Effects of resection volume on postoperative micturition symptoms and retreatment after transurethral resection of the prostate.

PURPOSE: Despite advances in technology, such as advent of laser enucleation and minimally invasive surgical therapies, transurethral resection of the prostate (TURP) remains the most widely performed surgical technique for benign prostatic hyperplasia (BPH). We evaluated resection volume (RV)-derived parameters and analyzed the effect of RV on post-TURP outcomes. METHODS: This observational study used data from patients who underwent TURP at two institutions between January 2011 and December 2021 Data from patients with previous BPH surgical treatment, incomplete data, and underlying disease affecting voiding function were excluded. The collected data included age, prostate-specific antigen, transrectal ultrasound (TRUS)- and uroflowmetry-derived parameters, RV, perioperative laboratory values, perioperative International Prostatic Symptom Score (IPSS), follow-up period, retreatment requirements and interval between the first TURP and retreatment. RESULTS: In 268 patients without prior BPH medication, there were no differences in prostate volume (PV), transitional zone volume (TZV), or RV according to IPSS. A total of 60 patients started retreatment, including medical or surgical treatment, within the follow-up period. There was a significant difference in RV/PV between the groups without and with retreatment respectively (0.56 and 0.37; p = 0.008). However, preoperative TRUS- and uroflowmetry-derived parameters did not differ between the two groups. Multiple linear regression analysis showed that RV (p = 0.003) and RV/TZV (p = 0.006) were significantly associated with differences in perioperative IPSS. In the multivariate logistic regression analysis, only RV/PV was correlated with retreatment (p = 0.010). CONCLUSION: Maximal TURP leads to improved postoperative outcomes and reduced retreatment rate, it may gradually become a requirement rather than an option.

Venadaparib Is a Novel and Selective PARP Inhibitor with Improved Physicochemical Properties, Efficacy, and Safety.

PARP inhibitors have been approved by the FDA for use in the treatment of patients with ovarian, breast, pancreatic, and prostate cancers. PARP inhibitors show diverse suppressive effects on PARP family members and PARP-DNA trapping potency. These properties are associated with distinct safety/efficacy profiles. Here, we report the nonclinical characteristics of venadaparib (also known as IDX-1197 or NOV140101), a novel potent PARP inhibitor. The physiochemical properties of venadaparib were analyzed. Furthermore, the efficacy of venadaparib against PARP enzymes, PAR formation, and PARP trapping activities, and growth inhibition of cell lines with BRCA mutations were evaluated. Ex vivo and in vivo models were also established to study pharmacokinetics/pharmacodynamics, efficacy, and toxicity. Venadaparib specifically inhibits PARP-1 and -2 enzymes. Oral administration of venadaparib HCl at doses above 12.5 mg/kg significantly reduced tumor growth in the OV_065 patient-derived xenograft model. Intratumoral PARP inhibition remained at over 90% until 24 hours after dosing. Venadaparib had wider safety margins than olaparib. Notably, venadaparib showed favorable physicochemical properties and superior anticancer effects in homologous recombination-deficient in vitro and in vivo models with improved safety profiles. Our results suggest the possibility of venadaparib as a next-generation PARP inhibitor. On the basis of these findings, phase Ib/IIa studies on the efficacy and safety of venadaparib have been initiated.

Lessons learned from clinical outcome and tumor features of patients underwent selective artery embolization due to postoperative bleeding following 2076 partial nephrectomies: propensity scoring matched study.

