Sejun Park

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.

Predictive Characteristics of Malignant Pheochromocytoma

Purpose The prognosis of patients with malignant pheochromocytoma is poor, but the predictive factors are not well understood. We aimed to identify the clinical characteristics predictive of malignancy after initial surgical removal in patients with pheochromocytoma. Materials and Methods We retrospectively reviewed the records of 152 patients diagnosed with pheochromocytoma, including 5 (3.3%) with metastasis at the time of the initial surgical excision and 12 (7.9%) who developed metastasis during follow-up. To determine the factors predictive of malignancy, we compared clinical, radiographical, and urinary chemical findings between patients with benign and malignant disease. Mean follow-up was 41.5 months (range, 0.9-298 months) after surgery. Results Malignant tumors were significantly larger than benign tumors (11.1±4.0 cm vs. 6.2±3.4 cm, p<0.001), and postoperative persistence of arterial hypertension was more frequent after removal of malignant than benign tumors (p=0.001). Among the 147 patients without metastatic disease at diagnosis, those who developed metastasis had significantly lower concentrations of urinary catecholamine metabolites per unit of tumor, including vanillylmandelic acid (1.2 vs. 3.7 mg/day/cm, p=0.049), epinephrine (4.5 vs. 168.9 µg/day/cm, p=0.008), and norepinephrine (13.1 vs. 121.8 mg/day/cm, p<0.001). The overall 5-year metastasis-free survival rate was 84.4% and was significantly higher in patients with smaller tumors (≤5.5 vs. >5.5 cm; 90.6% vs. 81.2%, p=0.025) and higher 24-hour secretion of vanillylmandelic acid (>2.1 vs. ≤2.1 mg/day/cm; 94.9% vs. 70.9%, p=0.019). Conclusions Large tumor size (>5.5 cm) and minimally elevated 24-hour urinary vanillylmandelic acid (≤2.1 mg/day/cm) were significantly associated with a higher probability of a malignant pheochromocytoma portending a lower metastasis-free survival and mandating more rigorous follow-up after surgery.

Value of immediate second resection of the tumor bed to improve the effectiveness of transurethral resection of bladder tumor.

BACKGROUND AND PURPOSE Current guidelines recommend routine second transurethral resection (TUR) for accurate diagnosis and to prevent understaging of muscle-invasive bladder cancer. We evaluated the diagnostic accuracy of immediate second resection of the tumor bed during initial TUR and its prognostic significance. PATIENTS AND METHODS Patients (n=126) undergoing TUR were prospectively randomized to undergo (n=63) or not undergo (n=63) immediate second resection of the tumor bed after complete TUR. Second resection was repeated until muscularis propria (MP) was identified in the specimen and the depth of tumor invasion was inspected. The results of second resection were compared with final pathology results for diagnostic accuracy. Recurrence and progression rates were compared in the two groups, and factors affecting recurrence were evaluated. RESULTS Patient age, sex distribution, number of tumors, pathologic T stage and grade were similar in the groups. MP was included in all TUR specimens in the immediate second resection group, compared with 41 of 63 (65.1%) in the nonsecond resection group. The concordance rate of second resection with final pathology was r=0.810 (P<0.01). The sensitivity and specificity of second resection for T(2) disease were 90.9% and 98.0%, respectively, and the positive and negative predictive values of second resection for T(2) disease were 90.0% and 96.2%, respectively. Among the 94 patients followed up, those in the second resection group had significantly higher 2-year recurrence-free survival rate (77.0% vs 45.8%, P=0.025), but there was no difference in progression-free survival rate. CONCLUSIONS Immediate second resection of the tumor bed after complete TUR improves the effectiveness of resection by immediately confirming the presence of MP in the specimen and accurately differentiating muscle-invasive disease. The advantages of immediate second resection were precise prediction of final pathology results and reduced early recurrence.

