Treatment of Localized Prostate Cancer with High PSA (＞20ng/ml)

The definition of high risk prostate cancer is unclear. Generally preoperative PSA, Biopsy Gleason score and DRE characteristics are used to describe this group of patients. But until now, there is no consensus for these prostate cancers and manystudies report different methods of classification and different treatment options, ranging from hormonal therapy to prostatectomy. Thus, there is a need to clarify the definition and treatment of high risk prostate cancers, especially localized prostate cancer with high PSA. Herein we review the literatures on high risk prostate cancers and their oncologic outcomesope

Clinical Outcomes of Bosniak Category IIF Complex Renal Cysts in Korean Patients.

PURPOSE: To assess the clinical reliability of the Bosniak IIF category and to determine the proper radiologic follow-up duration and intervals for category IIF complex renal cysts. MATERIALS AND METHODS: We studied 201 patients with category IIF renal cysts from January 1996 to January 2011. Renal cyst progression to category III was defined as an increase in complexity of the cyst in follow-up radiologic studies. We monitored radiologic changes and progression of renal cysts during the follow-up period and analyzed the pathologic results of those patients who were treated surgically. RESULTS: At a mean follow-up of 20 months, only 14 cases (7%) showed evidence of progression to stage III, with a mean time to progression of 11 months (range, 3 to 65 months). There were no significant differences in age, gender, cyst size, or change in cyst size between the progressive and non-progressive groups. Of 12 cases treated surgically, 10 cases (83.3%) showed renal cell carcinoma with pT1 stage, and there was no recurrence during postoperative follow-up of 23 months. Of the 187 patients without radiologic progression, 23 cases were treated surgically, and all of them showed benign cysts. CONCLUSIONS: The IIF category showed significant clinical reliability by a low rate of radiologic progression and a high rate of malignancy in the radiologic progressive group but a low rate of malignancy in the non-progressive group. Although it is hard to decide on a proper follow-up duration because of the variable time to progression, too frequent follow-up study seems to be unnecessary considering that most malignant cases were of a low stage.ope

A Comparative Study of Laparoendoscopic Single-Site Surgery Versus Conventional Laparoscopy for Upper Urinary Tract Malignancies

PURPOSE: The proper indication for laparoendoscopic single-site surgery (LESS) in urology is still under debate, especially for malignant diseases. We compared the perioperative outcomes between LESS and conventional laparoscopy (CL) for upper urinary tract malignancies. MATERIALS AND METHODS: We reviewed the records of 75 patients who underwent radical nephrectomy, nephroureterectomy with bladder cuff excision, or partial nephrectomy with the LESS or CL approach between December 2008 and December 2010. We compared characteristics and perioperative outcomes between patients who underwent LESS or CL. All operations were performed by three surgeons using the transperitoneal approach. RESULTS: For all three surgery types, no differences in patient characteristics, estimated blood losses, transfusion rates, or durations of hospital stay were found between the two groups. No complications were found between the two groups in those who underwent nephroureterectomy with bladder cuff excision; however, significantly more complications were found in the LESS group than in the CL group in those who underwent radical nephrectomy or partial nephrectomy. Most of the complications with LESS radical nephrectomy occurred in the early introduction period of the technique. CONCLUSIONS: No significant differences in perioperative outcomes were found between the LESS and CL groups in those who underwent radical nephrectomy or nephroureterectomy with bladder cuff excision. Therefore, the use of LESS in these cases is expected to expand as surgeons gain more experience with this technique and as other technical advances in laparoscopic instruments occur. However, partial nephrectomy with LESS should be performed restrictively considering the current level of surgical skill.ope

Laparoendoscopic single-site nephrectomy using a modified umbilical incision and a home-made transumbilical port.

PURPOSE: To assess the clinical utility of laparoendoscopic single-site surgery (LESS) nephrectomy using a modified umbilical incision and home-made transumbilical port in cases requiring extirpative surgery. MATERIALS AND METHODS: Initial consecutive 18 patients underwent LESS nephrectomies that were performed by a single surgeon. A home-made port was placed through a modified umbilical incision, the length of which had preoperatively been determined. The laparoscopic transperitoneal nephrectomy procedures were performed with various combinations of standard and articulating laparoscopic instruments. Patient characteristics and perioperative outcomes, including pathologic results, were recorded prospectively. RESULTS: All 18 extirpative surgeries, including simple nephrectomy (eight cases), radical nephrectomy (nine cases), and nephroureterectomy (one case), were completed successfully. The median operation time was 167 min (range 82-220), and the median blood loss was 250 mL (range 0-1050). All specimens were extracted intact through a modified umbilical incision (median length 2.5 cm, range 1.5-6.0). Final pathological analysis revealed a nonfunctioning kidney in five cases, a dysplastic kidney in three cases, a mixed epithelial and stromal tumor in one case, renal cell carcinoma in eight cases (T1: five cases, T3: three cases), and Ta ureter transitional cell carcinoma in one case. CONCLUSION: LESS nephrectomy using a home-made port and modified umbilical incision is feasible with both minimal incision and cost-effective. Our technique may be more useful for extirpative procedures in which a specimen needs to be removed intact, because incision length can be freely adjusted. Prospective comparisons are warranted to more clearly elucidate the utility of this surgical technique.ope

