Simple risk assessment in prostate cancer patients treated with primary androgen deprivation therapy: The Korean Cancer Study of the Prostate risk classification.

OBJECTIVES: To investigate the progression to castration-resistant prostate cancer after primary androgen deprivation therapy, and to build a simple risk prediction model for primary androgen deprivation therapy patients based on the Japan Cancer of the Prostate Risk Assessment criteria. METHODS: A total of 602 patients who received primary androgen deprivation therapy were entered into the Korean Cancer Study of the Prostate database. The effect of prognostic factors was determined by multivariate analysis. For each patient, the weight of all factors was totaled to give Korean Cancer Study-prostate scores; patients were divided into three risk groups according to their score. The probability of castration-resistant prostate cancer, cancer-specific survival and overall survival was estimated by Kaplan-Meier analysis. RESULTS: On multivariate analysis for castration-resistant prostate cancer, the significant variables were initial prostate-specific antigen (>40 ng/mL; 1 point), biopsy Gleason score (≥9; 1 point), clinical N1 (1 point), and non-regional lymph node (1 point), bone (1 point) and visceral (1 point) metastasis. The Korean Cancer Study-prostate scoring model was calculated on a scale of 0-6 (0: low, 1-2: intermediate, ≥3: high risk). The risk groups stratified castration-resistant prostate cancer (P < 0.0001), cancer-specific survival (P < 0.0001) and overall survival (P < 0.0001) by Kaplan-Meier curve. The Korean Cancer Study-prostate model predicted castration-resistant prostate cancer with a c-index of 0.7242, cancer-specific survival with a c-index of 0.7036 and overall survival with a c-index of 0.5890. The 5-year estimated castration-resistant prostate cancer/cancer-specific death rates were 10.3%/6.3% in the low-risk group, 48.4%/22.2% in the intermediate-risk group and 81.7%/53.1% in the high-risk group. CONCLUSIONS: The Korean Cancer Study-prostate risk classification, a modified Japan Cancer of the Prostate Risk Assessment model, is a simple scoring model for predicting oncological outcomes after primary androgen deprivation therapy.

Renal Function is Associated with Nephrometry Score After Partial Nephrectomy: A Study Using Diethylene Triamine Penta-Acetic Acid (DTPA) Renal Scanning.

PURPOSE: The aim of this study was to evaluate the effect of renal tumor anatomical characteristics on renal function change after partial nephrectomy using the scoring systems and the glomerular filtration rate (GFR) estimated from diethylene triamine penta-acetic acid (DTPA) scans. METHODS: Patients who underwent DTPA renal scans before and after partial nephrectomy from January 2009 to December 2011 were identified retrospectively. The anatomical characteristics of renal tumors were standardized using the RENAL, PADUA and C-index scoring systems. Associations between scoring systems and change in GFRs were evaluated using a correlation coefficient. Predictors of GFR change and postoperative new-onset chronic kidney disease (CKD) after partial nephrectomy were assessed. RESULTS: A total of 185 patients with a mean tumor size of 2.6 cm (median 2.3, range 0.5-10) were identified. Mean ischemia time was 21.5 min. The last DTPA renal scan was performed at a mean follow-up duration of 23.3 months after surgery, and the mean decrease in GFR was 8.1 ml/min. By multivariable analysis, preoperative GFR (ß = -039; p < 0.001), RENAL complexity score (ß = -5.32; p < 0.001), and C-index complexity (ß = -5.19; p < 0.001) were independent predictors of decreased GFR on DTPA. Of 175 patients in whom preoperative estimated GFR (eGFR) was > 60 ml/min/1.73 m(2), CKD developed in 14 (8 %) patients after surgery. Independent factors predicting new-onset CKD were preoperative eGFR (odds ratio [OR] 0.91; p = 0.047), age (OR 1.13; p = 0.003), and diabetes (OR 5.10; p = 0.038). CONCLUSIONS: Although each scoring system describing the complexity of renal tumors correlates with change in GFR after partial nephrectomy, RENAL and C-index score were significantly predictive of GFR reduction.

Prognostic factors of oncologic outcomes in metastatic chemotherapy-naïve castration-resistant prostate cancer treated with enzalutamide in actual clinical practice in East Asia.

