Practice Patterns of Korean Urologists Regarding Positive Surgical Margins after Radical Prostatectomy: a Survey and Narrative Review.

BACKGROUND: There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP. METHODS: A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire. In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers. RESULTS: We received replies from 91 of the 105 urologists (86.7%) in our sample population. Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response 'does not make a difference in treatment policy' prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012). CONCLUSION: The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Credé maneuver to adjust tape tension during trans-obturator tape mid-urethral sling in mixed urinary incontinence.

INTRODUCTION AND HYPOTHESIS: To evaluate the efficacy of intraoperative extrinsic manual bladder compression (Credé maneuver) for trans-obturator tape adjustment during mid-urethral sling surgery in women with stress urinary incontinence and those with mixed urinary incontinence. METHODS: The study included 148 randomly selected women who underwent mid-urethral sling surgery with trans-obturator tape for stress urinary incontinence between January 2016 and May 2017. Subgroup analysis of 66 women with mixed urinary incontinence included 43 patients from the Credé maneuver group and 23 from the non-Credé maneuver group. In the Credé maneuver group, the pattern of urine leakage was determined during the Credé maneuver, and tape tension was adjusted according to the pattern. RESULTS: The cure rate was 86.6% and improved rate was 11.9% in the Credé maneuver patients. The cure rate was 50.6% and improved rate was 38.3% in the non-Credé maneuver patients. The success rate was significantly higher in the Credé than in the non-Credé maneuver group (p = 0.023). In subgroup analysis of patients with mixed urinary incontinence, the cure rate was 81.4% and improved rate was 16.3% in the Credé maneuver group. The cure rate was 43.5% and improved rate was 47.8% in the non-Credé maneuver group. The cure rate was significantly higher in the Credé maneuver group (p = 0.007). CONCLUSIONS: Intraoperative trans-obturator tape adjustment using the Credé maneuver to identify the leaking pattern significantly improved the success rate in women with mixed urinary incontinence, and Credé maneuver-directed adjustment significantly improved the cure rate.

Radical prostatectomy for clinically localized prostate cancer in patients aged 75 years or older: comparison with primary androgen deprivation therapy.

OBJECTIVE: To determine whether radical prostatetomy (RP) is suitable for prostate cancer patients with age ≥75 years in comparison to primary androgen deprivation therapy (PADT). PATIENTS AND METHODS: A cohort study was conducted in clinically localized prostate cancer patients with ≥75 years of age who underwent RP or PADT at six institutions from 2005 to 2013. Patients who had less than 12 months of follow-up, or received neoadjuvant or adjuvant therapy were excluded. We compared clinical characteristics, cancer-specific and overall survivals, and post-treatment complication rates between two groups. RESULTS: We included 92 and 99 patients in the RP and PADT groups, respectively. In survival analyses, there were no significant differences in cancer-specific and overall survivals (p = .302 and .995, respectively). The incidence of serious adverse events (cardio- or cerebrovascular event, or bone fracture) was higher in the PADT group (p = .001). Multivariable analysis showed that PADT had a worse effect on the serious adverse events (OR 10.12, p = .038). CONCLUSIONS: In selected elderly patients, RP was safe and effective for treatment of localized prostate cancer, as compared to PADT. Surgical treatment options should be considered in elderly patients with respect to life expectancy, rather than chronological age.

Prognostic Factors of Penile Cancer and the Efficacy of Adjuvant Treatment after Penectomy: Results from a Multi-institution Study.

