ASO Author Reflections: High-Intensity Focused Ultrasound will Become the Routine Practice for Treatment of Localized Prostate Cancer.

PAST: Most prostate cancers are slow growing and are often diagnosed at an old age, which may result in treatment never being needed. However, definitive treatments such as radical prostatectomy and radiation therapy are often associated with many serious adverse effects, harming the physical and mental health of patients. PRESENT: In recent years, different types of minimally invasive therapy have been developed to achieve cancer control, continence, and even potency preservation, such as high-intensity focused ultrasound (HIFU). HIFU has been proposed for prostate cancer patients to provide an equivalent oncologic result to definitive treatment, with a reduced adverse effect profile, thus increasing the interest in HIFU for the treatment of localized prostate cancer. FUTURE: Sonablate® HIFU performed an outstanding cancer control in treating localized prostate cancer, with low biochemical recurrence and complication rates. As further long-term follow-up data mature, we anticipate the routine application of HIFU for localized prostate cancer within the next few years.

High-Intensity Focused Ultrasound (Sonablate®) for Prostate Cancer: Preliminary Outcomes in Taiwan.

PURPOSE: We reported preliminary outcomes of high-intensity focused ultrasound (HIFU) [Sonablate®] in the combination of transurethral resection of the prostate for localized prostate cancer in Taiwan. METHODS: Seventy-seven patients using Sonablate® HIFU for localized prostate cancer were enrolled in this study from April 2021 to December 2022. Prostate-specific antigen biochemical recurrence, International Index of Erectile Function (IIEF)-5 scores, International Prostate Symptom Score (IPSS), quality of life (QoL) scores, and postoperative complications were recorded during follow-up. RESULTS: Overall, 19.5% of patients were low-risk, 36.4% were intermediate-risk, and 44.1% were high-risk according to the D'Amico risk classification. The median follow-up was 12.09 ± 5.85 months, and the biochemical-free survival rates for the low-, intermediate-, and high-risk groups were 100% (15/15), 96.4% (27/28), and 79.4% (27/34), respectively. Four patients (5.2%) received salvage radiotherapy and all maintained biochemical-free survival. The mean IPSS and QoL scores before versus after HIFU were 10.4 versus 6.8 (p = 0.003) and 3.2 versus 3.0 (p = 0.096), respectively. There was no statistically significant change in preoperative and postoperative IIEF scores (20.6 vs. 19; p = 0.062) in patients who had an IIEF score of >15 at baseline and received nerve-sparing procedures (subtotal ablation). CONCLUSIONS: The results of Sonablate® HIFU in Taiwan indicated adequate short-term cancer control, excellent potency, and continence preservation. HIFU can achieve improvement of IPSS with low complication rates.

Prognostic value of PD-L1 combined positive score in patients with upper tract urothelial carcinoma.

PURPOSE: Upper tract urothelial carcinoma (UTUC) is relatively rare in Western countries. The impact of programmed death-ligand 1 (PD-L1) expression on UTUC remains unclear because previous studies have focused on bladder UC. We investigated the association of PD-L1 expression with clinicopathological features and prognosis in patients with UTUC. METHODS: We retrospectively reviewed the patients with UTUC that we treated at our institute from 2013 to 2018. In total, 105 patients with UTUC undergoing radical nephroureterectomy were analyzed to evaluate the PD-L1 expression on representative whole-tissue sections using the Combined Positive Score (CPS; Dako 22C3 pharmDx assay). A PD-L1 CPS ≥ 10 was considered positive. RESULTS: Among the 105 UTUC cases, 17.1% exhibited positive PD-L1 expression. A CPS ≥ 10 was significantly associated with higher tumor stage (≥ T2, p = 0.034) and lymph node invasion at diagnosis (p = 0.021). A multivariable analysis indicated that a CPS ≥ 10 was an independent prognostic predictor of shorter cancer-specific survival (hazard ratio [HR] = 4.59, 95% confidence interval [CI] = 1.66 - 12.7, p = 0.003) and overall survival (HR = 2.51, 95% CI = 1.19 - 5.27, p = 0.015). CONCLUSIONS: A PD-L1 CPS ≥ 10 in UTUC was associated with adverse pathological features and independently predicted worse cancer-specific and overall survival.

