Se Young Choi

Impact of Changing Trends in Medical Therapy on Surgery for Benign Prostatic Hyperplasia Over Two Decades

Purpose Following the introduction of medical therapy for benign prostatic hyperplasia (BPH), we determined the effect of the change in trends in medical therapy on the indication and outcome of surgical intervention for BPH. Materials and Methods We compared the basic characteristics of, weight of resected tissue of, transfusions in, and postoperative complications of patients who underwent surgery between 1985 and 1989 (before the advent of medical therapy for BPH), between 1995 and 1999 (when medical therapy was developed and became widely used as alternative treatment), and between 2005 and 2009 (when medical therapy superseded surgical intervention to become first-line treatment and when combination therapy became widely adopted). Results At our institution, the mean age and BMI of patients increased over the past two decades (p<0.001). Hypertension, operation history, and other comorbidities also increased significantly (p<0.001, p=0.005, and p<0.001, respectively). The indications for surgery in 1985 to 1989, 1995 to 1999, and 2005 to 2009 were as follows: acute urinary retention in 34.7%, 20.2%, and 15.1% of patients and symptomatic deterioration in 61.1%, 72.3%, and 73.0% of patients, respectively. Prostate volume and the weight of resected tissue increased from 34.4±14.5 ml to 61.3±32.4 ml and from 7.2±6.4 g to 10.8±7.6 g, respectively, over two decades. Patients who underwent surgery in 2005 to 2009 had their catheters removed earlier (p<0.001). Secondary hemorrhage within four postoperative weeks and repeat transurethral resection of the prostate within 1 year decreased significantly (p=0.03 and p=0.003, respectively). No statistically significant change in impaired detrusor contractility was found (p=0.523). Conclusions Although patients who underwent surgery were older after widespread use of medical therapy for BPH, advancements in surgical techniques have benefitted these patients.

Prognostic Factors for Survival of Patients With Synchronous or Metachronous Brain Metastasis of Renal Cell Carcinoma

Micro‐Abstract We evaluated the oncological outcomes of synchronous or metachronous brain metastasis (BM) of metastatic renal cell carcinoma. Although the type of BM, synchronous or metachronous, does not influence BM progression or the overall survival outcome, poor MSKCC risk, sarcomatoid component of histology, and multiple BMs are prognostic indicators for poor overall survival. Routine evaluation for BM is not recommended. Introduction: We evaluated the oncological outcomes of synchronous or metachronous brain metastasis (BM) of metastatic renal cell carcinoma (RCC) according to clinicopathologic factors. Patients and Methods: Patients with metastatic RCC (n = 93) with synchronous and metachronous BM were retrospectively identified. We analyzed patients and tumor characteristics, treatment methods, prognostic factors, BM progression, and overall survival (OS). Results: Seventy‐six patients (81.7%) received local therapy (stereotactic radiosurgery [60.2%], radiation therapy [22.6%], and neurosurgery [10.8%]), and 54 patients (58.1%) were treated with systemic medical therapy. In multivariable analysis, poor Memorial Sloan‐Kettering Cancer Center (MSKCC) risk (hazard ratio [HR] 3.672; 95% confidence interval [CI], 1.441‐9.36; P = .0064), sarcomatoid component (HR 4.264; 95% CI, 2.062‐8.820; P = .0001), and multiple BMs (HR 2.838; 95% CI, 1.690‐4.767; P = .0001) were prognostic indicators of a poorer OS outcome. Local (HR 0.436; 95% CI, 0.237‐0.802; P = .0076) and systemic treatment (HR 0.322; 95% CI, 0.190‐0.548; P < .0001) were independent factors for a better OS. Although OS from initial RCC diagnosis in patients with metachronous BM was better than that for patients with synchronous BM, there were no differences found between synchronous and metachronous patients in terms of BM progression and OS after the diagnosis of BM. Conclusions: Poor MSKCC risk, sarcomatoid component of histology, and multiple BMs are prognostic indicators for poor OS in patients with BM from metastatic RCC. Systemic and/or local treatment improves the OS. Because the type of BM, synchronous or metachronous, does not influence BM progression or the OS outcome, routine evaluation for BM is not recommended.

