Sang Hyub Lee

Comparison of postoperative estimated glomerular filtration rate between kidney donors and radical nephrectomy patients, and risk factors for postoperative chronic kidney disease

To compare post‐nephrectomy renal function between kidney donors and renal cell carcinoma patients, to evaluate trends in recovery, and to identify factors relevant to renal failure.

Robot-assisted laparoscopic retroperitoneal lymph node dissection for stage IIIb mixed germ cell testicular cancer after chemotherapy

Laparoscopic retroperitoneal lymph node dissection, especially when performed with the da Vinci Surgical System (Intuitive Surgical), has shown excellent cosmetic results with similar oncologic outcomes to those of open surgery. In this study, we present a case of robot-assisted retroperitoneal lymph node dissection performed in an 18-year-old man who was diagnosed with a stage IIIb mixed germ cell tumor and who was initially treated with radical orchiectomy, followed by chemotherapy. This case shows that robot-assisted retroperitoneal lymph node dissection is technically feasible, safe, and cosmetically favorable, even when performed on patients with high-stage disease or after chemotherapy.

Practice Patterns of Urologists in Managing Korean Men Aged 40 Years or Younger With High Serum Prostate-specific Antigen Levels

OBJECTIVE To investigate the practice patterns of urologists in managing Korean men aged 40 years or younger with high serum prostate-specific antigen (PSA). MATERIALS AND METHODS Data were collected from general health screenings conducted at 4 university hospitals between 2004 and 2012. Eligibility criteria were Korean men aged≤40 years who were seen by urologists for high PSA (>2.5 ng/mL). After excluding individuals with chronic prostatitis and any infectious symptoms and/or signs, the practice patterns of urologists managing 237 eligible men were analyzed. RESULTS The most common practice was observation after antibiotics (40.5%), followed by reassurance (38.4%), prostate biopsy (PBx) after antibiotics (11.8%), PBx after PSA follow-up (7.6%), and immediate PBx (1.7%). Antibiotics were prescribed empirically to 124 patients (52.3%). Of the entire patients, 145 of 237 (61.2%) had at least 1 follow-up PSA, and the follow-up PSA with median interval of 43 days (interquartile range, 26-149) was higher than initial PSA in 66 of 145 (45.5%). Of the 98 patients undergoing follow-up PSA after initial antibiotic treatment, 53 (54.1%) experienced a decline in PSA, whereas 45 (45.9%) experienced a rise in PSA. PBx was performed in 50 of 237 (21.1%), and only a single case (2%) of prostate cancer was diagnosed. CONCLUSION In managing men≤40 years with high PSA, the most common practice pattern was observation after antibiotic treatment despite lack of evidences. Furthermore, 1 in 5 urologists performed PBx to rule out cancer. Given the very low prevalence of cancer in this age group, clear guidelines are needed for appropriate management and consistency of care.

Acute Idiopathic Scrotal Edema Caused by Epstein-Barr Virus.

