Evaluation of histological variants of upper tract urothelial carcinoma as prognostic factor after radical nephroureterectomy.

PURPOSE: To evaluate the impact of variant histology on patients with upper tract urothelial carcinoma (UTUC) survival outcomes. MATERIALS AND METHODS: A total of 519 patients underwent radical nephroureterectomy without neoadjuvant therapy for UTUC at a single institution between May 2003 and December 2019. Multivariate Cox regression analysis evaluated the impact of variant histology on progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS). RESULTS: Among 84 patients (16.2%) with variant histology, the most frequent variant type was squamous cell differentiation (64.3%), followed by glandular differentiation (25.0%) and sarcomatoid variant (2.4%). They showed pathologically advanced T stage (for ≥ T3, 59.5% vs 33.3%, p < 0.001), higher tumor grade (96.4% vs 85.7%, p = 0.025), and higher rates of lymph node metastasis (17.9% vs 7.8%, p = 0.015), angiolymphatic invasion (41.7% vs 25.7%, p = 0.003), tumor necrosis (57.1% vs 29.0%, p < 0.001) and positive surgical margin (13.1% vs 5.7%, p = 0.015). On multivariate Cox regression analyses, variant histology was significantly associated with worse PFS (hazard ratio [HR] 2.23; 95% confidence interval [CI] 1.55-3.21; p < 0.001), CSS (HR 2.67; 95% CI 1.35-5.30; p = 0.005) and OS (HR 2.22; 95% CI 1.27-3.88; p = 0.005). In subgroup analysis, no significant survival gains of adjuvant chemotherapy occurred in patients with variant histology. CONCLUSIONS: Variant histology was associated with adverse pathologic features and poor survival outcomes. Our results suggest that patients with variant histology may require a close follow-up schedule and novel adjuvant therapy other than chemotherapy postoperatively.

The learning curve for transurethral enucleation with bipolar energy for benign prostate hyperplasia: a single-surgeon experience of 494 patients.

This study was performed to investigate the learning curve of transurethral enucleation with bipolar energy (TUEB) for benign prostatic hyperplasia. The study involved 494 consecutive patients who underwent TUEB for benign prostatic hyperplasia from August 2018 to March 2022 by one surgeon (SJJ, Seoul National University Bundang Hospital, Seongnam, Korea). The patients were followed up at 1 week, 1 month, 3 months, and 6 months postoperatively. To evaluate the learning curve of TUEB, perioperative parameters including the enucleation ratio (enucleated tissue weight/transitional zone volume), TUEB efficiency (enucleated tissue weight/operation time), and enucleation efficiency (enucleated tissue weight/enucleation time) were analyzed. Functional outcomes and postoperative complications were also assessed, including the International Prostate Symptom Score (IPSS), IPSS quality-of-life (QoL) score, and uroflowmetry outcomes. The patients' median age was 72 (interquartile range [IQR]: 66-78) years, and the estimated prostate volume and transitional zone volume were 63.0 (IQR: 46.0-90.6) ml and 37.1 (IQR: 24.0-60.0) ml, respectively. The enucleation ratio, TUEB efficiency, and enucleation efficiency were 0.60 (IQR: 0.46-0.54) g ml-1, 0.33 (IQR: 0.22-0.46) g min-1, and 0.50 (IQR: 0.35-0.72) g min-1, respectively, plateauing after 70 cases. The functional outcomes, including total IPSS, IPSS QoL score, and uroflowmetry outcomes, significantly improved at 6 months after TUEB (all P < 0.05), but without significant differences over the learning curve. Sixty-five (13.2%) patients developed complications after TUEB, 21.5% of whom experienced major complications (Clavien-Dindo grade ≥3). The rate of major complications declined as the number of TUEB cases increased (P = 0.013). Our results suggest that the efficiency of TUEB stabilized within 70 procedures.

Clinical value of prostate health index as an indicator for recommending magnetic resonance imaging in patients with gray-zone prostate-specific antigen level.

PURPOSE: To evaluate the usefulness of prostate health index (PHI) as an indicator for recommending magnetic resonance imaging (MRI) in patients with prostate-specific antigen (PSA) gray zone level < 10 ng/mL. METHODS: 443 patients who underwent prostate biopsy (PB) after serum PHI test and MRI between April 2019 and December 2022 were enrolled. For patients with visible lesion on MRI with Prostate Imaging Reporting and Data System Score (PI-RADS) ≥ 3, MRI-targeted PB was performed in addition to systematic 12-core PB. RESULTS: The optimal cutoff value of PHI for predicting PI-RADS ≥ 3 lesions was 39.6, which was significantly associated with overall prostate cancer (OR 3.07, p = 0.018) and clinically significant prostate cancer (csPCa) (OR 4.15, p = 0.006) at MRI-targeted PB cores. When MRI was restricted to patients with PHI ≥ 39.6 alone, 28.7% of unnecessary MRI could be saved at the cost of missing 13.6% of csPCa. When omitting MRI for patients with PHI < 39.6 and PSAD < 0.12 ng/mL2, unnecessary MRI could be reduced by 20.1% with the risk of missing 6.2% of csPCa. With addition of systematic PB, 21.0% of patients with negative MRI-targeted PB were diagnosed as csPCa. CONCLUSIONS: For patients in PSA gray zone, PHI of 39.6 might be an indicator for MRI and further MRI-targeted PB in additional to PSAD of 0.12 ng/mL2, reducing 20.1% of unnecessary MRI with the minimal risk of missing 6.2% of csPCa. To maximize csPCa detection, combining both MRI-targeted and systematic PB should be also considered.

