Young Goo Lee

Robot-Assisted Radical Cystectomy and Pelvic Lymph Node Dissection: A Multi-Institutional Study from Korea

PURPOSE To report short-term retrospective perioperative and pathologic outcomes of the first robot-assisted radical cystectomy (RARC) series in Korea. PATIENTS AND METHODS Between April 2007 and August 2009, 104 nonconsecutive patients, including 22 women, underwent RARC across seven institutions. We evaluated the outcomes in these cases, including operative variables, hospital recovery, pathologic outcomes, and complication rate. RESULTS The mean age of all patients was 63.6 years (range 39-82 years), and the mean body mass index was 23.6 kg/m(2) (range 16.0-31.8 kg/m(2)). Among the 104 patients, 60 had an ileal conduit and 44 had an orthotopic neobladder. The mean total operative time was 554 minutes, and the mean blood loss was 526 mL. The time to flatus and bowel movement was about 3 days, and the time until hospital discharge was about 18 days. The mean number of lymph nodes removed were 18, and 10 patients had node metastatic disease on final pathologic evaluation. Postoperative complications occurred in 28 (26.9%) patients. CONCLUSIONS Our initial experience with RARC appears to be favorable with acceptable operative, pathologic, and short-term clinical outcomes. The current series suggests that RARC is becoming more prevalent, not only in Western countries, but also in Asian countries, just as robot-assisted radical prostatectomy has also gained widespread acceptance. Data from long-term, large, prospective, multicenter, ideally randomized comparative studies with open radical cystectomy are needed to confirm the outcome of the novel operation reported here.

Primary Malignant Melanoma of the Female Urethra

We report here on a rare case of primary malignant melanoma of the female urethra. A 69-year-old female presented at our hospital with a several month history of dysuria, poor stream, gross hematuria, intermittent blood spots, and a painful mass at the external urethral meatus. The physical examination revealed a soft, small, chestnut-sized lesion through the urethral orifice. The mass was tan colored, ulcerated, covered with necrotic tissue, and protruded from the external urethral meatus. The mass was removed by wide local excision under spinal anesthesia. The pathological diagnosis was malignant melanoma of the urethra. Computed tomography of the abdomen as well as a whole-body bone scan showed no evidence of metastasis. The patient has been free of disease for 6 months postoperatively. We discuss the clinicopathologic features and treatment of this tumor.

Histologic type, staging, and distribution of germ cell tumors in Korean adults

OBJECTIVES To investigate the presentation of germ cell tumors (GCT) in terms of histology and stage, to better clarify the epidemiology of this disease in eastern Asia. METHODS Six hundred ninety-eight patients diagnosed with GCT between 1995 and 2004 were analyzed. Clinical parameters at the time of initial diagnosis were classified in terms of the American Joint Committee on Cancer (AJCC) tumor, nodes, metastasis staging (TNMS) system, the International Germ Cell Cancer Collaborative Classification (IGCCC), for high-risk stage I nonseminomatous GCT (NSGCT) of testis. RESULTS The anatomic distributions for the primary sites of the observed tumors were as follows: testis 471 cases (67%); central nervous system (CNS) 137 cases (20%); mediastinum 78 cases (11%), and retroperitoneum 12 cases (2%); 239 (51%) of 471 tumors with testicular primary were seminoma. High risk vs. non-high risk stage I NSGCT cases were 62 vs. 58. Of NSGCT of testis, 129 (58%), 73 (33%), and 21 (9%) of tumors presented with good, intermediate, and poor prognosis, respectively, based on IGCCC, whereas 231 (99%) patients were classified with a good prognosis and 3 (1%) with an intermediate prognosis amongst seminomas of testis; 193 (82%) cases presented as stage I testicular seminoma whereas 120 (54%) cases presented as stage I NSGCT. CONCLUSIONS Extragonadal primary GCTs are very common in Korean. Incidence of high risk NSGCT of testis with stage I disease was lower than in the Western report. NSGCT presents itself as a more aggressive form whereas seminoma is a very indolent tumor when compared with cases in Western countries.

Mirabegron as a treatment for overactive bladder symptoms in men (MIRACLE study): Efficacy and safety results from a multicenter, randomized, double-blind, placebo-controlled, parallel comparison phase IV study

To evaluate the efficacy and safety of mirabegron in males with overactive bladder (OAB) symptoms.