PURPOSE: To evaluate the clinical and tumor characteristics in patients undergoing selective artery embolization (SAE) for bleeding after partial nephrectomy (PN). METHODS: We retrospectively evaluated patients who underwent SAE from 2076 patients who underwent PN. The clinical and tumor characteristics of these patients were analyzed using entire data and propensity score matching (PSM). 76 patients who underwent PN (control, n = 38 patients; SAE, n = 38) were enrolled in PSM. RESULTS: SAE was performed in 41 patients who underwent open (19/1171), laparoscopic (4/60), and robot-assisted PN (18/845). The median period from PN to SAE was 12 days (interquartile range 8-24 day). The most common symptom of 31 (75.61%) patients was gross hematuria, followed by flank pain (3/41). Follow-up imaging revealed large pseudoaneurysm in 7 asymptomatic patients. The main reason for SAE on angiography was pseudoaneurysm (32/41), followed by arteriovenous fistula (5/41). Technical and clinical success was achieved in all patients. There was no statistical difference in the estimated glomerular filtration rate after 1 year, surgical methods, or baseline characteristics between the two groups. Conversely, there was statistically significant difference in ischemic time in the entire data and PSM. In the embolization group, renal masses showed statistically significant endophytic (p = 0.006) and posterior (p = 0.028) characteristics. CONCLUSIONS: SAE is an effective method for controlling postoperative bleeding while preserving renal function after PN. And, we suggest more attentive postoperative surveillance about vascular complications in patients with longer ischemia time or renal masses with endophytic and posterior locations.

Comparison of Oncologic Outcomes Between Two Alternative Sequences with Abiraterone Acetate and Enzalutamide in Patients with Metastatic Castration-Resistant Prostate Cancer: A Systematic Review and Meta-Analysis.

Sequential treatment of androgen receptor axis targeted agents (ARAT), abiraterone acetate (ABI) and enzalutamide (ENZA), in metastatic castration-resistant prostate cancer (mCRPC) demonstrated some positive effects, but cross-resistances between ABI and ENZA that reduce activity have been suggested. Therefore, we conducted a meta-analysis to compare oncologic outcomes between the treatment sequences of ABI-ENZA and ENZA-ABI in patients with mCRPC. The primary endpoint was a combined progression-free survival (PFS), and the secondary endpoint was overall survival (OS). A total of five trials on 553 patients were included in this study. Each of the included studies was retrospective. In two studies including both chemo-naïve and post-chemotherapy mCRPC patients, for ABI-ENZA compared with ENZA-ABI, pooled hazard ratios (HRs) for PFS and OS were 0.37 (p < 0.0001; 95% confidence intervals (CIs), 0.23-0.60) and 0.64 (p = 0.10; 95% CIs, 0.37-1.10), respectively. In three studies with chemo-naïve mCRPC patients only, for ABI-ENZA compared with ENZA-ABI, pooled HRs for PFS and OS were 0.57 (p = 0.02; 95% CIs, 0.35-0.92) and 0.86 (p = 0.39; 95% CIs, 0.61-1.21), respectively. The current meta-analysis revealed that ABI-ENZA had a significantly more favorable oncological outcome, but the level of evidence was low. Therefore, large-scale randomized trials may be needed.

Does an Alternative Sunitinib Dosing Schedule Really Improve Survival Outcomes over a Conventional Dosing Schedule in Patients with Metastatic Renal Cell Carcinoma? An Updated Systematic Review and Meta-Analysis.

Treatment-related adverse events (AEs) can obfuscate the maintenance of a conventional schedule of sunitinib in patients with metastatic renal cell carcinoma. Accordingly, alternative schedules seeking to improve the safety profile of sunitinib have been tested. Recently, two meta-analyses similarly described improved safety profiles favoring a two weeks on and one week off (2/1) schedule, but with conflicting results for survival outcomes. Therefore, we conducted an updated systematic review and meta-analysis, including all recently published studies and using complementary statistical methods. Endpoints included progression-free survival, overall survival, and AEs of 15 types. Eleven articles were included in this meta-analysis. Using adjusted findings, we noted statistically better results in progression-free survival (hazard ratio, 0.58; 95% confidence interval, 0.39-0.84; p = 0.005), but no difference in overall survival (hazard ratio, 0.66; 95% confidence interval, 0.42-1.04; p = 0.08). Moreover, the 2/1 schedule was beneficial for reducing the incidence of several AEs. Conclusively, our meta-analysis suggests that the 2/1 schedule holds promise as an alternative means of reducing AEs and maintaining patient quality of life. While the survival outcomes of the 2/1 schedule seem also to be favorable, the level of evidence for this was low, and the interpretation of these findings should warrant caution. Large scale randomized trials are needed to support these results.