Computer tomography-based shape of tumor contour and texture of tumor heterogeneity are independent prognostic indicators for clinical T1b-T2 renal cell carcinoma.

PURPOSE: To evaluate association between computer tomography (CT)-based features of renal cell carcinoma (RCC) and survival outcomes. METHODS: Data of 958 patients with clinical T1b-T2 RCC who underwent partial/radical nephrectomy from June 2003 to March 2022 were retrospectively evaluated. CT images of patients were reviewed by two radiologists for texture analysis of tumor heterogeneity and shape analysis of tumor contour. Patients were divided into three groups according to patterns of CT-based features: (1) favorable feature group (n = 117); (2) intermediate feature group (n = 606); and (3) unfavorable feature group (n = 235). Kaplan-Meier survival analysis and multivariate Cox regression analysis were performed to evaluate overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). RESULTS: RCCs with unfavorable CT-based feature showed larger size on CT, higher nuclear grade, higher rate of histologic necrosis, and higher rate of capsular invasion than those in the other two groups (all p < 0.001). Unfavorable feature was associated with poorer OS (p = 0.001), CSS (p < 0.001), and RFS (p < 0.001) on Kaplan-Meier analysis. In multivariate analysis, intermediate and unfavorable features were independent predictors for recurrence (hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.09-5.79, p = 0.031 and HR 3.71, 95% CI 1.58-8.73, p = 0.003, respectively), but not for overall death or RCC-specific death. CONCLUSIONS: A combination of irregular tumor contour feature with heterogeneous tumor texture feature on CT is associated with poor RFS in clinical T1b-T2 RCC preoperatively.

Evaluation of the efficiency of transurethral enucleation with bipolar energy according to prostate volume for patients with benign prostate hyperplasia.

Background: This study evaluated the efficiency and safety of transurethral enucleation with bipolar energy (TUEB) using a spatula loop according to prostate volume. Methods: We retrospectively evaluated 398 patients who underwent TUEB for benign prostatic hyperplasia at a single tertiary hospital between August 2018 and December 2022. The patients were divided into three groups according to estimated prostate volume (ePV): ≤40 mL (n = 67), 40-80 mL (n = 200), and ≥80 mL (n = 131). To compare the efficiency of TUEB, perioperative parameters including TUEB and enucleation efficiencies, were calculated as enucleated tissue weight per operation time and enucleated tissue weight per enucleation time, respectively. Preoperative and postoperative functional outcomes such as the International Prostate Symptom Score (IPSS), quality-of-life (QoL) score, maximum flow rate (Qmax), and post-void residual urine volume (PVR), were also compared. Results: The IPSS total score, voiding sub-score, Qmax, and PVR improved after TUEB in all groups (all p < 0.05). The TUEB and enucleation efficiencies increased with increasing ePVs (all P < 0.001). When comparing the three prostate volume groups, there were no significant differences in functional outcomes within 12 months after TUEB (all-Bonferroni adjusted P > 0.017). A total of 57 patients experienced adverse events after TUEB, with no significant differences between the three groups (p = 0.507). Conclusion: As prostate volume increases, the perioperative efficiency of TUEB is enhanced. Meanwhile, small prostates did not show significant differences in the improvement of functional outcomes and complications in comparison with larger prostates.

Possibilities and limitations of using low biomass samples for urologic disease and microbiome research.

With the dogma of sterile urine no longer held as truth, numerous studies have implicated distinct changes in microbial diversity and composition to diseased subgroups in both benign and malignant urological diseases, ranging from overactive bladder to bladder and prostate cancer. Further facilitated by novel and effective techniques of urine culture and sequencing, analysis of the genitourinary microbiome holds high potential to identify biomarkers for disease and prognosis. However, the low biomass of samples included in microbiome studies of the urinary tract challenge researchers to draw definitive conclusions, confounded by technical and procedural considerations that must be addressed. Lack of samples and adequate true negative controls can lead to overestimation of microbial influence with clinical relevance. As such, results from currently available studies and assessment of their limitations required a thorough understanding. The purpose of this narrative review was to summarize notable microbiome studies in the field of urology with a focus on significant findings and limitations of study design. Methodological considerations in future research are also discussed.

Comparison of systematic randomized 12-core transrectal ultrasonography-guided prostate biopsy with magnetic resonance imaging-transrectal ultrasonography fusion-targeted prostate biopsy.

