Establishment of an Antimicrobial Stewardship Program to Spare the Use of Oral Fluoroquinolones for Acute Uncomplicated Cystitis in Outpatients.

The increase in fluoroquinolone (FQ)-resistant Escherichia coli (EC) is a serious global problem. In addition, much of acute uncomplicated cystitis (AUC) cases are caused by EC. FQs have been selected for the treatment of cystitis in outpatients, and there is concern about treatment failure. It is therefore necessary to select appropriate antimicrobials to spare FQs. However, there are few reported effective antimicrobial stewardship programs (ASPs) for outpatients. We aimed to establish the effective ASP for outpatients diagnosed with AUC caused by EC, to spare the use of FQs, and to explore optimal oral antimicrobials for AUC. The study subjects were outpatients treated for AUC caused by extended-spectrum ß-lactamase-non-producing EC (non-ESBL-EC). Based on the antibiogram results, we recommended cefaclor (CCL) as the initial treatment for AUC, and educated clinical pharmacists who also worked together to advocate for CCL or cephalexin (CEX) prescriptions. FQ usages decreased, and cephalosporin (Ceph) prescriptions increased in all medical departments. The Ceph group (n = 114; CCL = 60, CEX = 54) in the non-FQ group had fewer treatment failures than the FQ group (n = 86) (12.3% vs. 31.4%). Cephs, including CCL and CEX, were effective treatments for AUC caused by non-ESBL-EC. Antimicrobial selection based on antibiogram results and the practice of an ASP in collaboration with clinical pharmacists were useful for optimizing antimicrobial therapy in outpatients.

Double Primary Cancer of the Prostate and Urothelial Cancer: A Single Institution Experience.

Prostate cancer (PCa) ranks as the second most common cancer in Japanese males, while bladder cancer (BC) holds the tenth spot. Among double urological cancers, the incidence of synchronous or metachronous BC and PCa is the highest. Reports on upper urinary tract (UUT) urothelial cancer (UC) in PCa patients are limited. Here, we present three cases of metachronous PCa and BC, with subsequent diagnosis of ureteral and renal pelvic cancer during the course of the disease. In the follow-up of patients with urological cancers, it is important to be aware not only of the progression of the initial cancer but also the potential development of a second cancer.

Intracellular Major Histocompatibility Complex Class II and C-X-C Motif Chemokine Ligand 10-Expressing Neutrophils Indicate the State of Anti-Tumor Activity Induced by Bacillus Calmette-Guérin.

(1) Background: Inflammatory responses induce the formation of both anti-tumor and pro-tumor neutrophils known as myeloid-derived suppressor cells (MDSCs). Intermittent intravesical infusion of Bacillus Calmette-Guérin (BCG) is an established cancer immunotherapy for non-muscle-invasive bladder cancer (NMIBC). However, the types of neutrophils induced via the inflammatory response to both tumor-bearing and BCG remain unclear. (2) Methods: We therefore analyzed neutrophil dynamics in the peripheral blood and urine of patients with NMIBC who received BCG therapy. Further, we analyzed the effects of BCG in a mouse intraperitoneal tumor model. (3) Results: BCG therapy induced the formation of CXCL10 and MHC class II-positive neutrophils in the urine of patients with NMIBC but did not induce MDSC formation. CXCL10- and MHC class II-expressing neutrophils were detected in peritoneal exudate cells formed after BCG administration. Partial neutrophil depletion using an anti-Ly6G antibody suppressed the upregulation of CXCL10 and MHC class II in neutrophils and reversed the anti-tumor activity of BCG in mouse models. (4) Conclusions: These results indicated that intracellular MHC class II- and CXCL10-expressing neutrophils indicate the state of anti-tumor activity induced via BCG. The status of neutrophils in mixed inflammation of immunosuppressive and anti-tumor responses may therefore be useful for evaluating immunological systemic conditions.

Initial Myeloid Cell Status Is Associated with Clinical Outcomes of Renal Cell Carcinoma.

