Seok Cho

Oncologic and Functional Outcomes after Partial Nephrectomy Versus Radical Nephrectomy in T1b Renal Cell Carcinoma: A Multicenter, Matched Case-Control Study in Korean Patients

Purpose The study was to compare the oncologic and functional outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for pathologically proven T1b renal cell carcinoma using pair-matched groups. Materials and Methods We reviewed our prospectively maintained database for RN and PN in T1b renal tumors surgically treated between 1999 and 2011 at five institutions in Korea. Of 611 patients treated with PN or RN for a solitary and NX/N0 M0 renal mass (4-7 cm), 577 (PN, 100; RN, 477) patients with pathologically confirmed pT1b remained for analysis. Study subjects were grouped by PN or RN, then matched by age, sex, comorbidities, body mass index, tumor size and depth, histologic type, and preoperative estimated glomerular filtration rate (eGFR) using propensities score. To evaluate oncologic outcomes, overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) rates were analyzed. The functional outcomes were evaluated by postoperative eGFR. Results The median follow-up in the RN group was 48.1 and 42.6 months in the PN group. The estimated 10-year CSS rate (PN 85.7% vs. RN 84.4%, p=0.52) and 5- and estimated 10-year PFS rates (PN: 86.4% and 79.2% vs. RN: 86.0% and 66.1%, p=0.66) did not differ significantly between groups. The estimated 10-year OS rate was significantly higher in the PN group (85.7%) compared to the RN group (73.3%) (p=0.003). PN was less likely to induce new-onset chronic kidney disease (CKD) and end-stage CKD compared with RN. Conclusion Our study suggests that patients treated with PN demonstrate a superior OS rate and postoperative renal function with analogous CSS and PFS rates compared with pair-matched patients treated with RN.

Current Status of Cryotherapy for Prostate and Kidney Cancer

In terms of treating diseases, minimally invasive treatment has become a key element in reducing perioperative complications. Among the various minimally invasive treatments, cryotherapy is often used in urology to treat various types of cancers, especially prostate cancer and renal cancer. In prostate cancer, the increased incidence of low-risk, localized prostate cancer has made minimally invasive treatment modalities an attractive option. Focal cryotherapy for localized unilateral disease offers the added benefit of minimal morbidities. In renal cancer, owing to the increasing utilization of cross-sectional imaging, nearly 70% of newly detected renal masses are stage T1a, making them more susceptible to minimally invasive nephron-sparing therapies including laparoscopic and robotic partial nephrectomy and ablative therapies. This article reviews the various outcomes of cryotherapy compared with other treatments and the possible uses of cryotherapy in surgery.

Robot-Assisted Radical Cystectomy with Total Intracorporeal Urinary Diversion: Comparative Analysis with Extracorporeal Urinary Diversion.

PURPOSE To compare the perioperative outcomes, postoperative complications, and early oncologic outcomes of intracorporeal urinary diversion (ICUD) with those of extracorporeal urinary diversion (ECUD) following robot-assisted radical cystectomy (RARC) performed by a single surgeon at a tertiary referral hospital. MATERIALS AND METHODS We reviewed a prospectively maintained, institutional review board-approved database of 70 patients treated with RARC and pelvic lymph node (LN) dissection for bladder cancer performed from 2007 through 2014. Data were collected for 64 patients who underwent either ICUD or ECUD. RESULTS Thirty-eight patients underwent ECUD, and the remaining 26 underwent ICUD. Urinary diversion was performed extracorporeally in the first 37 cases and performed intracorporeally thereafter. There were no significant differences in patient characteristics between the ECUD and ICUD groups. Mean total operative time was 468 minutes for ECUD and 581 minutes for ICUD (P < .05). Mean estimated blood loss was 265 and 148 mL, respectively (P < .05). Minor and total complication rates for patients with the ECUD were higher than in patients with the ICUD (minor: 47.4% vs. 15.4%; total: 57.9% vs. 30.8%; P < .05). All patients showed negative surgical margin, while 21% in the ECUD group and 26.9% in the ICUD group had pathologic stage T3 or T4 (P > .05). The mean LN yield was 23.2 and 31.8, respectively (P < .05). CONCLUSIONS From our experience, the results show that ICUD after RARC can be successful, with the benefits of decreased blood loss and lower transfusion and complication rates than ECUD. A larger series and long-term follow-up data will be necessary to support our results.