Clinical Significance of Multiparametric Magnetic Resonance Imaging as a Preoperative Predictor of Oncologic Outcome in Very Low-Risk Prostate Cancer

Currently, multiparametric magnetic resonance imaging (mpMRI) is not an indication for patients with very low-risk prostate cancer. In this study, we aimed to evaluate the usefulness of mpMRI as a diagnostic tool in these patients. We retrospectively analyzed the clinical and pathological data of individuals with very low-risk prostate cancer, according to the NCCN guidelines, who underwent mpMRI before radical prostatectomy at our institution between 2010 and 2016. Patients who did not undergo pre-evaluation with mpMRI were excluded. We analyzed the factors associated with biochemical recurrence (BCR) using Cox regression model, logistic regression analysis, and Kaplan⁻Meier curve. Of 253 very low-risk prostate cancer patients, we observed 26 (10.3%) with BCR during the follow-up period in this study. The median follow-up from radical prostatectomy was 53 months (IQR 33⁻74). The multivariate Cox regression analyses demonstrated that the only factor associated with BCR in very low-risk patients was increase in the pathologic Gleason score (GS) (HR: 2.185, p-value 0.048). In addition, multivariate logistic analyses identified prostate specific antigen (PSA) (OR: 1.353, p-value 0.010), PSA density (OR: 1.160, p-value 0.013), and suspicious lesion on mpMRI (OR: 1.995, p-value 0.019) as the independent preoperative predictors associated with the pathologic GS upgrade. In our study, the pathologic GS upgrade after radical prostatectomy in very low-risk prostate cancer patients demonstrated a negative impact on BCR and mpMRI is a good prognostic tool to predict the pathologic GS upgrade. We believe that the implementation of mpMRI would be beneficial to determine the treatment strategy for these patients.

Is Pelvic Plexus Block Superior to Periprostatic Nerve Block for Pain Control during Transrectal Ultrasonography-Guided Prostate Biopsy? A Double-Blind, Randomized Controlled Trial.

We evaluated whether pelvic plexus block (PPB) is superior to periprostatic nerve block (PNB) for pain control during transrectal ultrasonography (TRUS)-guided prostate biopsy (PBx). A prospective, double-blind, randomized, controlled study was performed at a single center; 46 patients were enrolled and randomly allocated into two groups: PPB (n = 23) and PNB (n = 23). The visual analogue scale (VAS) was used; pain scores were measured four times: during local anesthesia, probe insertion, sampling procedures, and at 15 min post procedures. No significant differences were observed in VAS scores during local anesthesia (2.30 for PPB vs. 2.65 for PNB, p = 0.537) or during probe insertion (2.83 for PPB vs. 2.39 for PNB, p = 0.569). Similarly, no differences in VAS scores were detected during the sampling procedures (2.83 for PPB vs. 2.87 for PNB, p = 0.867) and at 15 min post procedures (1.39 for PPB vs. 1.26 for PNB, p = 0.631). No major complications were noted in either group. Both PPB and PNB are comparably effective and safe methods for PBx related pain relief, and PPB is not superior to PNB. Local anesthetic method could be selected based on the preference and skill of the operator.

Neonatal Bladder Irritation Is Associated With Vanilloid Receptor TRPV1 Expression in Adult Rats.

PURPOSE: To evaluate whether mild chemical irritation of the bladder in neonatal rats is associated with persistent vanilloid receptor transient receptor potential vanilloid subfamily 1 (TRPV1) activity in adult rats. METHODS: Female Sprague-Dawley rats were used. Ten-day-old rat pups underwent bladder sensitization via intravesical infusion of 0.2% acetic acid in saline with or without prior bladder desensitization with capsaicin. After 8 weeks, 3 groups of rats (control [group 1], bladder sensitization [group 2], and bladder desensitization [group 3]) underwent cystometry. Inflammation of bladder tissue and the expression of TRPV1 in bladder tissue and dorsal root ganglia (DRG) were also evaluated. RESULTS: The bladder sensitization group showed more frequent voiding contractions. TRPV1 expression in adult bladder tissue was elevated in group 2. TRPV1 mRNA levels in the bladder and DRG were significantly higher in group 2 than in group 1. Moreover, group 2 had significantly more DRG neurons (identified by uptake of the retrograde label Fast Blue) that exhibited TRPV1 immunoreactivity. CONCLUSION: We found a significant association between neonatal bladder sensitization and persistent TRPV1 activity in adult rats. This is the first study to focus on the underlying pathogenesis of bladder overactivity from childhood to adulthood. Our findings could lead to the development of new strategies for the treatment and prevention of adult urinary symptoms arising from childhood urinary tract dysfunction.

