The First 100 Cases of Endoscopic Combined Intrarenal Surgery in Korea: Matched Cohort Analyses versus Shock-Wave Lithotripsy

Purpose@#This study presents our initial experience with endoscopic combined intrarenal surgery (ECIRS) for large renal stones and compares the results of a propensity score-matched cohort of patients undergoing shock-wave lithotripsy (SWL). @*Materials and Methods@#A total of 100 adults underwent ECIRS for renal stones between August 2017 and January 2019. For comparison, 2172 patients who underwent a first session of SWL between January 2005 and May 2018 were included in the SWL cohort.Propensity score matching was performed using maximal stone length (MSL), mean stone density (MSD), and stone heterogeneity index (SHI) scores. Stone-free rate (SFR) and success rate were compared between ECIRS and SWL. @*Results@#In the ECIRS group, the mean MSL, mean MSD, and mean SHI were 28.7±15.2 mm, 1013.9±360.0 Hounsfield units (HU), 209.4±104.0 HU, respectively. The SFR was 70%, and the success rate was 82.0% in this group. Although the ECIRS group had larger, harder, and more homogeneous stones than the SWL group, ECIRS showed a higher SFR and success rate than SWL. After propensity-score matching, SFR and success rate remained higher with ECIRS than with SWL (both, p<0.001). In multivariate logistic regression, smaller stone size [odds ratio (OR): 0.947, 95% confidence interval (CI): 0.913–0.979, p=0.002] and lower Seoul National University Renal Stone Complexity score (OR: 0.759, 95% CI: 0.610–0.935, p=0.011) were independent predictors of successful ECIRS. @*Conclusion@#ECIRS showed a higher SFR and success rate than SWL for large renal stones. Smaller stone size and lower complexity of stones were associated with a higher likelihood of successful ECIRS.

Prevention and management of urinary stone

The prevalence of urolithiasis is increasing not only in South Korea but also around the world. Urolithiasis has a high recurrence rate, therefore, reducing it is very important in the quality of life for stone formers. For this purpose, dietary modifications and drug therapy can be performed through stone analysis and 24-hour urine collection. Stone analysis is recommended for all stone formers, and the 24-hour urine collection is usually recommended for recurrent stone formers or high-risk groups. A general dietary modification for all stone formers includes a sufficient fluid intake, low levels of sodium, sugar, and animal protein, a normal calcium diet, as well as a high amount of citrate intake. Drug therapy should be performed in cases such as the recurrence of stones or increase of the existing ones, even after the application of preservation therapy, such as dietary modification. The ideal drug therapy should prevent the occurrence of urolithiasis, have no side effects, and have a suitable patientsʼ compliance. Follow-up should be performed periodically, through 24-hour urine collections and imaging studies. For follow-up imaging studies, a lowdose non-enhanced computed tomography is recommended, and it can be performed once a year if the patient is in a stable state. To control various and complex metabolic abnormalities in recurrent stone formers, multiple approaches may be required through diet modifications, drug therapy, treatment of the metabolic syndrome, and lifestyle modifications.

Does Early Retrograde Intrarenal Surgery Improve the Cost-Effectiveness of Renal Stone Management?

Purpose@#This study aimed to evaluate the cost-effectiveness of treatment with retrograde intrarenal surgery (RIRS) versus repeated shock wave lithotripsy (SWL) in patients with renal calculi. @*Materials and Methods@#The non-retreatment rates (NRRs) and their respective real-world costs for RIRS and SWL were derived through retrospective analysis of health insurance claims data from 2015 to 2017. Decision tree modeling was performed to demonstrate the cost-effectiveness of RIRS. Furthermore, sensitivity analysis was performed to examine the robustness of the results. @*Results@#Analysis of the obtained data showed that NRRs of single SWL ranged from 46% to 56%, whereas NRRs of single RIRS ranged from 75% to 93%. Introducing RIRS early in the treatment sequence was observed to be favorable for the reduction of overall failure (overall NRR, 0.997) compared to the results of repeated SWL (overall NRR, 0.928). The implementation of decision tree modeling revealed that the cost per retreatment-avoided increased with the introduction of RIRS at an earlier time (first line, second line, third line, fourth line: 18640 USD, 10376 USD, 4294 USD, 3377 USD, respectively). Probabilistic modeling also indicated that the introduction of RIRS as the first line of treatment was least likely to be cost-effective, when compared to other options of introducing RIRS as the second, third, or fourth line of treatment. @*Conclusion@#Performing RIRS as early as possible