Urinary continence after robot assisted laparoscopic radical prostatectomy

의학과/석사목적: 현재 국내 남성 암 중 전립선암이 5위를 차지할 만큼 그 유병률이 급속히 증가해 왔으며 최근 로봇이 수술에 도입되어 로봇을 이용한 전립선 적출술이 많이 시행되고 있다. 그러나 로봇의 장점에도 불구하고 여전히 많은 환자들이 수술 후 요실금으로 고통받고 있으며 이로 인해 삶의 질이 많이 떨어지고 있다. 본 연구에서는 로봇 보조 복강경 전립선 적출술 후 요실금의 빈도와 요자제 획득에 기여하는 요인은 어떠한 것이 있으며 요실금을 평가하는 데 있어 인터뷰와 설문지의 차이가 어떠한지를 확인하였다. 재료 및 방법: 전립선암으로 한 명의 술자에 의해 로봇 보조 근치적 전립선 적출술을 시행받은 862명 중 수술 후 1년 이상 외래에서 추적 관찰이 가능하였고 요실금에 대한 인터뷰 내용이 명확히 기록된 545명의 환자를 대상으로 하였다. 국소암 뿐만 아니라 진행성 암 환자도 모두 분석하였다. 인터뷰 결과 패드를 전혀 사용하지 않게 되었을 때를 요자제 획득으로 판단하였고 safety liner 1장이라도 사용하는 경우 요실금이 있는 것으로 간주하였다. 요자제 획득군과 요실금 지속군 간의 수술 전, 중, 후의 인자들과 병리 결과, 요역동학 검사 결과, 요실금에 대한 인터뷰와 설문지의 결과를 비교하였다. 결과: 전체 환자의 요자제 획득률은 545명 중 421명(77.2%)였으며, 이 중 378명(69.4%)은 1년 이내에 요자제를 획득하였다. 국소암 환자로 국한시키면 404명 중 331명(81.9%)가 요자제를 획득하였다. 요자제 획득군에서 요실금 지속군에 비해 수술 당시 나이가 젊고(63.0±7.5세 vs 67.3±7.0세, p<0.0001), 수술 전후의 Gleason 점수 낮았고(p=0.001, p=0.001), 임상적 병기가 낮았다(p<0.0001). 또한 신경혈관다발을 보존한 경우가 많았으며(p<0.0001) 방광 경부를 보존한 경우가 많았다(p=0.004). 수술 전 요역동학 검사에서 배뇨근 과활동성을 보인 사람은 상대적으로 요실금 지속의 빈도가 높았다(p=0.015). 인터뷰를 통해 요자제 획득으로 판단한 사람도 ICIQ 설문지 결과 요실금의 빈도와 양이 완벽하게 없다라고 응답한 비율은 각각 21.7%, 23.0%였으며 이 두 항목 모두 0점인 사람은 18.9%였다.결론: 수술 당시 나이가 많고 조직검사의 Gleason 점수가 높고 진행성 암이며 술 전 요역동학 검사에서 배뇨근 과활동성을 보인 환자는 수술 후 그렇지 않은 사람에 비해 요자제 획득의 가능성이 떨어진다. 또한 주치의가 기록하는 인터뷰 결과와 환자가 작성하는 설문지의 결과에는 차이가 있으므로 요실금에 대한 설문지 평가를 시행하여야 한다.ope

Simple, safe, and successful evacuation of severe organized clot retention using a catheter connected with wall suction: suction and fishing method

OBJECTIVE: To introduce a novel method to successfully remove organized hematoma. Endoscopic evacuation can be troublesome in some patients with a large amount of blood clots or organized hematoma. METHODS: We retrospectively reviewed medical records of 15 patients who were treated with a so-called "suction and fishing method" for severe clot retention. A large-bore catheter connected with a wall suction unit was inserted into the bladder through the resectoscope sheath, and subsequently a large volume of urine retention and quite a substantial amount of soft clots were removed (suction step). After awhile, negative pressure could not work when the catheter met large and organized fragments of blood clots. In this situation, large blood clots hanging on the catheter tip were removed by gently removing the catheter (fishing step). RESULTS: In all patients, clot retention was successfully managed with this method. Clot evacuation was performed without anesthesia in 9 patients when electrocauterization was not planned, and opioid analgesics were sufficient for pain control. In the other 6 patients, clot evacuation and fulguration were performed under anesthesia. Median time for clot evacuation was 20 minutes (range 5-55) and median estimated volume of clot evacuated was 200 mL (range 50-600). There was no procedure-related complication such as bladder rupture. CONCLUSION: The suction and fishing method is a simple, safe, and successful way to evacuate severe organized clot retention. It can resolve intractable clot retention and rapidly relieve related symptoms without anesthesia.ope