Predicting Recurrence and Progression of Non-Muscle-Invasive Bladder Cancer in Korean Patients: A Comparison of the EORTC and CUETO Models

Purpose This study aimed to confirm the utility of the European Organization for Research and Treatment of Cancer (EORTC) and the Spanish Urological Club for Oncological Treatment (CUETO) scoring systems and to determine which model is preferred as a prognostic model in Korean patients with non-muscle-invasive bladder cancer. Materials and Methods Between 1985 and 2011, 531 patients who were treated by transurethral resection of bladder cancer were retrospectively analyzed by use of the EORTC and CUETO models. Statistically, we performed Kaplan-Meier survival analysis; calculated Harrells concordance index, receiver operating characteristic (ROC) curve, and cutoff values; and performed univariate and multivariate Cox proportional hazards regression analyses. Results For risk of recurrence, with the use of the EORTC model, all groups had statistically significant differences except between the group with a score of 0 and the group with a score of 1-4. With the use of the CUETO model, all groups differed significantly. For risk of progression, with the use of the EORTC model, significant differences were observed between all groups except between the group with a score of 2-6 and the group with a score of 7-13. With the use of the CUETO model, a significant difference was observed between the group with a score of 0 and the other groups. The concordance index of the EORTC and CUETO models was 0.759 and 0.836 for recurrence and 0.704 and 0.745 for progression, respectively. The area under the ROC curve for the EORTC and CUETO models was 0.832 and 0.894 for recurrence and 0.722 and 0.724 for progression, respectively. Conclusions Both scoring systems, especially the CUETO model, showed value in predicting recurrence and progression in Korean patients, which will help in individualizing treatment and follow-up schedules.

Prostate Specific Antigen Velocity per Prostate Volume: A Novel Tool for Prostate Biopsy Prediction

OBJECTIVE To investigate whether altered prostate specific antigen (PSA) levels due to individual prostate growth may affect the PSA velocity (PSAV). MATERIALS AND METHODS Between January 2000 and December 2009, a total of 159 men with at least 2 transrectal ultrasonography (TRUS) procedures and concurrent PSA measurements underwent prostate biopsy because of suspicion of prostate cancer. We measured PSAV, prostate volume velocity (PVV), PSA density (PSAD), PSAD velocity (PSADV), and PSAV per initial volume. We then classified the total group into a prostate cancer (PC) group and non-PC group, and compared the 2 groups. We investigated which variables were exact to predict prostate biopsy using univariate and multivariate analyses, and assessed the diagnostic performance using the receiver operating characteristic (ROC) curve. RESULTS PVV showed a positive correlation with initial prostate volume in the total and non-PC group; PVV showed a positive correlation with PSAV, and initial prostate volume correlated with PSAV in the non-PC group. The PC group showed smaller prostate volumes, higher PSAD, higher PSADV, higher PSAV per initial volume, and longer follow-up periods. After adjusting for confounding factors, the odds ratios of prostate cancer across the quartile of PSAVD were 1, 1.889, 3.226, and 7.125 (P for trend = .007), and PSAV per initial volume were 1, 2.924, 2.937, and 7.536 (P for trend = .031). On the ROC curve, the areas under the curves (AUC) of PSAV per initial volume were higher than for PSAV and PSADV. CONCLUSION Altered PSA levels due to individual prostate growth may affect the use of PSAV to predict prostate biopsy outcomes in follow-up.

Urologic Diseases in Korean Military Population: a 6-year Epidemiological Review of Medical Records

We sought to describe the incidence rate of the urologic disease in the Korean military by reviewing diagnoses made in active duty soldiers from 2008 to 2013. A total of 72,248 first visits were generated in the Defense Medical Statistics Information System (DMSIS) with its gradually increasing trend over 6 years. A sharp increase of first visit was observed after implementation of the regular health check-up for all conscripted soldiers since 2013. Urolithiasis, prostatitis, epididymoorchitis, urethritis, and varicocele were prevalent. Prostatitis was the highest diagnosis made in the outpatient service, while varicocele was ranked the highest in the inpatient service. The incidence rates of urologic disease varied from 12.3 to 34.2 cases per 1,000 person-years. The urologic disease in conscripted men showed different distribution when we separated the population into conscripted and professional soldiers. Epididymoorchitis was the highest disease followed by urolithiasis, dysuresia, and balanoposthitis in 2013. This study underscores that the urologic disease has spent significant amount of health care resources in the Korean military. This calls for further study to find any significant difference and contributing factors of the urologic disease in the military and the civilian population.