Comparative Study of the Safety and Efficacy of First-Line Cisplatin and Carboplatin Chemotherapy in Elderly Patients with Metastatic Urothelial Carcinoma.

OBJECTIVES: Platinum-based chemotherapy is the standard treatment for metastatic urothelial carcinoma (mUC). However, considering elderly patients often experience comorbidities and frailty, the utility of cisplatin-based chemotherapy for elderly patients is still debatable. We conducted this study to compare the safety and efficacy of carboplatin and cisplatin in elderly patients with mUC. METHODS: This retrospective study enrolled elderly patients with mUC (defined as aged ≥70 years) who underwent first-line platinum-based chemotherapy between September 2001 and October 2018. The primary endpoints were chemotherapy-related adverse events (AEs), including treatment-related hospitalization or death. The secondary outcomes were overall survival (OS) and progression-free survival calculated by Kaplan-Meier analysis. RESULTS: In total, 108 elderly patients with mUC were enrolled and allocated into the cisplatin or carboplatin group. Patients treated with carboplatin-based chemotherapy had a significantly higher incidence of all grade ≥3 AEs (78.8 vs. 50.0%, p = 0.008) than those on cisplatin. AE-related hospitalization (47.5 vs. 19.1%, p = 0.002) and treatment-related death (17.5 vs. 4.4%, p = 0.02) were significantly increased in the carboplatin group. In the univariate analysis, the median OS in the cisplatin group was significantly increased compared with the carboplatin group (13.6 vs. 7.2 months, p = 0.045). The Cox multivariate regression model indicated that leukocytosis (HR 3.17, 95% CI 1.84-5.46, p < 0.001) and anemia (HR 2.02, 95% CI 1.11-3.65, p = 0.02) were independent prognostic factors. CONCLUSION: Elderly patients with mUC treated with cisplatin-based chemotherapy had better survival and safety profiles than those treated with carboplatin. Age itself was not a crucial factor in determining cisplatin eligibility.

Unusual presentation of upper urinary tract urothelial carcinoma in Taiwan: Direct comparison from Taiwan-Japan UTUC Collaboration Cohort.

OBJECTIVES: To carry out a comparison of upper urinary tract urothelial carcinoma characteristics and behavior between patients in Taiwan and Japan. METHODS: A Taiwan urinary tract urothelial carcinoma cohort was obtained from Kaohsiung Chang Gung Memorial Hospital, and a Japan urinary tract urothelial carcinoma cohort from Hirosaki University Hospital. The inclusion criteria were urinary tract urothelial carcinoma patients who underwent radical nephroureterectomy. Those who received perioperative chemotherapy were excluded. Finally, 765 patients in the Taiwan cohort and 325 in the Japan cohort were analyzed. The end-point of this study was to study the natural course of urinary tract urothelial carcinoma within 5 years between these two groups. RESULTS: The main finding was that urinary tract urothelial carcinoma patients in Taiwan were younger (P < 0.001), more were women (P < 0.001), with low-stage disease (P < 0.001), with more chronic kidney disease (P < 0.001), with less smoking history (P < 0.001), with more bladder cancer history (P = 0.002), with more multifocal (P < 0.001) and less high-grade disease (P = 0.015), as well as less lymphovascular invasion (P < 0.001) and more squamous differentiation (P < 0.001). However, the multivariate Cox regression analysis showed no racial difference in oncologic outcome, such as intravesical recurrence, systemic recurrence or cancer-specific death in primary and propensity-matched cohorts. Bladder cancer history was found to be the most important factor predicting intravesical recurrences, whereas stage was strongly associated with systemic recurrence and cancer specific mortality. CONCLUSIONS: The clinical characteristics of urinary tract urothelial carcinoma in Taiwan are significantly different from those of urinary tract urothelial carcinoma in Japan. However, there is no racial difference in stage-specific oncologic outcome after standard nephroureterectomy.

Does preoperative percutaneous nephrostomy insertion worsen upper-tract urothelial cancer oncological outcome? A retrospective single center study.