Q1 first reported acute idiopathic scrotal edema (AISE) in 1956. No specific cause has been identified. Here, we discuss 2 cases of AISE caused by acute Epstein–Barr viral (EBV) infection. A 13-year-old male and a 6-year-old boy visited our hospital because of penile, scrotal and perineal swelling. Both of them reported no trauma to the perineal area and had never experienced an allergic reaction to any medications. Laboratory tests including urinalysis were normal. Penile and scrotal color Doppler ultrasonography (US) of the first case revealed diffuse swelling of the penile, scrotal and bilateral inguinal wall soft tissue with hypervascularity in addition to small nodules in both inguinal areas. Scrotal US of the 6-year-old boy showed multiple enlarged lymph nodes in the right inguinal area and diffuse soft tissue swelling of the scrotal and perineal wall. Serologic testing for cytomegalovirus and EBV were performed in both cases, which revealed the presence of immunoglobulin G (IgG) and immunoglobulin M (IgM) to the viral capsid antigen (VCA) of EBV, indicating recent EBV infection. Their symptoms disappeared spontaneously within a few days. The clinical manifestations of AISE include scrotal edema without tenderness. Penile, perineal and inguinal involvement occur in 20%, 42% and 67% of patients with AISE, respectively. It can be easily diagnosed with ultrasound examination. Edematous thickening and increased vascularity are characteristic of AISE. Enlargement and increased vascularity of the inguinal lymph nodes are commonly detected by US. There are many hypothesized etiologies; however, the cause of AISE has not been identified. EBV infection in young children is usually asymptomatic or resembles other febrile infections. The most common site of lymphadenopathy is the anterior and posterior cervical areas, and sometimes axillary and inguinal lymph nodes can be affected. Antibodies to the EBV nuclear antigen, the early antigen and the VCA are most useful for diagnosis. Acute EBV infection is characterized by rapid elevation of IgM and IgG antibody responses to VCA and a detectable IgG response to early antigen. Therefore, the IgMVCA test is the most specific serologic test for diagnosis of acute EBV infection. The clinical features of our cases were similar to those of testicular torsion or acute epididymitis. However, we were able to diagnose AISE by scrotal US without difficulty. We suspected an unusual infection as the cause of scrotal edema, and incidentally we found that IgM-VCA was elevated in both cases, confirming acute EBV infection. According to previous reports, acute EBV infection in childhood may cause inguinal lymphadenopathy, which is consistent with the clinical manifestations in our cases. Therefore, we suspect that acute EBV infection caused our patients’ acute scrotal and perineal edema. Based on our cases and previous reports about EBV, we suggest that acute EBV infection is the cause of AISE.

Can prostate-specific antigen kinetics before prostate biopsy predict the malignant potential of prostate cancer?

Purpose To predict the malignant potential of prostate cancer (PCa) according to prostate-specific antigen velocity (PSAV), PSA density (PSAD), free/total PSA ratio (%fPSA), and digital rectal examination (DRE). Materials and Methods From January 2009 to December 2012, 548 adult male patients were diagnosed with PCa by prostate biopsy at four hospitals in Korea. We retrospectively analyzed 155 adult male patients with an initial PSA level ≤10 ng/mL and whose PSA levels had been checked more than two times at least 6 months before they had been diagnosed with PCa, with test intervals of more than 3 months. Patients with a urinary tract infection, and patients who had previously undergone cystoscopy or surgery of the prostate were excluded. We separated patients into two groups according to Gleason sum [Gleason sum ≤7 (n=134) or Gleason sum ≥8 (n=21)] and the presence of extracapsular invasion [organ confined (n=129) or extracapsular invasion (n=26)]. Differences between the groups were compared. Results The group with a Gleason sum ≥8 or extracapsular invasion of PCa showed high PSAV and significantly lower %fPSA. There were no significant differences in PSAD and the presence of an abnormality on DRE between two groups. Conclusion In PCa patients treated with other therapies besides prostatectomy, a high PSA velocity and a low %fPSA may predict high grade PCa with a Gleason sum ≥8 or the presence of extracapsular invasion.

Macroscopic hematuria caused by congenital portosystemic shunt and concomitant nutcracker syndrome.

Nutcracker syndrome (NCS) is an uncommon vascular abnormality that causes a variety of symptoms that range from asymptomatic microscopic hematuria to severe pelvic congestion. Congenital portosystemic shunt (CPSS) is an extremely rare anomaly that causes serious complications. Many cases of NCS and CPSS that have presented separately have been reported, but no cases of concomitant NCS and CPSS have been reported. We present a case of intermittent macroscopic hematuria in a patient with both NCS and CPSS. We diagnosed NCS on pressure gradient between the left renal vein (LRV) and the inferior vena cava. The presence of CPSS, which emerged from the LRV and connected to the extrahepatic portal vein, was confirmed on computed tomography. The interaction between NCS and CPSS resulted in mild intermittent macroscopic hematuria only, rather than the more common symptoms that occur when NCS or CPSS present separately.