Impact of Bladder Neck Stiffness on Lower Urinary Tract Symptoms in Patient With Benign Prostatic Hyperplasia

PURPOSE@#We evaluated the impact of bladder neck stiffness on lower urinary tract symptoms in the patient with benign prostatic hyperplasia using elastography.@*MATERIALS AND METHODS@#A total of 384 patients divided into three different groups according to the bladder neck stiffness based on ultrasound with elastography. Patients age, prostate specific antigen (PSA), International Prostate Symptom Score (IPSS), prostate volumetric parameters, residual urine volume, and laboratory data were collected and compared among the three groups.@*RESULTS@#Group 1 (n=121) showed low stiffness in both bladder neck adenoma. Group 2 (n=157) showed low to intermediated stiffness, and group 3 (n=106) showed significantly higher stiffness of bladder neck and adenoma compared to adjacent prostatic tissue. Significant differences among the 3 groups were found in the total prostate volume, transition zone volume, transition zone index, total IPSS, IPSS-voiding, IPSS-storage, residual urine volume, and quality of life. As the stiffness increased, prostate volumetric parameters, and residual urine volume were increased, and lower urinary tract symptoms became exacerbated. No significant difference was found in the patients' age and PSA.@*CONCLUSIONS@#Bladder neck stiffness affected the lower urinary tract symptoms and prostate volumetric parameters. These findings suggest that the change of bladder neck stiffness can be a novel parameter for the development of lower urinary tract symptoms/benign prostate hyperplasia.

A Rare Case of Bronchogenic Cyst Mistaken for Adrenal Tumor

Bronchogenic cysts are rare congenital malformations, most often occurring in the pulmonary parenchyma or posterior mediastinum. But they can develop in the ectopic area, especially in the retroperitoneal space. We report a case of adrenal bronchial cyst treated with laparoscopic excision. A 55-year-old woman was admitted with a left adrenal tumor on computed tomography during a study for dyspnea, cough, and sweats. The function of the adrenal glands was examined, and as a result, the adrenal tumors were determined to be nonfunctional. Magnetic resonance imaging showed about an 8-cm-sized large unilocular cystic lesion with mild and high signal intensities at left suprarenal fossa on T1 and T2 images. Iodine-123 metaiodobenzylguanidine scan showed no scintigraphic evidence of neuroendocrine tumor in the left adrenal gland. We performed laparoscopic adrenalectomy with transperitoneal approach. The round, cystic mass was completely excised saving normal adrenal tissues. The operative time was 75 minutes and there was no definitive bleeding and complication. The pathologic tissue weighed 35 g and measured 88 mm×45 mm×28 mm, and cystic changes were observed on the cut surface. The pathologic examination confirmed an adrenal bronchogenic cyst. We report a very rare disease, adrenal bronchial cyst, which could be easily and safely treated with laparoscopic surgery.

The Within-Group Discrimination Ability of the Cancer of the Prostate Risk Assessment Score for Men with Intermediate-Risk Prostate Cancer