Neurologic Mechanisms Underlying Voiding Dysfunction due to Prostatitis in a Rat Model of Nonbacterial Prostatic Inflammation.

PURPOSE: The neurological molecular mechanisms underlying the voiding dysfunction associated with nonbacterial chronic prostatitis/chronic pelvic pain syndrome remain poorly understood. In this study, we assessed whether prostate inflammation activated bladder afferent neurons, leading to bladder dysfunction, and sought to elucidate the underlying mechanisms. METHODS: Thirty male Sprague-Dawley rats were divided into 3 groups: sham-saline, formalin-injected, and capsaicin-pretreated and formalin-injected. Chemical prostatitis was induced by 0.1 mL of 10% buffered formalin injected into the ventral prostate. Capsaicin was injected subcutaneously to desensitize capsaicin-sensitive nerves. In each group, conscious cystometry was performed, and c-fos expression within the spinal cord was determined immunocytochemically. Double immunofluorescent staining with c-fos and choline acetyltransferase (ChAT) was performed. On the third day after pseudorabies virus (PRV) infection, c-fos and PRV double-staining was performed. RESULTS: Intraprostatic formalin significantly increased the maximal voiding pressure and decreased the intercontraction interval, compared with controls. Pretreatment with capsaicin significantly reversed these effects. More c-fos-positive cells were observed in the sacral parasympathetic nucleus (SPN) and dorsal gray commissure (DCM) in the prostatitis group than in the sham group. c-fos-positive cells decreased in the capsaicin-pretreated group. Preganglionic neurons labeled by c-fos and ChAT were observed in the SPN in rats with prostatitis. Interneurons labeled by c-fos and PRV were identified in the DCM after PRV infection. CONCLUSIONS: Our results suggest that prostate inflammation activates afferent nerve fibers projecting to the lumbosacral spinal cord, producing reflex activation of spinal neurons innervating the bladder and bladder hyperreflexia. This is mediated by capsaicin-sensitive prostate afferent neurons.

The Impact of Preoperative α-Adrenergic Antagonists on Ureteral Access Sheath Insertion Force and the Upper Limit of Force Required to Avoid Ureteral Mucosal Injury: A Randomized Controlled Study.

PURPOSE: Excessive bulking force during primary access of the ureteral access sheath may induce ureteral injury. We investigated the efficacy of preoperative α-blockade to reduce ureteral access sheath insertion force and determine the upper limit required to avoid ureteral injury. MATERIALS AND METHODS: In this randomized controlled trial 135 patients from a single institution who had ureteropelvic junction or renal pelvis stones and were scheduled to undergo retrograde intrarenal surgery were prospectively enrolled from December 2015 to January 2017. Of the patients 41 and 42 were randomly assigned to the control and experimental groups, respectively. The experimental group received α-blockade preoperatively. The 21 patients who were pre-stented were assessed separately. We developed a homemade device to measure maximal ureteral access sheath insertion force. RESULTS: Our ureteral access sheath insertion force measurement device showed excellent reproducibility. Higher insertion velocity resulted in greater maximal sheath insertion force. Maximal insertion force in the α-blockade group was significantly lower than in the control group at the ureterovesical junction (p = 0.008) and the proximal ureter (p = 0.036). Maximal insertion force in the α-blockade group was comparable to that in pre-stented patients. Female patients and patients 70 years old or older showed a lower maximal ureteral access sheath insertion force than their counterparts. The rate of grade 2 or greater ureteral injury was lower in the α-blockade group than in controls (p = 0.038). No injury occurred in any case in which ureteral access sheath insertion force did not exceed 600 G. CONCLUSIONS: Preoperative α-blockade and slow sheath placement may reduce maximal ureteral access sheath insertion force. If the force exceeds 600 G, a smaller diameter sheath may be an alternative. Alternatively the procedure can be terminated and followed later by pre-stented retrograde intrarenal surgery.

