differences were noted among Gangneung, Daegu and Jeonju (2.2, 2.7 and 2.3 ng/ml, respectively, p = 0.290). Biopsy candidates represented 7.3% (48 men), 17.7% (395), 25.5% (240) and 32.7% (36) of the 55 to 64, 65 to 74, 75 to 84 and 85 years or older groups, respectively, or 18.2% of the entire cohort of 719. Of biopsy candidates 268 (37.3%) had undergone biopsy, of whom cancer was detected in 76 (28.4%) for a cancer detection rate and estimated cancer detection rate of 1.93% and 5.17%, respectively. The age adjusted estimated cancer detection rate (55 years or older) was 3.36%. Cancer detection increased significantly with increasing prostate specific antigen, that is 12.3% at 3.0 to 4.0 ng/ml, 27.3% at 4.1 to 10.0 and 64.1% at greater than 10.0. The Gleason score was 2-6 in 41 men (53.9%), 7 in 14 (18.4%) and 8-10 in 21 (27.6%). CONCLUSIONS The estimated cancer detection rate in Korean men 55 years or older was 3.36%. The significance of the high rate in this population should be determined through repeat screening and further surveillance in the future.

Clinical significance of prognosis using the neutrophil-lymphocyte ratio and erythrocyte sedimentation rate in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma.

To evaluate the clinical significance of preoperative erythrocyte sedimentation rate (ESR) and neutrophil–lymphocyte ratio (NLR) as prognostic factors in patients undergoing radical nephroureterectomy for upper tract urothelial carcinoma (UTUC).

The Role of Endorectal Magnetic Resonance Imaging in Predicting Extraprostatic Extension and Seminal Vesicle Invasion in Clinically Localized Prostate Cancer

Purpose We aimed to assess the clinical value of endorectal magnetic resonance imaging (MRI) in predicting extraprostatic extension and seminal vesicle invasion in patients with clinically localized prostate cancer. Materials and Methods A total of 54 patients who underwent radical prostatectomy for clinically localized prostate cancer were retrospectively analyzed. The findings of endorectal MRI, performed at least 3 weeks after biopsy, were compared with the pathological results of radical prostatectomy specimens. The sensitivity, specificity, and accuracy of the detection of extraprostatic extension and seminal vesicle invasion were calculated. Results The sensitivity, specificity, and accuracy of the endorectal MRI findings were 50.0%, 82.6%, and 77.8% for the detection of extraprostatic extension, respectively, and 75.0%, 92.0%, and 90.7% for the detection of seminal vesicle invasion, respectively. The sensitivity of endorectal MRI in the detection of extraprostatic extension improved as the Gleason score increased. Conclusions Endorectal MRI findings demonstrated modest sensitivity for predicting extraprostatic extension, whereas specificity was relatively high. In addition, endorectal MRI showed better sensitivity for detecting high-grade tumors.

Preoperative Nomograms for Predicting Extracapsular Extension in Korean Men with Localized Prostate Cancer: A Multi-institutional Clinicopathologic Study

We developed a nomogram to predict the probability of extracapsular extension (ECE) in localized prostate cancer and to determine when the neurovascular bundle (NVB) may be spared. Total 1,471 Korean men who underwent radical prostatectomy for prostate cancer between 1995 and 2008 were included. We drew nonrandom samples of 1,031 for nomogram development, leaving 440 samples for nomogram validation. With multivariate logistic regression analyses, we made a nomogram to predicts the ECE probability at radical prostatectomy. Receiver operating characteristic (ROC) analyses were also performed to assess the predictive value of each variable alone and in combination. The internal validation was performed from 200 bootstrap re-samples and the external validation was also performed from the another cohort. Overall, 314 patients (30.5%) had ECE. Age, Prostate specific antigen (PSA), biopsy Gleason score, positive core ratio, and maximum percentage of biopsy tumor were independent predictors of the presence of ECE (all P values <0.05). The nomogram predicted ECE with good discrimination (an area under the ROC curve of 0.777). Our nomogram allows for the preoperative identification of patients with an ECE and may prove useful in selecting patients to receive nerve sparing radical prostatectomy.

Outcome of Prostate Biopsy in Men Younger than 40 Years of Age with High Prostate-Specific Antigen (PSA) Levels

Purpose Prostate cancer is rarely diagnosed in men younger than 40 years of age. At present, the available data show a low rate of cancer detection from prostate-specific antigen (PSA) screening of this group of young men. We analyzed the outcome of prostate biopsy results in patients of this age group with a high PSA. Materials and Methods Between October 1997 and August 2008, a total of 81 men less than 40 years of age were referred from the Health Care Promotion Center as the result of elevated PSA levels. Six men with prostatitis were excluded. The remaining 75 men were asymptomatic and had normal findings on the digital rectal examination (DRE) and were selected to have a transrectal ultrasound-guided prostate biopsy for suspected prostate cancer. The patients with sustained high PSA levels underwent repeat biopsies. Results The median age of the 75 men was 33 years (range, 26-40 years) and the mean PSA level was 6.57 ng/ml (range, 4.32-13.45 ng/ml). The results of the primary biopsy was 1 (1.3%) case of prostate cancer, 70 cases (93%) with benign tissue, 2 cases (2.6%) with inflammation, and 1 case each (1.3%) with high grade intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP). Of the 10 men who underwent a second biopsy, all had benign findings. Three of the men who underwent a third biopsy all had benign tissue findings. Conclusions The prostate cancer detection rate in young men less than 40 years of age with high PSA levels and normal DREs was very low. Repeat biopsy for sustained high PSA levels in young men less than 40 years of age may not be indicated.

A Prospective, Multicenter, Open-label Trial of Zoledronic Acid in Patients with Hormone Refractory Prostate Cancer

Purpose The short-term safety and efficacy of zoledronic acid for the treatment of skeletal metastasis was evaluated in patients with hormone-refractory prostate cancer. Patients and Methods A total of 19 hormone-refractory prostate cancer patients with bone metastases were enrolled. All patients received up to six infusions of zoledronic acid (4 mg, given intravenously over 15 minutes, every 3 - 4 weeks). Safety was assessed by monitoring a`dverse events and serum creatinine levels. Efficacy was assessed by monitoring skeletal-related events, brief pain inventory score, quality of life score, type of pain medication, and analgesic score. Mean age of patients was 67.3 years (46 - 86 years), mean time from diagnosis of bone metastases was 27.6 months (0 - 117 months), and mean time from diagnosis of hormone-refractory disease was 7.5 months (0 - 26 months). Results There was no clinically significant change in serum creatinine levels. Eleven adverse events (musculoskeletal disorders and systemic disorders) in 8 patients were classed as having a possible relationship to study drug. Fifteen patients completed six courses of zoledronic acid infusion. There were no significant changes in the brief pain inventory composite scores, quality of life questionnaire scores or analgesic score. No new skeletal-related events developed during the treatment period. Conclusion Zoledronic acid administered in this study as a 15-minute infusion demonstrated an acceptable and well-known safety profile in patients with refractory prostate cancer with bone metastases. However, prospective placebo-controlled clinical trials are required to elucidate the efficacy of zoledronic acid.