Statin use after radical prostatectomy reduces biochemical recurrence in men with prostate cancer

The impact of statin use on biochemical recurrence (BCR) of prostate cancer after radical prostatectomy (RP) is controversial.

Preoperative Factors Predictive of Posterolateral Extracapsular Extension After Radical Prostatectomy

Purpose In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making. Materials and Methods We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis. Results Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score ≥7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396). Conclusions PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.

The therapeutic effect of solifenacin succinate on the recovery from voiding dysfunction after radical prostatectomy in men with clinically localized prostate cancer: a prospective, randomized, controlled study.

OBJECTIVE To evaluate whether anticholinergic medication contributes to early recovery of continence and improvement of other voiding symptoms after radical prostatectomy (RP). PATIENTS AND METHODS A total of 78 patients with clinically localized prostate cancer who had incontinence at 1 week after RP were enrolled prospectively. The patients were allocated to one of the 2 groups: group 1 (α-adrenergic agonist [midodrine] plus an anticholinergic [solifenacin]) or group 2 (α-adrenergic agonist only). A urodynamic study and the International Continence Society male Short Form questionnaire were completed preoperatively and 4 months after RP. One-hour pad test and 3-day frequency volume chart at 1 and 4 months after medication were also analyzed. RESULTS The rate of continence, defined as being pad free, did not differ between the groups at 4 months (both 71.8%; P >.05). However, the decreased value of mean weight of daily pads worn by groups 1 and 2 were 51.5 vs 11.7 g, respectively (P = .005). The incontinence (P = .008) and quality of life (P = .044) subscale scores significantly worsened in group 2, whereas they remained unchanged in group 1. Maximal detrusor pressure and maximal urethral closure pressure significantly decreased in both groups, whereas maximal cystometric capacity increased significantly in group 1 only (290.8-332.0 cm H2O; P <.001). CONCLUSION Anticholinergics may facilitate early recovery from incontinence and prevent worsening of quality of life, which might be attributed to increased cystometric capacity after their use.

Penile length, digit length, and anogenital distance according to birth weight in newborn male infants

Purpose Anogential distance (AGD) and the 2:4 digit length ratio appear to provide a reliable guide to fetal androgen exposure. We intended to investigate the current status of penile size and the relationship between penile length and AGD or digit length according to birth weight in Korean newborn infants. Materials and Methods Between May 2013 and February 2014, among a total of 78 newborn male infants, 55 infants were prospectively included in this study. Newborn male infants with a gestational age of 38 to 42 weeks and birth weight>2.5 kg were assigned to the NW group (n=24) and those with a gestational age<38 weeks and birth weight<2.5 kg were assigned to the LW group (n=31). Penile size and other variables were compared between the two groups. Results Stretched penile length of the NW group was 3.3±0.2 cm, which did not differ significantly from that reported in 1987. All parameters including height, weight, penile length, testicular size, AGD, and digit length were significantly lower in the LW group than in the NW group. However, there were no significant differences in AGD ratio or 2:4 digit length ratio between the two groups. Conclusions The penile length of newborn infants has not changed over the last quarter century in Korea. With normal penile appearance, the AGD ratio and 2:4 digit length ratio are consistent irrespective of birth weight, whereas AGD, digit length, and penile length are significantly smaller in newborns with low birth weight.

Randomized clinical trial of a bladder neck plication stitch during robot-assisted radical prostatectomy.

Urinary incontinence after robot-assisted radical prostatectomy (RARP) is one of the most bothersome complications affecting patients′ daily lives. The efficacy of the bladder neck plication stitch technique in promoting an earlier return of continence was prospectively evaluated in 158 patients who underwent RARP for clinically localized prostate cancer by a single surgeon at our institute from March 2012 to January 2013. Patients were randomized 1:1 to undergo surgery with (n = 79) or without (n = 79) the bladder neck plication stitch, and their time to recovery from incontinence, defined as being pad free, was compared. Recovery from incontinence at 1, 3, and 6 months were observed in 22 (27.8%), 42 (53.2%), and 57 (72.2%) patients, respectively, treated with, and 23 (29.1%), 47 (59.5%), and 59 (74.7%) patients, respectively, treated without the bladder neck plication stitch, with no significant difference in time to recovery from incontinence between the two groups. Multivariate analysis showed that age, membranous urethral length and shape of the prostatic apex on magnetic resonance imaging were independent predictors of early recovery from urinary incontinence after RARP. The bladder neck plication stitch had no effect on time to recovery from postoperative urinary incontinence following RARP.