Effect of Climatic Parameters on Acute Urinary Retention Incidence.

OBJECTIVES: We investigated the effect of daily climatic parameters on spontaneous acute urinary retention (sAUR) and evaluated the risk factors for refractory/recurrent AUR. METHODS: A total of 4194 patients older than 40 years were diagnosed with AUR in the emergency department at Gangnam Severance Hospital, Seoul, from January 2007 to May 2016. To evaluate climatic parameters at sAUR onset, we included individuals living in the area around the hospital. We excluded patients with fever, who did not return to the hospital after the AUR episode or with AUR occurring within 2 weeks following admission for surgery or chemotherapy. RESULTS: Among 818 patients living in the two districts around the hospital, winter and October had the highest seasonal and monthly rates of sAUR development, respectively, and sAUR incidence increased with age. Daily temperature range and mean wind speed were significant risk factors for sAUR development. Several daily climatic parameters had seasonal effects on sAUR incidence. Over a mean follow-up of 0.98 years, 122 patients (14.9%) developed refractory/recurrent AUR. Transitional zone index (TZI; HR = 1.03; P = 0.002) and prostate-specific antigen (PSA) at the time of sAUR (HR = 1.01; P = 0.030) were significant predictors of refractory/recurrent AUR. Benign prostate hyperplasia medication and transurethral prostatectomy after sAUR were not risk factors for refractory/recurrent AUR. CONCLUSIONS: Cold temperature provoked sAUR in patients with higher age and International Prostate Symptom Score. Patients with higher TZI and PSA level at the time of sAUR had a greater risk of developing refractory/recurrent AUR.

Transurethral resection of the prostate for patients with Gleason score 6 prostate cancer and symptomatic prostatic enlargement: a risk-adaptive strategy for the era of active surveillance.

OBJECTIVE: To investigate whether transurethral resection of the prostate can be used as both (i) treatment for symptomatic prostatic enlargement in patients with prostate cancer and (ii) a risk-adaptive strategy for reducing prostate-specific antigen levels and broadening the indications of active surveillance. METHODS: We retrospectively reviewed data of 3680 patients who underwent prostate biopsies at a single institution (March 2006 to January 2012). Of 529 men who had Gleason score 6 prostate cancer and were ineligible for active surveillance, 86 (16.3%) underwent transurethral resection of the prostate for symptomatic prostatic enlargement. We assessed how changes in prostate-specific antigen and prostate-specific antigen density influenced the eligibility for active surveillance and the outcome of subsequent therapy. The following active surveillance criteria were used: prostate-specific antigen ≤ 10 ng/ml, prostate-specific antigen density ≤ 0.15, positive cores ≤ 3 and single core involvement ≤ 50%. RESULTS: The median age, pre-operative prostate-specific antigen and prostate volume were 71 years, 6.95 ng/ml, and 45.8 g, respectively. In 82.6% (71/86) of analyzed cases, ineligibility for active surveillance had resulted from elevated prostate-specific antigen level or prostate-specific antigen density. With a median resection of 16.5 g, transurethral resection of the prostate reduced the percentage of prostate-specific antigen and the percentage of prostate-specific antigen density by 34.5 and 50.0%, respectively, making 81.7% (58/71) of the patients eligible for active surveillance. Prostate-specific antigen level remained stabilized in all (21/21) patients maintained on active surveillance without disease progression during the median follow-up of 50.6 months. Among patients who underwent radical prostatectomy, 96.7% (29/30) exhibited localized disease. CONCLUSIONS: Risk-adaptive transurethral resection of the prostate may prevent overtreatment and allay prostate-specific antigen-associated anxiety in patients with biopsy-proven low-grade prostate cancer and elevated prostate-specific antigen. Additional benefits include voiding symptom improvement and the avoidance of curative therapy's immediate side effects.

Delayed redo pyeloplasty fails to recover lost renal function after failed pyeloplasty: early sonographic changes that correlate with a loss of differential renal function.