BACKGROUND: Penile cancer is a rare malignancy associated with high rates of mortality and morbidity. Currently, the efficacy of adjuvant treatment (AT), including radiotherapy and chemotherapy, for penile cancer remains unclear. Therefore, we investigated the prognostic factors for treatment outcomes and the efficacy of AT in consecutive patients who underwent penectomy for penile cancer at multiple Korean institutions between 1999 and 2013. METHODS: AT was defined as the administration of chemotherapy, radiotherapy, or both within 12 months after initial treatment. All patients were divided into two groups according to the AT status. RESULTS: Forty-three patients (median age 67.0 years) with a median follow-up after penectomy of 26.4 (interquartile range: 12.0-62.8) months were enrolled. Patients with AT had a significantly higher pathologic stage. However, no differences in age, histologic grade, or type of surgery were identified according to the presence of AT. The 3- and 5-year cancer-specific survival (CSS) rates were 79.0% and 33.0%, respectively. In a multivariate analysis, American Joint Committee on Cancer (AJCC) stage ≥ III disease was an independent predictor of CSS and recurrence-free survival (RFS). However, AT was not associated with CSS and RFS. The type of primary surgical treatment and inguinal lymph node dissection at diagnosis were also not significantly associated with overall survival, CSS, or RFS. CONCLUSION: AJCC stage ≥ III disease, which mainly reflects lymph node positivity, is a significant prognosticator in patients with penile cancer. By contrast, AT does not seem to affect CSS and RFS.

Daily use of sildenafil 50mg at night effectively ameliorates nocturia in patients with lower urinary tract symptoms associated with benign prostatic hyperplasia: an exploratory multicenter, double-blind, randomized, placebo-controlled study.

PURPOSE: To compare the efficacy and safety of sildenafil 25 mg qd, 25 mg bid or 50 mg qd - on treating lower urinary tract symptoms with benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: Men aged > 45 years with LUTS/BPH were randomly assigned to receive sildenafil 25 mg qd (n = 42), bid (n = 41), 50 mg qd (n = 38) or placebo (n = 41) for 8 weeks. Changes from baseline in International Prostate Symptom Score (I-PSS), maximum urinary flow rate (Qmax) and postvoid residual urine volume (PVR) were assessed at week 4 and week 8. RESULTS: Sildenafil 25 mg qd (-7.3 ± 5.8) and 25 mg bid (-7.0 ± 5.7) exhibited significant improvements of I-PSS compared to placebo (-5.2 ± 6.4) (p = 0.020, 0.025, respectively). In particular, voiding domain was more affected than storage domain. Only sildenafil 50 mg qd improved nocturia significantly (versus placebo, p = 0.027). Quality of life score was improved in all treatment groups. Qmax and PVR did not change significantly in all groups. All regimens were well tolerated. CONCLUSIONS: Sildenafil 25 mg qd, 25 mg bid and 50 mg qd are safe and effective to improve LUTS/BPH in long term, along with coexisting ED. In particular, nocturia is most well-controlled by 50 mg qd.

Radical Prostatectomy in Korean Men Aged 75-Years or Older: Safety and Efficacy in Comparison with Patients Aged 65-69 Years.

Prostate cancer is the most common type of male cancer worldwide. Although radical prostatectomy (RP) is advised for prostate cancer in patients with a life expectancy of more than 10 years by various guidelines, most elderly men still do not undergo the procedure regardless of increasing life expectancy. This study aimed to determine whether RP is suitable for patients with prostate cancer aged 75 years or older. A retrospective study of patients who underwent RP at 6 institutions between 2005 and 2012 was conducted. Patients were divided into 2 groups at the time of surgery: 65-69 years (younger group) and 75 years or older (older group). We compared clinical characteristics, pathological results, complication rates, and recurrence-free survival between the two groups. Compared with the younger group, the older group had significantly higher preoperative serum prostate-specific antigen level, pre- and postoperative Eastern Cooperative Oncology Group (ECOG) performance status grade, hypertension prevalence, and Gleason score at biopsy and RP. However, except urinary incontinence, there were no statistically significant differences in the peri- and post-operative complications. After median follow-up periods of 36 months (younger group) and 40 months (older group), the biochemical recurrence-free survival rates were not significantly different (P = 0.581). Although the urinary incontinence rate was higher in the older group, RP was a suitable option for selected Korean men aged 75 years or older with limited complication rates and excellent outcomes similar to those for patients aged 65-69 years.

Analysis of distress in patients undergoing radical prostatectomy: A multicenter prospective study.

