Evaluation of histological variants of upper tract urothelial carcinoma as prognostic factor after radical nephroureterectomy.

PURPOSE: To evaluate the impact of variant histology on patients with upper tract urothelial carcinoma (UTUC) survival outcomes. MATERIALS AND METHODS: A total of 519 patients underwent radical nephroureterectomy without neoadjuvant therapy for UTUC at a single institution between May 2003 and December 2019. Multivariate Cox regression analysis evaluated the impact of variant histology on progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS: Among 84 patients (16.2%) with variant histology, the most frequent variant type was squamous cell differentiation (64.3%), followed by glandular differentiation (25.0%) and sarcomatoid variant (2.4%). They showed pathologically advanced T stage (for ≥ T3, 59.5% vs 33.3%, p < 0.001), higher tumor grade (96.4% vs 85.7%, p = 0.025), and higher rates of lymph node metastasis (17.9% vs 7.8%, p = 0.015), angiolymphatic invasion (41.7% vs 25.7%, p = 0.003), tumor necrosis (57.1% vs 29.0%, p < 0.001) and positive surgical margin (13.1% vs 5.7%, p = 0.015). On multivariate Cox regression analyses, variant histology was significantly associated with worse PFS (hazard ratio [HR] 2.23; 95% confidence interval [CI] 1.55-3.21; p < 0.001), CSS (HR 2.67; 95% CI 1.35-5.30; p = 0.005) and OS (HR 2.22; 95% CI 1.27-3.88; p = 0.005). In subgroup analysis, no significant survival gains of adjuvant chemotherapy occurred in patients with variant histology. CONCLUSIONS: Variant histology was associated with adverse pathologic features and poor survival outcomes. Our results suggest that patients with variant histology may require a close follow-up schedule and novel adjuvant therapy other than chemotherapy postoperatively.

Computer tomography-based shape of tumor contour and texture of tumor heterogeneity are independent prognostic indicators for clinical T1b-T2 renal cell carcinoma.

PURPOSE: To evaluate association between computer tomography (CT)-based features of renal cell carcinoma (RCC) and survival outcomes. METHODS: Data of 958 patients with clinical T1b-T2 RCC who underwent partial/radical nephrectomy from June 2003 to March 2022 were retrospectively evaluated. CT images of patients were reviewed by two radiologists for texture analysis of tumor heterogeneity and shape analysis of tumor contour. Patients were divided into three groups according to patterns of CT-based features: (1) favorable feature group (n = 117); (2) intermediate feature group (n = 606); and (3) unfavorable feature group (n = 235). Kaplan-Meier survival analysis and multivariate Cox regression analysis were performed to evaluate overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). RESULTS: RCCs with unfavorable CT-based feature showed larger size on CT, higher nuclear grade, higher rate of histologic necrosis, and higher rate of capsular invasion than those in the other two groups (all p < 0.001). Unfavorable feature was associated with poorer OS (p = 0.001), CSS (p < 0.001), and RFS (p < 0.001) on Kaplan-Meier analysis. In multivariate analysis, intermediate and unfavorable features were independent predictors for recurrence (hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.09-5.79, p = 0.031 and HR 3.71, 95% CI 1.58-8.73, p = 0.003, respectively), but not for overall death or RCC-specific death. CONCLUSIONS: A combination of irregular tumor contour feature with heterogeneous tumor texture feature on CT is associated with poor RFS in clinical T1b-T2 RCC preoperatively.

Tumor contact length with bladder wall provides effective risk stratification for lesions with a VIRADS score of 2-3.