PURPOSE: To evaluate changes in differential renal function (DRF), as a functional outcome, in children who underwent redo pyeloplasty for management of failed pyeloplasty and to examine the factors that affect functional outcomes. MATERIALS AND METHODS: Between January 2002 and November 2010, a total of 18 patients who underwent redo pyeloplasty for persistent ureteropelvic junction obstruction after failed pyeloplasty were enrolled in this study. We assessed perioperative factors and evaluated changes in renal cortical thickness (RCT), renal function, and hydronephrosis by use of serial ultrasound and diuretic renography. RESULTS: The mean follow-up period was 44.83±28.86 months. After redo pyeloplasty, prevention of further functional deterioration was observed in only 12 of the 18 patients. After dividing the patients according to this observation, we discovered significant differences in both change in DRF (dDRF) and change in RCT (dRCT) (difference between before and after initial pyeloplasty) between the two groups (p<0.001). Additionally, we noted a significant positive correlation between dRCT and dDRF. All patients showed improvements in hydronephrosis grade and relief of symptoms compared with before redo pyeloplasty. CONCLUSIONS: Redo pyeloplasty should be considered in cases of failed pyeloplasty to preserve renal function and obtain relief from symptoms. If patients show severe deterioration of DRF or a decrease in RCT after initial pyeloplasty, preservation of DRF in these patients after redo pyeloplasty could be difficult. Therefore, redo pyeloplasty should be performed before severe deterioration of DRF or decrease in RCT.

Unrecognized kinetics of serum testosterone: impact on short-term androgen deprivation therapy for prostate cancer.

PURPOSE: To evaluate the kinetics of serum testosterone (T) recovery following short-term androgen deprivation therapy (ADT), as the understanding thereof is essential for the proper management of prostate cancer (PCa), especially intermittent ADT. MATERIALS AND METHODS: This prospective analysis included male sex offenders who voluntarily received leuprolide acetate in order to alleviate sexual aberrance. Thirty-three and 25 patients who received 3 and 6 months of ADT were assigned to Group A and Group B, respectively. Serum T levels were obtained every week during the on-cycle period, then monthly during the off-cycle period for at least 12 months. RESULTS: The kinetics of serum T during the on-cycle period were similar in both groups. After flare reaction at week 2, a nadir of 0.45±0.29 ng/mL was achieved. In Group A, an abrupt rebound-upsurge was observed during the first 2 month off-cycle period, which surpassed the baseline level and reached a plateau level of 8.74±2.11 ng/mL during the flare (p<0.001). This upsurge was followed by a gradual decline back to baseline over the following 10 months. In Group B, a gradual increase was observed, and a baseline level of 7.26±1.73 ng/mL was reached at 5 months. Thereafter, an ongoing upsurge that surpassed baseline levels was observed until 12 months (8.81±1.92 ng/mL; p=0.002). CONCLUSION: The kinetics of serum T recovery during the off-cycle period varied according to the duration of ADT. Serum T should be monitored beyond normalization, as an excessive rebound may improve quality-of-life, but hamper the treatment efficacy of PCa.

Impact of ectopic insertion on treatment outcome of primary non-refluxing megaureter.

OBJECTIVE: To investigate the characteristics of primary non-refluxing megaureter with ectopic insertion and its effects on renal function. METHODS: Of 118 patients diagnosed with primary non-refluxing megaureter, we retrospectively studied 33 patients who underwent surgical treatment. Depending on the position of ureteral insertion, patients were classified as having either an ectopic or orthotopic megaureter; clinical characteristics and renal function, were analyzed. RESULTS: Among the 36 primary non-refluxing megaureters, 7 (19.4%) had ectopic megaureter. A total of 34.5% of the orthotopic megaureter and all ectopic megaureter cases were women (P = .003). The mean value of maximum ureteral diameter was significantly wider for ectopic than for orthotopic megaureter (16.3 vs 12.1 mm, respectively, P = .029). Mean preoperative differential renal function (DRF) were 36.4% and 43.0% for ectopic and orthotopic megaureters, respectively (P = .164). After surgery, the mean DRF of ectopic megaureter had decreased from 50% to 18.8%, whereas the mean DRF of orthotopic megaureter was 42.9% (P <.001). At the time of surgery, the mean age of patients was 4.6 months in the ectopic megaureter and 16.7 months in the orthotopic megaureter (P = .005). CONCLUSION: In our study, all the cases of an ectopic megaureter occurred in women, and the ureteral dilatation was comparatively more severe than in orthotopic megaureters. In addition, despite early surgical treatment, renal function deteriorated gradually. Further analyses are necessary to determine whether earlier surgical intervention for preventing deterioration of renal function is worthwhile or not.