PURPOSE: To analyze the degree of psychological distress experienced pre- and postoperatively in patients who underwent radical prostatectomy after being diagnosed with prostate cancer. MATERIALS AND METHODS: Patients diagnosed with prostate cancer who underwent radical prostatectomy without history of psychiatric disorders were included in this study. The degree of psychological distress was evaluated using hospital anxiety and depression scale (HADS) and distress thermometer (DT) questionnaires preoperatively and at 1, 3, 6, and 12 months postoperatively. RESULTS: Distress was high preoperatively and decreased over the entire period. In addition, HADS-anxiety and HADS-depression scores showed an improved severity, shifting from an abnormal state to a borderline state in some patients. However, the DT score, including emotional problems, spiritual concerns, physical problems, family problems, and practical problems, was slightly higher at 1 month postoperatively compared to preoperatively. Furthermore, even at 12 months postoperatively, about one fifth of patients surveyed had a DT score of 4 or higher, requiring psychiatric intervention. CONCLUSIONS: Before and after radical prostatectomy, a significant number of patients complained of distress such as anxiety, depression, and insomnia, and they needed help from a specialist because of psychological distress even 12 months postoperatively. Therefore, a close evaluation of the patient's psychological distress and supportive treatment are needed during the entire pre- and postoperative period.

Pathological confirmation of nerve-sparing types performed during robot-assisted radical prostatectomy (RARP).

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Incremental nerve-sparing techniques (NSTs) improve postoperative erectile function after robot-assisted radical prostatectomy (RARP). However, there are no studies to date that histologically confirm the surgeon intended NST. Thus, in the present study, we histologically confirmed that the surgeon performed the nerve preservation as his intended NSTs during RARP. Also, we found that there was more variability in fascia width outcome on the left side compared with the right. Therefore, when performing nerve preservation on the surgeon's non-dominant side, we need to pay more close attention. OBJECTIVES: To confirm that the surgeon achieved true intended histological nerve sparing during robot-assisted radical prostatectomy (RARP) by studying RP specimens. To aid the novice robotic surgeon to develop the skills of RARP. PATIENTS AND METHODS: Between June 2008 and May 2009, 122 consecutive patients underwent RARP by a single surgeon (K.K.B.). The degree of nerve sparing (wide resection [WR], interfascial nerve sparing [ITE-NS], intrafascial nerve sparing [ITR-NS]) on both sides was recorded. The posterior sectors of RP specimens from distal, mid, and proximal parts were evaluated. Fascia width (FW) of each position in RP specimens were compared across nerve-sparing types (NSTs). FW was recorded at 15 ° intervals (3-9 o'clock position), measured as the distance between the outermost prostate gland and surgical margin. The slides were reviewed by an experienced uropathologist who was 'blinded' to the NST. RESULTS: In all, 93 men were included. The overall mean (sd) FW was the greatest in the order of WR, ITE-NS, and ITR-NS, at 2.42 (1.62), 1.71 (1.40) and 1.16 (1.08) mm, respectively (P < 0.001). FW was statistically significantly correlated with the surgical technique used. When the surgeon intended to perform various levels of nerve sparing, these were reflected in the FW. Interestingly, the left-side FW showed more variability than the right side. We suspect that this was a result of the surgeon's right-hand dominance. Erectile function (EF) recovery rate according to NST was 88.9%, 77.3%, 65.6%, 56.3%, and 0% in bilateral ITR-NS, ITR-NS/ITE-NS, bilateral ITE-NS, ITE-NS/WR, and bilateral WR, respectively. To further validate and confirm these preliminary findings, additional studies involving multicentre cohorts would be required. CONCLUSIONS: The surgeon intended dissection and FW correlate, with ITR-NS providing the narrowest FW and the EF recovery rate was the highest in bilateral ITR-NS. There was more variability in FW outcome on the left side than the right. The novice robotic surgeon should consider this variability when performing RARP. It may have implications for technique improvement on nerve preservation for EF.

Impacting factors for recovery of erectile function within 1 year following robotic-assisted laparoscopic radical prostatectomy.

