Clinical significance of multiparametric MRI and PSA density as predictors of residual tumor (pT0) following radical prostatectomy for T1a-T1b (incidental) prostate cancer

PURPOSE: The aim of this study was to evaluate predictors of residual tumor and clinical prognosis in T1a-T1b (incidental) prostate cancer by analysis of specimens from men undergoing surgery for benign prostatic hyperplasia. MATERIALS AND METHODS: We retrospectively reviewed medical records of incidental prostate cancer patients who had undergone radical prostatectomy. Patients whose tumor statuses were further confirmed by prostate biopsy, or who had used androgen deprivation therapy before radical prostatectomy, were excluded. Clinical and pathological parameters were analyzed to evaluate residual tumor and clinical prognosis. We used univariate and multivariate logistic regression analyses, as well as receiver operator characteristics, to predict residual tumor (pT0). RESULTS: The final analysis included 95 patients. Among these patients, 67 (70.53%) exhibited residual tumor, whereas 28 (29.47%) did not (pT0). Pathology findings showed that 44 (65.67%), 16 (23.88%), and 7 patients (10.45%) exhibited Gleason scores of G6, G7, and ≥G8, respectively. Fifty-seven and 10 patients exhibited pathologic T stages T2 and T3, respectively. Mean follow-up duration was 70.26 (±34.67) months. Biochemical recurrence was observed in 11 patients; none were pT0 patients. Multivariate logistic regression showed that low prostate-specific antigen density after benign prostatic hyperplasia surgery and invisible lesion on multiparametric magnetic resonance imaging were significantly associated with pT0. Additionally, a combination of these factors showed an increase in the diagnostic accuracy of pT0, compared with mpMRI alone (AUC 0.805, 0.767, respectively); this combination showed sensitivity, specificity, and positive predictive values of 71.6%, 89.3%, and 94.1%, respectively. CONCLUSION: Our results suggest that patients with incidental prostate cancer who have both prostate-specific antigen density ≤0.08 after benign prostatic hyperplasia surgery as well as invisible cancer lesion on multiparametric magnetic resonance imaging should be considered for active surveillance.ope

Clinical significance and predictors of oncologic outcome after radical prostatectomy for invisible prostate cancer on multiparametric MRI

BACKGROUND: The objective of our study was to evaluate the clinical significance of invisible prostate cancer (iPCa) on multiparametric magnetic resonance imaging (mpMRI) by analyzing clinical parameters and oncologic outcomes. METHODS: We retrospectively reviewed the records of patients treated with radical prostatectomy (RP) from 2010 to 2015 at our institution. Before RP, all patients were confirmed to have prostate cancer based on prostate biopsy. We excluded patients who underwent neoadjuvant therapy. Additionally, we excluded patients who had incomplete mpMRI based on PI-RADS (Prostate Imaging Reporting and Data System). iPCa was defined as having no grade 3 or higher region of interests using a scoring system established by PI-RADS without limitations on interpretation from mpMRI by radiologists. We selected patients with iPCa using this protocol. We analyzed data using univariate and multivariate cox regression analysis, logistic analysis, Kaplan-Meier curves, and receiver operator characteristic curves to predict biochemical recurrence (BCR). RESULTS: A total of 213 patients with iPCa were selected according to the patient selection protocol. Among them, pathological findings showed that Gleason score (GS) G6, G7 and ≥ G8 were present in 115 cases (54.0%), 78 cases (36.6%), and 20 cases (9.4%), respectively. Further, extracapsular extension (ECE), positive surgical margins (PSM), and lymphovascular invasion (LVI) were present in 28 (13.1%), 18 (8.5%), and 3 cases (1.4%), respectively. Seminal vesicle invasion (SVI) was observed in one case (0.5%). During a median follow-up time of 51 months, BCR was observed 29 cases. Adverse pathology (AP) was defined as GS ≥8, ECE, SVI and LVI. AP and prostate specific antigen (PSA) were significantly associated with BCR. Moreover, PSA > 6.2 ng/ml was suggested as a cut-off value for predicting BCR. CONCLUSIONS: In our results, cases of iPCa had clinically significant PCa, and AP and poor prognosis were also observed in some. Additionally, we found that PSA is the most clinically reliable predictor of oncologic outcome. We suggest that active treatment and diagnosis should be considered for patients with iPCa with PSA > 6.2 ng/ml.ope