The therapeutic outcome of immune checkpoint inhibition (ICI) can be improved through combination treatments with ICI therapy. Myeloid-derived suppressor cells (MDSCs) strongly suppress tumor immunity. MDSCs are a heterogeneous cell population, originating from the unusual differentiation of neutrophils/monocytes induced by environmental factors such as inflammation. The myeloid cell population consists of an indistinguishable mixture of various types of MDSCs and activated neutrophils/monocytes. In this study, we investigated whether the clinical outcomes of ICI therapy could be predicted by estimating the status of the myeloid cells, including MDSCs. Several MDSC indexes, such as glycosylphosphatidylinositol-anchored 80 kD protein (GPI-80), CD16, and latency-associated peptide-1 (LAP-1; transforming growth factor-ß1 precursor), were analyzed via flow cytometry using peripheral blood derived from patients with advanced renal cell carcinoma (n = 51) immediately before and during the therapy. Elevated CD16 and LAP-1 expressions after the first treatment were associated with a poor response to ICI therapy. Immediately before ICI therapy, GPI-80 expression in neutrophils was significantly higher in patients with a complete response than in those with disease progression. This is the first study to demonstrate a relationship between the status of the myeloid cells during the initial phase of ICI therapy and clinical outcomes.

Fibroblast growth factor receptor type 4 as a potential therapeutic target in clear cell renal cell carcinoma.

BACKGROUND: Several clear cell renal cell carcinoma (ccRCC) cases harbour fibroblast growth factor receptor 4 (FGFR4) gene copy number (CN) gains. In this study, we investigated the functional contribution of FGFR4 CN amplification in ccRCC. METHODS: The correlation between FGFR4 CN determined via real-time PCR and protein expression evaluated using western blotting and immunohistochemistry was assessed in ccRCC cell lines (A498, A704, and 769-P), a papillary RCC cell line (ACHN), and clinical ccRCC specimens. The effect of FGFR4 inhibition on ccRCC cell proliferation and survival was assessed via either RNA interference or using the selective FGFR4 inhibitor BLU9931, followed by MTS assays, western blotting, and flow cytometry. To investigate whether FGFR4 is a potential therapeutic target, a xenograft mouse model was administered BLU9931. RESULTS: 60% of ccRCC surgical specimens harboured an FGFR4 CN amplification. FGFR4 CN was positively correlated with its protein expression. All ccRCC cell lines harboured FGFR4 CN amplifications, whereas ACHN did not. FGFR4 silencing or inhibition attenuated intracellular signal transduction pathways, resulting in apoptosis and suppressed proliferation in ccRCC cell lines. BLU9931 suppressed tumours at a tolerable dose in the mouse model. CONCLUSION: FGFR4 contributes to ccRCC cell proliferation and survival following FGFR4 amplification, making it a potential therapeutic target for ccRCC.

Effect of Extracellular Signal-Regulated Protein Kinase 5 Inhibition in Clear Cell Renal Cell Carcinoma.

(1) Background: Extracellular signal-regulating kinase 5 (ERK5) has been implicated in many cellular functions, including survival, proliferation, and vascularization. Our objectives were to examine the expression and effect of ERK5 in clear cell renal cell carcinoma (ccRCC). (2) Methods: The expressions of ERK5 and its regulating micro-RNA miR-143 were investigated using immunohistochemistry and quantitative reverse transcriptase PCR in surgical specimens of ccRCC patients. With invitro and in vivo studies, we used pharmacologic ERK5 inhibitor XMD8-92, RNA interference, pre-miR-143 transduction, Western blotting, MTS assay, apoptosis assay, and subcutaneous xenograft model. (3) Results: A strong ERK5 expression in surgical specimen was associated with high-grade (p = 0.01), high-recurrence free rate (p = 0.02), and high cancer-specific survival (p = 0.03). Expression levels of ERK5 and miR-143 expression level were correlated (p = 0.049). Pre-miR-143 transduction into ccRCC cell A498 suppressed ERK5 expression. ERK5 inhibition enhanced cyclin-dependent kinase inhibitor p21 expression and decreased anti-apoptotic molecules BCL2, resulting in decreased cell proliferation and survival both in ccRCC and endothelial cells. In the xenograft model, ERK5 inhibitor XMD8-92 suppressed tumor growth. (4) Conclusions: ERK5 is regulated by miR-143, and ERK5 inhibition is a promising target for ccRCC treatment.

Surgical and focal treatment for metastatic renal cell carcinoma: A literature review.