INTRODUCTION: Neurovascular bundle preservation generally results in good postoperative sexual function after radical prostatectomy. However, erectile function (EF) after radical prostatectomy is still a significant concern. The same surgical technique often results in different EF outcomes. AIM: We evaluated factors that correlate with recovery of EF within 1 year after robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: From January 2008 to May 2009, 145 consecutive patients underwent RALP by one surgeon. Patients were followed postoperatively at 3-month intervals and assessed for EF recovery, defined as an erection sufficient for penetrative intercourse with satisfaction. Baseline demographics, medical comorbidities, degree of nerve sparing, and perioperative and postoperative variables were recorded. Univariate and multivariate analyses were used to determine factors associated with EF recovery. MAIN OUTCOME MEASURES: Postoperative sexual outcomes were attained prospectively via our erectile state questionnaire. RESULTS: Complete follow-up EF data were available on 89 men. Within 1-year follow-up, 56 men (62.9%) recovered EF and 33 men (37.1%) did not. In univariate logistic regression analysis, race (black), diabetes mellitus, hyperlipidemia, and clinical T2 carcinoma of the prostate were associated with diminished EF. Higher-preoperative Sexual Health Inventory for Men score and incremental nerve sparing (enhanced lateral prostatic fascia sparing) were associated with higher odds of recovering potency. In multivariate analysis, hyperlipidemia was primary comorbidity associated with diminished EF, and bilateral nerve sparing with a minimum unilateral-enhanced status was the impacting factor for EF recovery within 1 year after surgery. CONCLUSIONS: Bilateral nerve preservation with a minimum unilateral-enhanced status is associated with improved recovery of EF, and hyperlipidemia is a significant negative predictive factor of postoperative EF recovery within 1 year following RALP. Therefore, it is important to control hyperlipidemia as well as to use the proper surgical technique in maximizing EF recovery within 1 year after radical prostatectomy.

Transobturator adjustable tape for severe stress urinary incontinence and stress urinary incontinence with voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: This prospective multicenter study was conducted to evaluate the efficacy and safety of an adjustable mid-urethral sling (MUS) using transobturator adjustable tape (TOA) in women with severe stress urinary incontinence or combined stress urinary incontinence (SUI) and voiding dysfunction (VD). METHODS: One day after placement of TOA, the tension was adjusted. Six months after surgery, changes in several questionnaires and uroflowmetry (UFM) parameters were evaluated. RESULTS: Among the 65 women enrolled in the study, 27 (41.5%) required postoperative tension readjustments. At 6 months, the complete cure rate of SUI was 84.4%, and patient satisfaction with the operation was 86.2%. There was improvement in the total scores on several questionnaires. There were no significant changes in postoperative UFM parameters. CONCLUSION: Our results support the use of TOA as an effective modality for the treatment of SUI in women at risk for persistent postoperative SUI or obstructive symptoms.

Evaluation of preoperative bioimpedance spectroscopy quantification of body composition on predicting postoperative outcomes following robotic assisted radical prostatectomy (RARP).

INTRODUCTION: Bioimpedance spectroscopy (BIS) is a novel, precise quantification of body composition (BC) using low electrical currents through tissue. Accurate BC quantification may better predict postoperative outcomes. We compared BIS-BC and body mass index (BMI) for correlation with post-surgical outcomes in robotic assisted radical prostatectomy (RARP) patients. MATERIALS AND METHODS: Preoperative BIS-BC and BMI analyses were conducted on men with biopsy-proven prostate cancer undergoing RARP. Height, weight, percentage and fat mass (PFM, FM), percentage and fat-free mass (PFFM, FFM), percentage and total body water (PTBW, TBW), and percentage and intracellular/extracellular water (PICW, PECW, ICW, ECW) were obtained using the ImpediMed SFB7 Device (San Diego, CA, USA). Preoperative PSA, biopsy and pathologic Gleason scores, prostate volume, percentage tumor volume, margin status, operative time, estimated blood loss (EBL) and pathologic stage were recorded. Spearman's rank correlation was estimated to evaluate the association between BIS-BC results, BMI, and post-surgical outcomes. RESULTS: Between April 2009 and August 2010, 63 men had been enrolled in this ongoing study. Fourteen were of normal weight (18.5 kg/m2-24.9 kg/m2), 33 were overweight (25 kg/m2-29.9 kg/m2) and 16 were obese (BMI ≥ 30 kg/m2). Mean age was 60.7 years, mean preoperative PSA was 7.4 ng/mL, and median Gleason was 7. BMI correlated with FFM (p = 0.002), FM (p = 0.01), and PTBW (p = 0.02). FM correlated with preoperative PSA (p = 0.01). PFFM (p = 0.03), PFM (p = 0.03) and PTBW (p = 0.04) correlated with % tumor volume. ICW (p = 0.01) and TBW (p = 0.009) correlated with EBL. BMI (p = 0.04), PECW (p = 0.04), FM (p = 0.05), and PICW (p = 0.03) correlated with pathologic tumor stage. CONCLUSIONS: BMI correlates with BIS-BC FFM, FM and PTBW. PFFM, PFM and PTBW correlated with % tumor volume. ICW and TBW correlated with EBL. BMI, PECW, FM, and PICW correlated with pathologic tumor stage. BIS-BC metrics may be helpful in predicting post-RARP outcomes. Further study is required to validate these predictions.