OBJECTIVES: To evaluate the diagnostic performance of the tumor contact length (TCL) in the prediction of MIBC (muscle-invasive bladder cancer) in lesions corresponding to the vesical imaging-reporting and data system (VIRADS) score 2-3. METHODS: This is a single institution, retrospective study targeting 191 consecutive patients assigned of VIRADS score 2-3, who had pre-transurethral resection MRI from July 2019 to September 2021. Logistic regression analyses were performed to determine meaningful predictors of MIBC for this score group, and a nomogram was plotted with those variables. The diagnostic performance of each predictor was compared at predefined thresholds (VIRADS score 3 and TCL 3 cm) using the generalized linear model and ROC analysis. RESULTS: Both VIRADS score and TCL remained independent predictors of MIBC for this score group (odds ratio 7.3 for VIRADS score, and 1.3 for TCL, p < 0.01 for both). The contribution of TCL to the probability of MIBC in the nomogram was greater than that of the VIRADS score. VIRADS score had a sensitivity of 0.54 (14/26), specificity of 0.92 (203/221), and diagnostic accuracy of 0.88 (217/247), and TCL showed a sensitivity of 0.89 (23/26), specificity of 0.95 (209/221), and diagnostic accuracy of 0.94 (232/247). The difference in sensitivity (p = 0.03) and accuracy (p = 0.04) was statistically significant. The AUC was also significantly wider for TCL than for VIRADS (0.97 vs. 0.73, p < 0.01). CONCLUSION: A simple index, TCL, may be helpful in further risk stratification for MIBC in patients with a score of VIRADS 2-3. CLINICAL RELEVANCE STATEMENT: For bladder cancer patients with insufficient qualitative evidence of muscle layer invasion using VIRADS categorization, TCL, a simple quantitative indicator defined as the curvilinear contact length between the bladder wall and the tumor, may be helpful in risk stratification. KEY POINTS: • Even when only lesions with score 2-3 were targeted, VIRADS was still a meaningful indicator of MIBC. • With a predefined threshold of 3 cm applied, TCL outperformed VIRADS in the score 2-3 group, in predicting MIBC. • A longer TCL for a lesion with a VIRADS score 2 may warrant an additional warning for MIBC, whereas a shorter TCL for a lesion with a score 3 may indicate a lower risk of MIBC.

Polygenic risk score in prostate cancer.

PURPOSE OF REVIEW: This study was conducted in order to review the outcomes regarding polygenic risk score (PRS) in prediction of prostate cancer (PCa). With the increasing proficiency of genetic analysis, assessment of PRS for prediction of PCa has been performed in numerous studies. Genetic risk prediction models for PCa that include hundreds to thousands of independent risk-associated variants are under development. For estimation of additive effect of multiple variants, the number of risk alleles carried by an individual is summed, and each variant is weighted according to its estimated effect size for generation of a PRS. RECENT FINDINGS: Currently, regarding the accuracy of PRS alone, PCa detection rate ranged from 0.56 to 0.67. A higher rate of accuracy of 0.866-0.880 was observed for other models combining PRS with established clinical markers. The results of PRS from Asian populations showed a level of accuracy that is somewhat low compared with values from Western populations (0.63-0.67); however, recent results from Asian cohorts were similar to that of Western counterparts. Here, we review current PRS literature and examine the clinical utility of PRS for prediction of PCa. SUMMARY: Emerging data from several studies regarding PRS in PCa could be the solution to adding predictive value to PCa risk estimation. Although commercial markers are available, development of a large-scale, well validated PRS model should be undertaken in the near future, in order to translate hypothetical scenarios to actual clinical practice.

Predicting factor analysis of postoperative complications after robot-assisted radical cystectomy: Multicenter KORARC database study.

OBJECTIVES: To evaluate postoperative complications following robot-assisted radical cystectomy in patients diagnosed with bladder cancer and reveal if there are predictors for postoperative complications. METHODS: Prospectively collected medical records of 730 robot-assisted radical cystectomy patients between 2007/04 and 2019/05 in 13 tertiary referral centers were reviewed. Perioperative outcomes were compared between two groups by postoperative complications (complication vs non-complication). We assessed recurrence-free survival, cancer-specific survival, and overall survival between groups. Regression analyses were implemented to identify factors associated with postoperative complications. RESULTS: Any total and high-grade complication (Clavien-Dindo grade ≥3) rates were 57.8% and 21.1%, respectively. Patients in complication group had significantly higher proportion of diabetes mellitus (P = 0.048), chronic kidney disease (P = 0.011), dyslipidemia (P < 0.001), longer operation time (P = 0.001), more estimated blood loss (P = 0.001), and larger intraoperative fluid volume (P < 0.001). There was a significant difference in cancer-specific survival (log-rank P = 0.038, median cancer-specific survival: both groups not reached). Dyslipidemia (odds ratio 2.59, P = 0.002) and intraoperative fluid volume (odds ratio 1.0002, P = 0.040) were significantly associated with high-grade postoperative complications. Diabetes mellitus (odds ratio 1.97, P = 0.028), chronic kidney disease (odds ratio 1.89, P = 0.046), dyslipidemia (odds ratio 5.94, P = 0.007), and intraoperative fluid volume (odds ratio 1.0002, P = 0.009) were significantly associated with any postoperative complications. CONCLUSIONS: Patients with diabetes mellitus, chronic kidney disease, dyslipidemia, or a relatively large intraoperatively infused fluid volume are more likely to develop postoperative complications. Patients with postoperative complications might have a possibility of lower cancer-specific survival rate.

