Potential Role of Macrophage Polarization in the Progression of Hunner-Type Interstitial Cystitis.

BACKGROUND: Hunner-type interstitial cystitis (HIC) is a chronic inflammatory condition of the bladder. However, it remains unclear whether there is a causal relationship between the presence of Hunner lesions and seemingly normal-appearing areas in the bladder (non-Hunner lesions). This study aimed to investigate the fundamental aspects of HIC by examining potential genetic differences between Hunner and non-Hunner lesions and elucidate their role as potential markers in the progression and suppression of the disease. METHODS: This cross-sectional study enrolled patients with HIC (n = 10) who underwent supratrigonal cystectomy along with augmentation cystoplasty. Full-thickness bladder tissue was collected from Hunner and non-Hunner lesions in the same patient. Normal bladder tissue biopsies were also obtained as controls. Whole transcriptome analysis was performed to analyze the gene expression patterns and immune cell populations. RESULTS: The mucosal layers of patients exhibited similar pathway dysregulation across Hunner and non-Hunner lesions, with immunerelated pathways being prominently affected. In the mucosal layer, genes related to anti-inflammatory and immune suppression were downregulated in Hunner lesions compared to non-Hunner lesions. Moreover, in Hunner lesions, genes related to macrophage differentiation and polarization, such as VSIG4, CD68, MAFB, and LIRB4, were downregulated. The cell fraction of M2 macrophages was found to decrease in Hunner lesions. Immunohistochemical staining revealed an elevated fraction of M1 macrophages and a reduced fraction of M2 macrophages in Hunner lesions compared to those in non-Hunner lesions. In the muscular layer, transcriptomic evidence of muscle thickness was observed in both Hunner and non-Hunner lesions; however, the difference was not significant. CONCLUSION: Hunner lesions showed a reduced expression of anti-inflammatory and immunosuppressive factors compared to non-Hunner lesions, along with alterations in immune cell populations. This study suggests the possibility that macrophage polarization is related to the progression from non-Hunner lesions to Hunner lesions, suggesting its relevance to the characteristics of autoimmune diseases.

Recurrence after postoperative intravesical instillation therapy in Hunner type interstitial cystitis.

We performed a prospective, single-arm study comparing outcomes between transurethral ablation plus postoperative instillation of hyaluronic acid and chondroitin sulfate (HACS group) and transurethral ablation only in patients with Hunner type interstitial cystitis (historical control group). A total of 78 patients were enrolled, and 51 were included in the per-protocol analysis set. The 2-year recurrence rate was 47.1% (95% CI, 32.9-61.5) in the HACS group, which was significantly lower than that in the control group (86.2%; 95% CI, 74.6-93.9, P < 0.001). After instillation therapy, the hazard ratio for recurrence was 0.38 (95% CI, 0.23-0.65, P < 0.001). The HACS group had an increased recurrence-free survival with the median interval not being reached, while it was 11.4 months in the control group (95% CI, 8.8-13.8, P < 0.001). Regardless of the instillation treatment, there were significant improvements in all symptom questionnaire scores and pain compared to the baseline. However, in the instillation group, improvement was stable even after 12 months. In patients with Hunner type interstitial cystitis, intravesical instillation of hyaluronic acid and chondroitin sulfate after transurethral ablation significantly reduced the recurrence rate and maintained symptom improvement for more than 1 year.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

The Anterolateral Approach, Revisited for Benign Jugular Foramen Tumors With Predominant Extracranial Extension: Microsurgical Anatomy and Case Series (SevEN-012).