Accompanied by the development of systemic therapy for metastatic renal cell carcinoma, the concept of focal treatment, including surgical treatment, has been changing. Although immediate cytoreductive nephrectomy was essentially considered for synchronous metastatic renal cell carcinoma patients, the CARMENA trial and SURTIME trial revealed the negative impact of immediate cytoreductive nephrectomy. Therefore, immediate cytoreductive nephrectomy is currently considered only for a limited number of patients. Besides, deferred cytoreductive nephrectomy seems to have efficacy for overall survival in prior retrospective studies. Two randomized controlled trials, the PROBE trial (NCT04510597) and the NORDIC-SUN trial (NCT03977571), are underway to elucidate deferred cytoreductive nephrectomy. Metastasectomy is also considered in metastatic renal cell carcinoma patients because previous studies demonstrated the overall survival benefit of metastasectomy. However, since all reports were retrospective studies, physicians could exclude the patients who were not expected to show the efficacy of metastasectomy. Therefore, an adequate patient selection for metastasectomy is important. A common factor predicting better overall survival was complete resection. Radiotherapies for metastatic lesions during systemic therapy showed approximately 90% local disease control rate at 1 year. However, no report has demonstrated that radiotherapy improves survival so far. Since surgical and focal treatments for metastatic renal cell carcinoma patients generally have minimal evidence, further investigations are needed.

Outcomes of Living Kidney Transplantation for Mitochondrial Disease Patients: A Case Series.

PURPOSE: Mitochondrial disease can affect many organs, including the brain, nerves, heart, liver, eyes, ears, pancreas, and kidneys. Kidney transplantation is a treatment option for renal failure due to mitochondrial disease; however, the prognosis of patients who undergo kidney transplantation for mitochondrial disease is unknown. Here we evaluated the outcomes of kidney transplant recipients with mitochondrial disease. METHODS: Clinical data were obtained from 4 kidney transplantation recipients who were followed at our department. Of the 4 transplantations, 3 were performed in our department: 2 patients received kidneys from their fathers, and a third from his wife. The fourth recipient received a kidney from her mother-who had a mitochondrial genetic abnormality-at another hospital. Of the 4 recipients, 3 were diagnosed with mitochondrial disease before the transplantation, and the fourth was diagnosed after. All recipients had sensorineural deafness and diabetes mellitus, and only 1 had a history of encephalopathy and stroke-like episodes before the transplantation. RESULTS: One patient died 2 years after transplantation due to encephalopathy progression with stable kidney function. The grafted kidney of the patient who received it from her mother lost function at 5 years post-transplantation. A graft biopsy revealed focal segmental glomerular sclerosis due to mitochondrial disease. The other patients' kidney functions remained stable. None of the recipients experienced rejection. CONCLUSIONS: In kidney transplantation for mitochondrial disease, attention should be paid to the exacerbation of comorbidities, while careful consideration should be given to donors with a mitochondrial genetic abnormality.

Body composition changes following chemotherapy for testicular germ cell tumor: obesity is the long-term problem.

Metabolic syndrome is a long-term complication of systemic chemotherapy for testicular germ cell tumor (TGCT). It is believed to be caused by secondary hypogonadism or toxic medicines because of orchidectomy followed by systemic chemotherapy. In this study, changes in the body composition of patients over time were quantitatively analyzed up to 24 months after chemotherapy. This study retrospectively analyzed 44 patients with TGCT who underwent chemotherapy at our institution from January 2008 to December 2016. Subcutaneous and visceral fat areas and psoas and skeletal muscle areas were measured by computed tomography before and immediately after chemotherapy as well as 3 months, 6 months, 12 months, and 24 months after chemotherapy. The subcutaneous and visceral fat indices and psoas and skeletal muscle indices were calculated as each area divided by body height squared. The total fat area had already significantly increased 3 months after the initiation of chemotherapy (P = 0.004). However, it did not return to prechemotherapeutic levels even at 24 months after chemotherapy. The skeletal muscle area was significantly decreased at the end of chemotherapy (P < 0.001); however, the value returned to baseline within 12 months. In multivariable analysis, the prechemotherapeutic skeletal muscle index and number of chemotherapy cycles were independently associated with the reduction of skeletal muscle at the end of chemotherapy (P = 0.001 and P = 0.027, respectively). In patients with TGCT, skeletal muscle mass decreased during chemotherapy and recovered within 12 months, whereas fat mass progressively increased from the initiation of chemotherapy until 24 months after chemotherapy.