Daily Mean Temperature and Urolithiasis Presentation in Six Cities in Korea: Time-Series Analysis

Seasonal variation in urinary stone presentation is well described in the literature. However, previous studies have some limitations. To explore overall cumulative exposure-response and the heterogeneity in the relationships between daily meteorological factors and urolithiasis incidence in 6 major Korean cities, we analyzed data on 687,833 urolithiasis patients from 2009 to 2013 for 6 large cities in Korea: Seoul, Incheon, Daejeon, Gwangju, Daegu, and Busan. Using a time-series design and distributing lag nonlinear methods, we estimated the relative risk (RR) of mean daily urolithiasis incidence (MDUI) associated with mean daily meteorological factors, including the cumulative RR for a 20-day period. The estimated location-specific associations were then pooled using multivariate meta-regression models. A positive association was confirmed between MDUI and mean daily temperature (MDT), and a negative association was shown between MDUI and mean daily relative humidity (MDRH) in all cities. The lag effect was within 5 days. The multivariate Cochran Q test for heterogeneity at MDT was 12.35 (P = 0.136), and the related I2 statistic accounted for 35.2% of the variability. Additionally, the Cochran Q test for heterogeneity and I2 statistic at MDHR were 26.73 (P value = 0.148) and 24.7% of variability in the total group. Association was confirmed between daily temperature, relative humidity and urolithiasis incidence, and the differences in urolithiasis incidence might have been partially attributable to the different frequencies and the ranges in temperature and humidity between cities in Korea.

Prognostic factors of oncologic outcomes in metastatic chemotherapy-naïve castration-resistant prostate cancer treated with enzalutamide in actual clinical practice in East Asia

OBJECTIVES We aimed to evaluate the prognostic factors for chemotherapy-naïve castration-resistant prostate cancer (CRPC) treated with enzalutamide in actual clinical practice using easily accessible clinical variables. METHODS AND MATERIALS We retrospectively reviewed the following data from 113 patients with chemotherapy-naïve CRPC treated with enzalutamide: serum levels of prostate-specific antigen (PSA), testosterone, hemoglobin, total protein, albumin, and alkaline phosphatase (ALP); platelet, neutrophil, and lymphocyte counts; neutrophil-to-lymphocyte ratios (NLRs); and liver profiles. PSA progression-free survival (PFS), radiological PFS, and overall survival were estimated by Cox regression analysis. RESULTS Compared with baseline levels, laboratory values at 2 months showed significantly lower PSA (160.2 ± 351.5 ng/ml vs. 47.4 ± 117.1 ng/ml) and ALP levels (201.86 ± 223.77 IU/l vs. 148.25 ± 146.81 IU/l) and a significantly higher percentage of lymphocytes (28.1% ± 10.6% vs. 31.2% ± 9.7%); those at 1 month showed a significantly lower percentage of neutrophils (61.0% ± 11.0% vs. 57.1% ± 12.5%). In the multivariate analysis, poor prognostic factors for PSA PFS were Gleason score ≥ 9 (hazard ratio [HR] 2.022; P = 0.0250); visceral metastasis (HR 3.143; P = 0.0002); high NLR (HR 1.205; P = 0.0126); and high ALP (HR 1.002; P = 0.0015). For radiological PFS, high NLR (HR 1.249; P = 0.0002) and high ALP (HR 1.002; P = 0.0001) were associated with poor outcomes. The predictors of poor overall survival were visceral metastasis (HR 3.155; P < 0.0001); high NLR (HR 1.341; P < 0.0001); and high ALP (HR 1.001; P = 0.0017). CONCLUSION Enzalutamide is less effective in patients with metastatic chemotherapy-naïve CRPC with Gleason scores ≥ 9, visceral metastasis, high NLR, and high ALP.