BACKGROUND AND OBJECTIVES: The anterolateral approach (ALA) enables access to the mid and lower clivus, jugular foramen (JF), craniocervical junction, and cervical spine with added anterior and lateral exposure than the extreme lateral and endoscopic endonasal approach, respectively. We describe the microsurgical anatomy of ALA with cadaveric specimens and report our clinical experience for benign JF tumors with predominant extracranial extension. METHODS: A stepwise and detailed microsurgical neurovascular anatomy of ALA was explored with cadaveric specimens. Then, the clinical results of 7 consecutive patients who underwent ALA for benign JF tumors with predominant extracranial extension were analyzed. RESULTS: A hockey stick skin incision is made along the superior nuchal line to the anterior edge of the sternocleidomastoid muscle (SCM). ALA involves layer-by-layer muscle dissection of SCM, splenius capitis, digastric, longissimus capitis, and superior oblique muscles. The accessory nerve runs beneath SCM and is found at the posterior edge of the digastric muscle. The internal jugular vein (IJV) is lateral to and at the level of the accessory nerve. The occipital artery passes over the longissimus capitis muscle and IJV and into the external carotid artery, which is lateral and superficial to IJV. The internal carotid artery (ICA) is more medial and deeper than external carotid artery and is in the carotid sheath with the vagus nerve and IJV. The hypoglossal and vagus nerves run along the lateral and medial side of ICA, respectively. Prehigh cervical carotid, prejugular, and retrojugular surgical corridors allow deep and extracranial access around JF. In the case series, gross and near-total resections were achieved in 6 (85.7%) patients without newly developed cranial nerve deficits. CONCLUSION: ALA is a traditional and invaluable neurosurgical approach for benign JF tumors with predominant extracranial extension. The anatomic knowledge of ALA increases competency in adding anterior and lateral exposure of extracranial JF.

The Asia-Pacific AMS800 artificial urinary sphincter consensus statement.

This Asia-Pacific (AP) AMS 800™ artificial urinary sphincter (AUS) consensus statement aims to provide a set of practical recommendations to assist surgeons with the AMS 800 device surgery. The AP consensus committee consisted of key opinion leaders with extensive experience with AMS 800 surgery across several AP countries. The panel reviewed and discussed relevant findings with emphasis on locoregional and specific clinical challenges relevant to the AP region. Recommendations were made in key areas namely (1) patient selection and informed consent process; (2) preoperative assessment; (3) dealing with co-existing urological disorders; (4) surgical principles and intraoperative troubleshooting; (5) postoperative care; (6) special populations; and (7) cost analysis and comparative review. The AMS 800 device should be offered to males with moderate to severe stress urinary incontinence (SUI). Full informed consent should be undertaken, and emphasis is placed on surgical contraindications and high-risk candidates. The presence of a surgical mentor or referral to experts is recommended in complex AUS candidates. Preoperative cystoscopy with or without multichannel urodynamic study is necessary and patients with pre-existing urological disorders should be treated adequately and clinically stable before surgery. Adherence to strict patient selection and safe surgical principles are critical to ensure excellent clinical outcomes and minimize complications. Given that InhibiZone-coated device is not available in many AP countries, the use of prophylactic antibiotics pre-and post-operatively are recommended. The AMS 800 device should be prepared according to the manufacturer's guidelines and remains a cost-effective treatment for male SUI. The AMS 800 device remains the surgical benchmark for male SUI but is associated with certain mechanical limitations and a unique set of complications.

Factors associated with quality of life in patients with benign prostatic hyperplasia, 2009-2016.

This study analyzed the factors affecting the health-related quality of life of patients with benign prostatic hyperplasia (BPH) according to age. We also aimed to determine appropriate strategies to improve their quality of life. Data from the Korea Health Panel Survey (2009-2016) were used in this study. A total of 3806 patients with BPH were divided into 2 groups: younger adults (aged under 65 years) and older adults (aged over 65 years). In addition, a logistic regression analysis was conducted to identify factors affecting the quality of life of young and older patients with BPH. In younger adult patients with BPH, the higher the level of education, the higher the quality of life by a factor of 1.379, and the more intense the physical activity, the lower the quality of life by a factor of 0.791. Also, the longer the sitting time, the lower the quality of life by a factor of 0.765. In contrast, for older adult patients with BPH, the quality of life improved by factors of 1.601 and 2.921, respectively, for health insurance and higher income level. In addition, it was found that the quality of life decreased by a factor of 0.754 in patients who drink alcohol. In order to improve the quality of life of the middle-aged adult population with BPH, it is necessary to reduce sitting time through constant physical activity. Moreover, the cost of medical care should be reduced and the quality of life increased through reductions in surgical treatment, as the burden of medical expenses will degrade the quality of life for older adults.

The impact of Hunner lesion-type interstitial cystitis/bladder pain syndrome on health-related quality of life and the effects of transurethral ablation.