Easily removable ureteral catheters for internal drainage in children: a preliminary report.

PURPOSE: We review our experience using a new and easily removable ureteral catheter in patients who underwent complicated ureteral reimplantation. Our goal was to shorten hospital stay and lower anxiety during catheter removal without fear of postoperative ureteral obstruction. MATERIALS AND METHODS: Between April 2009 and September 2010, nine patients who underwent our new method of catheter removal after ureteral reimplantation were enrolled. Patients who underwent simple ureteral reimplantation were excluded from the study. Following ureteral reimplantation, a combined drainage system consisting of a suprapubic cystostomy catheter and a ureteral catheter was installed. Proximal external tubing was clamped with a Hem-o-lok clamp and the rest of the external tubing was eliminated. Data concerning the age and sex of each patient, reason for operation, method of ureteral reimplantation, and postoperative parameters such as length of hospital stay and complications were recorded. RESULTS: Of the nine patients, four had refluxing megaureter, four had a solitary or non-functional contralateral kidney and one had ureteral stricture due to a previous anti-reflux operation. The catheter was removed at postoperative week one. The mean postoperative hospital stay was 2.4 days (range 1-4 days), and the mean follow-up was 9.8 months. None of the patients had postoperative ureteral obstructions, and there were no cases of migration or dislodgement of the catheter. CONCLUSION: Our new method for removing the ureteral catheter would shorten hospital stays and lower levels of anxiety when removing ureteral catheters in patients with a high risk of postoperative ureteral obstruction.

Transmesocolic approach for left side laparoscopic pyeloplasty: comparison with laterocolic approach in the initial learning period.

PURPOSE: To evaluate the outcome of transmesocolic (TMC) laparoscopic pyeloplasty compared with conventional laterocolic procedure for surgeons with limited experience. MATERIALS AND METHODS: We started laparoscopic pyeloplasty for ureteropelvic junction obstruction in 2009. Since then, 21 patients of left side disease have undergone this surgery in our institution. To access the left ureteropelvic junction, we used the conventional laterocolic approach in 9 patients, while the transmesocolic approach was used in the remaining 12 patients, and perioperative results and follow-up data were then compared. RESULTS: The mean operative time using the transmesocolic approach was significantly shorter than the conventional laterocolic approach (242 vs. 308 min, p=0.022). Furthermore, there was no complication or open conversion. Postoperative pain was significantly decreased in the TMC group (2.8 vs. 4.0 points, measured using the visual analogue scale on the first postoperative day, p=0.009). Postoperative complications were encountered in two patients. All patients were symptom-free after 1 year of follow-up, and radiologic success rates for each group were 92 and 89%, respectively. CONCLUSION: Direct exposure of the ureteropelvic junction via the mesocolon saves time during the colon mobilization procedure. The approach is safe and feasible even for surgeons with limited experience, and has success rates similar to those of the conventional laterocolic approach.

The significance of detrusor wall thickness as a prognostic factor in pediatric bladder outlet obstruction.

PURPOSE: The purpose of this study is to determine detrusor thickness as a prognostic factor in posterior urethral valves. METHODS: The medical information of 41 patients diagnosed with posterior urethral valves at our institute was retrospectively reviewed. The serum creatinine level after bladder decompression, results of ultrasonography, and voiding cystourethrography were compared between groups divided according to the final bladder and renal function. Detrusor thickness was measured using Müller's method. RESULTS: The median detrusor thickness was 1.3 mm (0.4-2.5 mm). After median 45.6 months (7.2-96.0 months) of follow-up, impaired bladder function (IBF) was observed in 14 patients. In multivariate analysis, detrusor thickness greater than 1.3 mm (odds ratio, 32.6; 95% confidence interval, 3.1-340.6; P = .004) was the only independent risk factor for later IBF. Final renal function impairment developed in 24 patients (58.5%), and 3 patients (7.3%) were diagnosed with end-stage renal disease after median 66.0 months (32.4-133.2 months) of follow-up period. On multivariate analysis, age-specific elevated serum creatinine level at presentation (odds ratio, 11.1; 95% confidence interval, 1.1-112.5; P = .042) was an independent risk factor. CONCLUSIONS: Detrusor thickness more than 1.3 mm on ultrasonography was an independent prognostic factor for later IBF.