Prosthetic valve endocarditis due to highly beta-lactam-resistant Streptococcus oralis: a case report.

There are limited reports of patients with prosthetic valve infective endocarditis (IE) or recurrent IE due to highly beta-lactam-resistant viridans group streptococci. We present a case in which a patient with native valve IE due to beta-lactam-susceptible Streptococcus oralis developed prosthetic valve IE due to highly beta-lactam-resistant S. oralis . A 79-year-old man with a history of native aortic valve IE caused by beta-lactam-susceptible S. oralis 21 months prior to admission and aortic valve replacement was admitted to our hospital with a 2-week history of general malaise and low-grade fever. Transesophageal echocardiography showed a 20 mm vegetation on the prosthetic aortic valve, and emergency cardiovascular surgery was performed on admission day 2. Three sets of blood cultures on admission were positive for highly beta-lactam-resistant S. oralis . Vancomycin and cefazolin were administered as initial treatment. After the surgery, the patient was given vancomycin and gentamicin for 2 weeks, followed by vancomycin for 4 weeks. He was relapse-free at the 6-month follow-up. For patients with native valve IE due to S. oralis who have undergone valve replacement more than 1 year earlier, given the possibility of methicillin-resistant Staphylococcus aureus as well as S. oralis resistance to beta-lactams, it may be advisable to start vancomycin as an initial treatment and continue it until the infecting micro-organism has been proven to be susceptible to beta-lactams.

A Case of Coronal Intra-articular and Epiphyseal Fractures of the Metacarpal Head in Early Adolescence.

Intra-articular metacarpal head fracture is relatively rare. We report a case of coronal intra-articular and epiphyseal fractures of Salter-Harris type IV injury in the metacarpal head of the index finger. Surgery was performed by a dorsal approach. The volar fragment that was displaced proximally was gently reduced while bending the metacarpophalangeal (MP) joint, and it was fixed with cortical screws inserted proximal to the articular cartilage facilitating early rehabilitation. We consider the mechanism of injury to be a force applied from the distal phalanx that was transmitted unevenly to the volar side when the MP joint was slightly flexed. A three-dimensional computed tomography scan was useful in making the precise diagnosis, confirming the fracture pattern and planning fixation of the fracture.

GPI-80 Augments NF-κB Activation in Tumor Cells.

Recent studies have discovered a relationship between glycosylphosphatidylinositol (GPI)-anchored protein 80 (GPI-80)/VNN2 (80 kDa GPI-anchored protein) and malignant tumors. GPI-80 is known to regulate neutrophil adhesion; however, the action of GPI-80 on tumors is still obscure. In this study, although the expression of GPI-80 mRNA was detectable in several tumor cell lines, the levels of GPI-80 protein were significantly lower than that in neutrophils. To clarify the function of GPI-80 in tumor cells, GPI-80-expressing cells and GPI-80/VNN2 gene-deleted cells were established using PC3 prostate cancer cells. In GPI-80-expressing cells, GPI-80 was mainly detected in vesicles. Furthermore, soluble GPI-80 in the conditioned medium was associated with the exosome marker CD63 and was also detected in the plasma obtained from prostate cancer patients. Unexpectedly, cell adhesion and migration of GPI-80-expressing PC3 cells were not modulated by anti-GPI-80 antibody treatment. However, similar to the GPI-80 family molecule, VNN1, the pantetheinase activity and oxidative state were augmented in GPI-80-expressing cells. GPI-80-expressing cells facilitated non-adhesive proliferation, slow cell proliferation, NF-κB activation and IL-1ß production. These phenomena are known to be induced by physiological elevation of the oxidative state. Thus, these observations indicated that GPI-80 affects various tumor responses related to oxidation.

Restricted Wrist Rotation after an Ulnar Head Fracture: A Report of Two Cases.

Background Isolated ulnar head fracture is a rare entity, and the restriction of range of motion in the wrist is rarely reported. Case Description We report two cases of conservatively treated ulnar head malunion with restricted supination and pronation. The increased tension of the volar portion of the triangular fibrocartilage complex was observed, and the surgical treatment significantly improved the range of motion. Literature Review There are a few reports on isolated ulnar head fracture. Other causes of restricted supination and pronation of the wrist are mostly due to the interposition of soft tissues or loose bodies. Clinical Relevance Malunion after ulnar head fracture can cause restriction of wrist supination and pronation. Surgical intervention may be considered if restricted range of motion remains after conservative treatment.

