The Role of Reactive Oxygen Species, Inflammation, and Endoplasmic Reticulum Stress Response in the Finasteride Protective Effect against Benign Prostate Hyperplasia.

PURPOSE: Benign prostate hyperplasia (BPH) is a common age-related chronic condition. Its pathogenesis involves androgen imbalance, inflammation, oxidative stress, and endoplasmic reticulum (ER) stress. This study aims to assess the protective effect of finasteride, a 5α-reductase inhibitor, against testosterone propionate (TP)-induced BPH in rats and explore its potential mechanism of action. MATERIALS AND METHODS: TP-induced BPH rats received either saline or finasteride (1 mg/kg) orally once a day for 7 weeks. Prior to sacrificing the animals, blood samples were collected. After sacrifice, prostate and tissue around the prostate were dissected from seminal vesical for further analysis. Body weight, prostate weight, dihydrotestosterone (DHT), 5α-reductase type 2 (5-AR2), and prostate-specific antigen (PSA) levels were measured. In addition, HIF-1α, VEGF, MMP-2 expressions in prostate, oxidative stress, inflammation, and ER stress responses were analyzed to understand the mechanism of action of finasteride. RESULTS: Finasteride administration inhibited prostate enlargement, DHT, 5-AR2, and PSA levels in BPH rats. Additionally, finasteride inhibited angiogenesis markers such as HIF-1α, VEGF, and MMP-2. Moreover, components of oxidative stress, inflammation, and ER stress responses were significantly regulated by finasteride treatment. CONCLUSIONS: This study suggests that finasteride prevents BPH-associated symptoms by regulating angiogenesis, reactive oxygen species, ER stress responses, and inflammation, another mechanism to explain the effect of the 5α-reductase against BPH.

Endobronchial Metastasis of Renal Cancer Presented as Atelectasis.

The most common primary tumors associated with endobronchial metastasis (EBM) are colorectal, breast, and renal. When EBM is present, respiratory symptoms such as shortness of breath or hemoptysis accompanied by coughing usually appear. Herein, we report a case of atelectasis caused by EBM of renal cell carcinoma (RCC) in a 53-year-old man who underwent laparoscopic radical nephrectomy for RCC 5 years ago. The patient's primary RCC stage was pT1b, and the histological cell type was clear cell RCC with Fuhrman nuclear grade 3/4. At the time of EBM diagnosis, the patient was classified as "favorable" according to IMDC (International mRCC Database Consortium) risk calculator. The patient refused surgical treatment and received targeted therapy with sunitinib. A tumor mass spontaneously detached and came out through the airway during targeted therapy. Subsequently, the patient's respiratory symptoms were alleviated, and his atelectasis disappeared. This case shows that when there is atelectasis due to EBM of RCC, the obstructed bronchus may be reopened with targeted therapy without any interventional treatment.

The prognostic value of the pretreatment serum albumin to globulin ratio for predicting adverse pathology in patients undergoing radical prostatectomy for prostate cancer.

PURPOSE: Few studies have demonstrated the clinical significance of pretreatment serum albumin and globulin in prostate cancer (PCa). This study evaluated the association between the pretreatment albumin to globulin ratio (AGR) and clinicopathologic characteristics of nonmetastatic PCa in a large multicenter setting in Korea. MATERIALS AND METHODS: This study involved 742 patients with nonmetastatic PCa who underwent radical prostatectomy (RP) in seven institutions between January 2011 and December 2012. The AGR was calculated as follows: albumin/(total protein-albumin). Patients were divided into low and high AGR groups by a cutoff value from a receiver operating characteristic curve analysis. RESULTS: The best cutoff for the AGR was set at 1.53. The area under the curve of the AGR was 0.624 (95% confidence interval, 0.557-0.671; p<0.001). Patients who had a lower pretreatment AGR (<1.53) were identified as the low AGR group (n=398, 53.6%) and the remaining patients as the high AGR group (n=344, 46.4%). Preoperative AGR was significantly lower in patients with non-organ-confined disease (≥pT3) than in those with organ-confined disease (≤pT2) (p<0.001). The low AGR group had higher aggressive pathologic Gleason scores (pGS) (≥8) than did the high AGR group (p=0.016). Furthermore, the AGR was an independent prognostic factor for high pGS (≥8) and non-organ-confined disease (≥pT3), according to multivariate logistic regression analysis. CONCLUSIONS: A low AGR was closely associated with nonconfined disease (≥pT3) and high pGS (≥8). AGR can be a useful serological marker for predicting adverse pathology in patients with nonmetastatic PCa who undergo RP.