Evaluation of functional outcome of bilateral kidney tumors after sequential surgery.

BACKGROUND: There are limited data concerning patients treated with sequential bilateral kidney surgery. Current guidelines still lack an optimal surgical sequencing approach. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC). METHODS: A propensity score matched cohort of 267 patients (synchronous bilateral RCCs, N = 44 [88 lesions]; metachronous bilateral, N = 45 [90 lesions]; unilateral, N = 178) from two tertiary institutions were retrospectively analyzed. Synchronous bilateral RCCs were defined as diagnosis concomitantly or within 3 months of former tumor. Renal functional outcomes were defined as estimated glomerular filtration rate (eGFR) changes and de novo chronic kidney disease (CKD, stage ≥3) after surgery. Renal functional outcomes and clinical factors predicting de novo CKD were assessed using descriptive statistics and Cox regression analysis. RESULTS: In subgroup of bilateral RCCs, patients underwent sequential PN (N = 48), PN followed by RN (N = 8), or RN followed by PN (N = 25). Final postoperative estimated glomerular filtration rates (eGFRs) were 79.4, 41.4, and 61.2 ml/minute/1.73 m2, respectively (p = 0.003). There were significant differences in eGFR decline from baseline and de novo chronic kidney disease (CKD stage ≥ III) among groups, with PN followed by RN group showing the worst functional outcomes (all p <  0.05). Moreover, sequential PN subgroup in bilateral RCC showed significantly higher rate of de novo CKD than unilateral RCC group (13.8% vs. 6.9%, p = 0.016). On multivariate analysis, hypertension (p = 0.010) and surgery sequence (PN followed by RN, p <  0.001) were significant predictors of de novo CKD. CONCLUSIONS: The surgery sequence should be prudently determined in bilateral renal tumors. PN followed by RN showed a negative impact on renal functional preservation. Nephron-sparing surgery should be considered for all amenable bilateral RCCs.

Oncological outcome according to attainment of pentafecta after robot-assisted radical cystectomy in patients with bladder cancer included in the multicentre KORARC database.

OBJECTIVES: To investigate the oncological significance of a robot-assisted radical cystectomy (RARC)-related pentafecta in patients with bladder cancer. PATIENTS AND METHODS: Using the KORARC database, which includes data from 12 centres, data from 730 patients who underwent RARC between April 2007 and May 2019 were prospectively collected and retrospectively analysed. Pentafecta was achieved if patients met all of the following criteria: (i) negative soft tissue surgical margin; (ii) ≥16 lymph nodes removed; (iii) no major complications (Clavien-Dindo grade 3-5) within 90 days; (iv) no clinical recurrence within the first 12 months; and (v) no ureteroenteric stricture. Patients were divided into two groups according to pentafecta attainment, and a comparison of overall survival (OS) and cancer-specific survival (CSS) using multivariate Cox proportional analysis was then carried out. RESULTS: Of the 730 patients included in this analysis, 208 (28.5%) attained the RARC pentafecta; the remaining 522 (71.5%) did not. The mean age of the patients was 64.67 years, 85.1% were men, 53.6% received a conduit, 37.7% received orthotopic neobladders and the total complication rate was 57.8%. Those who attained the pentafecta received more neobladders (P = 0.039), were more likely to be treated with the intracorporeal technique (P < 0.001), had longer operating times (P = 0.020) and had longer console time (P = 0.021) compared with those who did not attain the pentafecta. Over a mean of 31.1 months of follow-up, the pentafecta attainment group had significantly higher OS and CSS rates compared with the non-attainment group (10-year OS 70.4% vs 58.1%, respectively [P = 0.016]; 10-year CSS 87.8% vs 70.0%, respectively [P = 0.036]). Multivariate analysis showed that the RARC pentafecta was a significant predictor of overall mortality (hazard ratio 0.561; P = 0.038). CONCLUSIONS: Patients who attained the RARC pentafecta had significantly better survival outcomes compared with those who did not. These criteria could be used to standardize assessment of the surgical quality of RARC. In the future, a similar study using an independent cohort is warranted to confirm our results.

Quantitation of bladder cancer for the prediction of muscle layer invasion as a complement to the vesical imaging-reporting and data system.