BACKGROUND: Physicians doubt percutaneous nephrostomy (PCN) insertion on cancer related hydronephrosis patients causes tumor seeding and worse cancer control. In this article, we attempted to determine if preoperative PCN alters cancer control in upper tract urothelial cancer (UTUC) patients. METHODS: Retrospective analysis of UTUC patients in a single center from 2005 to 2015. Exclusion criteria included lymph node metastasis, and patients underwent perioperative adjuvant chemotherapy or radiotherapy. There were 664 patients in this analysis, with clinico-pathological data being collected retrospectively for Cox-regression statistical analysis. Outcomes were measured by local recurrence, distant metastasis and cancer-specific death with Kaplan-Meier curves. RESULTS: There were respectively 25 and 639 UTUC cancers in the preoperative PCN and non-PCN insertion groups with mean follow-up duration of 37.9 and 48.6 months, respectively. The preoperative PCN group consisted of 17 patients (68%) with tumor located in the ureter, while the PCN-negative group included 236 patients (36%) with tumor located in the ureter being statistically significant. These two groups were comparable in gender, age, follow-up duration, tumor stage, and pathological features of the UTUC. As for the cancer control in the PCN group, 4(16%), 1(4%) and 1(4%) had local recurrence, distant metastasis and cancer-specific death respectively; in the non-PCN group, 101(15.8%), 96(15%) and 72(11.2%) exhibited local recurrence, distant metastasis and cancer-specific death respectively. Statistical analysis showed no difference in oncologic outcomes between these two groups.(p = 0.804, 0.201 and 0.254). CONCLUSIONS: Preoperative percutaneous nephrostomy on upper-tract urothelial cancer poses little risk on tumor seeding and could be considered as part of treatment strategy if renal function preservation is needed.

Comparisons of cancer detection rate and complications between transrectal and transperineal prostate biopsy approaches - a single center preliminary study.

BACKGROUND: Prostate biopsy remains the gold standard approach to verify prostate cancer diagnosis. Transrectal (TR) biopsy is a regular modality, while transperineal (TP) biopsy is an alternative for the patients who display persistently high levels of prostate-specific antigen (PSA) and thus have to undergo repeat biopsy. This study aimed to compare the cancer detection rates between TR and TP approaches and assess the post-bioptic complications of the two procedures. Besides, the feasibility of performing TP biopsies under local anesthesia was also evaluated. METHODS: A total of 238 outpatient visits meeting the criteria for prostate cancer biopsy were enrolled for this study. They were divided into two groups: the TP group (n = 130) consists of patients destined to undergo local anesthetic TP biopsy; and the TR group (n = 108) contained those who received TR biopsy as comparison. Age, PSA level, digital rectal exam (DRE) finding, prostate volume, and biopsy core number were used as the parameters of the multivariable analyses. The comparable items included cancer detection rate, complication rate, admission rate and visual analog scale (VAS) score. RESULTS: The cancer detection rates between TP and TR groups were quite comparable (45% v.s. 49%) (p = 0.492). However, the TP group, as compared to the TR group, had significantly lower incidence of infection-related complications (except epididymitis and prostatitis) that commonly occur after biopsies. None of the patients in the TP group were hospitalized due to the post-bioptic complications, whereas there was still a minor portion of those in the TR group (7.4%) requiring hospitalization after biopsy. Medians (25-75% quartiles) of visual analog scale (VAS) were 3 [3, 4] and 4 [3-5] respectively for the TP and TR procedures under local anesthesia, but no statistical significance existed between them (p = 0.085). CONCLUSIONS: Patients receiving TP biopsy are less likely to manifest infection-related complications. Therefore, TP biopsy is a more feasible local anesthetic approach for prostate cancer detection if there are concerns for infectious complications and/or the risk of general anesthesia.

Tract creation using plasma vaporization versus metal dilatation in percutaneous nephrolithotomy: A propensity score-matched analysis.