BACKGROUND: Significant clinical heterogeneity within contemporary risk group is well known, particularly for those with intermediate-risk prostate cancer (IRPCa). Our study aimed to analyze the ability of the Cancer of the Prostate Risk Assessment (CAPRA) score to discern between favorable and non-favorable risk in patients with IRPCa. METHODS: We retrospectively reviewed the data of 203 IRPCa patients who underwent extraperitoneal robot-assisted radical prostatectomy (RARP) performed by a single surgeon. Pathologic favorable IRPCa was defined as a Gleason score ≤ 6 and organ-confined stage at surgical pathology. The CAPRA score was compared with two established criteria for the within-group discrimination ability. RESULTS: Overall, 38 patients (18.7% of the IRPCa cohort) had favorable pathologic features after RARP. The CAPRA score significantly correlated with established criteria I and II and was inversely associated with favorable pathology (all P < 0.001). The area under the receiver operating characteristic curve for the discriminative ability between favorable and non-favorable pathology was 0.679 for the CAPRA score and 0.610 and 0.661 for established criteria I and II, respectively. During a median 37.8 (interquartile range, 24.6–60.2) months of follow-up, 66 patients (32.5%) experienced biochemical recurrence (BCR). Cox regression analysis revealed that the CAPRA score, as a continuous sum score model or 3-group risk model, was an independent predictor of BCR after RARP. CONCLUSION: The within-group discrimination ability of preoperative CAPRA score might help in patient counseling and selecting optimal treatments for those with IRPCa.

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

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. CONCLUSIONS: 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.

Near-Normalized Gene Expression Profiles in Bladder With Detrusor Overactivity in Rats With Bladder Outlet Obstruction After Deobstruction / 대한배뇨장애요실금학회지

PURPOSE: The pathophysiological role of detrusor overactivity (DO) in the bladder, which is commonly observed in various bladder diseases, is not well understood. DO appears in bladder outlet obstruction (BOO), and may continue even after subsequent deobstruction. DO therefore provides an excellent opportunity to observe molecular biological changes. METHODS: In this study, to understand the molecular effects of persistent DO after BOO induction and deobstruction, we performed awake cystometry on female Sprague-Dawley rats divided into 4 groups: a sham group, a BOO group, a deobstructed group with DO after BOO (DDO), and a deobstructed group without DO after BOO (non-DDO). Total RNA was extracted from the bladder samples, and gene expression profiles were compared between the sham and model groups. RESULTS: DO was observed in 5 of the 6 rats (83%) in the BOO group, and in 6 of the 13 rats (46%) in the deobstructed group. The non-DDO group showed a significantly greater residual volume than the DDO group. Through a clustering analysis of gene expression profiles, we identified 7,532 common upregulated and downregulated genes, the expression of which changed by more than 2 fold. In the BOO group, 898 upregulated and 2,911 downregulated genes were identified. The non-DDO group showed 3,472 upregulated and 4,025 downregulated genes, whereas in the DDO group, only 145 and 72 genes were upregulated and downregulated, respectively. CONCLUSIONS: Abnormal function and gene expression profiles in bladders after BOO were normalized in the BOO rats with DO after deobstruction, whereas in those without DO, abnormal function persisted and the gene expression profile became more abnormal. DO may play a protective role against the stress to the bladder induced by BOO and deobstruction as a form of adaptive neuroplasticity.

Associations of Self-Reported Erectile Function with Non-Invasive Measurements of Endothelial Function: A Preliminary Study

PURPOSE: To evaluate the association of self-reported erectile function and endothelial function using the EndoPAT device. MATERIALS AND METHODS: We prospectively enrolled 76 men (age> or =40 years) after obtaining a complete medical history and a self-reported questionnaire (International Index of Erectile Function-5 [IIEF-5], SEP Q2, Q3). Endothelial function was noninvasively measured with an EndoPAT 2000, recorded as the reactive hyperemia index (RHI), and analyzed according to the patients' baseline characteristics. RESULTS: The mean patient age and IIEF-5 score were 62.50+/-8.56 years and 11.20+/-6.36, respectively. In comparing the RHI according to erectile dysfunction (ED) risk factors, the RHI was significantly lower in older subjects (p=0.004). There was no difference in the RHI according to age, body mass index, waist circumference, obesity, smoking habit, or other comorbidities. When the subjects were divided into four groups according to the severity of ED, no statistical differences in the RHI value were found among the groups. There was no difference in IIEF-5 according to the RHI when categorized according to the normal cutoff value or quartile ranges. The second subdomain of IIEF-5 (erection firmness) was significantly correlated with the RHI value (R=0.309, p=0.007); however, this was not the case with the other IIEF-5 subdomains. Self-assessment showed a tendency toward a negative correlation with the RHI value (R=-0.202, p=0.080). CONCLUSIONS: The role of endothelial function measurement by the EndoPAT in the evaluation and management of ED patients remains inconclusive. However, further studies are needed to validate the role of endothelial function measurement, by the EndoPAT or any other device.