OBJECTIVES: To examine the diagnostic performance of Vesical Imaging-Reporting and Data System (VIRADS) and to find a quantitative indicator for predicting muscle layer invasion of bladder cancer. METHODS: 3-T MRI of 82 patients performed before transurethral resection of bladder tumors or radical cystectomy between July 2018 and June 2019 were retrospectively analyzed. For one index lesion of each patient, two radiologists independently assigned VIRADS score and measured tumor-wall interface (contact length between tumor and bladder wall) on T2-weighted, diffusion-weighted, and dynamic contrast-enhanced MRI. Inter-reader agreement was assessed, and logistic regression analysis was performed to find indicators of muscle layer invasion. Comparison of indicators' diagnostic performance was done with receiver operating characteristic (ROC) curve and generalized linear model analyses. Optimal cutoff point was determined by the Youden index J. RESULTS: Inter-reader agreement was at least substantial for VIRADS categorization (κ 0.77-0.81), and almost perfect for tumor-wall interface (intraclass correlation coefficient 0.88-0.90). Tumor-wall interface (odds ratio [OR] 1.90-2.00) and VIRADS score (OR 8.59-8.89) were independently associated with muscle layer invasion (p ≤ 0.02). For VIRADS, area under the ROC curve (AUROC) was 0.94, and the accuracy was 0.93 at score 3, the optimal threshold for predicting muscle layer invasion. Depending on the MRI sequence, tumor-wall interface showed AUROCs of 0.90-0.92 and accuracy of 0.84-0.90 at suggested thresholds (3 ± 0.3 cm). Tumor-wall interface showed insignificant differences in accuracy compared with VIRADS (p > 0.10), except as measured on diffusion-weighted images (p = 0.01). CONCLUSIONS: VIRADS is a good predictor of muscle layer invasion. As an independent quantitative indicator, tumor-wall interface may complement VIRADS to enhance prediction. KEY POINTS: • Vesical Imaging-Reporting and Data System (VIRADS) is a promising predictor of muscle invasion of bladder cancer with good reproducibility, as suggested by previous studies. • VIRADS score and the tumor-wall interface (curvilinear contact length between the tumor and the bladder wall) are independent predictors of muscle layer invasion. • As an easy-to-use quantitative indicator, tumor-wall interface is expected to be used as an indicator complementary to VIRADS, a qualitative indicator.

Favorable intermediate risk prostate cancer with biopsy Gleason score of 6.

BACKGROUND: To identify potential prognostic factors among patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6. METHODS: From 2003 to 2019, favorable intermediate risk patients who underwent radical prostatectomy were included in this study. All patients were evaluated preoperatively with MRI. Using PI-RADS scores, patients were divided into two groups, and clinic-pathological outcomes were compared. The impact of preoperative factors on significant pathologic Gleason score upgrading (≥ 4 + 3) and biochemical recurrence were assessed via multivariate analysis. Subgroup analysis was performed in patients with PI-RADS ≤ 2. RESULTS: Among the 239 patients, 116 (48.5%) were MRI-negative (PI-RADS ≤ 3) and 123 (51.5%) were MRI-positive (PI-RADS > 3). Six patients in the MRI-negative group (5.2%) were characterized as requiring significant pathologic Gleason score upgrading compared with 34 patients (27.6%) in the MRI-positive group (p < 0.001). PI-RADS score was shown to be a significant predictor of significant pathologic Gleason score upgrading (OR = 6.246, p < 0.001) and biochemical recurrence (HR = 2.595, p = 0.043). 10-years biochemical recurrence-free survival was estimated to be 84.4% and 72.6% in the MRI-negative and MRI-positive groups (p = 0.035). In the 79 patients with PI-RADS ≤ 2, tumor length in biopsy cores was identified as a significant predictor of pathologic Gleason score (OR = 11.336, p = 0.014). CONCLUSIONS: Among the patients with favorable intermediate risk prostate cancer with a biopsy Gleason score 6, preoperative MRI was capable of predicting significant pathologic Gleason score upgrading and biochemical recurrence. Especially, the patients with PI-RADS ≤ 2 and low biopsy tumor length could be a potential candidate to active surveillance.

Clinical and pathologic characteristics of familial prostate cancer in Asian population.