Adjuvant heparinization before manipulation of artery reduces early failure in primary arteriovenous fistula for end-stage renal disease patients.

BACKGROUND: Arteriovenous fistula (AVF) is the most preferred vascular access for hemodialysis patients, and early failure of AVF is one of the most avoidable complications of this procedure. We retrospectively evaluated whether adjuvant systemic heparinization just before arterial manipulation could reduce early failure of primary AVF. METHODS: Three hundred and fifty-six patients with end-stage renal failure who underwent primary AVF surgery from April 2009 to September 2020 were enrolled in this study. The patients were divided into two groups based on whether they received adjuvant heparinization or not. Patient backgrounds, frequency of early AVF failure, and bleeding events were compared between the two groups. Multivariate Cox regression analysis identified risk factors for early AVF failure. RESULTS: Early failure of AVF was observed in only 2 of 157 patients (1.2%) in the adjuvant group, and the incident was significantly lower than observed in the non-adjuvant group, i.e., 17 of 199 patients (8.5%) (p = 0.002). Bleeding events were not significantly different between the two groups. Seven of 157 patients (4.5%) in the adjuvant group and 7 of 199 patients (3.5%) in the non-adjuvant group experienced bleeding events (p = 0.785). Female sex, use of steroids, hypoalbuminemia, venous stenosis in pre-surgical evaluation, arterial spasm in the perioperative period, new-onset venous stenosis after AVF anastomosis, technical failure of surgery, no early cannulation after surgery, and non-adjuvant heparinization were related to early AVF failure in the multivariate regression analysis. CONCLUSION: Adjuvant systemic heparinization therapy just before arterial manipulation reduced early failure of primary AVF without increasing bleeding events.

Prognosis of Japanese metastatic renal cell carcinoma patients in the targeted therapy era.

BACKGROUND: The aims of this study were to investigate prognosis and validate prognostic models [Memorial Sloan-Kettering Cancer Center (MSKCC), International Metastatic Renal Cell Carcinoma Data Consortium (IMDC), and Japanese metastatic renal cancer (JMRC) models] in the targeted therapy era in Japanese patients with metastatic renal cell carcinoma. METHODS: We retrospectively analyzed 692 patients who were diagnosed with mRCC from January 2008 to August 2018 in the Michinoku Japan Urological Cancer Study Group database. Nivolumab as sequential therapy was widely used. Other immune checkpoint inhibitors were excluded from this study. RESULTS: The median overall survival (95% confident interval) in all, MSKCC favorable, intermediate, and poor risk patients was 41.0 months (33.9-46.8), not reached (63.5 to not estimable), 46.8 months (37.1-52.9), and 10.4 months (8.9-14.4), respectively. The median overall survival (95% confident interval) in IMDC favorable, intermediate, and poor risk patients was not reached (61.6 to not estimable), 47.4 months (41.4-56.5), and 11.5 (9.9-16.3), respectively. The c-index of the MSKCC, IMDC, and JMRC models calculated at mRCC diagnosis was 0.680, 0.689, and 0.700, respectively. No statistical differences were found in the c-index among the models. CONCLUSION: While the real-world overall survival in Japanese patients with mRCC in the targeted therapy era improved compared to that previously reported in the cytokine era, there was no clear difference in the survival of poor risk patients between these eras. There were no differences in the superiority among the models.

Range of Motion after the Sauvé-Kapandji and Darrach Procedures without Extensor Tendon Rupture.

Background Previous study demonstrated that distal radioulnar joint (DRUJ) plays a biomechanical role in extension and flexion of the wrist and suggested that fixation of the DRUJ could lead to loss of motion of the wrist. Little is known about the pre- and postoperative range of motion (ROM) after the Sauvé-Kapandji (S-K) and Darrach procedures without tendon rupture. To understand the accurate ROM of the wrist after the S-K and Darrach procedures, enrollment of patients without subcutaneous extensor tendon rupture is needed. Purpose This study aimed to investigate the pre- and postoperative ROM after the S-K and Darrach procedures without subcutaneous extensor tendon rupture in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Methods This retrospective study included 36 patients who underwent the S-K procedure and 10 patients who underwent the Darrach procedure for distal radioulnar joint disorders without extensor tendon rupture. Pre- and postoperative ROMs after the S-K and Darrach procedures were assessed 1 year after the surgery. Results In the S-K procedure, the mean postoperative ROM of the wrist flexion (40 degrees) was significantly lower than the mean preoperative ROM (49 degrees). In wrist extension, there were no significant differences between the mean preoperative ROM (51 degrees) and postoperative ROM (51 degrees). In the Darrach procedure, the mean postoperative ROM of the wrist flexion and extension increased compared with the mean preoperative ROM; however, there were no significant differences. Conclusion In the S-K procedure, preoperative ROM of the wrist flexion decreased postoperatively. This study provides information about the accurate ROM after the S-K and Darrach procedures. Level of Evidence This is a Level IV, therapeutic study.

