Wan Song

Comparison of Perioperative Outcomes of Robotic Versus Laparoscopic Partial Nephrectomy for Complex Renal Tumors (RENAL Nephrometry Score of 7 or Higher)

Purpose To compare the perioperative outcomes of laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy (RPN) for moderately or highly complex tumors (RENAL nephrometry score≥7). Materials and Methods A retrospective analysis was performed for 127 consecutive patients who underwent either LPN (n=38) or RPN (n=89) between 2007 and 2013. Perioperative outcomes were compared. Results There were no significant differences between the two groups with respect to patient gender, laterality, RENAL nephrometry score, or body mass index. The RPN group had a slightly higher RENAL nephrometry score (7.8 vs. 7.5, p=0.061) and larger tumor size (3.0 cm vs. 2.5 cm, p=0.044) but had a lower Charlson comorbidity index (3.7 vs. 4.4, p=0.017) than did the LPN group. There were no significant differences with respect to warm ischemia time, estimated blood loss, intraoperative complications, or operative time. Only one patient who underwent LPN had a positive surgical margin. There were statistically significant differences in surgical marginal width between the LPN and RPN groups (0.6 cm vs. 0.4 cm, p=0.001). No significant differences in postoperative complications were found between the two groups. Owing to potential baseline differences between the two groups, we performed a propensity-based matching analysis, in which differences in surgical margin width between the LPN and RPN groups remained statistically significant (0.6 cm vs. 0.4 cm, p=0.029). Conclusions RPN provides perioperative outcomes comparable to those of LPN and has the advantage of healthy parenchymal preservation for complex renal tumors (RENAL score≥7).

Incidence of kidney, bladder, and prostate cancers in Korea: An update.

The incidence of cancer is sharply increasing. Cancer is a leading cause of death as well as a significant burden on society. The incidence of urological cancer has shown a higher than average increase and will become an important concern in the future. Therefore, an overall and accurate understanding of the incidence of urological cancer is essential. In this study, which was based on the Korea National Cancer Incidence Database, annual incident cases, age-standardized incidence rates, annual percentage change (APC), and distribution by age group were examined in kidney, bladder, and prostate cancers, respectively. From 1999 to 2011, the total number of each type of urological cancer was as follows: kidney cancer (32,600 cases, 25.5%), bladder cancer (37,950 cases, 29.7%), and prostate cancer (57,332 cases, 44.8%). The age-standardized incidence rates of prostate cancer showed a significant increase with an APC of 12.3% in males. Kidney cancer gradually increased with an APC of 6.0% for both sexes and became the second most frequent urological cancer after 2008. Bladder cancer showed no significant change with an APC of -0.2% for both sexes and has decreased slightly since 2007. The distribution of kidney cancer according to age showed two peaks in the 50- to 54-year-old and 65- to 69-year-old age groups. Bladder and prostate cancers occurred mostly in the 70- to 74-year-old age group. The proportions of male to female were 2.5:1 in kidney cancer and 5.6:1 in bladder cancer. We have summarized the incidence trends of kidney, bladder, and prostate cancers and have provided useful information for screening and management of these cancers in the future.

High-Intensity Focused Ultrasound as Salvage Therapy for Patients With Recurrent Prostate Cancer After Radiotherapy