BACKGROUND: We investigated prevalence of familial and hereditary prostate cancer (PCa) in Asian population, and compared clinical characteristics between familial and sporadic disease. METHODS: Pedigrees of 1102 patients who were treated for PCa were prospectively acquired. Clinical and pathologic characteristics and biochemical recurrence (BCR)-free survival were compared between familial PCa and sporadic PCa in patients who underwent radical prostatectomy (RP; n = 751). RESULTS: The prevalence of familial, first-degree familial, and hereditary PCa was found to be 8.4%, 6.7%, and 0.9%, respectively; similar result was obtained in patients who underwent RP (8.4%, 6.4%, and 0.9%). Patients with familial PCa were significantly younger than those with sporadic PCa (63.3 vs 65.6 years; P = .015). However, preoperative variables (prostate-specific antigen, clinical stage, biopsy Gleason score [GS], and percentage of positive biopsy cores) and postoperative variables (surgical GS, upgrading rate, pathologic stage, and percentage of tumor volume) did not correlate with family history (P range: .114-.982). Kaplan-Meier analysis of 5-year BCR-free survival revealed no significant difference between sporadic (82.7%), familial (89.4%; P = .594), and first-degree familial (87.1%; P = .774) PCa. Analysis of p53, Bcl-2, Ki67, and other immunohistochemistry biomarkers revealed that only increasing p53 expression and first-degree familial PCa approached significance (P = .059). CONCLUSION: The prevalence of familial PCa was somewhat lower in the Asian population than in other ethnic groups. Clinical and pathologic variables and selected histologic biomarker abnormalities were not significantly different in patients with and without a family history of PCa. BCR-free survival following RP was also unaffected by family history.

Effect of personalized extracorporeal biofeedback device for pelvic floor muscle training on urinary incontinence after robot-assisted radical prostatectomy: A randomized controlled trial.

AIMS: To investigate the effectiveness of a novel personalized extracorporeal biofeedback device (Anykegel) for pelvic floor muscle training (PFMT) on the recovery of postprostatectomy urinary incontinence (PPI) after robot-assisted laparoscopic radical prostatectomy (RARP) through a randomized controlled trial. METHODS: A total of 84 patients who underwent RARP were randomized either to the intervention group (42) (receiving biofeedback-PFMT using a novel device in addition to verbal and written instruction) or to the control group (42). Patients were evaluated 1, 2, and 3 months after surgery. Incontinence severity was measured by the 24-hour pad test. The International Prostate Symptom Score (IPSS) and the International Index of Erectile Function (IIEF-5) questionnaire were also assessed. RESULTS: The intervention group showed a significantly smaller volume of urine loss at the 1-month follow-up than the control group on a 24-hour pad test (71.0 g vs 120.8 g; P = .028). However, from the 2-month follow-up visit, no significant differences were observed between the two groups. In addition, in the 1-month follow-up data of the IPSS-total score, the intervention group demonstrated significantly favorable changes from baseline with improved scores compared to the control group (0.25 ± 9.15 vs -3.81 ± 8.98; P = .046). Regarding the IIEF-5 score changes, no significant differences were reported throughout the study periods. CONCLUSIONS: The personalized extracorporeal biofeedback device for PFMT offers a significant positive effect on the recovery of PPI after RARP, especially in the early postoperative period. Furthermore, patients can be offered more convenience through performing the regular exercise at any place with ease.

The effect of short-term preoperative ureteral stenting on the outcomes of retrograde intrarenal surgery for renal stones.

OBJECTIVES: To evaluate the effect of preoperative ureteral stenting duration on the outcomes of retrograde intrarenal surgery (RIRS). PATIENTS AND METHODS: We reviewed our database of patients who underwent RIRS between May 2011 and April 2017 at our institution. The patients were divided into three groups according to preoperative ureteral stenting duration: group 1: no stenting, group 2: short preoperative stenting (< 7 days) and group 3: long preoperative stenting (≥ 7 days). We compared the rate of ureteral injury, other perioperative complications, ureteral dilation and readmission, stone-free rate (SFR) and operative time among the groups. RESULTS: A total of 560 patients (215 in group 1, 177 in group 2 and 168 in group 3) were included in this study. The mean of maximum stone size was 13.1 (± 6.2) mm, the mean number of stones was 2.3 (± 1.9) and preoperative ureteral stenting duration was 7.2 (± 3.7) days. There were no significant differences in operative time (75.6, 78.5 and 82.4 min, p = 0.280), SFR (79.1, 84.2 and 81.0%, p = 0.433), ureteral injury rate (7.0, 5.1 and 2.4%, p = 0.123) and other perioperative complication rates (12.1, 6.8 and 6.0%, p = 0.061). The only one case of grade IV ureteral injury occurred in group 1 and the rate of ureteral dilation was significantly higher than in group 2 and 3 (14.9, 5.7 and 6.0%, p < 0.001). CONCLUSION: Although preoperative ureteral stenting duration has no significant effect on operative outcomes, it is an effective procedure for reducing the rate of intraoperative ureteral balloon dilation and preventing high-grade ureteral injuries.

Analysis of factors affecting re-admission after retrograde intrarenal surgery for renal stone.