Clinical Efficacy of Solifenacin in the Management of Diabetes Mellitus-Associated Versus Idiopathic Overactive Bladder Symptoms: A Multicenter Prospective Study.

PURPOSE: To compare the clinical efficacy of anticholinergics for managing diabetes mellitus-associated overactive bladder (DM OAB) versus idiopathic overactive bladder (OAB) in Korean women. METHODS: We conducted a multicenter, prospective, parallel-group, open-label, 12-week study. Women (20-65 years old) with OAB symptoms for over 3 months were assigned to the DM OAB and idiopathic OAB groups. Changes in the Overactive Bladder Symptom Score (OABSS), urgency, urinary urgency incontinence, nocturia, daytime frequency according to a voiding diary, uroflowmetry, and postvoid residual urine volume (PVR) at the first visit (V1), week 4 (V2), and week 12 (V3) were compared. RESULTS: No significant difference was found between the baseline patient characteristics of the DM OAB and idiopathic OAB groups. Treatment with solifenacin was associated with improvements in urgency, urinary urgency incontinence, nocturia, frequency according to a voiding diary, and the total OABSS between V1 and V2 and between V1 and V3. Moreover, a significant improvement in urgency and urge incontinence was found between V2 and V3 in the DM OAB group. However, no significant changes were found in any other parameters. There were no significant differences between the DM OAB group and the idiopathic OAB group except for urgency and urge incontinence at V2 (3.71 vs. 2.28 and 0.47 vs. 0.32, respectively). CONCLUSIONS: The patients who received solifenacin demonstrated improved urgency, urinary urgency incontinence, nocturia, frequency according to a voiding diary, and total OABSS. Management with solifenacin was equally effective for both DM-related OAB and idiopathic OAB.

A Personalized and Learning Approach for Identifying Drugs with Adverse Events.

PURPOSE: Adverse drug events (ADEs) are associated with high health and financial costs and have increased as more elderly patients treated with multiple medications emerge in an aging society. It has thus become challenging for physicians to identify drugs causing adverse events. This study proposes a novel approach that can improve clinical decision making with recommendations on ADE causative drugs based on patient information, drug information, and previous ADE cases. MATERIALS AND METHODS: We introduce a personalized and learning approach for detecting drugs with a specific adverse event, where recommendations tailored to each patient are generated using data mining techniques. Recommendations could be improved by learning the associations of patients and ADEs as more ADE cases are accumulated through iterations. After consulting the system-generated recommendations, a physician can alter prescriptions accordingly and report feedback, enabling the system to evolve with actual causal relationships. RESULTS: A prototype system is developed using ADE cases reported over 1.5 years and recommendations obtained from decision tree analysis are validated by physicians. Two representative cases demonstrate that the personalized recommendations could contribute to more prompt and accurate responses to ADEs. CONCLUSION: The current system where the information of individual drugs exists but is not organized in such a way that facilitates the extraction of relevant information together can be complemented with the proposed approach to enhance the treatment of patients with ADEs. Our illustrative results show the promise of the proposed system and further studies are expected to validate its performance with quantitative measures.