Concurrent and predictive validation of robotic simulator Tube 3 module

Purpose We previously described a new procedure specific module (Tube 3) to allow the practice of vesicourethral anastomosis after robot-assisted radical prostatectomy. Herein, we report a predetermined proficiency level of Tube 3 and preliminary validation to explore whether this new module can lead to performance improvement in the da Vinci system. Materials and Methods Eight urology residents and three urology fellows performed the Tube 3 module 1 hour daily for 7 days. The learning curve was depicted through a scatterplot and the stable point was identified through the cumulative sum chart. Concurrent and predictive validations were performed with the da Vinci system. The mean time to complete the task and end product rating score between Tube 3 training group and no Tube 3 training group were compared. Results Concerning the learning curve, about 41 repetitions comprising about 5 hours were needed to achieve this stable point when the mean time to complete Tube of 384 seconds was set as a target. With regarding to the concurrent and predictive validation, there significant differences were evident in the mean time to complete 16 needle passages and the vesicourethral anastomosis and the end product rating score. Conclusions The virtual reality (VR) simulator can yield sufficient improvement in technical performance in Tube 3 within 5 hours. The acquired proficiency can be transferable to the vesicourethral anastomosis using the da Vinci system.

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.

Standardized analysis of complications after robot-assisted radical cystectomy: Korea University Hospital experience

Purpose To analyze the complications after robot-assisted radical cystectomy (RARC) by use of a standardized reporting methodology by a single surgeon. Materials and Methods We prospectively reviewed a maintained institutional database of 52 patients who underwent RARC to manage bladder cancer and were followed up in 3 months by a single surgeon at Korea University Medical Center from 2007 through 2014. All complications within 90 days of surgery were defined and categorized into 5 grades according to the Clavien-Dindo classification. Logistic regression analysis was used to identify predictors of complications. Results Fifty percent of patients (26 of 52) experienced a complication of any grade <90 days after surgery, and 11 patients (21.2%) experienced a major complication. Complications were grouped in systems-based categories. Fifty complications occurred in 52 patients and hematologic complication (transfusion) was the most common (13 of 52). Wound dehiscence, anastomotic leakage, urinary tract obstruction, mechanical obstruction, and thromboembolism occurred as major complications. Mean estimated blood loss (EBL) was 247 mL and mean total operative time was 496 minutes. The mean number of lymph nodes harvested was 24.6, with 30.5 for extended dissection. EBL (over 300 mL), operative time, and method of urinary diversion were significant negative predictors of minor complications, whereas EBL (over 300 mL) was a significant negative predictor of major complications (p<0.05). Conclusions The present results show that the complication rate reported by use of a standardized methodology after robotic radical cystectomy is still considerable although comparable to that of contemporary robot series. EBL, operative time, and diversion methods were predictors of complications.

Decision Based on Narrow Band Imaging Cystoscopy without a Referential Normal Standard Rather Increases Unnecessary Biopsy in Detection of Recurrent Bladder Urothelial Carcinoma Early after Intravesical Instillation