PURPOSE: To investigate the factors associated with hospital readmission (HR) after retrograde intrarenal surgery (RIRS) among renal stone patients. METHODS: The study included patients who underwent RIRS from June 2011 to December 2017. Patients who were readmitted due to surgery-related complications were evaluated retrospectively. Patient demographics including age, medical comorbidity, body mass indices, ASA score, perioperative parameters and stone factors were compared with total cohorts. HR was defined as visits to the Emergency Room or unplanned admission within 30 days after discharge. The factors affecting HR rates were analyzed using uni- and multi-variate analyses. RESULTS: A total of 572 patients were enrolled into the study. The mean age was 57.6 ± 14.1 years and the mean stone diameter was 13.4 ± 6.2 mm. The mean complication rate was 6.1% and the median hospitalization time was 2.1 ± 3.4 days. HR occurred in 20 patients (3.5%). Compared to non-admission patients, readmitted patients had a higher rate of bilateral RIRS (20.0% vs 12.2%, p = 0.035), number of stones (4.65 vs 2.2, p = 0.041) and higher stone complexity score (4.15 vs 2.11, p = 0.003). Multivariate analysis showed bilateral RIRS (OR 1.091, p = 0.031) and stone complexity (OR 1.405, p = 0.003) were significant factors to predict re-admission after RIRS. CONCLUSION: Patients with complex renal stones or those who underwent bilateral RIRS were more likely to have a higher rate of re-admission. Proper perioperative management to prevent complications should be planned based on these predictive factors.

Effect of Starting Penile Rehabilitation with Sildenafil Immediately after Robot-Assisted Laparoscopic Radical Prostatectomy on Erectile Function Recovery: A Prospective Randomized Trial.

PURPOSE: It has not been clearly proved in real practice whether early rehabilitation with phosphodiesterase type 5 inhibitors starting immediately after radical prostatectomy improves erectile function recovery more effectively than delayed treatment with the same regimen. We performed a prospective randomized trial to identify this. MATERIALS AND METHODS: Patients with prostate cancer and an IIEF-5 (International Index of Erectile Function-5) preoperative score of 17 or greater were randomly assigned to receive sildenafil 100 mg regularly twice per week for 3 months immediately after urethral catheter removal as the early group or only 3 months after nerve sparing robot-assisted laparoscopic radical prostatectomy as the delayed group. The study primary end point was the full erectile function recovery rate, defined as an IIEF-5 score of 17 or greater, during the 12 months. RESULTS: Of the 120 randomized patients the proportion who achieved full recovery was significantly higher during the 12 months in the early group than in the delayed group (ß = 0.356, p <0.001, generalized estimating equation). After 9 months postoperatively the proportion of patients who achieved full recovery steadily increased to 41.4% at 12 months in the early group while patients in the delayed group showed no further improvement. Thus, full recovery was achieved in only 17.7% of patients at 12 months. Only early sildenafil treatment independently improved full recovery at 12 months (HR 2.943, p = 0.034). CONCLUSIONS: Our trial provides clinical data to suggest that earlier rehabilitation with phosphodiesterase type 5 inhibitors can contribute to the recovery of erectile function after radical prostatectomy in the clinical setting.

Preoperative cholesterol level as a new independent predictive factor of survival in patients with metastatic renal cell carcinoma treated with cyto-reductive nephrectomy.

BACKGROUND: The obesity and lipid metabolism were previously proposed to be related with the clinical outcomes of metastatic renal cell carcinoma (mRCC). We tried to investigate the relationship between preoperative cholesterol level (PCL) and survival outcomes in patients with mRCC. METHODS: We analysed the data of 244 patients initially treated with cyto-reductive nephrectomy after being diagnosed with mRCC. Patients were stratified into two groups according to the PCL cut-off level of 170 mg/dL. The postoperative survival rates were compared using Kaplan-Meier analysis and the possible predictors of patients' cancer-specific survival (CSS) and overall survival (OS) were tested using multivariate Cox-proportional hazard models. RESULTS: The low cholesterol group showed significantly worse postoperative CSS (p = 0.013) and OS (p = 0.009) than the high cholesterol group. On multivariate analysis, low PCL was revealed as an independent predictor of worse CSS (hazard ratio [HR], 2.162; 95% CI, 1.221-3.829; p = 0.008) and OS (HR, 2.013; 95% CI, 1.206-3.361; p = 0.007). Subsequent subgroup analysis showed that these results were maintained in the clear cell subgroup but not in the non-clear cell subgroup. CONCLUSION: Decreased PCL was significantly correlated with worse survival outcomes in patients with mRCC treated with cytoreductive nephrectomy. The underlined mechanism is still uncharted and requires further investigation.