Purpose To evaluate the oncologic outcomes and postoperative complications of high-intensity focused ultrasound (HIFU) as a salvage therapy after external-beam radiotherapy (EBRT) failure in patients with prostate cancer. Materials and Methods Between February 2002 and August 2010, we retrospectively reviewed the medical records of all patients who underwent salvage HIFU for transrectal ultrasound-guided, biopsy-proven locally recurred prostate cancer after EBRT failure (by ASTRO definition: prostate-specific antigen [PSA] failure after three consecutive PSA increases after a nadir, with the date of failure as the point halfway between the nadir date and the first increase or any increase great enough to provoke initiation of therapy). All patients underwent prostate magnetic resonance imaging and bone scintigraphy and had no evidence of distant metastasis. Biochemical recurrence (BCR) was defined according to the Stuttgart definition (PSA nadir plus 1.2 ng/mL). Results A total of 13 patients with a median age of 68 years (range, 60-76 years) were included. The median pre-EBRT PSA was 21.12 ng/mL, the pre-HIFU PSA was 4.63 ng/mL, and the period of salvage HIFU after EBRT was 32.7 months. The median follow-up after salvage HIFU was 44.5 months. The overall BCR-free rate was 53.8%. In the univariate analysis, predictive factors for BCR after salvage HIFU were higher pre-EBRT PSA (p=0.037), pre-HIFU PSA (p=0.015), and short time to nadir (p=0.036). In the multivariate analysis, there were no significant predictive factors for BCR. The complication rate requiring intervention was 38.5%. Conclusions Salvage HIFU for prostate cancer provides effective oncologic outcomes for local recurrence after EBRT failure. However, salvage HIFU had a relatively high rate of complications.

Incidence and management of extended-spectrum beta-lactamase and quinolone-resistant Escherichia coli infections after prostate biopsy.

OBJECTIVE To provide an overview of the incidence, bacteriologic characteristics, and antimicrobial resistance in acute prostatitis after transrectal ultrasonography (TRUS)-guided prostate biopsy. MATERIALS AND METHODS We reviewed the medical records of 9568 patients who underwent TRUS-guided biopsy between March 1995 and May 2013. These patients received oral quinolone and/or cephalosporin and intramuscular aminoglycoside as antibiotic prophylaxis. In patients with acute prostatitis, blood and urine cultures were obtained on hospital admission. The incidences of acute prostatitis and antimicrobial resistance were examined according to time period. RESULTS A total of 11,345 cases of TRUS-guided biopsy were performed for 9568 patients. Acute prostatitis developed in 103 patients (0.91%). In 63 patients, the causative organism was isolated from blood and/or urine culture. The most frequent etiologic organism was Escherichia coli, which was present in 47 of 49 patients (95.9%) in blood and from 39 of 41 patients (95.1%) in urine. Extended-spectrum beta-lactamase (ESBL)-producing E coli were detected continuously since 2008 and found in 10 patients (21.3%) in blood and 8 patients (20.5%) in urine. Forty-four patients (93.6%) in blood and 36 patients (92.3%) in urine of the positive cultures and all cases with ESBL-producing E coli infection showed resistance to quinolone. ESBL-producing E coli were susceptible to imipenem, amikacin, and cefoxitin. CONCLUSION In the treatment of acute prostatitis after TRUS-guided biopsy, quinolone is not an effective antimicrobial of choice. We should take into account antimicrobial-resistant patterns because of the high prevalence of quinolone resistance and emergence of an ESBL-producing strain.

Multiple cores of high grade prostatic intraepithelial neoplasia and any core of atypia on first biopsy are significant predictor for cancer detection at a repeat biopsy

Purpose To investigate the differences in the cancer detection rate and pathological findings on a second prostate biopsy according to benign diagnosis, high-grade prostatic intraepithelial neoplasia (HGPIN), and atypical small acinar proliferation (ASAP) on first biopsy. Materials and Methods We retrospectively reviewed the records of 1,323 patients who underwent a second prostate biopsy between March 1995 and November 2012. We divided the patients into three groups according to the pathologic findings on the first biopsy (benign diagnosis, HGPIN, and ASAP). We compared the cancer detection rate and Gleason scores on second biopsy and the unfavorable disease rate after radical prostatectomy among the three groups. Results A total of 214 patients (16.2%) were diagnosed with prostate cancer on a second biopsy. The rate of cancer detection was 14.6% in the benign diagnosis group, 22.1% in the HGPIN group, and 32.1% in the ASAP group, respectively (p<0.001). When patients were divided into subgroups according to the number of positive cores, the rate of cancer detection was 16.7%, 30.5%, 31.0%, and 36.4% in patients with a single core of HGPIN, more than one core of HGPIN, a single core of ASAP, and more than one core of ASAP, respectively. There were no significant differences in Gleason scores on second biopsy (p=0.324) or in the unfavorable disease rate after radical prostatectomy among the three groups (benign diagnosis vs. HGPIN, p=0.857, and benign diagnosis vs. ASAP, p=0.957, respectively). Conclusions Patients with multiple cores of HGPIN or any core number of ASAP on a first biopsy had a significantly higher cancer detection rate on a second biopsy. Repeat biopsy should be considered and not be delayed in those patients.