Indications for a second prostate biopsy in patients suspected with prostate cancer after an initial negative prostate biopsy.

BACKGROUND: The present study aimed to evaluate the indications for a second prostate biopsy in patients suspected with prostate cancer after an initial negative prostate biopsy. METHODS: The present study included 421 patients who underwent repeat prostate biopsy between January 2007 and December 2015 at three hospitals. Clinicopathological data, including patient age, body mass index, history of prostate biopsy, prostate volume, prostate-specific antigen (PSA) level, PSA density, PSA velocity, and PSA fluctuation patterns, were analyzed. The patients were stratified into two groups based on the first PSA pattern (increase/decrease) within 1 year after the initial negative prostate biopsy. RESULTS: Prostate cancer was detected in 100 (23.8%) of the 421 patients at the second prostate biopsy. In patients with a PSA decrease at the first follow-up, prostate volume and number of increases in the PSA level from the initial prostate biopsy were predictors for prostate cancer diagnosis at the second prostate biopsy. In patients with a steady PSA increase after the initial prostate biopsy, prostate volume and number of biopsy cores were predictors for prostate cancer diagnosis at the second prostate biopsy. CONCLUSION: The indications for a second prostate biopsy are a low prostate volume and a high number of increases in the PSA level among patients with a PSA decrease at the first follow-up and a low prostate volume and a high number of biopsy cores among patients with a PSA increase at the first follow-up.

Epidemiology of prostate cancer in South Korea.

BACKGROUND: Prostate cancer (PCa) is the second most frequently diagnosed cancer in male. In South Korea, PCa incidence has increased significantly, while its mortality rate has decreased steadily. To optimize the distribution of public medical resources, it is essential to analyze the contemporary epidemiology of PCa. METHODS: National population data from the National Health Insurance Statistical Yearbook and the annual report of national cancer registration and statistics in Korea were assessed. From the data, the incidence, prevalence, and mortality rates of PCa were calculated. The data were presented with reference to other types of cancers occurring in various countries from different continents. RESULTS: From 2007 to 2013, PCa incidence doubled (from 5,516 per year to 10,855 per year), while its prevalence in Korean men tripled (from 18,830 to 51,411) during the same period. The mortality rate increased slightly, from 4.2 in 2000 to 5.9 in 2007 and 6.0 in 2013 (per 100,000, age adjusted). PCa incidence increased significantly faster in men aged < 70 years than in the older age group. CONCLUSION: PCa prevalence in South Korea has increased significantly, mainly due to the rise in its incidence. As the country is facing major changes, including westernization of dietary habits and rapid population aging, its prevalence would continue to increase in near future.

Factors associated with continuing medical therapy after transurethral resection of prostate.

OBJECTIVE: To report the clinical characteristics of patients who have persistent lower urinary tract symptoms (LUTS) after surgery for benign prostatic hyperplasia (BPH) and continue their medical therapy postoperatively. MATERIALS AND METHODS: We retrospectively studied 372 patients who underwent transurethral resection of prostate for LUTS/BPH in 8 institutions to determine the differences between patients who continued LUTS/BPH medications for >3 months after surgery and those who did not. Preoperative, intraoperative, and postoperative clinical parameters were assessed. The Student t test and chi square test were used to compare each parameter between patient groups. Multivariate logistic regression analysis was performed to identify risk factors for persistent LUTS and continuing medical therapy after surgery. RESULTS: There were 205 patients (55.1%) who continued their LUTS/BPH medications for >3 months postoperatively. They reported poorer International Prostate Symptom Scores and uroflowmetry results after surgery. Multivariate analysis showed that age >70 years (odds ratio [OR], 2.474; P = .001), history of diabetes (OR, 1.949; P = .040), history of cerebrovascular accident (OR, 5.932; P = .001), any previous LUTS/BPH medication use (OR, 5.384; P = <0.001), and previous antimuscarinic drug use (OR, 2.962; P = .016) were significantly associated with symptom persistency and continuing medical therapy. CONCLUSION: Many patients have persistent voiding dysfunction after surgical treatment for LUTS/BPH. Older age, history of diabetes, history of cerebrovascular accidents, and preoperative antimuscarinic drug uses are possible risk factors.