Purpose The purpose of this study was to calculate the operating characteristics of narrowband imaging (NBI) cystoscopy versus traditional white light cystoscopy (WLC) in common clinical scenarios involving suspicion of bladder urothelial carcinoma (UC). Materials and Methods Sixty-three consecutive patients initially underwent WLC and then NBI in a single session for evaluation of microscopic hematuria (group I, n=20), gross hematuria (group II, n=19), and follow-up for prior UC (group III, n=24), by an experienced urologist. All lesions that were abnormal in contrast with adjacent normal mucosa were diagnosed as positive and biopsied. Results Sixty-six biopsies from 47 patients were performed. Pathologic examination showed 17 cases of UC from 21 sites. While the overall sensitivity of NBI was similar to that of WLC (100% vs. 94.1%), the specificity of NBI was significantly lower than that of WLC (50% vs. 86.9%, p < 0.001), particularly in group III (38.9% vs. 88.9%, p=0.004). Based on identification by NBI only, 23 additional biopsies from 18 cases were performed for identification of one patient with UC, who belonged to group III. In this group, to identify this specific patient, 15 additional biopsies were performed from 10 patients. All seven cases with positive findings from NBI within 2 months after the last intravesical therapy were histologically proven as negative. Conclusion In evaluation for recurrence early after intravesical instillation, the decision based on NBI increased unnecessary biopsy in the absence of an established standard for judging NBI.

Tumor-Specific Immunity Induced by Cryoablation in a Murine Renal Cell Carcinoma Model

Purpose To evaluate tumor-specific immunity and define the mechanisms involved in the cryoimmunologic response, we compared the tumor control efficacy and immunologic responses of cryoablation with those of surgical excision in a tumor rechallenge model. Materials and Methods Sixty BALB/c mice with RENCA tumors that were generated in the left flank area underwent cryoablation or radical excision. The mice successfully treated were rechallenged with RENCA or an undifferentiated colon carcinoma cell line, CT26, in the contralateral right flank area. The recurrence rate after tumor rechallenge in each group was then observed. To assess the immunologic response of each treatment modality, fluorescent-activated cell sorting (FACS) analysis and a cytotoxicity assay using 51Cr release were performed. Results After reinoculation of the RENCA cells, the rate of tumor growth was significantly higher in the surgical excision group than in the cryoablation group (94.4% vs. 11.1%, p=0.001). In the cryoablation group, the tumor growth rate was significantly increased after rechallenge of CT26 cells compared with RENCA (94.1% vs. 11.1%, p=0.001). The cryoablation group showed an elevated CD3, CD4, CD8 T, and natural killer cell count in the FACS analysis and also showed significantly increased cytotoxicity in the 51Cr release assay compared with the excision group. Conclusions These results showed that cryoablation, compared to surgical resection, was more effective in preventing tumor growth after rechallenge with RENCA cells and that this response was tumor-specific, because the CT26 cells did not have the same effect.

Characteristics of Prostate Cancer by Opportunistic Screening in Korean Men with a Prostate-Specific Antigen Level Less Than 4.0 ng per Milliliter

Background/Aims/Objectives: We studied the detection rate of prostate cancer (PCa) among Korean men with a prostate-specific antigen (PSA) level of less than 4.0 ng/mL. Methods: A total of 1,680 men with PSA ≤4 ng/mL had a prostate biopsy from January 2004 to December 2014. The differences in clinical factors were analyzed and their independent predictive implications were evaluated. Results: PCa was diagnosed in 331 (19.6%) and 99 of these 331 cancers (14.9%) had a Gleason score of 7 or higher. The detection rate of PCa increased from 6.67% (≤0.5 ng/mL) to 20.36% (3.01-3.9 ng/mL). There were significant differences in age 65.7 vs. 62.1 years, prostate volume 33.4 vs. 38.2 g, PSA density 0.10 vs. 0.08 ng/mL/mL between men with and without PCa. On multivariable analysis, age and prostate volume were the best independent discriminative parameters. When comparing PCa patients with a Gleason score less than 6 to those with a 7 or higher, patients with a Gleason score 7 or higher were older (67.2 vs. 64.8 years). Conclusions: Even when the PSA level is less than 4 ng/mL, PCas, including high-grade cancers, were detected in a significant number of men. In this group, patients with PCa were older and had a smaller prostate volume and high-grade cancers were detected more frequently in older cancer patients.

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.