PURPOSE: Interstitial cystitis/bladder pain syndrome (IC/BPS) has a negative impact on quality of life. We compared health-related quality of life (HRQoL) of patients with IC/BPS with patients having other diseases using the EuroQol five-dimension (EQ-5D) and evaluated whether the HRQoL is improved after surgery. METHODS: We compared EQ-5D of patients with Hunner lesion type IC/BPS with patients who had other diseases that cause chronic and severe pain including arthritis and cancer from a cross-sectional analysis of responses to the 2012-2016 Korea National Health and Nutrition Examination Survey. Changes in EQ-5D after transurethral coagulation (TUC) or resection (TUR) were measured in the IC/BPS participants. RESULTS: Compared to the EQ-5D index of normal population, patients with arthritis, cancer and IC/BPS had - 0.07 (95% CI - 0.07, - 0.06), - 0.01 (95% CI - 0.02, - 0.01), and - 0.21 (95% CI - 0.23, - 0.20) lower scores, respectively. Patients with IC/BPS were 35.9, 9.24, and 9.05 times more likely to have "extreme problem" in pain/discomfort, anxiety/depression, and usual activities EQ-5D domains, respectively, than patients without arthritis/cancer. After TUC or TUR, EQ-5D index was 0.90 in the TUC group and 0.92 in the TUR group. CONCLUSION: IC/BPS patients have worse HRQoL than healthy individuals. However, after surgical treatment, HRQoL is restored to a level close to normal.

A Prospective Observational Study of the Recurrence Characteristics of Hunner Lesion After Repeated Transurethral Ablation in Patients With Interstitial Cystitis/Bladder Pain Syndrome.

PURPOSE: The aim of this study was to investigate the rate and pattern of recurrence for patients with Hunner lesion (HL) type interstitial cystitis/bladder pain syndrome (IC/BPS) after transurethral ablation. METHODS: This prospective study included 210 patients with HL type IC/BPS. The primary outcomes were the recurrence rate according to 3 patterns of recurrence: pattern A (according to the relationship with the previous surgical site), pattern B (according to the bladder zone), and pattern C (according to the number of lesions). The secondary outcomes were recurrencefree time after treatment according to pattern A and pattern C. RESULTS: The pattern A recurrence rate was 50.8% in the same site (A1), 6.7% at a new site (A2), and 42.5% at mixed sites (A3). The pattern B recurrence rate was 10.5% for the anterior wall, 59.0% for the posterior wall, 69.5% for the lateral wall, and 69.0% for the dome area. Multiple lesions recurred as multiple lesions in 75.8% of cases. The pattern C recurrence rate was 10.8% for C1 (single → single), 6.7% for C2 (single → multiple), 6.7% for C3 (multiple → single), and 75.8% for C4 (multiple → multiple). The recurrence-free time in pattern A was 13 months for A1, 12.5 months for A2, and 8 months for A3, with a significant difference between A1 and A3 (P=0.008). There was no significant difference in recurrence-free time in pattern C, either with single or multiple HLs. CONCLUSION: The distinct recurrence characteristics of HLs was not predictable despite repeated ablations. Complete remission should not be expected because the whole bladder was to have the potential to develop the HLs even after repeated transurethral ablation.

Regrowth factors of WHO grade I skull base meningiomas following incomplete resection.

OBJECTIVE: The role of adjuvant radiation therapy following incomplete resection of WHO grade I skull base meningiomas (SBMs) is controversial, and little is known regarding the behavior of residual tumors. The authors investigated the factors that influence regrowth of residual WHO grade I SBMs following incomplete resection. METHODS: From 2005 to 2019, a total of 710 patients underwent surgery for newly diagnosed WHO grade I SBMs. The data of 115 patients (16.2%) with incomplete resection and without any adjuvant radiotherapy were retrospectively assessed during a mean follow-up of 78 months (range 27-198 months). Pre-, intra-, and postoperative clinical and molecular factors were analyzed for relevance to regrowth-free survival (RFS). RESULTS: Eighty patients were eligible for analysis, excluding those who were lost to follow-up (n = 10) or had adjuvant radiotherapy (n = 25). Regrowth occurred in 39 patients (48.7%), with a mean RFS of 50 months (range 3-191 months). Significant predictors of regrowth were Ki-67 proliferative index (PI) ≥ 4% (p = 0.017), Simpson resection grades IV and V (p = 0.005), and invasion of the cavernous sinus (p = 0.027) and Meckel's cave (p = 0.027). After Cox regression analysis, only Ki-67 PI ≥ 4% (hazard ratio [HR] 9.39, p = 0.003) and Simpson grades IV and V (HR 8.65, p = 0.001) showed significant deterioration of RFS. When stratified into 4 scoring groups, the mean RFSs were 110, 70, 38, and 9 months for scores 1 (Ki-67 PI < 4% and Simpson grade III), 2 (Ki-67 PI < 4% and Simpson grades IV and V), 3 (Ki-67 PI ≥ 4% and Simpson grade III), and 4 (Ki-67 PI ≥ 4% and Simpson grades IV and V), respectively. RFS was significantly longer for score 1 versus scores 2-4 (p < 0.01). Tumor consistency, histology, location, peritumoral edema, vascular encasement, and telomerase reverse transcriptase promoter mutation had no impact on regrowth. CONCLUSIONS: Ki-67 PI and Simpson resection grade showed significant associations with RFS for WHO grade I SBMs following incomplete resection. Ki-67 PI and Simpson resection grade could be utilized to stratify the level of risk for regrowth.