Prognostic factors after salvage radiotherapy alone in patients with biochemical recurrence after radical prostatectomy

To evaluate the oncological outcome and to assess prognostic factors of salvage radiotherapy alone in patients with biochemical recurrence after radical prostatectomy.

Impact of preoperative and postoperative membranous urethral length measured by 3 Tesla magnetic resonance imaging on urinary continence recovery after robotic-assisted radical prostatectomy

INTRODUCTION We sought to investigate the impact of preoperative and postoperative membranous urethral length (MUL) on urinary continence using 3 Tesla (3T) magnetic resonance imaging (MRI) after robotic-assisted radical prostatectomy (RARP). METHODS Between 2008 and 2013, 190 men with RARP underwent preoperative and postoperative MRI. Patients who received adjuvant radiotherapy or who were lost to followup were excluded, leaving 186 patients eligible for analysis. Preoperative MUL was estimated from the prostate apex to the penile bulb, while postoperative MUL was estimated from the bladder neck to penile bulb. Patients with no pads or protection were considered to have complete continence. Logistic regression analysis was used to identify predictors associated with urinary incontinence at six and 12 months. RESULTS Age was commonly associated with urinary incontinence at six and 12 months. In addition, diabetes mellitus (DM) was another factor associated with urinary incontinence at 12 months. When adjusting these variables, preoperative MUL ≤16 mm (95% confidence interval [CI] 1.01-1.14; p=0.022), postoperative MUL ≤14 mm (95% CI 1.16-9.80; p=0.025) and percent change of MUL >18% (95% CI 1.17-7.23; p=0.021) were significantly associated with urinary incontinence at six months. However, at 12 months, preoperative MUL ≤13.5 mm (95% CI 1.85-19.21; p=0.003) and postoperative MUL ≤13 mm (95% CI 1.24-13.84; p=0.021) had impacts on urinary incontinence, but not percent change of MUL. CONCLUSIONS Preoperative and postoperative MUL were significantly associated with urinary continence recovery after RARP. Therefore, efforts to preserve MUL are highly recommended during surgery for optimal continence outcomes after RARP.

Location of positive surgical margin and its association with biochemical recurrence rate do not differ significantly in four different types of radical prostatectomy.

Purpose To analyze the location of the positive surgical margin (PSM) and its association with the biochemical recurrence (BCR) rate in cases of radical prostatectomy (RP) according to the type of surgery. Materials and Methods We retrospectively analyzed 1,880 cases of RP. Baseline characteristics were analyzed. Locations of the PSM were recorded in the four surgery groups as apex, anterior, posterolateral, and base and were analyzed by using chi-square test. The association of the location of the PSM with the BCR rate was analyzed by using Kaplan-Meier survival analysis according to the type of surgery, which included radical perineal prostatectomy (RPP, n=633), radical retroperitoneal prostatectomy (RRP, n=309), laparoscopic radical prostatectomy (LRP, n=164), and robot-assisted laparoscopic radical prostatectomy (RALRP, n=774). Results A PSM was found in a total of 336 cases (18%): 122 cases of RPP (18%), 67 cases of RRP (17%), 29 cases of LRP (17%), and 119 cases of RALRP (15%). The PSM rate did not differ significantly by surgical type (p=0.142). The location of the PSM was the apex in 136 cases (7.2%), anterior in 67 cases (3.5%), posterolateral in 139 cases (7.3%), and base in 95 cases (5.0%), and showed no significant difference according to surgical type (p=0.536, p=0.557, p=0.062, and p=0.109, respectively). The BCR rate according to the location of the PSM did not differ significantly for the four types of surgery (p=0.694, p=0.301, p=0.445, and p=0.309 for RPP, RRP, LRP, and RALRP, respectively). Conclusions The location of the PSM seemed to be unrelated to type of RP. There was no significant correlation between the BCR rate and the location of the PSM for any of the RP types.