Effect of pre-operative internal obturator muscle mass index in MRI on biochemical recurrence of prostate cancer patients after radical prostatectomy: a multi-center study.

BACKGROUND: Recent reports show that the pre-operative or post-operative skeletal mass index (sarcopenia) affects survival rates for various cancers; however, the link between prostate cancer survival and sarcopenia is unclear. Therefore, this study examined the effect of the pre-operative internal obturator muscle (IOM) mass index on biochemical recurrence (BCR) of prostate cancer (PCa) patients who underwent radical prostatectomy. METHODS: In total, 222 patients, who underwent open, laparoscopic, or robot-assisted radical prostatectomy at seven centers in 2011 and were followed up for 5 years, were enrolled. BCR was examined in the context of pre-operative IOM mass index and BMI. RESULTS: The mean age of the patients was 67.82 ± 6.23 years, and the mean pre-operative prostate-specific antigen (PSA) level was 11.61 ± 13.22 ng/ml. There was no significant difference in baseline characteristics between the low and high IOM mass index groups (p > 0.05). Age, pre-op PSA level, ECE, and T-stage were associated with BCR (p = 0.049, p < 0.001, p = 0.001, p = 0.004, respectively). BMI, prostate volume, Gleason score, resection margin, N-stage, M-stage and IOM mass index was not associated with BCR (p > 0.05). CONCLUSIONS: Pre-operative IOM mass index was not associated with BCR; however, long-term follow-up is necessary to evaluate cancer-specific and overall survival of PCa patients.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report.

RATIONALE: Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown. PATIENT CONCERNS: We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank. DIAGNOSES: The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy. INTERVENTIONS: The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap. OUTCOMES: No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively. LESSONS: In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

Effect of preoperative urethral dilatation on preventing urethral stricture after holmium laser enucleation of the prostate: A randomized controlled study.

INTRODUCTION: We aimed to evaluate the effect of preoperative urethral dilatation during holmium laser enucleation of the prostate (HoLEP) on the prevention of urethral stricture. METHODS: A total of 72 patients without urethral stricture underwent HoLEP for benign prostatic hyperplasia (BPH). Recruited patients were randomly divided into two groups (groups A and B). Patients in group A (36 patients, experimental group) received preoperative urethral dilatation and patients in group B (36 patients, control group) did not. Each patient was evaluated at four weeks, 12 weeks, and 24 weeks after surgery. The effectiveness of preoperative urethral dilatation was evaluated based on the International Prostate Symptom Score (IPSS), peak urine flow rate (Qmax), voided volume, and post-void residual (PVR) volume. To diagnose urethral stricture, Qmax <10 mL/s, as assessed using uroflowmetry and findings of visualization through retrograde urethrography and urethroscopy, were used. RESULTS: Among 72 initial participants, 33 patients in group A and 31 patients in group B completed the experiment. Preoperative characteristics were well-balanced between groups. At each postoperative visit, there was no significant difference in voiding symptoms between groups. Two patients (6.06%) in group A and five patients (15.15%) in group B showed a Qmax <10 mL/s on uroflowmetry (p=0.013). On urethroscopy, no patient in group A (0%) and two patients in group B (6.45%) (p=0.021) showed urethral stricture after HoLEP. CONCLUSIONS: Preoperative urethral dilatation during HoLEP decreased the incidence of urethral stricture. This procedure could be useful to reduce the risk of urethral stricture after transurethral prostate surgery. One limitation of the current study is the single-centre design. Also, we sought to determine the efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery within a short time period, which could be another limitation of the study. Despite these limitations, to the best of our knowledge, the present study is the first reported prospective, randomized trial analyzing the safety and efficacy of preoperative urethral dilatation for the prevention of urethral stricture after transurethral prostate surgery.