Feasibility of a deep learning-based diagnostic platform to evaluate lower urinary tract disorders in men using simple uroflowmetry.

PURPOSE: To diagnose lower urinary tract symptoms (LUTS) in a noninvasive manner, we created a prediction model for bladder outlet obstruction (BOO) and detrusor underactivity (DUA) using simple uroflowmetry. In this study, we used deep learning to analyze simple uroflowmetry. MATERIALS AND METHODS: We performed a retrospective review of 4,835 male patients aged ≥40 years who underwent a urodynamic study at a single center. We excluded patients with a disease or a history of surgery that could affect LUTS. A total of 1,792 patients were included in the study. We extracted a simple uroflowmetry graph automatically using the ABBYY Flexicapture® image capture program (ABBYY, Moscow, Russia). We applied a convolutional neural network (CNN), a deep learning method to predict DUA and BOO. A 5-fold cross-validation average value of the area under the receiver operating characteristic (AUROC) curve was chosen as an evaluation metric. When it comes to binary classification, this metric provides a richer measure of classification performance. Additionally, we provided the corresponding average precision-recall (PR) curves. RESULTS: Among the 1,792 patients, 482 (26.90%) had BOO, and 893 (49.83%) had DUA. The average AUROC scores of DUA and BOO, which were measured using 5-fold cross-validation, were 73.30% (mean average precision [mAP]=0.70) and 72.23% (mAP=0.45), respectively. CONCLUSIONS: Our study suggests that it is possible to differentiate DUA from non-DUA and BOO from non-BOO using a simple uroflowmetry graph with a fine-tuned VGG16, which is a well-known CNN model.

The usefulness of patient-specific 3D nasal silicone implant using 3D design and order form.

PURPOSE: The need for customized implants has continuously increased, but patient-specific silicone implants are not yet commonly used in the plastic surgery market. We sought to validate the effectiveness of a 3D customized nasal implant design in terms of design and lead time compared with a manually customized implant by a surgeon. MATERIALS AND METHODS: Based on the computed tomography (CT) findings of 15 patients who planned rhinoplasty, a surgeon wrote order forms reflecting the surgical plan and subsequently designed implants manually using epoxy on a 3D printed skull. Separately, engineers analyzed the CT findings and designed 3D implants based on the order forms. RESULTS: Epoxy designs were 3D-scanned, converted into a stereolithography format and compared with 3D implant designs to assess which method had a smaller margin of error as per the preoperative order form. Moreover, the lead time in all steps are compared. Nasion thickness, tip thickness, glabella starting point, glabella width, radix width, and total volume were comparatively analyzed. In all parameters, the error rate of the 3D design is relatively lower than that of the epoxy design. The former also had a lower total volume and a faster manufacturing time. CONCLUSION: With novel 3D customized nasal implants, the limitations of ready-made silicone implants are addressed, and it is now possible to preoperatively design implants more accurately, quickly, and conveniently.

The role of apparent diffusion coefficient as a predictive factor for tumor recurrence in patients with cerebellopontine angle epidermoid tumor.