Hypercholesterolemia Is Associated with a Shorter Time to Castration-Resistant Prostate Cancer in Patients Who Have Undergone Androgen Deprivation Therapy

Purpose The goal of this study was to investigate the association between hypercholesterolemia and the time required for progression to castration-resistant prostate cancer (CRPC) in patients who have undergone androgen deprivation therapy (ADT). Materials and Methods Data from 154 patients with prostate cancer between 2005 and 2012 were reviewed retrospectively. ADT was employed as a treatment modality for these patients either due to multiple bone metastases at the time of diagnosis or due to old age in combination with other morbidities. Serum cholesterol levels and statin use were reviewed. We analyzed the factors associated with the development of CRPC after ADT treatment. The mean follow-up period was 34.8 months. Results The mean age of the patients was 71.3 years old and their mean prostate-specific antigen level was 141.8±212.6 ng/mL. Their mean cholesterol level was 175.9±37.7 mg/dL, and 14 patients (9.1%) were statin users. CRPC developed in 44 patients (28.6%), and the mean duration from ADT treatment to CRPC was 24.1 months. In a multivariate analysis, hypercholesterolemia was associated with the development of CRPC (hazard ratio [HR]=1.017, p<0.001), depending on clinical T stage (p=0.005) and the presence of bone metastasis (p<0.001). A subanalysis showed that hypercholesterolemia was associated with the development of CRPC in patients with bone metastasis (HR=1.032, p<0.001), but not in patients without bone metastasis. Conclusions Hypercholesterolemia may be associated with the development of CRPC after ADT in patients with bone metastasis. Further studies with longer follow-up periods and larger samples are needed to validate this finding.

Impact of Adjuvant Androgen-Deprivation Therapy on Disease Progression in Patients with Node-Positive Prostate Cancer

Purpose The survival benefits of adjuvant androgen-deprivation therapy (ADT) in prostate cancer and lymph node metastasis remain unclear. We assessed the role of ADT in disease progression after radical prostatectomy (RP). Materials and Methods Of 937 patients who underwent RP, we identified 40 (4.2%) who had lymph node metastasis. A total of 18 received adjuvant ADT (ADT group) and 22 were observed (observation group). Clinical progression-free survival (PFS), cancer- specific survival (CSS), and overall survival (OS) were compared in the 2 groups. Prognostic factors for clinical progression and biochemical recurrence (BCR) were analyzed. Results The 5-year PFS, CSS, and OS of the entire cohort were 75.0%, 85.0%, and 72.5%, respectively. In the ADT group, 6 patients (33.3%) showed clinical progression at a median 42.7 months. The 5-year PFS, CSS, and OS rates of this group were 72.2%, 83.3%, and 72.2%, respectively. In the observation group, 14 patients (63.6%) received salvage therapy owing to BCR. Nine patients (40.9%) with BCR in the observation group showed clinical progression at a median 43.4 months after RP. The 5-year PFS, CSS, and OS rates of this group were 77.2%, 86.4%, and 72.8%, respectively. In the observation group, the BCR rate was lower in patients with pT3a or less disease than in those with pT3b disease. Conclusions Adjuvant ADT in node-positive prostate cancer did not reduce or delay disease progression or improve survival. Because a substantial number of untreated patients with pT3a or less disease did not experience recurrence, administration of ADT should be initiated carefully. However, in patients with pT3b disease, adjuvant ADT and radiotherapy could be considered.