Preoperative Underweight Patients with Upper Tract Urothelial Carcinoma Survive Less after Radical Nephroureterectomy

The prognostic impact of body mass index (BMI) in patients with upper tract urothelial carcinoma (UTUC) is an ongoing debate. Our study aimed to investigate the prognostic role of BMI in patients treated with radical nephroureterectomy (RNU) for UTUC from a multi-institutional Korean collaboration. We retrospectively reviewed data from 440 patients who underwent RNU for UTUC at four institutions in Korea. To avoid biasing the survival estimates, patients who had previous or concomitant muscle-invasive bladder tumors were excluded. BMI was categorized into approximate quartiles with the lowest quartile assigned to the reference group. Kaplan-Meier and multivariate Cox regression analyses were performed to assess the influence of BMI on survival. The lower quartile BMI group showed significantly increased overall mortality (OM) and cancer specific mortality (CSM) compared to the 25%-50% quartiles and upper quartile BMI groups. Kaplan-Meier estimates showed similar results. Based on multivariate Cox regression analysis, preoperative BMI as a continuous variable was an independent predictor for OM and CSM. In conclusion, preoperative underweight patients with UTUC in Korea survive less after RNU. Preoperative BMI may provide additional prognostic information to establish risk factors.

Seasonal Variation of Urinary Symptoms in Korean Men with Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia

PURPOSE: To examine seasonal variations in urinary symptoms in Korean men with lower urinary tract symptoms and benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: Records were obtained from a consecutive database of LUTS/BPH patients from March 2010 to February 2014. A total of 1,185 patients were suitable for analysis. The International Prostate Symptom Score (IPSS), uroflowmetric parameters, prostate volume-related parameters, and serum prostate-specific antigen levels were evaluated. RESULTS: Based on the month during which they were examined, patients were categorized into cold, hot, or intermediate season groups. The IPSS score was significantly different between the cold and the hot season groups (17.3+/-6.9 vs. 16.1+/-7.4, respectively; p=0.020). Storage symptom scores were significantly aggravated in the cold (6.8+/-3.3; p=0.030) and intermediate groups (6.9+/-3.5; p=0.032) compared with the hot season group (6.3+/-3.4), with this observation primarily driven by the individual scores for frequency and urgency. Quality of life (QOL) scores were worse in the cold compared with the hot season group (4.0+/-1.1 vs. 3.8+/-1.1, respectively; p=0.012). There were also significant differences between the cold and hot season groups in voided volume (278.7+/-148.5 vs. 255.9+/-145.1, respectively; p=0.034) and postvoid residual volume (26.4+/-37.6 vs. 32.2+/-41.0, respectively; p=0.039). CONCLUSIONS: Different urinary symptoms and uroflowmetric parameters were associated with changes in seasons. QOL and IPSS parameters might be worse in cold weather seasons compared with hot weather seasons.

Pathologic Outcomes in Men with Low-risk Prostate Cancer Who Are Potential Candidates for Contemporary, Active Surveillance Protocols

The purpose of this study was to determine whether contemporary active surveillance (AS) protocols could sufficiently discriminate significant from indolent tumors in men with low-risk prostate cancer. We retrospectively analyzed 312 patients with low-risk prostate cancer treated with radical prostatectomy. After exclusion of patients with fewer than 10 cores taken at biopsy and those who received neo-adjuvant treatment, 205 subjects satisfied the final inclusion criteria. Five widely accepted AS protocols were employed in this study. A total of 82.0% of the patients met the inclusion criteria of at least one protocol, and 18% did not meet any criteria of published AS protocols. A significant proportion of patients had non-organ-confined disease (8.6% to 10.6%) or a Gleason score of 7 or greater (18.6% to 23.9%) between the different AS criteria. Among patients who did not meet any AS criteria, 32.4% of patients had a pathologically insignificant cancer. Our results indicated a significant adverse pathology in patients who met the contemporary AS protocols. On the other hand, some patients in whom expectant management would be appropriate did not meet any criteria of published AS protocols. None of the clinical or histological criteria reported to date is able to sufficiently discriminate aggressive tumors from indolent ones.