The association between an abnormal post-voiding urine volume and a lower estimated glomerular filtration rate in patients with type 2 diabetes with no voiding symptoms

Background/Aims Diabetic cystopathy is a frequent complication of diabetes mellitus. This study assessed the association between the post-voiding residual (PVR) urine volume and diabetic nephropathy in type 2 diabetics with no voiding symptoms. Methods This study investigated 42 patients with type 2 diabetes who were followed regularly at our outpatient clinic between July 1, 2008 and June 30, 2009. No patient had voiding problems or International Prostate Symptom Scores (IPSSs) ≥ 12. An urologist performed the urological evaluations and the PVR was measured using a bladder scan. A PVR > 50 mL on two consecutive voids was considered abnormal, which was the primary study outcome. Results The mean patient age was 60 ± 10 years; the IPSS score was 3.7 ± 3.3; and the diabetes duration was 11.9 ± 7.8 years. Seven of the 42 patients (16.7%) had a PVR > 50 mL. The presence of overt proteinuria or microalbuminuria was associated with an increased risk of a PVR > 50 mL (p < 0.01). Patients with a PVR > 50 mL had a significantly lower estimated glomerular filtration rate (eGFR) compared with those with a PVR ≤ 50 mL (59.2 ± 27.1 mL/min/1.73 m2 vs. 28.7 ± 23.3 mL/min/1.73 m2; p < 0.001). Multivariate logistic analysis revealed that a lower eGFR (odds ratio, 0.94; 95% confidence interval, 0.88 to 0.99; p = 0.04) was a significant risk factor for a PVR > 50 mL. Conclusions Patients with diabetic nephropathy had a significantly higher PVR and a lower eGFR was associated with an abnormal PVR.

Do patients benefit from total intracorporeal robotic radical cystectomy

Ji Sung Shim1 , Tae Gyun Kwon2 , Koon Ho Rha3 , Young Goo Lee , Ji Youl Lee , Byong Chang Jeong , Jong Hyun Pyun , Sung Gu Kang1 , Seok Ho Kang1 Department of Urology, Korea University College of Medicine, Seoul, Department of Urology, Kyungpook National University College of Medicine, Daegu, Department of Urology, Yonsei University College of Medicine, Seoul, Department of Urology, Hallym University Kangnam Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Department of Urology, The Catholic University of Korea College of Medicine, Seoul, Department of Urology, Sungkyunkwan University College of Medicine, Seoul, Korea

MP27-07 CAN WE PREDICT THE LEARNING CURVE FOR HOLMIUM LASER ENUCLEATION OF THE PROSTATE (HOLEP) BY USING SIMULTANEOUS PARAMETER OF ENUCLEATION-MORCELLATION?

INTRODUCTION AND OBJECTIVES: Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive laser therapy for benign prostatic hyperplasia. However, a steep operative learning curve may be the main drawback to use of HoLEP. The enucleation ratio or efficacy were known as one of the parameters for estimating the learning curve. But this parameter is only focused on time of enucleation not considering morcellation, even though operators spend time of enucleation and morcellation simultaneously during HoLEP surgery. The aim of this study was to evaluate a various method to assess the learning curve of HoLEP of a single surgeon. METHODS: Ninety-two consecutive cases performed by the single surgeon were enrolled. Intraoperative measures, including enucleation time, enucleation ratio (enucleated weight/transitional zone volume), enucleation efficacy (enucleated weight / enucleation time), consumed energy, morcellation time, morcellation efficacy (enucleated weight / morcellation time) and enucleationmorcellation efficacy (enucleated weight/enucleation and morcellation time) were analyzed. Perioperative morbidity, length of hospital stay and length of urinary drainage were also investigated. In addition, functional outcomes such as Qmax, post-void residual volume, IPSS and QoL scores at 3 and 6months were also investigated. RESULTS: The mean age of the patients was 72.9 years (49-86) with a mean prostate volume of 59.2 cc (34-180) on transrectal ultrasonography. Within all procedures, mean total operative time was 86.5 minutes (45-260 minutes) with a mean enucleated weight of 42.2 g (25-120 g). Mean enucleation time, consumed energy, morcellation time and enucleation ratio were 48.9 12.1 min, 67.5 22.8 kJ, 22.4 14.5 min and 0.64 0.32 g/mL, respectively. In terms of efficiency, enucleation efficacy, morcellation efficacy and enucleation-morcellation efficacy were 0.42 0.37 g/min, 4.24 1.26 g/min and 0.24 0.11 g/min, respectively. Perioperative complications were observed in 12 of 92 (13.0%). Of these, 10 were urinary tract infection and 2 was urethral stricture. Considering the learning curve, the plateau of enucleation efficacy was reached after 38 cases. However, considering enucleation and morcellation time simultaneously, enucleationmorcellation efficacy has an increasing trend even after 38 cases and has remained roughly constant after 55 cases. Based on these criteria, we divided cases into two groups. Enucleation efficiency was significantly higher after 38 cases. Morcellation efficiency was also higher in the second group, however, the difference was not significant. Enucleation-morcellation efficiency was significantly higher after 55 cases. Perioperative morbidities, hospital length of stay, urinary drainage length and functional outcomes at 3 and 6months were not significantly different between the groups based on these criteria. CONCLUSIONS: Although the learning curve did not interfere with functional results, our results demonstrated that even after 38 cases, surgical skill advances are still needed. Of these factors, morcellation time is as important as enucleation time in the whole surgical procedure. Enucleation-morcellation efficacy might be considered a better parameter for estimating the operative learning curve of HoLEP rather than enucleation efficacy alone.