OBJECTIVES: To share our 10-year experience of tract creation by using plasma vaporization compared with metal dilatation in percutaneous nephrolithotomy. METHODS: We retrospectively reviewed the medical records of 230 patients who had undergone 244 percutaneous nephrolithotomy procedures at Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan, from January 2007 to December 2016, and divided the patients into the plasma (n = 130) and metal (n = 114) groups. All patients underwent percutaneous nephrolithotomy by either a bipolar resectoscope mounted with a plasma vaporization button electrode or metal dilatation for tract creation. Propensity score matching was applied to reduce selection bias. Perioperative and postoperative data analysis included procedure time, length of hospital stay, blood transfusion rate, any early and late complications, stone-free rate, renal function, and time of need for pain control. RESULTS: Before propensity score matching, there were significantly shorter hospital stay (2.6 vs 3.8 days, P < 0.01), less operating time (66.1 vs 108.1 min, P < 0.01) and no blood transfusion rate (0 vs 4 [3.5%], P = 0.031) in the plasma vaporization group. After propensity score matching, there was no statistically significant difference in the patients' baseline characteristics. There were significantly shorter hospital stay (odds ratio 0.46, 95% confidence interval 0.32-0.66; P < 0.001) and shorter average operating time (odds ratio 0.98, 95% confidence interval 0.97-0.99, P < 0.001) in the plasma vaporization group. CONCLUSIONS: In comparison with metal dilatation, the plasma vaporization technique is a safe and effective method for creating the nephrostomy tract for percutaneous nephrolithotomy, based on shorter postoperative stay, less operating time, zero blood transfusion rate, acceptable stone-free rate and no major complications.

Methylation of SPARCL1 Is Associated with Oncologic Outcome of Advanced Upper Urinary Tract Urothelial Carcinoma.

Advanced upper urinary tract urothelial carcinoma (UTUC) is often associated with poor oncologic outcomes. The secreted protein acidic and rich in cysteine-like 1 (SPARCL1) protein, belongs to the SPARC-related family of matricellular proteins. Much literature has been published describing the role of SPARCL1 in the prognosis many cancers. In this study, methylated promoter regions in high-grade and high-stage upper urinary urothelial tumours compared with normal urothelium were analyzed and revealed that SPARCL1 was the most significantly hypermethylated gene in UTUC tissues. Then we prospectively collected UTUC samples and adjacent normal urothelium for pyrosequencing validation, identifying significant CpG site methylation in UTUC tissues. In addition, SPARCL1 RNA levels were significantly lower in UTUC samples. Multivariate Cox regression analysis from 78 patients with solitary renal pelvic or ureteral pT3N0M0 urothelial carcinomas revealed that only negative SPARCL1 expression and nonpapillary tumour architecture were independently associated with systemic recurrence (p = 0.011 and 0.008, respectively). In vitro studies revealed that the behaviour of BFTC-909 cells was less aggressive and more sensitive to radiation or chemotherapy after SPARCL1 overexpression. Thus, SPARCL1 could be considered as a prognostic marker and help decision-making in clinical practice.

Aristolochic Acid Affects Upper Tract Urothelial Cancer Behavior through the MAPK Pathway.

The prevalence of upper tract urothelial carcinoma (UTUC) in Taiwan is relatively higher than thatin Western countries. Aristolochic acid (AA), which is widely used in traditional Chinese herbology, is now recognized to be one of the carcinogens for UTUC. Numerous UTUC patients have chronic kidney diseases or end-stage renal diseases; however, little literature hasreported on theoncogenic pathway of AA-related UTUC. The aim of our study was to identify the potential target treatment for AA-related UTUC. Here, we established an AA pre-exposure followed bya 3-methylcholanthrene (MCA) stimulus tumorigenic cell model. We not only demonstrated that AA pre-exposure MCA stimulus tumorigenic cells have more behaviors of cell migration and invasion by enhancing the metalloproteinases (MMP) activity, which is compatible with clinical findings of AA-related UTUC, but we also validated that AA pre-exposure MCA stimulus tumorigeniccells could be activated through the mitogen-activated protein kinases (MAPK) pathway. We further dissected the route of the MAPK pathway and found that the p38 and extracellular signal regulated kinases (ERK) sub-pathways might play essential roles in AA pre-exposure urothelial cancer cell lines. This consequence was also corroborated with a tissue study in AA-exposed patients.

Primary whole-gland ablation for localized prostate cancer with high-intensity focused ultrasound: The important predictors of biochemical recurrence.