Comparison of biochemical recurrence in prostate cancer patients treated with radical prostatectomy or radiotherapy

Purpose We evaluated the biochemical recurrence (BCR) of prostate cancer patients treated by radical prostatectomy (RP) or radiotherapy (RT). Materials and Methods Patients who underwent RP or RT as primary definitive treatment from 2007 were enrolled for this study. They were divided into two groups; the low-intermediate risk group and the high risk group according to the National Comprehensive Cancer Network guidelines. We compared differences such as age, prostate specific antigen, Gleason score, follow-up duration, clinical T staging, and BCR. Their BCR-free survival rates were analyzed. Results A total of 165 patients were enrolled. There were 115 patients in the low-intermediate risk. Among them, 88 received RP and 27 underwent RT. BCR occurred in 9 of the RP patients (10.2%) and 3 of the RT patients (11.1%). For the high risk group, 50 patients were included. RP was performed in 25 patients and RT in 25 patients. BCR was observed in 4 of the RP patients (16%) and 12 of the RT patients (48%). There were no differences in BCR-free survival for the low-intermediate group (p=0.765). For the high risk group, the RP group had a higher BCR free survival rate (p=0.032). Conclusions No difference of BCR and BCR-free survival was seen in the low-intermediate risk group but lower BCR and better BCR-free survival were observed for patients that received RP in the high risk group. RP should be a more strongly considered option when deciding the treatment method for selected high risk patients.

Which Patients Should We Follow up beyond 5 Years after Definitive Therapy for Localized Renal Cell Carcinoma

Purpose Up to 10% of recurrences develop beyond 5 years after curative treatment of localized renal cell carcinoma (RCC). Clinicopathologic features were evaluated to determine which factors are associated with late recurrence. Materials and Methods A total of 753 patients were diagnosed with localized RCC from January 2000 to June 2008. We enrolled 225 patients who were treated surgically and had a minimal recurrence-free survival of 60 months. Patients who had recurrence beyond 5 years after nephrectomy were defined as the late recurrence group and the remaining patients as the recurrence-free group. Multivariate logistic regression analyses and the Cox proportional hazard model were used for determination of features associated with late recurrence. Results In multivariate analyses, age older than 60 (p=0.030), Fuhrman grade ≥ 3 (p=0.042), and pT stage ≥ pT2 (p=0.010) showed statistical association with late recurrence. The Cox proportional hazard model showed significant differences in recurrence-free survival when we classified the patients based on pT2 (p=0.007) and on patient age ≥ 60 years (p=0.039). Conclusion Patient age greater than 60 years, Fuhrman grade ≥ 3, and tumor stage ≥ pT2 are independent risk factors of recurrence more than 5 years after surgery in patients with RCC. Therefore, close lifelong follow-up is recommended for patients with these risk factors.

Involvement of fibroblast growth factor receptor genes in benign prostate hyperplasia in a Korean population.

Fibroblast growth factors (FGFs) and their receptors (FGFRs) have been implicated in prostate growth and are overexpressed in benign prostatic hyperplasia (BPH). In this study, we investigated whether single nucleotide polymorphisms (SNPs) of the FGFR genes (FGFR1 and FGFR2) were associated with BPH and its clinical phenotypes in a population of Korean men. We genotyped four SNPs in the exons of FGFR1 and FGFR2 (rs13317 in FGFR1; rs755793, rs1047100, and rs3135831 in FGFR2) using direct sequencing in 218 BPH patients and 213 control subjects. No SNPs of FGFR1 or FGFR2 genes were associated with BPH. However, analysis according to clinical phenotypes showed that rs1047100 of FGFR2 was associated with prostate volume in BPH in the dominant model (GA/AA versus GG, P = 0.010). In addition, a significant association was observed between rs13317 of FGFR1 and international prostate symptom score (IPSS) in the additive (TC versus CC versus TT, P = 0.0022) and dominant models (TC/CC versus TT, P = 0.005). Allele frequency analysis also showed significant association between rs13317 and IPSS (P = 0.005). These results suggested that FGFR genes could be related to progression of BPH.