Can robot-assisted laparoscopic radical prostatectomy (RALP) be performed very soon after biopsy?

PURPOSE: To identify the perioperative and oncological impact of different intervals between biopsy and robot-assisted laparoscopic radical prostatectomy (RALP) for localized prostate cancer. METHODS: All consecutive patients with localized prostate cancer who underwent RALP with primary curative intent in January 2008-July 2014 in a large tertiary hospital were enrolled in this retrospective cohort study. The patients were divided into groups according to whether the biopsy-RALP interval was ≤2, ≤4, ≤6, or >6 weeks. Estimated blood loss and operating room time were surrogates for surgical difficulty. Surgical margin status and continence at the 1 year were surrogates for surgical efficacy. Biochemical recurrence (BCR) was defined as two consecutive postoperative prostate serum antigen values of ≥0.2 ng/ml. RESULTS: Of the 1446 enrolled patients, the biopsy-RALP interval was ≤2, ≤4, ≤6, and >6 weeks in 145 (10 %), 728 (50.3 %), 1124 (77.7 %), and 322 (22.3 %) patients, respectively. The >6 week group had a significantly longer mean operation time than the ≤2, ≤4, and ≤6 week groups. The groups did not differ significantly in terms of estimated blood loss or surgical margin status. Kaplan-Meier analysis showed that interval did not significantly affect postoperative BCR-free survival. Multivariable Cox proportional hazards model analysis showed that interval duration was not an independent predictor of BCR (≤2 vs. >2 weeks, HR = 0.859, p = 0.474; ≤4 vs. >4 weeks, HR = 1.029, p = 0.842; ≤6 vs. >6 weeks, HR = 0.84, p = 0.368). CONCLUSION: Performing RALP within 2, 4, or 6 weeks of biopsy does not appear to adversely influence surgical difficulty or efficacy or oncological outcomes.

Perineural Invasion and Lymphovascular Invasion are Associated with Increased Risk of Biochemical Recurrence in Patients Undergoing Radical Prostatectomy.

PURPOSE: This study was designed to determine whether perineural invasion (PNI) and lymphovascular invasion (LVI) are independent predictors for biochemical recurrence (BCR) of prostate cancer (PCa) following radical prostatectomy (RP) in the Asian population. METHODS: The study population comprised 2394 PCa patients undergoing RP at our institution in Korea. After excluding 360 patients, we compared the baseline characteristics between the groups according to the presence of PNI or LVI and estimated BCR-free survival using the Kaplan-Meier survival. Multivariate Cox regression model was adopted to identify significant predictive factors of BCR following RP. RESULTS: Among 2034 patients, PNI and LVI were detected in 69.3 and 12.4 % patients, respectively. Patients with PNI or LVI had higher rates of advanced biopsy and pathological Gleason score (≥7), and higher proportions of advanced clinical and pathological T stage ≥3, extraprostatic extension, seminal vesicle invasion, and surgical margin positivity. Notably, BCR-free survival was lower in patients with PNI or LVI compared with that in patients without these markers and lower in patients with both markers compared with that in other populations of patients. Moreover, PNI (hazard ratio [HR] = 2.11) and LVI (HR = 1.57) were significant predictors of BCR. The presence of the two markers was associated with a higher risk of BCR (HR = 4.60) compared with the presence of either marker alone (HR = 3.47). CONCLUSIONS: PNI and LVI are adverse pathologic parameters and independent predictors for BCR, and the concurrent presence of PNI and LVI resulted in poorer outcomes for BCR in PCa patients who underwent RP.

Clinical efficacy of combination therapy with an alpha blocker and low-dose sildenafil on post-therapy lower urinary tract symptoms after low-dose-rate brachytherapy for prostate cancer.