Probe-Based Confocal Laser Endomicroscopy During Transurethral Resection of Bladder Tumors Improves the Diagnostic Accuracy and Therapeutic Efficacy

PURPOSE: This study was designed to assess the diagnostic accuracy and therapeutic efficacy of probe-based confocal laser endomicroscopy (pCLE), which provides real-time, in vivo histological information during transurethral resection of bladder tumors. METHODS: We performed a prospective study between August 2013 and August 2014. pCLE was performed on a total of 119 lesions in 75 patients. We analyzed the diagnostic accuracy of pCLE by comparing the confocal image reports with the pathology reports of surgical specimen. Confocal images were interpreted by a single urologist blinded to the pathology reports. The therapeutic efficacy was analyzed by comparing the outcomes in pCLE and non-pCLE groups. RESULTS: In a total of 119 lesions, 23 were benign and 96 were malignant. The detection accuracy for malignant lesions with pCLE was determined with a sensitivity and a positive predictive value (PPV) of 91.7% and 93.6%, respectively. For high-grade versus low-grade bladder cancer, sensitivity and PPV of pCLE were 94.5% and 89.7%, respectively. Distinguishing carcinoma in situ from inflammatory lesions also was accurate with sensitivity, specificity, and PPV of 71.4%, 81.3%, and 83.3%, respectively. The Kaplan-Meier curves revealed that the recurrence-free survival rate was significantly higher in the pCLE group than in the non-pCLE group (p = 0.031). CONCLUSIONS: Probe-based confocal laser endomicroscopy is a promising method to provide the surgeon during the transurethral resection of a bladder tumor with real-time tumor histology, regardless of the tumor's gross appearance. Furthermore, it also may improve the therapeutic efficacy with longer recurrence-free periods.ope

Clinical Significance of Multiparametric Magnetic Resonance Imaging as a Preoperative Predictor of Oncologic Outcome in Very Low-Risk Prostate Cancer

Currently, multiparametric magnetic resonance imaging (mpMRI) is not an indication for patients with very low-risk prostate cancer. In this study, we aimed to evaluate the usefulness of mpMRI as a diagnostic tool in these patients. We retrospectively analyzed the clinical and pathological data of individuals with very low-risk prostate cancer, according to the NCCN guidelines, who underwent mpMRI before radical prostatectomy at our institution between 2010 and 2016. Patients who did not undergo pre-evaluation with mpMRI were excluded. We analyzed the factors associated with biochemical recurrence (BCR) using Cox regression model, logistic regression analysis, and Kaplan⁻Meier curve. Of 253 very low-risk prostate cancer patients, we observed 26 (10.3%) with BCR during the follow-up period in this study. The median follow-up from radical prostatectomy was 53 months (IQR 33⁻74). The multivariate Cox regression analyses demonstrated that the only factor associated with BCR in very low-risk patients was increase in the pathologic Gleason score (GS) (HR: 2.185, p-value 0.048). In addition, multivariate logistic analyses identified prostate specific antigen (PSA) (OR: 1.353, p-value 0.010), PSA density (OR: 1.160, p-value 0.013), and suspicious lesion on mpMRI (OR: 1.995, p-value 0.019) as the independent preoperative predictors associated with the pathologic GS upgrade. In our study, the pathologic GS upgrade after radical prostatectomy in very low-risk prostate cancer patients demonstrated a negative impact on BCR and mpMRI is a good prognostic tool to predict the pathologic GS upgrade. We believe that the implementation of mpMRI would be beneficial to determine the treatment strategy for these patients.ope

Efficacy and Safety of Robotic Procedures Performed Using the da Vinci Robotic Surgical System at a Single Institute in Korea: Experience with 10000 Cases