Early dutasteride monotherapy in men with detectable serum prostate-specific antigen levels following radical prostatectomy: A prospective trial.

PURPOSE: To investigate the effects of early administration of dutasteride in patients with detectable serum prostate-specific antigen (PSA) levels after radical prostatectomy (RP). MATERIALS AND METHODS: A prospective open-label study, with a cumulative analysis of asymptomatic increase in PSA following RP, was conducted from January 2005 to December 2013. An early increase in PSA level was defined as detectable serum PSA level> 0.04 ng/mL. Patients with PSA level>0.04 ng/mL were treated with dutasteride 0.5 mg daily. Serum PSA level and biochemical recurrence (BCR) were monitored. We divided the patients into 2 groups based on the serum PSA response after dutasteride treatment. RESULTS: Eighty patients were included in the study. At the median follow-up of 51.8 months, 56 patients (70.0%) showed a decrease of greater than 10% in serum PSA level, and 24 showed increased PSA levels. Twelve of the 56 patients with PSA response showed subsequently increased PSA. Intergroup differences in preoperative PSA levels, PSA nadir levels, and Gleason score of 6 or less were significant (p=0.028, p=0.030, and p=0.035, respectively). A multivariate analysis revealed that Gleason score of 6 or less (p=0.018) and PSA nadir levels (p=0.011) were predictive factors for PSA response after early dutasteride treatment in men with increased PSA levels following RP. CONCLUSIONS: Early monotherapy of dutasteride showed a decline in serum PSA levels in men with lower nadir PSA levels, and a Gleason score 6, when the serum PSA was detected after RP.

Ureteropelvic junction obstruction and renal cell carcinoma in a patient with solitary functioning kidney.

We present a case of ureteropelvic junction obstruction (UPJO) and renal cell carcinoma (RCC) in a solitary functioning kidney (SFK), managed by robot-assisted dismembered pyeloplasty with partial nephrectomy in a single stage. To our best knowledge, we report the first case of UPJO with RCC in a congenital SFK.

Clinical significance of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males: a prospective randomised control trial.

The cystoscopic removal of ureteral stents causes discomfort and pain, especially in young male patients. We aimed to evaluate the usefulness of ureteral stent removal by flexible cystoscopy on pain and satisfaction in young males. In total, 104 patients undergoing ureteroscopic removal of stones with indwelling of ureteral stent (May 2013-July 2015) were randomised to receive a ureteral stent removal by either rigid cystoscopy (group 1) or flexible cystoscopy (group 2). Visual analogue scale (VAS) pain score and satisfaction scale score were assessed immediately after stent removal. All patients were males and the mean age was 22.72 ± 2.49 years. Group 2 showed significantly lower VAS pain score (p < 0.001) and higher satisfaction scale score (p < 0.001) than group 1. Ureteral stent removal by flexible cystoscopy may offer advantages on pain and satisfaction to young male patients.

Prostate volume and prostate-specific antigen in men with Parkinson's disease are not different compared to age-matched control group: A prospective, case-controlled multicenter study.