Robot-assisted laparoscopic radical prostatectomy after previous cancer surgery

Robot-assisted laparoscopic radical prostatectomy has become a frequently used alternative treatment option in the management of prostate cancer. As more operations are performed, more challenging patient conditions are encountered, for example those with previous abdominal cancer surgery. We present our experience of robot-assisted laparoscopic radical prostatectomy (RALP) in patients with previous cancer surgery. Seven patients with a history of previous surgery for malignancy underwent RALP. All the prostatectomies were performed using the da Vinci™ S surgical system by a single surgeon. All operations were approached transperitoneally. We reviewed perioperative data and surgical outcomes retrospectively. The mean age at surgery was 68.43 years (range 63–82). The mean operative time was 214 ± 47.32 min, and the median estimated blood loss was 500 ml (range 200–1,300). The mean hospital stay was 6.57 ± 2.15 days, and the mean duration of catheterization was 8.29 ± 3.09 days. Nerve-sparing procedure and pelvic lymph node dissection were performed in six patients. Rectal injury occurred in one patient who had undergone hemi-colectomy 15 years previously and was resolved by primary closure. Positive surgical margin was found in three patients. Although one patient had an intraoperative rectal injury, RALP in a patient with previous cancer surgery seems to be feasible and safe in experienced handsope

Comparison of oncological results, functional outcomes, and complications for transperitoneal versus extraperitoneal robot-assisted radical prostatectomy: a single surgeon's experience

BACKGROUND AND PURPOSE: To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy. PATIENTS AND METHODS: From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed. RESULTS: Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p < 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group. CONCLUSIONS: The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomyope

Urologic robot-assisted laparoendoscopic single-site surgery using a homemade single-port device: a single-center experience of 68 cases

PURPOSE: To describe our experience with robot-assisted laparoendoscopic single-site (R-LESS) surgeries and evaluate a homemade port system as an effective access technique. PATIENTS AND METHODS: Between May 2009 and April 2010, 68 consecutive R- LESS urologic operations were performed in our institution. A 4 to 5 cm long incision was made over the umbilicus. After the inner ring of the Alexis wound retractor was placed into the peritoneum, a common size 7 surgical glove was then applied over the external side of the wound retractor. A homemade single port was established by inserting two 12-mm trocars and two 8-mm trocars through fingers of a surgical glove and securing it to the port. RESULTS: Sixty-eight patients underwent R-LESS, including partial nephrectomy in 51, nephroureterectomy in 12, radical nephrectomy and adrenalectomy in 2 each, and simple nephrectomy in 1. Mean patient age was 56 years (range 16-81 y). Mean body mass index was 23.9 kg/m(2) (range 17.2-32.9 kg/m(2)). The mean operative time was 219 minutes (range 109-382 min). Mean estimated blood loss 319 mL (range 50-1550 mL), and change in hematocrit was 5.2 % (range 0.0-14.8%). At a mean follow-up of 8 months, there were no port-related complications, and cosmesis was excellent. CONCLUSIONS: R-LESS is feasible and can be safely applied to a variety of urologic operations, considering the low intraoperative complication rate. Our homemade single-port device provides adequate range of motion and is more flexible in port placement for R-LESS than the current multichannel port.ope

Lymphocele after extraperitoneal robot-assisted radical prostatectomy: A propensity score-matching study

OBJECTIVES: To investigate the incidence of lymphocele and determine the risk factors for postoperative lymphocele after extraperitoneal robot-assisted radical prostatectomy by using propensity score-matching. METHODS: A total of 483 patients underwent extraperitoneal robot-assisted radical prostatectomy for prostate cancer between January 2009 and August 2011. Of these, 200 patients underwent pelvic lymph node dissection during robot-assisted radical prostatectomy. All patients underwent magnetic resonance imaging or computed tomography postoperatively to detect lymphocele after robot-assisted radical prostatectomy. Propensity scores for an established control group were calculated for each patient using multivariate logistic regression based on the following covariates: age, body mass index, preoperative prostate-specific antigen level, prostate volume calculated by transrectal ultrasound, biopsy Gleason sum and clinical tumor stage. RESULTS: Lymphocele was identified in 41 patients (20.5%). There were no statistical differences in variables used in propensity score-matching. Operation time, estimated blood loss, catheterization and surgical margin positivity did not show differences between the two groups. Seminal vesicle invasion (P = 0.015) and tumor volume (P = 0.042) between the two groups were significantly different. In the multivariate logistic regression model, extracapsular extension (P = 0.017, odds ratio 4.231), seminal vesicle invasion (P = 0.028, odds ratio 2.643) and the number of positive lymph nodes (P = 0.041, odds ratio 3.532) were independent risk factors for lymphocele development after extraperitoneal robot-assisted radical prostatectomy with pelvic lymph node dissection. CONCLUSIONS: Lymphocele might preferentially develop in cases with seminal vesicle invasion and large tumor volume. Additionally, extracapsular extension, seminal vesicle invasion, and the number of positive lymph nodes are independent risk factors for postoperative lymphocele after extraperitoneal robot-assisted radical prostatectomy.ope