In Gab Jeong

Factors Determining Functional Outcomes After Radical Prostatectomy: Robot-Assisted Versus Retropubic

BACKGROUND Early studies reported comparative results of functional outcomes between robot-assisted (RARP) and retropubic radical prostatectomy (RRP). However, well-controlled single-surgeon prospective studies comparing the outcomes are rare. OBJECTIVE To compare functional outcomes after RARP and RRP performed by a single surgeon, and to identify factors predictive of early return of continence and potency. DESIGN, SETTING, AND PARTICIPANTS A total of 763 consecutive patients undergoing RP between 2007 and 2010 were prospectively included and serially followed postoperatively for comparative analysis. INTERVENTION RARP was performed in 528 patients, and 235 underwent RRP. MEASUREMENTS Continence was defined as being completely pad free. Potency was defined as having erection sufficient for intercourse with or without a phosphodiesterase type 5 inhibitor. Continence and potency recovery were checked serially by interview and questionnaire at 1, 3, 6, 9, 12, 18, and 24 mo postoperatively. Cox proportional hazards method analyses was performed to determine predictive factors for early recovery. RESULTS AND LIMITATIONS After the initial 132 cases, patients who underwent RARP demonstrated faster recovery of urinary continence compared to RRP patients. Potency recovery was more rapid in the RARP group at all evaluation time points, beginning from the initial cases. In multivariate analysis, younger age and longer preoperative membranous urethral length seen by prostate magnetic resonance imaging (MRI) demonstrated statistical significance as independent prognostic factors for continence recovery; younger age, surgical method (RARP vs RRP), and higher preoperative serum testosterone were independent prognostic factors for potency recovery. The limitations of the present study were that it was nonrandomized and used interview to evaluate potency recovery. CONCLUSIONS Patients after RARP demonstrated superior functional recovery. Moreover, membranous urethral length on preoperative MRI and patient age were factors independently predictive of continence recovery, while patient age and higher preoperative serum testosterone were independent prognostic factors for potency recovery.

Association Between Metabolic Syndrome and the Presence of Kidney Stones in a Screened Population

BACKGROUND Components of metabolic syndrome have been associated with kidney stone disease, but little evidence is available to support a relationship between metabolic syndrome and kidney stone development in healthy large screened populations. STUDY DESIGN Cross-sectional analysis. SETTING & PARTICIPANTS Data were obtained from 34,895 individuals who underwent general health screening tests between January 2006 and December 2006 at the Asan Medical Center. PREDICTOR Metabolic syndrome was defined according to criteria established by the National Cholesterol Education Program Adult Treatment Panel III, American Heart Association, and National Heart, Lung, and Blood Institute. OUTCOMES & MEASUREMENTS The presence of kidney stones was evaluated using computed tomography or ultrasonography. RESULTS Of all those screened, 839 (2.4%) had radiologic evidence of kidney stones and metabolic syndrome was diagnosed in 4,779 (13.7%). The multivariable-adjusted OR for kidney stones increased with an increasing quintile of waist circumference and systolic/diastolic blood pressure (P < 0.001). Age, sex, hypertension, and metabolic syndrome status were independent risk factors for kidney stones. The presence of metabolic syndrome had an OR of 1.25 (95% CI, 1.03-1.50) for kidney stone prevalence. In participants with hypertension, the OR for the presence of kidney stones was 1.47 (95% CI, 1.25-1.71) compared with that for participants without hypertension after adjustment for other variables. LIMITATIONS Cross-sectional design, absence of stone composition. CONCLUSION Metabolic syndrome is associated with a significantly increased risk of kidney stone development. Our findings suggest the need for interventional studies to test the effects of preventing and treating metabolic syndrome on the risk of kidney stone development.