OBJECTIVES: We aimed to evaluate the prognostic factors for chemotherapy-naïve castration-resistant prostate cancer (CRPC) treated with enzalutamide in actual clinical practice using easily accessible clinical variables. METHODS AND MATERIALS: We retrospectively reviewed the following data from 113 patients with chemotherapy-naïve CRPC treated with enzalutamide: serum levels of prostate-specific antigen (PSA), testosterone, hemoglobin, total protein, albumin, and alkaline phosphatase (ALP); platelet, neutrophil, and lymphocyte counts; neutrophil-to-lymphocyte ratios (NLRs); and liver profiles. PSA progression-free survival (PFS), radiological PFS, and overall survival were estimated by Cox regression analysis. RESULTS: Compared with baseline levels, laboratory values at 2 months showed significantly lower PSA (160.2 ± 351.5 ng/ml vs. 47.4 ± 117.1 ng/ml) and ALP levels (201.86 ± 223.77 IU/l vs. 148.25 ± 146.81 IU/l) and a significantly higher percentage of lymphocytes (28.1% ± 10.6% vs. 31.2% ± 9.7%); those at 1 month showed a significantly lower percentage of neutrophils (61.0% ± 11.0% vs. 57.1% ± 12.5%). In the multivariate analysis, poor prognostic factors for PSA PFS were Gleason score ≥ 9 (hazard ratio [HR] 2.022; P = 0.0250); visceral metastasis (HR 3.143; P = 0.0002); high NLR (HR 1.205; P = 0.0126); and high ALP (HR 1.002; P = 0.0015). For radiological PFS, high NLR (HR 1.249; P = 0.0002) and high ALP (HR 1.002; P = 0.0001) were associated with poor outcomes. The predictors of poor overall survival were visceral metastasis (HR 3.155; P < 0.0001); high NLR (HR 1.341; P < 0.0001); and high ALP (HR 1.001; P = 0.0017). CONCLUSION: Enzalutamide is less effective in patients with metastatic chemotherapy-naïve CRPC with Gleason scores ≥ 9, visceral metastasis, high NLR, and high ALP.

Oncological effect of palliative transurethral resection of the prostate in patients with advanced prostate cancer: a propensity score matching study.

PURPOSE: We investigated the oncologic effect of palliative transurethral resection of the prostate (pTURP) in patients with prostate cancer who received primary androgen deprivation therapy. METHODS: We reviewed 614 patients, including 83 who underwent pTURP; those with incidental prostate cancer were excluded. Patients were divided into the TURP group and non-TURP group. Propensity score matching was performed for comorbidity, initial prostate-specific antigen (PSA), TNM stage, and Gleason score (GS). The Kaplan-Meier method was used to confirm castration-resistant prostate cancer (CRPC), cancer-specific survival (CSS), and overall survival (OS). Cox regression was performed to confirm factors affecting CSS. RESULTS: Before matching, the TURP group had a worse TNM stage (p < 0.01) and GS (p = 0.028) and larger prostate volume (50.1 vs. 39.0 cc, p = 0.005) than the non-TURP group. The most common reason for pTURP was acute urinary retention. After matching, the TURP group showed worse outcomes in CRPC (p = 0.003), CSS (p = 0.003), and OS (p = 0.026). In multivariate analysis, factors for predicting CSS were a positive core percent [hazard ratio (HR) 1.015, p = 0.0272], GS (10 vs. ≤8; HR 6.716, p = 0.0008), and TURP within 3 months after biopsy (HR 2.543, p = 0.0482). The resection weight (HR 1.000, p = 0.9730), resection time (HR 1.000, p = 0.3670), and blood transfusion (HR 0.630, p = 0.1860) were not associated with CSS. CONCLUSIONS: The oncologic effect of pTURP as cytoreductive operation seems to be limited. Patients who had to receive pTURP due to cancer-related symptoms, especially early necessity of pTURP (within 3 months after biopsy), showed worse clinical courses; therefore, they should be treated more carefully and actively.

Factors associated with testosterone recovery after androgen deprivation therapy in patients with prostate cancer.

PURPOSE: We investigated factors affecting testosterone recovery after androgen deprivation therapy (ADT) withdrawal in patients with prostate cancer. MATERIALS AND METHODS: The medical records of patients who underwent radical prostatectomy with ADT were retrospectively reviewed. In all, 221 patients were included in the analysis. Testosterone recovery was defined as supra-castration (SC) (testosterone levels in serum >50 ng/dL) or out of hypogonadism (OH) (>300 ng/dL) after ADT withdrawal. Kaplan-Meier analyses were used to estimate testosterone recovery after ADT cessation. Cox regression analyses were used to determine the factors affecting the recovery of testosterone. RESULTS: After ADT, 206 patients (93.2%) recovered to the SC level and 122 patients (55.2%) recovered to the OH level. Patients treated with ADT for ≤18 months recovered to OH in a mean of 6.8 months (74.6%), but patients treated with ADT for >18 months recovered in a mean of 9.7 months (27.5%). In multivariate analyses, age (hazard ratio [HR], 0.915; p<0.001), serum level of sex hormone-binding globulin (SHBG) (HR, 1.015; p=0.002), initial testosterone level (HR, 1.002; p=0.002), and ADT duration (HR, 0.915; p<0.001) were associated with recovery to the OH level after ADT withdrawal, and hypertension (HR, 0.697; p=0.029) and duration of ADT (HR, 0.979; p=0.012) were significantly associated with recovery to SC. CONCLUSIONS: In patients treated with ADT for ≤18 months, testosterone recovers to the OH level more often and faster after ADT cessation. Age, SHBG level, initial testosterone level, and ADT duration are associated with testosterone recovery.