Intracranial epidermoid tumors are slowly growing benign tumors, but due to adjacent critical neurovascular structures, surgical resection is challenging, with the risk of recurrence. The apparent diffusion coefficient (ADC) has been used to evaluate the characteristics of brain tumors, but its utility for intracranial epidermoid tumors has not been specifically explored. This study analyzed the utility of preoperative ADC values in predicting tumor recurrence for patients with intracranial epidermoid tumors. Between 2008 and 2019, 21 patients underwent surgery for cerebellopontine angle (CPA) epidermoid tumor, and their preoperative ADC data were analyzed. The patients were divided into two groups: the recurrence group, defined by regrowth of the remnant tumor or newly developed mass after gross total resection on magnetic resonance imaging (MRI); and the stable group, defined by the absence of growth or evidence of tumor on MRI. Receiver operating characteristic (ROC) analysis was used to obtain the ADC cutoff values for predicting tumor recurrence. The prognostic value of the ADC was assessed using Kaplan-Meier curves. The minimum ADC values were significantly lower in the recurrence group than in the stable tumor group (P = 0.020). ROC analysis showed that a minimum ADC value lower than 804.5 × 10-6 mm2/s could be used to predict higher recurrence risk of CPA epidermoid tumors. Non-total resection and mean and minimum ADC values lower than the respective cutoffs were negative predictors of recurrence-free survival. Minimum ADC values could be useful in predicting the recurrence of CPA epidermoid tumors.

Comparison of Efficacy of Different Surgical Techniques for Benign Prostatic Obstruction.

PURPOSE: We compared success rates of 3 surgical techniques (holmium laser enucleation of the prostate [HoLEP], transurethral resection of the prostate [TURP], and photoselective laser vaporization prostatectomy [PVP]) for treatment of benign prostatic obstruction (BPO). We aimed to identify preoperative clinical variables and urodynamic parameters that predict surgical success. METHODS: A total of 483 patients who underwent surgical treatment for BPO at Samsung Medical Center between 2006 and 2017 were retrospectively analyzed; of these 361, 81, and 41 patients underwent HoLEP, TURP, and PVP, respectively. Prostate-specific antigen, prostate volume, urodynamic parameters, and International Prostate Symptom Score (IPSS)/quality of life (QoL) index were evaluated preoperatively; uroflowmetry, postvoid residual urine, and IPSS/QoL index were measured 6 months postoperatively. Surgical success was defined based on IPSS, maximum flow rate, and QoL index and predictive factors were identified using multiple logistic regression analyses. RESULTS: Success rates of HoLEP, TURP, and PVP were 67.6%, 65.4%, and 34.1%, respectively, and the HoLEP and TURP groups were not significantly different. Regression analysis revealed prostate volume ≥50 mL and bladder outlet obstruction index (BOOI) ≥40 to be independent factors predicting HoLEP success. Only high preoperative QoL could predict the success of TURP, whereas other urodynamic parameters remained unrelated. CONCLUSION: Patients treated with HoLEP and TURP displayed equivalent efficacies, but PVP was relatively less efficient than both. Preoperative variables of prostate volume ≥50 mL and BOOI ≥40 were independent predictive factors for the success of HoLEP but not of TURP.

The behavior of residual tumors following incomplete surgical resection for vestibular schwannomas.

The management of vestibular schwannoma (VS) with residual tumor following incomplete resection remains controversial and little is known regarding postoperative tumor volume changes. The behavior of residual tumors was analyzed for 111 patients who underwent surgery for newly diagnosed VS between September 2006 and July 2017. The postoperative tumor volume changes were assessed during a mean follow-up of 69 months (range 36-147 months). Fifty-three patients underwent imaging surveillance following incomplete resection. There was no residual tumor growth in 44 patients (83%). A significant regression of residual tumor volume was noted in the no growth group at postoperative 1 year (p = 0.028), 2 years (p = 0.012), but not from 3 years onwards. Significant predictors of regrowth were immediate postoperative tumor volume ≥ 0.7 cm3 (HR 10.5, p = 0.020) and residual tumor location other than the internal auditory canal (IAC) (HR 6.2, p = 0.026). The mean time to regrowth was 33 months (range 5-127 months). The 2-, 5-, and 10-year regrowth-free survival rates were 90.6%, 86.8%, and 83%, respectively. In conclusion, significant residual tumor regression could occur within 2 years for a VS with an immediate postoperative tumor volume less than 0.7 cm3 or residual tumor in IAC.

Apparent diffusion coefficient as a prognostic factor in clival chordoma.