The Value of Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma in the Era of Targeted Therapy

PURPOSE We evaluated the value of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma in the targeted therapy era. MATERIALS AND METHODS We reviewed the records of 78 patients treated with targeted therapy for metastatic renal cell carcinoma between 2006 and 2009. A total of 45 patients underwent cytoreductive nephrectomy followed by targeted therapy (cytoreductive nephrectomy group) and 33 were treated with targeted therapy alone (noncytoreductive nephrectomy group). We estimated progression-free and overall survival using Kaplan-Meier curves. The prognostic significance of each variable was estimated with a Cox proportional hazards regression model. RESULTS Clinicopathological variables did not differ in the 2 groups except for Karnofsky performance status and sarcomatoid feature. The treatment response rate did not differ in the 2 groups (23.1% vs 30.3%, p = 0.488). Median progression-free survival was 11.7 and 9.0 months in the cytoreductive and noncytoreductive nephrectomy groups (p = 0.270), and median overall survival was 21.6 and 13.9 months, respectively (p = 0.128). On multivariate analysis Karnofsky performance status (HR 2.9, 95% CI 1.4-5.7, p = 0.003) and sarcomatoid features (HR 2.9, 95% 1.3-6.7, p = 0.013) were independent predictors of progression-free survival. Karnofsky performance status (HR 3.3, 95% 1.7-6.5, p = 0.001), sarcomatoid features (HR 2.7, 95% 1.2-6.2, p = 0.021) and liver metastasis (HR 2.7, 95% 1.0-7.1, p = 0.045) were independent predictors of overall survival. CONCLUSIONS We found no significant differences in tumor response or survival between the 2 groups. Prospective trials are needed to confirm our results.

Prognostic Factors for Chronic Kidney Disease After Curative Surgery in Patients With Small Renal Tumors

OBJECTIVES To investigate the incidence and predictive factors associated with newly developed chronic kidney disease (CKD) after curative surgery in patients with small renal tumors. METHODS From 1998 to 2005, we retrospectively investigated 225 patients undergoing partial nephrectomy (PN) or radical nephrectomy (RN) for renal tumors, of size <or= 4 cm, with normal contralateral kidney. The glomerular filtration rate (GFR) was calculated using the four-variable modification of diet in renal disease formula. CKD was defined as GFR of < 60 mL/min per 1.73 m(2). Demographic and clinicopathologic parameters were evaluated using Cox proportional hazards model to determine the variables independently associated with the development of postoperative CKD. RESULTS A total of 129 (57.3%) and 96 (42.7%) patients were included in the RN and PN groups. A total of 97 patients (43.1%) developed CKD; 86 (66.7%) underwent an RN and 11 (11.5%) underwent a PN. The 2-year probability of absence of CKD with an RN and a PN was 58.3% and 95.7%, respectively (P <.001). Among 20 patients with diabetes, 12 (60.0%) developed CKD: 10 patients underwent an RN and 2, a PN. The 2-year probability of absence of CKD with and without diabetes was 46.5% and 76.4%, respectively (P = .006). The multivariate analysis showed that age (P = .001), type of operation (P <.001), preoperative GFR (P = .001), and diabetes (P = .042) were associated with the development of CKD. CONCLUSIONS The results of this study show that nephron-sparing surgery for small renal mass should be attempted to prevent CKD in all eligible patients, especially those with diabetes.

Methotrexate, vinblastine, doxorubicin and cisplatin combination regimen as salvage chemotherapy for patients with advanced or metastatic transitional cell carcinoma after failure of gemcitabine and cisplatin chemotherapy

We investigated the safety and efficacy of a methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC) combination regimen as second-line chemotherapy for patients with advanced or metastatic transitional cell carcinoma who failed first-line gemcitabine and cisplatin (GC) chemotherapy. Thirty patients who had progressed or relapsed after GC chemotherapy as first-line treatment were enrolled in this study. The major toxicities were neutropaenia and thrombocytopaenia. A grade 3 or 4 neutropaenia occurred in 19 (63.3%) and a grade 3 or 4 thrombocytopaenia developed in nine patients (30.0%). There were no life-threatening complications during the study. The overall response was 30%. A complete response was achieved in two patients (6.7%) and a partial response in seven (23.3%). The overall disease control rate was 50%. Seven out of 16 patients who had responded previously to GC responded to M-VAC, while 2 out of 14 who had not responded to GC responded to M-VAC. The median response duration was 3.9 months and the median progression-free survival was 5.3 months. The median overall survival was 10.9 months. M-VAC showed encouraging efficacy and reversible toxicities in patients who had progressed after GC chemotherapy and, especially, M-VAC appears to be a reasonable option as a sequential treatment regimen in patients who responded previously to GC chemotherapy.