OBJECTIVES: To identify predictive factors of biochemical recurrence for patients undergoing high-intensity focused ultrasound treatment for localized prostate cancer. METHODS: We retrospectively identified patients receiving whole-gland prostate ablation with high-intensity focused ultrasound for localized prostate cancer from 2009 to 2015. All the patients received pre-high-intensity focused ultrasound radical transurethral resection of the prostate. We included perioperative parameters as follows: age, preoperative prostate volume, stage of operation, initial prostate-specific antigen, T stage, postoperative prostate-specific antigen nadir, Gleason score, time to prostate-specific antigen nadir and the presence of prostate-specific antigen biochemical recurrence. Multivariable Cox regression and Kaplan-Meier analysis were used for investigating predictors of recurrence, and receiver operating characteristic analysis was used for the cut-off values of prostate-specific antigen nadir. RESULTS: Among 182 patients, 26.9% had prostate-specific antigen biochemical recurrence after high-intensity focused ultrasound during the median follow-up period of 32.21 months. Gleason score ≥7 (Gleason score 7, hazard ratio 2.877, P = 0.027), stage ≥T2b (T2b, hazard ratio 3.16, P = 0.027) and prostate-specific antigen nadir (hazard ratio 1.11, P < 0.001) were statistically significant, whereas there was no significance in prostate volume and initial prostate-specific antigen. We posit that a cut-off level of prostate-specific antigen nadir 0.43 ng/mL might be considered as an independent predictive factor for prostate-specific antigen biochemical recurrence in high-intensity focused ultrasound patients in multivariate analysis (P < 0.001, hazard ratio 7.39, 95% confidence interval 3.56-15.37), and created a new nadir-related prediction model for biochemical recurrence prediction. CONCLUSIONS: Postoperative prostate-specific antigen nadir of 0.43 ng/mL can be considered an important predictive factor for biochemical recurrence in primary whole-prostate gland high-intensity focused ultrasound treatment, and the nadir-related prediction model might provide a reference for early salvage treatment. Furthermore, Gleason score ≥7, stage ≥T2b might be associated with unfavorable outcomes, although prostate volume and higher initial prostate-specific antigen appear not to be associated with biochemical recurrence for the high-intensity focused ultrasound treatment.

MiR-30a-5p Inhibits Epithelial-to-Mesenchymal Transition and Upregulates Expression of Tight Junction Protein Claudin-5 in Human Upper Tract Urothelial Carcinoma Cells.

The involvement of microRNAs (miRNAs) in cancer development and their potential as prognostic biomarkers are becoming increasingly known. However, the signature of miRNAs and their regulatory roles in tumorigenesis of upper tract urothelial carcinoma (UTUC) remain to be elucidated. This study aimed to profile the miRNA expression pattern in UTUC tumor tissues and identify candidate miRNAs with prognostic and/or therapeutic functions. METHODS AND RESULTS: We collected 22 UTUC tissue and adjacent normal tissues samples from patients who underwent nephroureterectomy. The miRNAs signatures of three selected UTUC samples using next-generation sequencing showed that miR-30a-5p was significantly downregulated in UTUC tumors compared to adjacent normal tissues. The differentially-expressed miRNAs were specifically validated by quantitative real-time polymerase chain reaction. In addition, the miRNA expression signatures were analyzed with the transcriptome profile characterized by microarray. Further in vitro studies indicated that overexpression of miR-30a-5p significantly suppressed proliferation, migration, and epithelial-to-mesenchymal transition (EMT) in cultured BFTC-909 UTUC cells. As a potential target gene of miR-30a-5p in the tight junction pathway suggested by the pathway enrichment analysis, the reduced expression of tight junction protein claudin-5 in UTUC cells was demonstrated to be upregulated by miR-30a-5p genetic delivery. CONCLUSIONS: Taken together, our findings demonstrated that miR-30a-5p inhibits proliferation, metastasis, and EMT, and upregulates the expression of tight junction claudin-5 in UTUC cells. Thus, miR-30a-5p may provide a promising therapeutic strategy for UTUC treatment.

Comparisons of Oncological and Functional Outcomes Between Primary Whole-Gland Cryoablation and High-Intensity Focused Ultrasound for Localized Prostate Cancer.