Acid-base disorders after orthotopic bladder replacement: comparison of an ileal neobladder and an ileal conduit

Abstract Objectives: For many years, creation of an orthotopic neobladder after cystectomy has been popular. In the present study, we measured the extent of metabolic acidosis in patients with ileal neobladders compared with ileal conduits and defined risk factors for development of metabolic acidosis. Methods: We retrospectively studied 95 patients, who underwent radical cystectomy and urinary diversion to treat invasive bladder cancer from January 2001 to December 2014 at Hallym University Kangnam Sacred Heart Hospital, through investigation of acid-base balance, serum electrolyte levels and renal function one month and one year after operation. Results: One month after the operation, metabolic acidosis was found from 18 patients (31.0%) in an ileal neobladder group and from 4 (14.8%) in an ileal conduits group. One year after the operation, the numbers became 11 (22.9%) and 2 (10.0%), respectively. However, there was not a statistical difference. The blood biochemical profiles of the two groups did not differ significantly after urinary diversion. Logistic analysis revealed that lower estimated glomerular filtration rate (eGFR) was associated with metabolic acidosis at one month (odds ratio, OR = 0.94 [0.91–0.97]; p < 0.001) and one year (OR = 0.94 [0.92–0.97]; P = 0.001) after urinary diversion. In multivariate analysis, lower eGFR is a significant risk factor for metabolic acidosis at one month. Conclusions: Patients with ileal neobladders and conduits are at the similar risk of metabolic acidosis. A close association between renal function and development of metabolic acidosis was observed, especially stronger in an early period after operation.

Oncologic Outcomes and Predictive Factors for Recurrence Following Robot-Assisted Radical Cystectomy for Urothelial Carcinoma: Multicenter Study from Korea

The aim of our study was to evaluate intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns in a multicenter series of patients treated with robot-assisted radical cystectomy (RARC) for urothelial carcinoma (UC) of the bladder. Between 2007 and 2015, 346 patients underwent RARC at multiple tertiary referral centers in Korea. Descriptive statistics were used for demographics and perioperative variables. Survival and recurrence were estimated with Kaplan-Meier analysis. Logistic regression models were used to determine predictors of recurrence. Median follow-up was 33 months (interquartile range [IQR], 7–50). The numbers of patients with organ-confined and lymph node (LN)-positive disease were 237 (68.4%) and 68 (19.7%), respectively. LN density (1–20 vs. > 20) was 13.6% and 6.1%, with a median of 17 nodes removed (IQR, 9–23). In logistic regression analysis, type of LN dissection, and pathologic tumor stage were significant predictors of cancer recurrence and death from cancer. Local, distal recurrence and secondary UC occurred in 7 (2.0%), 53 (15.3%), and 4 (1.2%) patients, respectively. The 5-year overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were 78%, 84%, and 73%, respectively. At last follow-up, RFS for extended pelvic LN dissection vs. standard pelvic LN dissection was 70% and 47% (P = 0.038). In addition, at last follow-up, LN density (0 vs. 1–20 vs. over 20) was 67%, 41%, and 29%, respectively (P < 0.001). Patients undergoing RARC in this multi-institutional cohort demonstrated intermediate-term oncologic outcomes, predictive factors for recurrence, and recurrence patterns that were not unusual.

A sequential comparison of postoperative voiding function between two different transobturator sling procedures

INTRODUCTION We evaluated sequential postoperative voiding function of two types of sling procedures (Monarc® and ALIGN®) in patients with stress urinary incontinence. METHODS Ninety-one women diagnosed with urodynamic stress incontinence were randomly assigned to the study. All enrolled patients underwent Monarc or ALIGN procedure. They were postoperatively evaluated at one day, one week, one month, three months, 12 months, and 24 months. The voiding function was evaluated with uroflowmetry and post-void residual urine. Patients were asked if voiding had changed after surgery and had to complete the incontinence quality of life scale (I-QoL) questionnaire at 12 months. RESULTS The Monarc (n=47) and ALIGN (n=44) groups had similar demographic characteristics. The maximal flow rate (Qmax) was significantly decreased on the first day after surgery and gradually increased during the following weeks. Comparing the two groups at one week, the ALIGN group had a significantly decreased Qmax than the Monarc group (17.6 ± 5.2 vs. 20.7 ± 5.0; p=0.004). However, at one, three, 12, and 24 months, there were no significant differences between the two groups. CONCLUSIONS This study demonstrated that an absorbable tensioning suture in the Monarc mesh could increase Qmax compared to ALIGN at one week after surgery. An absorbable tensioning suture may reduce the risk of an early postoperative voiding dysfunction compared to other meshes that do not have this.