PURPOSE: To evaluate the efficacy and safety of robotic procedures performed using the da Vinci Robotic Surgical System at a single institute. MATERIALS AND METHODS: We analyzed all robotic procedures performed at Severance Hospital, Yonsei University Health System (Seoul, Korea). Reliability and mortality rates of the robotic surgeries were also investigated. RESULTS: From July 2005 to December 2013, 10267 da Vinci robotic procedures were performed in seven different departments by 47 surgeons at our institute. There were 5641 cases (54.9%) of general surgery, including endocrine (38.0%), upper (7.7%) and lower gastrointestinal tract (7.5%), hepato-biliary and pancreatic (1.2%), and pediatric (0.6%) surgeries. Urologic surgery (33.0%) was the second most common, followed by otorhinolaryngologic (7.0%), obstetric and gynecologic (3.2%), thoracic (1.5%), cardiac (0.3%), and neurosurgery (0.1%). Thyroid (40.8%) and prostate (27.4%) procedures accounted for more than half of all surgeries, followed by stomach (7.6%), colorectal (7.5%), kidney and ureter (5.1%), head and neck (4.0%), uterus (3.2%), thoracic (1.5%), and other (2.9%) surgeries. Most surgeries (94.5%) were performed for malignancies. General and urologic surgeries rapidly increased after 2005, whereas others increased slowly. Thyroid and prostate surgeries increased rapidly after 2007. Surgeries for benign conditions accounted for a small portion of all procedures, although the numbers thereof have been steadily increasing. System malfunctions and failures were reported in 185 (1.8%) cases. Mortality related to robotic surgery was observed for 12 (0.12%) cases. CONCLUSION: Robotic surgeries have increased steadily at our institution. The da Vinci Robotic Surgical System is effective and safe for use during surgery.ope

Impact of Early Salvage Androgen Deprivation Therapy in Localized Prostate Cancer after Radical Prostatectomy: A Propensity Score Matched Analysis

PURPOSE: Androgen deprivation therapy (ADT) is used as a salvage treatment for men with biochemical recurrence (BCR) of prostate cancer (PCa) following initial radical prostatectomy (RP). The optimal time at which to begin salvage ADT (sADT) remains controversial. In this retrospective study, we evaluated the efficacy of initiating sADT in patients before prostate-specific antigen (PSA) values met the clinical definition of BCR. MATERIALS AND METHODS: We identified 484 PCa patients who received sADT for BCR after RP. Median follow-up was 82 months. Propensity score matching was performed based on preoperative PSA level, pathologic T stage, and Gleason score. Patients were assigned to two groups of 169 patients each, based on PSA levels at the time of sADT: Group A (without meeting of the definition of BCR) and Group B (after BCR). Kaplan-Meier survival analyses and Cox regression analyses were performed. RESULTS: The median PSA level at sADT initiation was 0.12 ng/mL in group A and 0.42 ng/mL in group B. Kaplan-Meier analyses showed that group A had favorable disease progression-free survival (DPFS) and distant metastasis-free survival (DMFS), but did not have better cancer-specific survival (CSS) than group B. In subgroup analyses, group A showed better CSS rates in the non-organ confined PCa group. In Cox regression analyses, early sADT was associated significantly with DPFS and DMFS rates, however, did not correlate with CSS (p=0.107). CONCLUSION: Early sADT after RP improved DPFS and DMFS. Furthermore, early sADT patients demonstrated better CSS in non-organ confined PCa.ope

Predictors of adverse pathologic features after radical prostatectomy in low-risk prostate cancer

BACKGROUND: Prostate-specific antigen (PSA) screening more frequently detects early stage prostate cancer (PC). However, adverse pathologic features (APFs) after radical prostatectomy (RP) in low-risk PC occur. Previous related studies had utilized outdated staging criteria or small sample cohorts. In this study, we analyzed predictors of APFs after RP in low-risk PC using classification under the current criteria. MATERIALS AND METHODS: We retrospectively reviewed medical records of 546 low-risk PC patients who had undergone RP. Low-risk PC was defined as PC with clinical T1-T2a, Gleason score 4.5 ng/mL and number of positive cores > 2 in low-risk PC were significantly associated with APFs, and suggested as cut-off values for predicting APFs. CONCLUSIONS: PSA > 4.5 ng/mL and number of positive cores > 2 in low-risk PC were associated with presence of APFs and patients with such records should be considered carefully to provide active surveillance.ope