PURPOSE: Patients with Parkinson's disease (PD) suffer from gait disturbance as well as lower urinary tract symptoms (LUTS). There have been no reports that evaluated the prostate volume (PV) and prostate-specific antigen (PSA) of patients with PD. In this study, we prospectively evaluated PV and PSA in men with PD. METHODS: From May 2009 to January 2012, 60 PD patients and 60 age-matched non-PD patients with LUTS enrolled at three centers in Korea. All participants (PD as well as non-PD patients) had LUTS at presentation. We measured the PV using a transrectal ultrasonography and checked the serum PSA level in patients with PD and their non-PD counterparts, who served as the age-matched control group, and then compared the data of both groups. Patients with abnormal digital rectal examination results and/or serum PSA levels >4.0 ng/mL underwent prostate biopsy. RESULTS: The mean patient age was 71.37 ± 7.36 years and 70.85 ± 6.31 years for PD and non-PD patients (P = 0.651), respectively. There were no significant statistical differences between the two groups in terms of total PV (28.56 ± 14.59 in PD vs. 29.21 ± 10.41 in non-PD, P = 0.727), transition zone PV (12.72 ± 8.76 vs. 12.73 ± 6.68, P = 0.993), and total serum PSA (1.88 ± 2.80 vs. 2.01 ± 2.02, P = 0.759). In the PD group, seven patients had PSA levels >4.0 ng/mL (range, 4.12-11.18 ng/mL). Among these patients, prostate cancer (PC) was detected in two patients. In the non-PD group, PSA levels >4.0 ng/mL were detected in nine patients (range, 4.16-8.28 ng/mL). Among these patients, PC was detected in three patients. The PC occurrence rate was similar in both groups. CONCLUSIONS: Our data show that a neurologic lesion causing PD does not affect PV and PSA. As both groups have a similar PC occurrence rate, it is clear that prostate evaluation is necessary for PD as well as non-PD patients.

Cystic Angiomyolipoma Mimicking Cystic Renal Cell Carcinoma on Computed Tomography Image.

We report on a 44-year-old male patient with cystic angiomyolipoma (AML) simulating cystic renal cell carcinoma on computed tomography (CT). The CT scan showed a 2.8-cm left renal cystic mass with an enhancing solid component. No fat density was identified in the mass. These findings were indicative of a cystic renal cell carcinoma. Robot-assisted laparoscopic partial nephrectomy was performed, but the final histologic result was a cystic AML. Herein, we would review the preoperative CT findings, which could have suggested cystic AML.

Upgrading and upstaging of low-risk prostate cancer among Korean patients: a multicenter study.

Only 54% of prostate cancer cases in Korea are localized compared with 82% of cases in the US. Furthermore, half of Korean patients are upgraded after radical prostatectomy (41.6%-50.6%). We investigated the risk factors for upgrading and/or upstaging of low-risk prostate cancer after radical prostatectomy. We retrospectively reviewed the medical records of 1159 patients who underwent radical prostatectomy at five hospitals in Honam Province. Preoperative data on standard clinicopathological parameters were collected. The radical prostatectomy specimens were graded and staged and we defined a "worsening prognosis" as a Gleason score ≥ 7 or upstaging to ≥ pT3. Multivariate logistic regression models were used to assess factors associated with postoperative pathological upstaging. Among the 1159 patients, 324 were classified into the clinically low-risk group, and 154 (47.5%) patients were either upgraded or upstaged. The multivariable analysis revealed that the preoperative serum prostate-specific antigen level (odds ratio [OR], 1.131; 95% confidence interval [CI], 1.007-1.271; P= 0.037), percent positive biopsy core (OR: 1.018; 95% CI: 1.002-1.035; P= 0.032), and small prostate volume (≤30 ml) (OR: 2.280; 95% CI: 1.351-3.848; P= 0.002) were predictive of a worsening prognosis. Overall, 47.5% of patients with low-risk disease were upstaged postoperatively. The current risk stratification criteria may be too relaxed for our study cohort.

Ureteral penetration caused by drilling during internal pelvic bone fixation: delayed recognition.

A 49-year-old man was referred to our department with profuse serous fluid discharge from a Penrose drain after undergoing internal fixation with metal screws for multiple pelvic bone fractures. A definite ureteral penetration was identified that was orientated from the lateral to the medial aspect of the right distal ureter. The patient was surgically treated with excision of the 2-cm injured ureteral segment, end-to-end ureteroureterostomy, and double J ureteral stent placement. To our knowledge, a penetrating ureteral injury caused by bone drilling has not been reported previously in the published literature. This case shows that surgeons who do pelvic surgery, including orthopedic surgeons, should be familiar with the anatomical relationship of the ureter and its potential injuries.