PURPOSE: To investigate the efficacy of tamsulosin monotherapy and tamsulosin with low-dose sildenafil combination therapy on lower urinary tract symptoms (LUTS) following low-dose-rate (LDR) brachytherapy in early prostate cancer patients. METHODS: From March 2008 to June 2014, of the 212 prostate cancer patients with a Gleason score ≤7 who received LDR brachytherapy, 80 patients with a prostate volume ≤35 g and progressed LUTS following implantation were selected. All 80 patients took tamsulosin 0.4-mg monotherapy until 1 month after implantation. Then, the patients were divided into two groups; 45 patients received tamsulosin 0.4-mg monotherapy, and 35 patients received tamsulosin 0.4-mg plus sildenafil 25-mg combination therapy due to erectile dysfunction. LUTS were compared between the two groups using the International Prostate Symptom Score (IPSS), the mean maximum flow rate (Q max) and the pre-implantation post-voiding residual (PVR) volume at 1 and 3 months after implantation. RESULTS: The pre-implantation total IPSS, Q max and PVR for the monotherapy and combination therapy groups were 14.0 ± 6.7, 14.3 ± 3.2 ml/s and 36.3 ± 16.7 ml and 15.3 ± 5.6, 13.7 ± 4.5 ml/s and 39.0 ± 23.4 ml, respectively. At 1 month post-implantation, both groups showed increases in total IPSS and PVR, but no statistically significant differences were observed (P = 0.078, P = 0.23). At 3 months post-implantation, the combination therapy group showed a greater decrease in total IPSS compared with the monotherapy group (P = 0.035), but there were no statistically significant differences in the Q max and PVR between the two groups. CONCLUSION: Tamsulosin plus low-dose sildenafil combination therapy is a beneficial treatment for post-implantation progression of LUTS.

High preoperative neutrophil-lymphocyte ratio predicts biochemical recurrence in patients with localized prostate cancer after radical prostatectomy.

PURPOSE: To investigate the association between preoperative neutrophil-lymphocyte ratio (NLR) and oncological outcomes in patients with localized prostate cancer (PCa) after radical prostatectomy (RP). METHODS: We retrospectively reviewed the records of 1367 patients who underwent RP between November 2003 and April 2012. Patients who underwent a concurrent biopsy/procedure in other organs, had evidence of acute infection, or had systemic inflammatory disease were excluded. We divided the patients by NLR level and analyzed their perioperative outcomes. To determine NLR significance, we performed a multivariate logistic regression analysis of the pathological adverse outcomes and a Cox proportional hazard analysis of the biochemical recurrence (BCR), which was defined as a prostate-specific antigen level ≥0.2 ng/mL on two consecutive tests. RESULTS: Among the 1367 patients, 158 (11.6 %) in the high-NLR (≥2.5) group had a higher biopsy Gleason score (p < 0.001), pathological Gleason score (p < 0.001), and pathological stage (p < 0.001) than patients in the low-NLR (<2.5) group (n = 1209, 88.4 %). Multivariate analysis revealed that high NLR was significantly correlated with adverse pathological outcomes of higher pathological stage (HR 1.688; 95 % CI 1.142-2.497; p = 0.009) and extracapsular extension (HR 1.698; 95 % CI 1.146-2.516; p = 0.008). Kaplan-Meier analysis showed significantly worse BCR-free survival (p < 0.001) in patients with a high NLR. A high NLR was a significant predictor of BCR after RP (HR 1.358; 95 % CI 1.008-1.829; p = 0.044). CONCLUSIONS: High NLR was significantly related to unfavorable clinicopathological outcomes and worse BCR-free survival. Further studies are needed to clarify the correlation between NLR and PCa.

A New Sliding-Loop Technique in Renorrhaphy for Partial Nephrectomy: A Feasibility Study in a Porcine Model.

BACKGROUND: We developed a sliding-loop technique that narrowed both sides of the parenchyma in a porcine model and compared it with the conventional sliding-clip technique. METHODS: Three pigs (30-40 kg) were reused following another experiment conducted by the same researchers. Bilateral kidneys were harvested within 30 minutes after euthanasia. Two partial nephrectomies per kidney were performed on opposite surfaces. All kidney defects were of the same size (diameter of 2.5-3 cm with a depth of 1.0-1.5 cm). The sliding-clip technique and sliding-loop technique were performed separately. In the sliding-loop technique, we created a 1-cm loop at the end of a Vicryl and placed a tetrafluoroethylene polymer pledget in front of the knots passing through the needle. The needle then crossed the loop after passing through the renal parenchyma. A Weck clip was placed and slid on one side to tighten the suture. Tightening was controlled with an equivalent force using a digital push-pull gauge. Three stitches were placed at each renorrhaphy site. The distance between repaired renal surfaces was measured at 5 different points (3 suture sites and 2 middle sites between sutures). RESULTS: The results of the 2 techniques were compared by using the independent t test. The mean distance between renal surfaces was significantly narrower in the sliding-loop technique than in the conventional technique (1.80 ± 1.08 mm vs 5.28 ± 2.46 mm, P < .001). CONCLUSION: In the porcine model, the sliding-loop technique more effectively closed the partial nephrectomy defects compared with the conventional sliding-clip technique.