Clinical utility of head computed tomography scan during systemic therapy for metastatic renal cell carcinoma.

OBJECTIVES: The utility of brain metastasis screening in asymptomatic metastatic renal cell carcinoma is controversial. Our study evaluated the utility of routine head computed tomography during systemic therapy. METHODS: We retrospectively investigated 152 metastatic renal cell carcinoma patients who did not initially have brain metastasis at Yamagata University Hospital from January 2008 to July 2019. Patients who routinely received head computed tomography scan together with routine contrast-enhanced chest/abdominal/pelvic computed tomography scan every 2-4 months during systemic therapy ("Routine head computed tomography" group, n = 95) and patients without routine head computed tomography ("No routine head computed tomography" group, n = 57) were compared. RESULTS: Brain metastasis occurred in 16 patients in the "Routine head computed tomography" group and six patients in the "No routine head computed tomography" group. There was no statistical difference in overall survival after metastatic renal cell carcinoma diagnosis between groups (53.4 vs 37.3 months, respectively, P = 0.357) and neurological symptom-free survival after metastatic renal cell carcinoma diagnosis (53.4 vs 36.6 months, P = 0.336). Although there was no statistical difference on incidence of unrecovered neurological symptom (25.0% vs 50.0%, P = 0.334), fewer patients in the "Routine head computed tomography" group required craniotomy (0% vs 66.7%, P = 0.002). In the "No routine head computed tomography" group, the neurological symptom resolved for all patients without craniotomy. CONCLUSIONS: Routine head computed tomography during systemic therapy for metastatic renal cell carcinoma is not significantly associated with improved brain metastasis prognosis. However, routine head computed tomography enables brain metastasis diagnosis in the asymptomatic phase, which can avoid craniotomy.

Effect of general self-efficacy on promoting health-related quality of life during recovery from radical prostatectomy: a 1-year prospective study.

BACKGROUND: The decline of health-related quality-of-life (QOL) during the year after radical prostatectomy is severe. General self-efficacy (GSE) is an effective psychological factor for long-term regulation of patient behavior and emotions. GSE is expected to facilitate enhanced health-related quality of life. We evaluated changes in GSE and analyzed the relationship between GSE and prostate cancer-specific and general health-related QOL. METHODS: We conducted a longitudinal survey with 104 patients who underwent radical prostatectomy and administered the General Self-efficacy Scale (GSES), Expanded Prostate Cancer Index Composite (EPIC), and SF8 Health Survey (SF-8). ANCOVA was performed to compare EPIC and SF-8 between GSES high and low-medium groups. RESULTS: GSES scores increased significantly after 6 months. Regarding EPIC urinary summary scores, high GSES group was significantly higher than low-medium group at 1 month (mean score difference [MSD], 7.3; 95% CI 1.1-13.2, P = 0.016), 3 months (MSD, 6.8; 95% CI 0.7-12.8, P = 0.028), and 6 months (MSD, 6.3; 95% CI 0.9-11.7, P = 0.022). High GSES group had significantly higher SF-8 physical component summary score at 6 months (MSD, 3.2; 95% CI 1.4-5.0, P = 0.001), and significantly higher SF-8 mental component summary score at 1 month (MSD, 2.6; 95% CI 0.4-4.9, P = 0.022), 3 months (MSD, 2.7; 95% CI 0.8-4.6, P = 0.007), and 6 months (MSD, 2.8; 95% CI 1.0-4.6, P = 0.003). CONCLUSION: This study suggests that high GSE was associated with better prostate cancer-specific and general health-related QOL after radical prostatectomy.