We aimed to compare the complications and pathological outcomes between systematic 12-core transrectal ultrasonography guided prostate biopsy (TRUS-PB) and magnetic resonance imaging-TRUS fusion targeted prostate biopsy (MRI-TRUS FTPB). We examined 10,901 patients who underwent prostate biopsy from May 2003 to December 2017 retrospectively. Among them, 10,325 patients underwent 12-core TRUS-PB and 576 patients underwent MRI-TRUS FTPB. The clinicopathological features and complications in both groups were compared. After propensity score matching, there were no significant differences in the clinical features and complication rates between both groups (P > .05). In the multivariate analyses, the prostate volume was shown to be the only significant predictor of overall complications, infectious complications, bleeding related complications, and Clavien-Dindo grade ≥ 2 complications after prostate biopsy (P < .001). The present study demonstrates the safety of MRI-TRUS FTPB in terms of complications, compared with that of TRUS-PB. Although the combination of MRI-TRUS FTPB and 12-core TRUS-PB provides enhanced diagnostic power, MRI-TRUS FGB alone could provide a reasonable diagnostic value for prostate cancer if the apparent diffusion coefficient suspicious grade of prostate cancer is ≥4. When the Likert suspicious grade of prostate cancer on the apparent diffusion coefficient map of multiparametric MRI was 3, 13.9% (27/194) of the patients were diagnosed with clinically significant prostate cancer (csPCa); 44.4% (12/27) of them were confirmed as csPCa at the MRI-targeted cores. When the apparent diffusion coefficient suspicious grade was ≥4, 43.0% (108/251) were diagnosed with csPCa; 76.8% (83/108) of them were confirmed to have csPCa at the MRI-targeted cores.

Outcomes of men aged ≤50 years treated with radical prostatectomy: a retrospective analysis.

Previous studies investigating prostate cancer (PCa) features in younger men have reported conflicting findings. This study aimed to investigate pathologic outcomes and biochemical recurrence (BCR) status in younger men who underwent radical prostatectomy (RP) for PCa. Records of 2057 patients who underwent RP at Seoul National University Bundang Hospital (Seongnam, Korea) between 2006 and 2015 were reviewed; patients were divided according to age into the younger and older groups (men aged ≤50 and >50 years, respectively). Postoperative BCR status and functional outcomes and clinicopathologic features were compared between both groups. All analyses were repeated after propensity score matching. Younger men were more likely to have low-risk disease (P < 0.001), lower pathologic Gleason score (P < 0.001) and pathologic stages (P < 0.001) than older men. The pathologic Gleason score (P = 0.002) and rates of extracapsular extension (P = 0.004) were lower in younger men after propensity score matching. In multivariate analysis, age at RP was not an independent predictor of BCR-free survival after RP (P = 0.669). Moreover, at 1 year after RP, younger men with preoperative 5-item International Index of Erectile Function score ≥22 (n = 228) showed more favorable results for urinary continence (defined as nonuse of pads daily) (99.4% vs 95%, P = 0.009) and erections sufficient for vaginal intercourse (81.8% vs 55.5%, P = 0.001). Younger men had more favorable clinicopathologic features at RP than their older counterparts. Although age was not an independent predictor of BCR status outcome, younger men had better functional outcomes following RP.

Predictors of pathological upgrading in low-risk prostate cancer patients without hypointense lesions on an apparent diffusion coefficient map of multiparametric magnetic resonance imaging.

PURPOSE: To examine the clinicopathological features and identify the predictors of pathological upgrading in low-risk prostate cancer (PCa) patients without hypointense lesions on the apparent diffusion coefficient (ADC) map calculated from multiparametric magnetic resonance imaging. METHODS: We reviewed the medical records of 1905 PCa patients who underwent radical prostatectomy between 2007 and 2015. All ADC images were graded using the five-grade Likert scale; the positive hypointense lesions were graded 4-5. We analyzed 256 patients with low-risk classifications according to D'Amico criteria. Patients were classified into two groups according to the pathologic upgrading in the surgical specimens. The predictive factors for pathologic upgrading were evaluated using a multivariate logistic regression analysis. RESULTS: In 256 patients with low-risk PCa, the percentage of positive cores [odds ratio (OR) 1.09; 95 % confidence interval (CI) 1.02-1.16], the percentage of cancer in the positive cores (OR 1.07, 95 % CI 1.03-1.12), and the presence of hypointensity on an ADC map (OR 2.28; 95 % CI 1.23-4.22) were independent predictors of pathologic upgrading. Notably, 138 of low-risk patients (53.9 %) had no hypointense lesions on an ADC map. Of these 138 patients, the percentage of positive cores (OR 1.09; 95 % CI 1.01-1.18) and the percentage of cancer in the positive cores (OR 1.06; 95 % CI 1.01-1.12) remained independent predictors of pathologic upgrading. CONCLUSIONS: In low-risk PCa patients without hypointense lesions on an ADC map, biopsy-related parameters such as the percentage of positive cores and the percentage of cancer in the positive cores were independent predictors of pathological upgrading following radical prostatectomy.