PURPOSE: The aim of this study was to conduct a prospective, single-institutional comparison for primary whole-gland cryoablation and high-intensity focused ultrasound (HIFU) in localized prostate cancer with respect to oncological and functional outcomes. METHODS: From October 2008 to December 2013, a total of 114 and 120 patients with primary whole-gland cryoablation and HIFU for localized prostate cancer, respectively, were enrolled in the study. Prostate-specific antigen (PSA) biochemical recurrence defined by Phoenix definition, salvage treatment-free rate, metastasis-free rate, and PSA biochemical recurrence-free survival analyzed using the Kaplan-Meier method were for oncological outcomes. Functional outcomes included complications and serial International Index of Erectile Function (IIEF)-5 scores, International Prostate Symptom Score (IPSS), and related quality of life (QoL) scores. RESULTS: During the mean follow-up duration of approximately 2 years, the PSA biochemical recurrence rates of the two groups were similar (cryoablation 25.4 %, HIFU 18.3 %). In terms of functional outcomes, patients with HIFU had significantly lower IPSS (5.70 vs. 9.04 at 24 months; p = 0.030), lower erectile dysfunction rate (65.6 vs. 88.0 %; p = 0.015), and higher IIEF-5 score (9.36 vs. 4.18 at 24 months; p = 0.028) than patients with cryoablation. CONCLUSIONS: In this study, both primary whole-gland cryoablation and HIFU demonstrated good oncological outcomes for localized prostate cancer. We validated the safety of the two treatment modalities and identified the importance of combined HIFU and transurethral resection of the prostate. The HIFU patients experienced better urinary function improvement and more possible sexual function preservation than the cryoablation patients; therefore, HIFU may provide better quality of life for patients with localized prostate cancer.

Prognostic model to predict survival in patients with metastatic upper tract urothelial carcinoma treated with cisplatin-based chemotherapy.

OBJECTIVES: To create a novel prognostic model to predict survival in metastatic upper tract urothelial carcinoma patients treated with cisplatin-based chemotherapy. METHODS: After institutional review board approval, patients who had metastatic upper tract urothelial carcinoma and were treated with cisplatin based chemotherapy from 2000 to 2012 at Kaohsiung Chang Gung Memorial Hospital were retrospectively reviewed. Significantly predictive factors were identified by multivariate Cox regress analyses. Kaplan-Meier curves were plotted to estimate overall survival. Several prognostic models were validated by using our cohort, and Harrell's c-index was calculated to evaluate their predicting performances. RESULTS: The present study consisted of 136 patients with a median age of 62 years and a median follow-up visit of 13.6 months. Multivariate analyses showed that renal function, performance status, liver metastasis and number of metastatic sites was independently related to survival. Based on these four variables, we constructed a prognostic model "renal function, performance status, liver metastasis, number of metastatic sites" with significantly different survival (P < 0.001). C-index results were renal function, performance status, liver metastasis, number of metastatic sites model 0.80 (0.69-0.90), Bajorin model 0.72 (0.61-0.83), Taguchi model 0.77 (0.67-0.87) and Tanaka model 0.78 (0.69-0.88). Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model achieved the highest c-index in this study. CONCLUSIONS: Our renal function, performance status, liver metastasis, number of metastatic sites prognostic model could be useful for providing prognostic information on survival in patients with metastatic upper tract urothelial carcinoma.

Predictors of prostate-specific antigen biochemical recurrence in patients undergoing primary whole-gland prostate cryoablation.

PURPOSE: Cryoablation has been proven as a less invasive, safe, and effective treatment for localized prostate cancer. We attempted to identify the predictors of biochemical recurrence after prostate cryoablation for localized prostate cancer in this study. METHODS: We reviewed 114 patients who underwent primary whole-gland prostate cryoablation for localized prostate cancer from October 2008 to March 2013. The perioperative parameters included age >70 years, initial prostate-specific antigen (PSA), preoperative prostate volume, Gleason score, T stage, D'Amico risk group, postoperative PSA nadir, time to PSA nadir, and PSA biochemical recurrence, defined by Phoenix definition (nadir plus 2 ng/mL). Receiver operating characteristic (ROC) analysis was used for the best cutoff value of PSA nadir for PSA biochemical recurrence. The parameters were analyzed in binary logistic regression and Kaplan-Meier analysis for PSA biochemical recurrence. RESULTS: A total of 31.6 % (N = 36) patients had PSA biochemical recurrence during the median follow-up of 34.87 ± 16.49 months. ROC analysis revealed that the best cutoff value for biochemical recurrence prediction was when the PSA nadir = 0.3 ng/mL. On multivariate analysis and Kaplan-Meier analysis, the D'Amico high-risk group [hazard ratio (HR) 6.552; p = 0.014], PSA nadir >0.3 ng/mL (HR 34.062; p < 0.001), and time to PSA nadir <3 months (HR 4.144; p = 0.021) were statistically significant for PSA biochemical recurrence. CONCLUSIONS: The D'Amico high-risk group, postoperative PSA nadir >0.3 ng/mL, and time to PSA nadir <3 months predict biochemical recurrence in primary whole-gland prostate cryoablation.