Effect of prostate gland weight on the surgical and oncological outcomes of extraperitoneal robot-assisted radical prostatectomy

BACKGROUND: Robot-assisted radical prostatectomy (RARP) is performed by urologists as one of the surgical procedures for treating prostate cancer. Numerous studies have been published with regard to the impact of prostate weight on performing RARP but were limited by the insufficient number of patients and use of the transperitoneal approach. This study aimed to determine the effect of prostate gland weight on the surgical and short-term oncological outcomes of RARP using the extraperitoneal approach. METHODS: In total, 1168 patients who underwent extraperitoneal RARP (EP-RARP) performed by a single surgeon at Yonsei University Severance Hospital between May 2009 and May 2016 were included in the study. The patients were divided into 4 groups according to the prostate weight measured by transrectal ultrasonography preoperatively. Intraoperative and postoperative outcomes were analyzed retrospectively. One-way analysis of variance and the chi-square test were used in the statistical analyses. RESULTS: Age, the Gleason score, clinical stage, and pathological stage were significantly different. Patients with a larger prostate size had a longer console time and higher estimated blood loss (P < 0.05). There were no significant differences between the 4 groups in length of hospital stay, duration of catheterization, blood transfusion, body mass index, prostate-specific antigen (PSA) level, history of abdominal surgery, intraoperative complications, positive surgical margin, incidence of lymphocele, and PSA recurrence after 1 year. CONCLUSIONS: The console time and estimated blood loss were significantly increased with a larger prostate size. However, there were no significant differences in the oncologic outcome and intraoperative complications, suggesting that EP-RARP requires meticulous bleeding control in patients with a prostate weighing > 75 g, and if appropriate management is implemented for blood loss intraoperatively, EP-RARP can be performed regardless of the prostate size.ope

Age-adjusted Charlson Comorbidity Index as a prognostic factor for radical prostatectomy outcomes of very high-risk prostate cancer patients

PURPOSE: Prostate cancer (PC) is a devastating and heterogeneous condition with diverse treatment options. When selecting treatments for patients with very high-risk PC, clinicians must consider patient comorbidities. We investigated the efficacy of the age-adjusted Charlson Comorbidity Index (ACCI) as a prognostic factor for patient outcomes after radical prostatectomy (RP). MATERIALS AND METHODS: We retrospectively investigated the medical records of PC patients at our institution who underwent RP from 1992 to 2010. Very high-risk PC was defined according to National Comprehensive Cancer Network guidelines. Patients with incomplete medical records or who had received neoadjuvant therapy were excluded. Preoperative comorbidity was evaluated by the ACCI, and the prognostic efficacy of the ACCI was analyzed using univariable and multivariable Cox regression, competing risk regression model and Kaplan-Meier curves. RESULTS: Our final analysis included 228 men with a median age of 66 years (interquartile range 62-71) and median prostate specific antigen of 10.7 ng/mL. There were 41 (18%) patients with an ACCI score >3 and 88 (38.6%) patients with a biopsy Gleason score >8. Preoperative evaluation revealed that 159 patients (69.7%) had a non-organ confined tumor (>/=T3). Following RP, 8-year prostate cancer-specific survival (PCSS) and overall survival (OS) rates were 91.6% and 83.4%, respectively. Competing risk regression analysis revealed that ACCI was significantly associated with other-cause survival and OS (p3.ope

Remediation of the water and the ecosystem for lagoons in the eastern coast of Korea : focused on a conservation about Yongrang-ho and Choungcho-ho