Cavernous Hemangiolymphangioma of the Testis without Cutaneous Hemangiomatosis in an Elderly Patient.

Hemangiolymphangioma is an extremely rare malformation of both the lymphatic and blood vessels. To date, however, there are no reports in the literature of a hemangiolymphangioma of the testis. An 84-year-old man visited our hospital for investigation of a 1-month episode of a rapidly growing mass in his right scrotum. Scrotal ultrasonography revealed a multilobulated mass with septation in the testis. Testicular tumor markers were within the normal limit. Radical orchiectomy was performed. At surgery, a red, wide-based, nodular tumor was found on the testis. Histological examination of the resected specimen showed it to be a cavernous hemangiolymphangioma. Here we report this first case of a cavernous hemangiolymphangioma of the testis without cutaneous hemangiomatosis in an elderly patient.

First case of peritoneal seeding of prostate cancer during robot-assisted laparoscopic radical prostatectomy.

Peritoneal seeding with no further metastases of prostate cancer is very rare. To the best of our knowledge, there are only three cases reported in the available literature. There has not yet been a report of a patient undergoing robot-assisted laparoscopic radical prostatectomy (RALRP) that might have resulted in peritoneal seeding. We describe a patient who presented with a prostate-specific antigen (PSA) recurrence and who was found to have a solitary metastasis on the liver, 2 years after RALRP. The patient underwent open excision of the mass, which was densely adherent to the liver. Pathologic examination revealed metastatic adenocarcinoma, which stained positive for PSA. Our patient represents an unusual case of a surgically documented peritoneal seeding of prostate adenocarcinoma during RALRP.

The direct anti-cancer effect of a single instillation of epirubicin after transurethral resection of bladder tumor for non-muscle-invasive bladder cancer.

PURPOSE: To evaluate the direct anti-cancer effect of a single instillation of epirubicin (SIE) after transurethral resection of bladder tumor (TURBT) for non-muscle-invasive bladder cancer (NMIBC) by analysis of immediate urine cytology (IUC). MATERIALS AND METHODS: We reviewed the records of 158 patients who had IUC after TURBT for NMIBC. Fifty-six patients were treated with SIE after TURBT and 102 patients were not treated with SIE. The direct anti-cancer effect of SIE was compared in the two groups according to the result of IUC. The relationship between SIE and IUC in NMIBC was analyzed by use of multivariate Cox proportional hazards regression models. RESULTS: The IUC-positive rate was 33.9% in the SIE group and 42.1% in the non-SIE group (p=0.005). The IUC-positive rate was lower in the SIE group than in the non-SIE group for each factor, including tumor stage, tumor grade, tumor size, tumor multiplicity, and preoperative urine cytology. Multivariate Cox proportional hazards regression analysis revealed that SIE was significantly associated with a negative IUC result in patients with NMIBC (HR, 0.163) (p<0.001). CONCLUSIONS: These results indicate the direct anti-cancer effect of SIE in patients who undergo TURBT for NMIBC.

Floating Hem-o-Lok Clips in the Bladder without Stone Formation after Robot-Assisted Laparoscopic Radical Prostatectomy.

Hem-o-Lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) are widely used in robot-assisted laparoscopic radical prostatectomy because of their easy application and secure clamping. To date, there have been some reports of intravesical migration of these clips causing urethral erosion, bladder neck contractures, and subsequent calculus formation. We report the first case of bladder migration of Hem-o-Lok clips without stone formation after robot-assisted laparoscopic radical prostatectomy. The Hem-o-Lok clips were found during urethral dilation with a guide wire for bladder neck contracture under cystourethroscopy. The Hem-o-Lok clips were floating in the bladder without stone formation and were removed by a cystoscopic procedure.