Diagnostic value of anteroposterior diameter of fetal renal pelvis during second and third trimesters in predicting postnatal surgery among Korean population: useful information for antenatal counseling.

OBJECTIVE: To establish prognostic data regarding fetal hydronephrosis using the anteroposterior diameter (APD) and the need for interventional surgery in the Korean population. METHODS: A total of 187 children with an APD of ≥ 4 mm on obstetric ultrasound scans at any gestational age were retrospectively reviewed. The affected renal units were divided into 2 groups: surgical and nonsurgical. The ultrasound findings were compared at 3 gestational ages: second trimester (15-26 weeks' gestation), early third trimester (27-33 weeks' gestation), and late third trimester (34-40 weeks' gestation). RESULTS: The area under the receiver operating characteristic curve was 0.770, 0.828, and 0.812 at the second, early third, and late third trimesters, respectively. A 100% sensitivity for predicting postnatal surgery could be achieved at a cutoff APD of 5 mm during the second trimester, 8 mm during the early third trimester, and 10 mm during the late third trimester if scheduled antenatal ultrasound scans were performed. A cutoff APD of 11 mm during the second trimester was of diagnostic value in selecting children at risk of postnatal surgery with an odds ratio of 5.13 (95% confidence interval 1.62-16.25), with relatively high sensitivity and specificity. With a cutoff of 15 mm during the early third and late third trimesters, the odds ratio was 11.51 (95% confidence interval 5.05-26.23) and 6.94 (95% confidence interval 3.30-14.57), respectively. CONCLUSION: Compared with an APD of 10 mm, the most commonly used standard cutoff value in predicting postnatal hydronephrosis and its outcome, an APD cutoff of 5, 8, and 10 mm during the second, early third, and late third trimesters, respectively, is more specific in predicting the need for postnatal surgical intervention in the Korean population.

Transvesicoscopic ureteral reimplantation in children with bilateral vesicoureteral reflux: surgical technique and results.

OBJECTIVES: To report our initial experience with transvesicoscopic cross-trigonal ureteral reimplantation (TVUR), describing stepwise the surgical procedure and determining critical aspects of this surgery in the actual surgical field. SUBJECTS AND METHODS: Between September 2008 and April 2010, 48 patients with bilateral vesicoureteral reflux (VUR) underwent TVUR. To identify the critical aspects affecting the surgical difficulty, we divided our TVUR procedure into four steps: TVUR set-up, mobilization of ureters, creation of submucosal tunnels, and ureterovesical anastomosis. To evaluate the evolution of our TVUR, we analyzed changes in the operative time and complications versus increase in surgeon experience (dividing our cases into three groups: the first third, the second third, and the last third). Changes in operative time for all four steps of TVUR were analyzed separately, as well as change in overall operative time. RESULTS: Of a total of 48 cases, 45 patients underwent TVUR successfully except for 3 cases of open conversion. Among the 45 cases, the mean overall operative time was 155.6 min. In 1 patient, proximal migration of the ureteral catheter occurred. No other perioperative complications were observed. The mean postoperative hospital stay was 1.6 days. The VUR resolution rate was 96.4%. Upon analysis of our results by step, Step 4 (ureterovesical anastomosis) required the largest portion of the overall operative time in most cases. During the early period of our TVUR, we encountered several technical difficulties. However, the operative times for all four steps were stabilized with increasing number of cases, without deteriorating surgical outcomes. CONCLUSIONS: Our report demonstrates that TVUR might potentially be a safe and effective alternative to open ureteral reimplantation in children with VUR, with a shorter learning curve than expected.