Clival chordoma is a rare disease with high recurrence rates even after a combination of surgical resection and radiotherapy. Apparent diffusion coefficient (ADC) has been used to evaluate aggressive features of chordoma, but its utility for clival chordoma has not been explored specifically. In this study, the utility of preoperative ADC values was analyzed for predicting tumor progression and recurrence in patients with clival chordoma. Between 2012 and 2019, a total of 30 operated cases were analyzed with available preoperative ADC data. Receiver operating characteristic (ROC) analysis was used to obtain ADC cutoff values for predicting tumor aggressiveness. The mean and minimum ADC values were significantly lower in the aggressive tumor group than in the stable tumor group (both P < 0.001). ROC analysis showed that a mean cutoff ADC value of 1198 × 10-6 mm2/s and minimum ADC value of 895.5 × 10-6 mm2/s could be used to predict aggressive features of clival chordoma. Subtotal resection, partial resection, and mean and minimum ADC values that were lower than cutoff values were negative predictors of overall survival and progression-free survival. In conclusion, mean and minimum ADC values could be useful in predicting aggressiveness of clival chordoma.

Radiosurgery vs. microsurgery for newly diagnosed, small petroclival meningiomas with trigeminal neuralgia.

Trigeminal neuralgia (TN) is an excruciating pain that can occur with petroclival meningiomas (PCMs). Gamma knife radiosurgery (GKRS) is an appealing option for small PCMs, but the role of microsurgery (MS) compared to GKRS is not well defined for small PCMs with regard to TN relief. From January 2009 to September 2019, 70 consecutive patients were treated by GKRS or MS for newly diagnosed, small (< 3.5 cm) PCMs with TN. GKRS or MS were performed for 35 patients each. The surgical outcome and TN control according to Barrow Neurological Institute (BNI) score were retrospectively analyzed and compared between GKRS and MS. The predominant origin of PCMs was upper clival (49%) with trigeminal nerve compression at the medial dorsal root entry zone. Tumor control rates were equally 94% with GKRS or MS for a mean tumor size and volume of 2.3 cm and 5.3 cm3, respectively. The preoperative BNI scores were mostly II (40%) and IV (37%) with GKRS and MS, respectively. TN relief without medications (BNI scores I and II) was achieved in 13 of 35 patients (37%) with GKRS and 32 of 35 patients (91%) with MS during a mean follow-up of 50.5 months. The most common complications after GKRS and MS were dysesthesia (23%) and diplopia (9%), respectively. MS could be more effective than GKRS in providing prompt, medication-free pain relief from TN for small PCMs. The risks of MS have to be considered carefully in experienced hands, especially for small PCMs.

Robotic Sacrocolpopexy for Treatment of Apical Compartment Prolapse.

Abdominal sacrocolpopexy is the gold-standard treatment for apical compartment prolapse, as it is more effective and durable than the transvaginal approach. In the current era of minimally invasive surgery, laparoscopic sacrocolpopexy techniques have been described, but have not gained popularity due to their complexity and steep learning curves. To overcome this problem, robotic sacrocolpopexy was introduced, and has shown equivalent outcomes and safety compared to open and laparoscopic sacrocolpopexy based on findings that have been accumulated over 15 years.

Changes in uroplakin expression in the urothelium of patients with ulcerative interstitial cystitis/bladder pain syndrome.

Purpose: We evaluated changes in the expression of uroplakin (UP) in the urothelium of patients with ulcerative interstitial cystitis/bladder pain syndrome (IC/BPS). Materials and Methods: Bladder samples were collected from 19 patients with ulcerative IC/BPS who were treated with augmentation ileocystoplasty and from 5 control patients. Frequency-volume charts, the pain visual analogue scale (VAS), and the O'Leary-Sant interstitial cystitis symptom index (ICSI) and problem index (ICPI) were used to evaluate the patients' symptoms preoperatively. The expression levels of UP-Ib and UP-III in the urothelium were compared between the IC/BPS patients and control patients. Results: Sixteen women and three men with IC/BPS were evaluated. Their values for preoperative mean voiding frequency, number of nocturia episodes, and functional bladder capacity as recorded in frequency-volume charts were 21.1±12.8, 5.9±4.2, and 151.1±62.7 mL, respectively. The mean pain VAS, ICSI, and ICPI scores were 8.4±1.3, 17.7±2.2, and 14.7±1.8, respectively. Immunofluorescence staining showed that UP-Ib and UP-III were localized in the urothelium. Upon Western blot analysis, the expression of UP-III was significantly increased in the IC/BPS group compared with the control group. However, expression of UP-Ib did not differ significantly between the IC/BPS and control groups. Conclusions: UP-III was significantly upregulated in patients with ulcerative IC/BPS. UP-III is a potential biomarker for the diagnosis of ulcerative IC/BPS.