Elimination of Hunner's Ulcers by Fulguration in Patients With Interstitial Cystitis: Is It Effective and Long Lasting?

PURPOSE: To evaluate the outcome of fulguration of Hunner's ulcers (HUs) in painful bladder syndrome/interstitial cystitis (PBS/IC) that is refractory to conservative treatment. MATERIALS AND METHODS: Patients diagnosed with refractory PBS/IC and treated with fulguration between 2011 and 2013 were identified through screening of medical records. To evaluate treatment outcomes, voiding diaries, the visual analogue scale (VAS) for pain, and two IC symptom questionnaires (pelvic pain and urgency/frequency scale [PUF] and O'Leary-Sant IC symptom index and IC problem index [OS]) were used. Fulguration was deemed to be successful if the VAS score was <2 or less than half of the preoperative VAS score. RESULTS: In total, 27 patients with PBS/IC in whom conservative treatments had failed were enrolled. Two months after fulguration, decreases were observed in the mean 24-hour urinary frequency (from 16.0 to 10.2), 24-hour urgency episodes (8.0 to 1.8), and the VAS (5.8 to 1.2), PUF symptom (15.1 to 7.0), PUF bother (8.4 to 2.7), OS symptom (15.1 to 7.2), and OS problem (13.8 to 6.0) scores. At 5 and 10 months, all variables had worsened. At 2, 5, and 10 months, the success rates were 94.1%, 70.0%, and 33.3%, respectively. Four patients underwent one repeat fulguration on average 11.3 months after the first fulguration. Repeat fulguration was not significantly associated with any clinical characteristics. CONCLUSIONS: In PBS/IC that was refractory to medication or other conservative treatments, HU elimination by fulguration effectively improved symptoms. However, this effect decreased gradually over time.

Retropubic versus robot-assisted laparoscopic prostatectomy for prostate cancer: a comparative study of postoperative complications.

PURPOSE: To compare the complications of radical retropubic prostatectomy (RRP) with those of robot-assisted laparoscopic prostatectomy (RALP) performed by a single surgeon for the treatment of prostate cancer. MATERIALS AND METHODS: The postoperative complications of 341 patients who underwent RRP and 524 patients who underwent RALP for prostate cancer at the Asan Medical Center between July 2007 and August 2012 were retrospectively reviewed and compared. Complications were classified according to the modified Clavien classification system. RESULTS: RALP was associated with a shorter length of hospital stay (mean, 7.9 days vs. 10.1 days, p<0.001) and duration of urethral catheterization (6.2 days vs. 7.5 days, p<0.001) than RRP. Major complications (Clavien grade III-IV) were less common in the RALP group than in the RRP group (3.4% vs. 7.6%, p=0.006). There were no significant differences in medical complications between procedures. Considering surgical complications, urinary retention (7.0% vs. 2.7%, p=0.002) and wound repair (4.1% vs. 0.2%, p<0.001) were more common after RRP than after RALP. Extravasation of contrast medium during cystography was more common in the RRP group than in the RALP group (10.0% vs. 2.1%, p<0.001). CONCLUSIONS: RALP is associated with a lower complication rate than RRP.

Preoperative factors predictive of posterolateral extracapsular extension after radical prostatectomy.

PURPOSE: In radical prostatectomy (RP) procedures, sparing the neurovascular bundles adjacent to the posterolateral aspect of the prostatic fascia has often been suggested as a possible risk factor for positive surgical margins. Here we aimed to quantify the probability of extracapsular extension (ECE) at the posterolateral side of the prostate to aid in nerve-sparing decision making. MATERIALS AND METHODS: We evaluated 472 patients who underwent RP between July 2007 and January 2012. All patients underwent preoperative magnetic resonance imaging (MRI) with diffusion-weighted imaging and apparent diffusion coefficient mapping. We analyzed 944 side-specific prostate lobes with preoperative variables. To quantify the risk of side-specific posterolateral ECE after RP, we developed a risk-stratification scoring system through logistic regression analysis. RESULTS: Overall, 20.6% of 944 prostate lobes had ECE. In the multivariate analysis, prostate-specific antigen (PSA), biopsy Gleason score ≥7, percentage of side-specific cores with tumor, and posterolateral ECE on MRI were independent predictive factors of posterolateral ECE. On internal and external validation to calculate the predicted risk, the Hosmer-Lemeshow goodness-of-fit test showed good calibration (p=0.396). CONCLUSIONS: PSA, biopsy Gleason score, percentage of side-specific cores with tumor, and posterolateral ECE on MRI are independent predictors of posterolateral ECE. The scoring system derived from this study will provide objective parameters for use when deciding if the neurovascular bundle can be safely spared.