Comparison of retroperitoneoscopic and transperitoneal laparoscopic adrenalectomy for right-sided benign tumors: a single-institute experience.

INTRODUCTION: There is a lack of data regarding the appropriateness of transperitoneal and retroperitoneal approaches for right-sided laparoscopic adrenalectomy. The aim of this study was to determine whether there is any difference between right-sided transperitoneal laparoscopic adrenalectomy (TLA) and retroperitoneal laparoscopic adrenalectomy (RLA). MATERIAL AND METHODS: Our surgery database was reviewed to identify patients who underwent right-sided laparoscopic adrenalectomy with a retroperitoneal or transperitoneal approach since 2000. Fifty-five patients were enrolled (31 RLA and 24 TLA). Patient characteristics, as well as operative and perioperative details, were compared between the two groups. RESULTS: There was no difference in patient characteristics between the groups. There was a statistically significant difference (p=0.02) in blood loss (31.7±16.4 vs. 56.9±65.5 ml) between RLA and TLA when the patient's BMI was >26. There was no significant difference in operative time, conversion to open surgery, length of hospitalization, or time to oral intake between the groups. CONCLUSIONS: Right-sided laparoscopic adrenalectomy can be performed safely and effectively via either RLA or TLA. Surgeons can adopt either approach with confidence depending on their preference if they are familiar with that approach.

The role of laparoscopy-assisted renal autotransplantation in the treatment of primary ureteral tumor.

BACKGROUND: To evaluate the effect and safety of laparoscopy-assisted renal autotransplantation treatment for primary ureteral cancer (PUC). METHODS: Medical records of patients undergoing hand-assisted retroperitoneoscopic nephroureterectomy­extracorporeal total ureterectomy­renal autotransplantation­pyelocystostomy (Lap AutoTx) were analyzed. Demographic, intraoperative, and postoperative data were assessed. RESULTS: Fifteen patients diagnosed with PUC underwent this novel approach. Three kidneys were abandoned owing to the detection of residual cancer on the renal pelvic junction, surgeon's judgment on three severe atherosclerotic arteries, and palpable pelvic lymph nodes proven to be evidence of metastatic disease by frozen section analysis. Twelve patients (mean ± SD age 67.5 ± 7.5 years) were treated with Lap AutoTx for PUC successfully. No perioperative mortality occurred. One patient with solitary kidney experienced delayed graft function that required short-term hemodialysis. Three recurrent superficial diseases in three patients were treated with transurethral resection. The mean ± SD follow-up duration was 12.1 ± 6.7 months (range 3­24 months). The renal pelvicaliceal system was easily examined by flexible cystoscopy. CONCLUSIONS: Lap AutoTx is less invasive compared with the traditional two-incisional manner and can be performed safely even among elderly patients. Compared with other currently used therapies, this novel treatment can be used to successfully treat PUC with the added advantages of total resection of the ureteral lesion, preservation of the renal function, and simplification of follow-up procedures.Primary ureteral cancer (PUC) is an aggressive disease and has a poor prognosis.1 Studies have shown high prevalence and invasiveness of PUC in Taiwan.2,3 Nephroureterectomy with excision of the bladder cuff is still believed to be the gold standard treatment for PUC.4 Most PUC occurs among individuals aged more than 60 years, and most of these patients are also at high risk of chronic kidney disease (CKD).5,6 Nephroureterectomy not only results in excessive loss of renal function, but also puts the patient at risk of CKD, which contributes to the progression of end-stage renal disease requiring dialysis. In addition, diminished renal function after nephroureterectomy compromises the possible use of adjuvant chemotherapy for advanced disease.Endoscopic surgery (ES) and segmental resection (SR) can be used for renal preservation in PUC cases, but there still are limitations to these approaches, and indefinite invasive ureteroscopy is required during follow-up. Only a few studies have focused on renal autotransplantation (AutoTx) after extracorporeal total ureterectomy (ETU) for PUC. This type of treatment possesses advantages of total resection of malignant ureteral lesions, preservation of renal function, and simplification of follow-up protocols. In two reported case series, all cases involved surgery performed with the traditional 2-incision approach, and only a few cases involved pure PUC.7,8 We have reported that hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) for the treatment of PUC is less invasive and results in better functional outcomes with fewer complications and comparable oncologic control compared with open nephroureterectomy.9 In this study, we report our experience of this treatment combined with ETU and AutoTx for pure PUC.