Expression of Ki-67 and COX-2 in Patients With Upper Urinary Tract Urothelial Carcinoma

OBJECTIVES To investigate the prognostic value of Ki-67, cyclooxygenase-2 (COX-2), E-cadherin, and retinoblastoma protein (pRB) in patients with urothelial carcinoma of the upper urinary tract. METHODS From January 1998 to December 2005, the specimens from 107 patients with urothelial carcinoma of the upper urinary tract who had undergone nephroureterectomy were analyzed. The expression of Ki-67, COX-2, E-cadherin, and pRB was examined by immunochemistry on tissue microarray sections. The correlation of the immunoreactivity with the pathologic parameters and progression-free and cancer-specific survival were examined. RESULTS Ki-67 and COX-2 were overexpressed in 26 (24%) and 38 patients (36%), respectively. The loss of E-cadherin expression was observed in 66 patients (62%). Altered pRB expression was found in 37 patients (34%). Overexpression of Ki-67 (P = .041 and P = .006, respectively) and COX-2 (P = .002 and P = .001, respectively) was associated with the pathologic stage and grade. Multivariate analysis showed that Ki-67 overexpression (P = .002), T stage (P = .009), and lymph node metastases (P = .009) were independent predictors of progression-free survival. In addition, Ki-67 overexpression (P = .007) and pathologic T stage (P = .003) were independent predictors of cancer-specific survival. No association was found between the pathologic findings and prognosis and the other markers (E-cadherin and pRB). CONCLUSIONS Our results suggest that Ki-67 overexpression is an independent predictor of the progression of urothelial carcinoma of the upper urinary tract. Patients with Ki-67 overexpression should be followed up more closely. In addition, they might be candidates for future prospective therapy trials.

Followup of Unilateral Renal Function After Laparoscopic Partial Nephrectomy

PURPOSE We assessed the change in unilateral renal function after laparoscopic partial nephrectomy to determine factors affecting the course and factors predicting the postoperative glomerular filtration rate decrease. MATERIALS AND METHODS From prospectively collected data on 116 patients who underwent laparoscopic partial nephrectomy we evaluated the glomerular filtration rate of the operated kidney using diethylenetriaminepentaacetic acid scans done preoperatively, and 3 months, and 1, 2 and 3 years postoperatively. Kidney volume was measured from the arterial phase of dynamic computerized tomography of the kidney done before and 3 months postoperatively to calculate the volume reduction. We analyzed clinicopathological and operative factors with the potential to influence the perioperative glomerular filtration rate decrease. RESULTS In all patients the glomerular filtration rate was significantly decreased by 3 months postoperatively. It remained significantly lower compared to preoperative function despite the trend toward progressive recovery, which was noted until 3 years postoperatively. Recovery in individuals was significantly influenced by patient age (less than 55 vs 55 years or greater), medical comorbidities, tumor size (less than 2.5 vs 2.5 cm or greater), kidney volume reduction (less than 20% vs 20% or greater) and collecting system repair at surgery. Independent determinants of postoperative renal function were the preoperative glomerular filtration rate (β = 0.410, 95% CI 0.424-1.084; p <0.001), the percent of renal parenchymal volume reduction (β = 0.273, 95% CI 0.168-0.766; p = 0.003) and pelvicalyceal system repair (β = 0.284, 95% CI 2.960-15.788; p = 0.005). CONCLUSIONS Function of the kidney undergoing laparoscopic partial nephrectomy progressively recovers after a significant decrease immediately after surgery. Although recovery differs according to patient age, comorbidities and tumor size, factors that independently predicted the postoperative glomerular filtration rate decrease were the renal parenchymal volume reduction and pelvicalyceal system repair.

Prognostic value of body mass index in Korean patients with renal cell carcinoma.