환경공학전공/석사[한글]본 논문에서는 동해안 석호중 여러 오염원이 밀집되어 있고 도심지 인근에 위치하여 오염이 심화된 영랑호와 청초호에 대한 수질 및 생태계 현황 등을 조사·분석하고, 석호관리의 문제점 및 수질 개선방안에 관하여 연구하였다.영랑호는 동해안 다른 석호와는 달리 레저중심의 관광지로 개발되어 있고, 청초호는 어항, 상업항 등 복합기능을 가진 호수로의 특징을 가지고 있다. 또한 속초시내에 위치하여 콘도, 아파트, 골프장 등에서 발생하는 오수와 선박수리, 냉동, 수산식품가공공장 등의 산업시설로부터 발생되는 각종 폐수 등의 오염원으로부터 노출되어 있다.그리고 인근지역에서 유입되는 토사로 인하여 매립위기에 처해 있고, 호소 퇴적층의 부패, 물고기들의 폐사 및 심한 부영양화 현상들이 나타나고 있는 것으로 조사되었으며, 특히 영랑호의 경우 하구에 수문을 만들어 수위를 높임으로써 해수의 유입이 감소하여 담수화가 심화되어 기수호로서의 특성을 상실할 위기에 처해있는 실정이다.청초호의 경우 관광엑스포 유원지 개발을 위해 총면적 411,015㎡을 매립하였고, 영랑호는 주변에 축대설치 및 일주도로를 건설하여 수중 수초대가 많이 훼손되었다. 그리고 1998년부터 2002년도까지 영랑호, 청초호의 부영양화 지수(TSI)는 60~70의 범위로 호소의 영양상태가 부영양호, 과부영양호 상태였다.또한 영랑호 심층의 연도별 염분도 조사결과 1960년대 24~28‰, 1970년대 6~16‰, 2000년대 4~7‰로 조사되었고, 1969년과 1993년도의 어류상 조사결과를 비교해 보아도 담수 어류는 5종이 증가하였고, 해수 어류는 2종이 감소한 것으로 나타나 해수유입 감소에 따른 담수화가 진행된 것을 알 수 있었다.이러한 현상들을 최소화하기 위해 그간 호소 준설, 하수관거 설치 등 다각적인 수질정화사업도 추진되었으나, 그 효과가 미미한 것으로 나타났다.따라서 석호의 수질개선을 위해서는 점 및 비점오염원 등의 호소외적 오염요소 유입 제어와 준설, 해수유입 증가, 수중폭기 등의 호소내적 오염요소의 제어방법을 병행하여 실시하여야 하며, 동시에 석호실태 정밀조사 실시와 특성에 맞는 개선방안 강구, 관리의 일원화 및 법제도의 활용, 행정기관별 명확한 역할 분담, 석호의 가치극대화를 위한 홍보강화 등의 정책적인 관리방안도 추진되어야 할 것으로 판단된다. [영문]To suggest improvement for the water quality and the ecosystem management, the present condition of the water quality and ecosystem of Lagoon Youngrang and Choungcho, with eutrophic condition in east coast, was investigated and the problems of the lagoon water was discussed.The surrounding of the Youngrang lagoon has been developed into a touristic attraction while the Choungcho lagoon has the function of a fishing port as well as a commercial fishing port. The Choungcho lagoon is located at the Sokcho river and it is polluted through the wastewater which occurs from various domestic sewages and industrial facilities.Choungcho lagoon reclaimed a total of 411,015㎡ for the purpose of the tourism expos amusement park development. And in the surrounding of the Youngrang lagoon a road was constructed thus it cause a great damage to the wetland zone.From 1998 until 2002, the TSI(Trophic State index) of the Lagoon Youngrang and Choungcho were by 60~70. On the basis of the TSI, the nutrition condition of these lakes can be classfied into a eutrophic or hypertrophic lake.Moreover, as the result of Lagoon Youngrang yearly salinity hypolimnion investigation, it was found out that the salinity was in 1960 24~28‰, 1970 6~16 ‰ and 2000 4~7‰. In 1993 the number of the freshwater fish species increased 5 times compared to 1969, while the sea fish species number dropped 2 species. Therefore those changes shows that the replacement of salt water by fresh water progressed considerably.Several improvements such as lagoon and marshes dredging and sewer installation for improving the water quality was carried out but there were still no signs of improvement.Consequently, to recover the water quality and the ecosystem of the lagoon in the east coast, effective management of point and non-point pollution sources from a lagoon watershed and lagoon basin should be accomplished. Moreover, environmental policy development for an efficient lagoon management must be supported.ope