Double-barreled colon conduit and colostomy for simultaneous urinary and fecal diversions: long-term follow-up.

BACKGROUND: Best strategies for simultaneous urinary and stool diversion remain indeterminate. Here we present what is to our knowledge the longest outcome data on double-barreled colon conduit and colostomy (DBCCC) in a cohort of patients needing simultaneous urinary and fecal diversion. METHODS: We identified 9 patients who underwent DBCCC between March 2002 and March 2013. Nine patients who underwent separate urinary and fecal diversion (colostomy plus percutaneous nephrostomy or ureterocutaneostomy) served as the control group. We compared demographics, comorbidities, follow-up morbidities, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30-item questionnaire in the two groups. RESULTS: The preservation of renal function was better in the DBCCC group. There were significant improvements in global state of health, fatigue, insomnia, appetite, bowel habit, and social function in the DBCCC group. In comparison with the separate urinary and fecal diversion group, the patients in the DBCCC group had statically significant improvement in global health status, functional scales, and symptom scales. CONCLUSIONS: Compared with the separate urinary and fecal diversion technique, DBCCC provides preservation of renal function, easy stoma bag care, better quality of life, and improved body image for patients who need simultaneous urinary and fecal diversion.

Subclassification of upper urinary tract urothelial carcinoma by the neutrophil-to-lymphocyte ratio (NLR) improves prediction of oncological outcome.

OBJECTIVE: To examine the potential role of the neutrophil-to-lymphocyte ratio (NLR) for subclassification of localised upper urinary tract urothelial carcinoma (UUT-UC). PATIENTS AND METHODS: From 2004 to 2010, 234 patients with localised UUT-UC underwent radical nephroureterectomy (RNU). NLRs were only obtained under afebrile conditions before RNU. Patients that underwent neoadjuvant or adjuvant chemotherapy were excluded. The prognostic impact of the NLR was assessed using the log-rank test and multivariate analyses. RESULTS: Only advanced pathological stage (>T2) and a NLR of >3 were independently associated with metastasis (P < 0.001 and P = 0.02, respectively) and cancer-specific mortality (P = 0.002 and P = 0.006, respectively). The use of a NLR of >3 further identified a poor prognostic group, especially in patients with T3 UUT-UC for metastasis-free survival and cancer-specific survival (log-rank test, both P < 0.001). CONCLUSIONS: For localised UUT-UC, pathological stage and preoperative NLR independently predict systemic recurrence and cancer-specific death after RNU. Using the NLR for subclassification of T3 UUT-UC seems to further identify a poor prognostic group and may help with clinical decisions about treatment intervention in clinical practice.

Oncological impact of endoscopic bladder cuff management during nephroureterectomy varies according to upper urinary tract tumor location.

OBJECTIVES: To compare the oncological outcome between extravesical excision and transurethral excision for bladder cuff management in patients undergoing nephroureterectomy with upper urinary tract urothelial cancer. METHODS: From January 2005 to December 2010, 396 patients were enrolled in the present retrospective study. Nephroureterectomy was carried out either by endoscopic or extravesical bladder cuff excision. The oncological outcome between these two procedures was analyzed in patients with different tumor locations. RESULTS: The average age of the patients was 66.41 ± 10.52 years, and the median follow-up duration was 40.65 ± 23.84 months. For upper urinary tract urothelial cancer management, extravesical bladder cuff excision was carried out in 240 patients, whereas the endoscopic method was carried out in 156 patients. Previous bladder cancer is still the most independent predictor for bladder recurrence (P < 0.001). In addition, endoscopic bladder cuff management for low ureteral tumor was also independently associated with more bladder tumor recurrence (P = 0.017). Non-organ confined pathological stage still independently predicted metastasis (P < 0.001) and cancer-specific death (P < 0.001). CONCLUSIONS: There are similar oncological outcomes after nephroureterectomy combined with extravesical or endoscopic bladder cuff management for patients with upper urinary tract urothelial cancer above the low ureter. However, there is a higher incidence of bladder tumor recurrence for the low ureteral tumor after nephroureterectomy with endoscopic bladder cuff excision.