Clinical guidelines for interstitial cystitis/bladder pain syndrome.

The clinical guidelines for interstitial cystitis and related symptomatic conditions were revised by updating our previous guidelines. The current guidelines define interstitial cystitis/bladder pain syndrome as a condition with chronic pelvic pain, pressure or discomfort perceived to be related to the urinary bladder accompanied by other urinary symptoms, such as persistent urge to void or urinary frequency in the absence of confusable diseases. The characteristic symptom complex is collectively referred as hypersensitive bladder symptoms. Interstitial cystitis/bladder pain syndrome is divided into Hunner-type interstitial cystitis and bladder pain syndrome; Hunner-type interstitial cystitis and bladder pain syndrome represent interstitial cystitis/bladder pain syndrome with Hunner lesions and interstitial cystitis/bladder pain syndrome without Hunner lesions, respectively. So-called non-Hunner-type interstitial cystitis featured by glomerulations or bladder bleeding after distension is included in bladder pain syndrome. The symptoms are virtually indistinguishable between Hunner-type interstitial cystitis and bladder pain syndrome; however, Hunner-type interstitial cystitis and bladder pain syndrome should be considered as a separate entity of disorder. Histopathology totally differs between Hunner-type interstitial cystitis and bladder pain syndrome; Hunner-type interstitial cystitis is associated with severe inflammation of the urinary bladder accompanied by lymphoplasmacytic infiltration and urothelial denudation, whereas bladder pain syndrome shows little pathological changes in the bladder. Pathophysiology would also differ between Hunner-type interstitial cystitis and bladder pain syndrome, involving interaction of multiple factors, such as inflammation, autoimmunity, infection, exogenous substances, urothelial dysfunction, neural hyperactivity and extrabladder disorders. The patients should be treated differently based on the diagnosis of Hunner-type interstitial cystitis or bladder pain syndrome, which requires cystoscopy to determine the presence or absence Hunner lesions. Clinical studies are to be designed to analyze outcomes separately for Hunner-type interstitial cystitis and bladder pain syndrome.

Diagnostic challenges of posterior fossa hemangioblastomas: Refining current radiological classification scheme.

Hemangioblastomas (HBMs) are known to exhibit very typical radiological features and thus classified by well-established radiological classification scheme. We reviewed our series of posterior fossa HBMs in order not only to evaluate the relevance of current classification scheme, but also to possibly refine it. Also, we added descriptions on several cases with unusual radiological magnetic resonance imaging (MRI) findings in which differential diagnosis was challenging. We retrospectively reviewed preoperative MRI of 118 patients with pathologically diagnosed posterior fossa HBMs at our institution between 2002 and 2015. Total 128 tumors were included to this study and classified into four categories based on the presence and nature of cystic components: extratumoral cystic (Type Ce, classical cystic with a mural nodule), intratumoral cystic (Type Ci), mixed cystic (Type Cm), and solid (Type S). The association with von Hippel-Lindau (VHL) disease was also investigated. In 118 patients (65 male and 53 female), 79 (66.9%) had solitary HBMs and 39 (33.1%) were diagnosed with VHL disease. Type Ce with typical radiological findings was the most prevalent type of HBM (63.3%), followed by Type S (21.1%). HBMs with intratumoral cysts were uncommon (Type Ci, 11.7%) and mixed extratumoral and intratumoral cysts (Type Cm) accounted for only 3.9%. No intergroup differences were observed in the proportions of each subtype between the solitary and VHL disease-associated HBMs. The blood loss was much lower in Type Ce than in other subtypes. In Type Cm, radical resection was often challenging as the differentiation between intratumoral and extratumoral cysts was difficult resulting in incomplete resection. Refined radiological classification scheme is more practical because it does not only help surgeons determine whether the cystic wall should be removed or not, but also covers cases with atypical radiological presentations. For solid and extraparenchymal HBMs, differential diagnosis is more difficult as well as very critical as surgical removal is often very challenging.