Comparison of Oncologic Outcomes and Complications According to Surgical Approach to Radical Prostatectomy: Special Focus on the Perineal Approach

Introduction The objective of the study was to compare oncologic outcomes and complications in patients with prostate cancer who underwent radical perineal prostatectomy (RPP), radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), or robotic‐assisted radical prostatectomy (RARP). Materials and Methods We retrospectively reviewed 2617 patients who underwent RPP (n = 673), RRP (n = 396), LRP (n = 223), or RARP (n = 1325) between 1995 and 2013. Clinicopathological outcomes were compared according to surgical approach. Kaplan–Meier and Cox regression analyses were carried out to assess oncologic outcomes. Complications were stratified according to the Clavien classification system. Results The 5‐year biochemical recurrence (BCR)‐free survival after RPP was 75.3%, which was higher than for RRP (71.4%; P = .007) and comparable with LRP (76.1%; P = .666) and RARP (75.3%; P = .898). In multivariate analysis, RPP was comparable with LRP (P = .591) and RARP (P = .089) whereas RRP was associated with increased BCR (P < .001). No significant difference was seen in 5‐year cancer‐specific survival (RPP, 99.0%; RRP, 98.7%; LRP, 100.0%; and RARP, 99.8%; P = .071). The 5‐year overall survival after RPP was 97.0%, which was lower than for RARP (99.6%; P = .007), but comparable with RRP (96.2%; P = .792) and LRP (99.1%; P = .606). Overall complication rates were 25.1% for RPP, 36.4% for RRP, 16.1% for LRP, and 9.4% for RARP (P < .001), respectively. After RPP, wound dehiscence (10.3%) was the most common complication. However, approximately 75% of complications were minor. Conclusion RPP showed acceptable oncologic outcomes compared with other surgical approaches. Careful attention is required to prevent wound dehiscence. Micro‐Abstract We compared oncologic outcomes and complications in patients with prostate cancer after different surgical approaches. After retrospective analysis of 2617 patients, radical perineal prostatectomy (RPP) showed acceptable biochemical recurrence‐free survival, cancer‐specific survival, and overall survival compared with other surgical approaches. After RPP, approximately 75% of complications were Grade I or II. However, careful attention is required to prevent wound dehiscence.

Refining the American Urological Association and American Society for Radiation Oncology guideline for adjuvant radiotherapy after radical prostatectomy using the pathologic Gleason score.

Recently, it has been suggested that the guideline for adjuvant radiotherapy (ART) following radical prostatectomy (RP) sponsored by the American Urological Association and American Society for Radiation Oncology (AUA/ASTRO) may result in a significant overtreatment. Thus, the objective of the present study was to refine the AUA/ASTRO guideline for ART in patients at risk for biochemical recurrence (BCR) after RP. To this end, we reviewed our prospectively maintained database and selected 193 patients who met the AUA/ASTRO ART criteria. With a median follow-up of 24.0 months, BCR rate was 17.6% (34/193). When stratified by the Gleason score, BCR rate in men with Gleason score 6 was 6.8%. There was no significant association between BCR-free survival and surgical margin (P = 0.690) and pathologic stage (P = 0.353) in patients with the Gleason score 6. However, in patients with positive surgical margins (PSMs)/pathologic stage ≥T3, there was a significant difference in BCR-free survival according to Gleason score (≤ 7 vs 8-10, P = 0.047). Multivariate Cox regression analysis demonstrated that pathologic stage ≥T3 (HR = 2.106; P= 0.018), PSMs (HR = 2.411; P= 0.003), and pathologic Gleason score 8-10 (HR = 4.715; P< 0.001) were independent predictors of BCR after RP. Therefore, in addition to pathologic stage ≥T3 and PSMs, Gleason score 8-10 predicts BCR after RP. In patients with Gleason score 6, observation rather than ART may be more appropriate regardless of stage and surgical margin status.