Prevalence and risk factors of bladder neck contracture after radical prostatectomy.

PURPOSE: To evaluate the prevalence of bladder neck contracture (BNC) and its risk factors in patients undergoing radical prostatectomy in Korea. MATERIALS AND METHODS: We analyzed data from 488 patients with prostatic cancer who underwent radical prostatectomy performed by seven surgeons in seven hospitals, including 365 open radical prostatectomies (ORPs), 99 laparoscopic radical prostatectomies (LRPs), and 24 robot-assisted laparoscopic radical prostatectomies (RARPs). Patients with BNCs were compared with those without BNCs to identify the risk factors for BNC occurrence. RESULTS: Overall, BNCs occurred in 21 of 488 patients (4.3%): 17 patients (4.7%) who underwent ORP, 4 patients (4%) who underwent LRP, and no patients who underwent RARP. In the univariate analysis, men with BNCs had a longer length of time before drain removal (12 days vs. 6.8 days, p<0.001), which reflected urinary leakage through the vesicourethral anastomosis. In the multivariate analysis, the length of time before drain removal was the only predictor of BNC (odds ratio, 1.12; p=0.001). Intraoperative blood loss was higher in patients with BNC, but the difference was not statistically significant. CONCLUSIONS: The most significant factor related to BNC occurrence after radical prostatectomy in our study was the length of time before drain removal, which reflects urinary leakage from the vesicourethral anastomosis. The proper formation of a watertight anastomosis to decrease urinary leakage may help to reduce the occurrence of BNC.

Is there a difference in laterality during robot-assisted radical prostatectomy? Assessment of lymph node yield and neurovascular bundle dissection.

BACKGROUND AND PURPOSE: The da Vinci Surgical System (dVSS) has been reported to eliminate innate hand dominance of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its own inherent "handedness" resulting from the fixed left-right preference of specific instrument docking and assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB) dissections as well as positive surgical margin rates as procedure points during robot-assisted radical prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency. PATIENTS AND METHODS: Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010 were identified. Surgeon instrument preference and port placement were consistent across all cases. Pathologic LN yield was stratified by the intended limits of dissection (limited or extended) and laterality. In addition, fascial widths (FW) were prospectively measured for 93 consecutive patients, a narrower FW indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections. RESULTS: A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right compared with the left (3.26 vs 2.76, P=0.010). This difference was not seen in the extended LN dissection (P=0.96). Average FW was narrower on the right surgical margin compared with the left (1.99 vs 2.64 mm, P<0.001). CONCLUSIONS: Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved on the right compared with the left using the dVSS during RARP. This can be attributed to surgeon handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these potential differences is important for the preoperative planning before RARP.

Defining optimal laser-fiber sweeping angle for effective tissue vaporization using 180 W 532 nm lithium triborate laser.

PURPOSE: The goal of this study is to identify the most efficient sweeping angle (SA) during photoselective vaporization of the prostate (PVP). MATERIALS AND METHODS: Experiments were conducted with GreenLight XPS™ laser at 120 and 180 W. Ten blocks of porcine kidney were used for each SA (0, 15, 30, 45, 60, 90, and 120 degrees). Vaporization efficiency was assessed by the amount of tissue removed per time. The coagulation zone (CZ) thickness was also measured. RESULTS: Maximal vaporization rate (VR) was achieved at SA 15 and 30 degrees. Irrespective of power, VR increased and CZ decreased linearly with decreasing SA from 120 to 30 degrees. The CZ was the thinnest at SA 30 degrees. CONCLUSIONS: Optimal vaporization occurred at a SA of 15 degrees and 30 degrees with the lowest CZ at 30 degrees. Contrary to a previous recommendation for a wider SA (60 degrees or greater), a narrower SA (30 degrees) achieved the maximal tissue vaporization efficiency.