Current Status of Radical Prostatectomy for High-Risk Prostate Cancer

Despite the wide application of prostate-specific antigen-based screening leading to a profound stage migration in prostate cancer (PC), a significant percentage of men are still being diagnosed with clinically high-risk disease that requires aggressive treatment. Optimal management in these patients remains challenging, and strong advocates for radical prostatectomy (RP), radiotherapy, androgen deprivation therapy, and, increasingly, a multimodal approach abound. Currently, surgery for high-risk PC is frequently applied. RP offers an attractive opportunity for tumor excision either as a definitive management or as a first step in multimodal therapy. Nevertheless, this approach is still controversial. In this review, we discuss the current evidence for the role of RP in this clinical setting, including surgical considerations and outcomes. The role of robot-assisted RP, which is increasingly utilized in Korea in this clinical scenario, is discussed.

Accuracy of Methods for Urinary Detection in Women with Stress Urinary Incontinence

PURPOSE: We assessed the accuracy of urinary detection by visualization compared with a method using the urethral channel of a transurethral, three-channel urodynamic catheter. MATERIALS AND METHODS: This was a case series of 52 patients presenting with stress urinary incontinence over 2 years. Patients underwent video-urodynamic studies in both the supine and the erect positions by use of two techniques for measuring leak point pressure (LPP) by one examiner. LPP was determined as the intravesical pressure simultaneous to the starting point of urethral pressure changes through the urethral channel of a urodynamic catheter (LPP-ure) and then by visualization (LPP-vis) during different events. We also measured the time related to the provocations and the time to mark the leakage on the urodynamic machine by the examiner. RESULTS: The LPP-ure values (cough supine: 42.1+/-18.7, cough erect: 42.1+/-21.8, Valsalva supine: 42.2+/-23.3, Valsalva erect: 41.0+/-22.6 cmH2O) were significantly lower than the LPP-vis values (89.9+/-29.4, 97.4+/-30.4, 70.6+/-25.2, and 74.4+/-32.6 cmH2O, respectively, all p<0.001). Whereas the actual leakages happened during the pressure increases, urodynamic recording by visualization was done after those increases had finished. CONCLUSIONS: The use of visualization as a urinary detection method entails potential errors that cannot be adjusted for on that time scale. Our results emphasize the need to standardize the methodologies used for urinary leakage detection, because this measurement is closely related to the accuracy of measurement of leak point pressure.

The Effect of Suprapubic Magnetic Stimulation in Patients with Neurogenic Detrusor Overactivity

PURPOSE: To evaluate the effect of suprapubic magnetic stimulation (SMS) with the use of an arm-type magnetic stimulator for the treatment of patients with neurogenic detrusor overactivity. MATERIALS AND METHODS: Eleven patients with neurogenic detrusor overactivity were enrolled in this study. All patients underwent more than 16 SMS sessions, two times per week, with the use of an arm-type magnetic stimulator. Objective success was defined as a significant reduction (> or =50%) in the total number of leakage episodes per 24 hours, whereas subjective success was defined as the request to continue treatment. RESULTS: Five (71.4%) of 7 patients who had urinary incontinence before treatment reported objective success, and 3 patients showed no incontinence. A total of 6 (75.0%) of 8 patients showed increased average voiding volume. One patient showed an adverse effect of back pain after SMS and dropped out. Seven patients (70.0%) of 10 patients wanted to continue this treatment. They showed significant improvements in frequency/volume chart data, quality of life scores, and urodynamic data. CONCLUSIONS: SMS can be a safe, non-invasive and effective option for the treatment of neurogenic detrusor overactivity.

Median Raphe Cyst on Glans Penis / 대한남성과학회지

Median raphe cyst is a relatively uncommon disease and is caused by a defect in the embryonic development of male genitalia. Here, we report a case of median raphe cyst on the glans penis in a 20-year-old male, which was successfully treated by surgical excision.