PURPOSE Whether body mass index is a prognostic factor in patients with renal cell carcinoma continues to be debated. We investigated the association between body mass index, and clinical/pathological features and prognosis in a large cohort of Korean patients with renal cell carcinoma. MATERIALS AND METHODS The medical records of 1,017 patients with renal cell carcinoma who underwent curative surgery between 1988 and 2006 were reviewed. Mean followup was 76.9 months. We analyzed the association of body mass index at surgery with tumor pathological features, and its associations with cancer specific survival and overall survival were evaluated using the Kaplan-Meier method and Cox regression models. Additional survival analysis was performed in a subgroup of 897 patients with T1-4N0M0 disease. RESULTS Of the 1,017 patients 363 (35.7%), 526 (51.7%) and 128 (12.6%) had a body mass index of less than 23 (normal), 23 to 27.5 (overweight) and 27.5 or greater (obese) kg/m(2), respectively. Overweight and obese patients had less aggressive tumors, such as less lymph node and/or distant metastases (p = 0.001), low pathological T stage (p = 0.047) and low Fuhrman grade (p = 0.033) vs normal weight patients. In terms of cancer specific survival and overall survival multivariate analysis showed that overweight (p = 0.040 and p = 0.047, respectively) and obese (p = 0.024 and p = 0.010, respectively) patients had good survival rates compared to those with a body mass index in the normal range in the cohort (T1-4NallMall) groups. In addition, overweight (p = 0.022 and p = 0.029, respectively) and obese (p = 0.009 and p = 0.002, respectively) status was significantly associated with cancer specific and overall survival in the T1-4N0M0 groups. CONCLUSIONS Our findings suggest that overweight and obese Korean patients with renal cell carcinoma have more favorable pathological features and a better prognosis than those with a normal body mass index.

Periprostatic Implantation of Human Bone Marrow-derived Mesenchymal Stem Cells Potentiates Recovery of Erectile Function by Intracavernosal Injection in a Rat Model of Cavernous Nerve Injury

OBJECTIVE To evaluate whether periprostatic implantation (PPI) of human bone marrow-derived mesenchymal stem cells (hBMSCs) potentiates recovery of erectile function after intracavernosal injection (ICI) of hBMSCs in a rat model of cavernous nerve (CN) injury. METHODS Sprague-Dawley rats that had undergone bilateral CN injury were treated by ICI with or without PPI of hBMSCs (10 rats per group). hBMSCs were harvested from healthy human donors. Fibrin scaffolds were used for PPI of hBMSCs. After 4 weeks, erectile responses to electric pelvic ganglion stimulation were studied. The expression of neuronal nitric oxide synthase (nNOS)-positive nerve fibers and smooth muscle/collagen ratio was evaluated in each penis. RESULTS ICI of hBMSCs slightly improved erectile function compared with the control group (maximal intracavernosal pressure/mean arterial pressure, 39.1% vs 21.7%; P=.060), but a combination of PPI and ICI significantly improved erectile function (45.0%, P=.007). After stem cell therapy, the number of nNOS-positive nerve fibers increased significantly in the PPI+ICI group (P=.017). The smooth muscle/collagen ratio increased significantly after stem cell therapy in the ICI and PPI+ICI groups (both P<.001). CONCLUSION ICI of hBMSCs in a rat model of CN injury results in recovery of penile erection by decreasing corporeal smooth muscle deterioration and collagen deposition. PPI of hBMSCs potentiates recovery of erectile function by ICI of hBMSCs via regeneration of nNOS-containing nerve fibers.

Prognostic implication of capsular invasion without perinephric fat infiltration in localized renal cell carcinoma.

OBJECTIVES To analyze the prognostic value of capsular invasion without perinephric fat infiltration in patients with localized renal cell carcinoma (RCC) Stage pT1-pT2N0M0. METHODS A total of 288 patients with RCC (conventional type) confined to the kidney (pT1-pT2N0M0) who underwent radical nephrectomy from January 1993 to November 2004 at our institution were included in our study. The disease of all patients was staged according to the 2002 TNM classification system. Pathologic findings, including T stage, nuclear grade, and capsular invasion, were retrospectively reviewed. Disease-specific survival was compared according to the capsular invasion. RESULTS Tumor invasion of the renal capsule was identified in 108 (37.5%) of the 288 patients. Of the 230 patients with Stage pT1, 78 (33.9%) had lesions invading the renal capsule and 30 (51.7%) of 58 patients with Stage pT2 had capsular invasion. Involvement of the renal capsule was associated with a worse pT stage (P = 0.015). The 5-year disease-specific survival rate for patients with no capsular invasion versus with capsular invasion was 91.8% versus 84.3%, respectively (P = 0.132). For patients with pT1 tumors, the 5-year disease-specific survival rate was 95.6% for patients without capsular invasion and 92.6% for those with capsular invasion (P = 0.299). For patients with pT2 tumors, the 5-year disease-specific survival rate was 90.5% for patients without capsular invasion and 73.8% for those with capsular invasion (P = 0.031). CONCLUSIONS Renal capsular invasion is associated with a worse stage in localized RCC. Patients with Stage pT2 RCC and capsular invasion appear to have a worse prognosis than those with equivalently staged RCC without capsular invasion.