Neoadjuvant Therapy Prior to Radical Prostatectomy

The terminology “neoadjuvant” stemmed from Greek “neos” that means new or before and the Latin language “adjuvāre” that means help or aid. Neoadjuvant therapy is the application of systemic care before operation or radiotherapy. Neoadjuvant therapy has some benefits in several tumors such as the bladder, testis, breast, colon, and lung. Conceptually, neoadjuvant therapy may decrease the size of the tumor before surgery or eliminate concealed micrometastases. In cases of neoadjuvant therapy before radiation therapy, shrinkage of the tumor is able to localize the site of the target with optimal doses while decreasing radiation exposure to surrounding normal tissue.

Factors associated with testosterone recovery after androgen deprivation therapy in patients with prostate cancer

Purpose We investigated factors affecting testosterone recovery after androgen deprivation therapy (ADT) withdrawal in patients with prostate cancer. Materials and Methods The medical records of patients who underwent radical prostatectomy with ADT were retrospectively reviewed. In all, 221 patients were included in the analysis. Testosterone recovery was defined as supra-castration (SC) (testosterone levels in serum >50 ng/dL) or out of hypogonadism (OH) (>300 ng/dL) after ADT withdrawal. Kaplan-Meier analyses were used to estimate testosterone recovery after ADT cessation. Cox regression analyses were used to determine the factors affecting the recovery of testosterone. Results After ADT, 206 patients (93.2%) recovered to the SC level and 122 patients (55.2%) recovered to the OH level. Patients treated with ADT for ≤18 months recovered to OH in a mean of 6.8 months (74.6%), but patients treated with ADT for >18 months recovered in a mean of 9.7 months (27.5%). In multivariate analyses, age (hazard ratio [HR], 0.915; p<0.001), serum level of sex hormone-binding globulin (SHBG) (HR, 1.015; p=0.002), initial testosterone level (HR, 1.002; p=0.002), and ADT duration (HR, 0.915; p<0.001) were associated with recovery to the OH level after ADT withdrawal, and hypertension (HR, 0.697; p=0.029) and duration of ADT (HR, 0.979; p=0.012) were significantly associated with recovery to SC. Conclusions In patients treated with ADT for ≤18 months, testosterone recovers to the OH level more often and faster after ADT cessation. Age, SHBG level, initial testosterone level, and ADT duration are associated with testosterone recovery.

In vitro, in vivo, and clinical tests of a novel flexible ureteroscope for the diagnosis and treatment of kidney and ureteral diseases

Purpose Despite advances in flexible ureteroscopy, the high cost and long repair time of ureteroscopes limit their use in the urology. We compared the performance of a novel flexible ureteroscope (fURS) ‘HF-EH’ with that of the two contemporary fURSs ‘URF-P6’ and ‘COBRA’. Materials and Methods We compared in vitro measurements of deflection angle, irrigation flow rate, and image quality between HF-EH and URF-P6 while also inspecting renal collecting systems in five female pigs. For clinical testing, we performed retrograde intrarenal surgeries using HF-EH in four patients. Experienced urologists compared performance parameters (irrigation, convenience, and maneuverability) between the HF-EH and COBRA. Results The flow rate of HF-EH (21.0 mL/min) was worse, and its resolution (1.59 line pairs/mm) was inferior to that of URF-P6 (28.7 mL/min and 3.17 line pairs/mm, respectively). However, HF-EH was superior to URF-P6 in terms of loss of deflection angle with the insertion of accessories (1.8% vs. 12.7%). In vivo and clinical testing revealed that the performance parameters of HF-EH were slightly inferior to those of conventional domestic fURSs. We successfully performed retrograde intrarenal surgeries using HF-EH in four patients and achieved stone-free statuses in two. None of the patients exhibited any procedure-related complications. Conclusions Although we observed that two of the three performance parameters of the novel ureteroscope ‘HF-EH’ were inferior to those of the conventional ureteroscope, we successfully used HF-EH to perform retrograde intrarenal surgeries in patients. Further studies on performance and durability are warranted for making HF-EH commercially available.