Urethral realignment with maximal urethral length and bladder neck preservation in robot-assisted radical prostatectomy: Urinary continence recovery

PURPOSE: To evaluate early recovery of urinary continence after robot-assisted radical prostatectomy (RARP) with urethral realignment using bladder neck preservation (BNP) and maximal urethral length preservation (MULP). METHODS: Patients who underwent RARP between 2014 and 2017 owing to prostate cancer with a Gleason score ≤ 7 (3+4), ≤ cT2c stage, and prostate-specific antigen level < 20 ng/ml were investigated. Patients with tumors of the bladder neck or apex on magnetic resonance imaging were excluded. A total of 266 patients underwent the operation using the standard method between 2014 and 2015 (group 1), while 305 patients underwent urethral realignment between 2016 and 2017 (group 2). Continence was defined as wearing no pad or one security pad. RESULTS: The continence rates immediately after Foley catheter removal, at 2 weeks, and at 1, 3, 6, and 12 months after operation in group 2 were 46.9%, 63.0%, 73.4%, 90.1%, 94.8%, and 98.7%, respectively. The continence rate at 1 month in group 2 was significantly higher than that in group 1 (65.4% versus 73.4%, p = 0.037). The multivariate regression analysis showed that age and surgical method were factors affecting early continence recovery. The positive surgical margin rates were 18.0% and 14.8% in groups 1 and 2, respectively (p = 0.288). Biochemical recurrence occurred in 14.7% and 8.2% in groups 1 and 2, respectively (p = 0.015). CONCLUSION: Urethral realignment using BNP and MULP resulted in rapid continence recovery and good oncological results after RARP in young patients with a Gleason score ≤ 7 and organ-confined disease.ope

Noninvasive studies may have potential to replace cystoscopy in non-muscle invasive bladder cancer follow-up

Bladder cancer has a high recurrence rate which requires frequent follow-up. Cystoscopy is currently the gold standard for follow-up which is invasive and undesirable procedure for patients. We aimed to investigate the feasibility of noninvasive studies for follow-up of non-muscle invasive bladder cancer. This retrospective study was done for non-muscle invasive bladder cancer patients with abnormal lesion at follow up cystoscopy, therefore those needed transurethral resection of bladder tumor (TUR-BT). Inclusion criteria was patients who had preoperative bladder magnetic resonance imaging (MRI) within 1 month to TUR-BT and urine cytology results. MRI, urine cytology, and surgical pathology results were analyzed for sensitivity, specificity, positive and negative predictive values, accuracy, diagnostic odds ratio, and number needed to misdiagnose for the diagnostic performance of non-invasive studies. From total of 2,258 TUR-BT cases, 1,532 cases of primary TUR-BT and 481 cases which bladder MRI were not done was excluded. Finally, 245 cases of TUR-BT were included. Combined urine cytology and bladder MRI showed 96% sensitivity, 43% specificity, 89% positive and 67% negative predictive values, 87% accuracy, 16.2 diagnostic odds ratio, and 7.4 number needed to misdiagnose values. Among nine false-negative cases, three (1.2%) were missed by the radiologist, two (0.8%) had an empty bladder during magnetic resonance imaging, and three (1.2%) had gross hematuria which needed cystoscopy despite of bladder MRI or urine cytology result. Only one case (0.4%) was missed based on symptoms and noninvasive tests. However, none of the false-negative cases showed rapid extensive progression requiring radical or partial cystectomy. The combination of bladder MRI and urine cytology was comparable to cystoscopy for the follow-up of recurred lesions in non-muscle invasive bladder cancer patients for sensitivity, but not for specificity. However, it may reduce the need for cystoscopy and allowing patients to have choices for follow up diagnostic methods. Also, additional imaging tests to evaluate kidney, ureter and peri-vesical lesions can be reduced.ope

Is the extirpative surgery for primary tumor helpful for the patients with metastatic urothelial cancer at the time of diagnosis?

The stagnant mortality rates for metastatic urothelial cancer (UC) have provoked efforts to find novel treatments. To test the utility of the extirpative surgery for primary tumor as an option for these patients, we investigated the perioperative and oncologic outcomes of surgery for primary tumors in metastatic UC patients.We reviewed the medical records of 130 metastatic UC patients (bladder: 88, upper tract UC: 42) at diagnosis from November 2005 to November 2016. A total of 56 patients (surgery group) underwent chemotherapy with extirpative surgery for the primary tumor, and 74 patients (non-surgery group) received chemotherapy. We evaluated perioperative outcomes, cancer-specific survival (CSS), and overall survival (OS) using Kaplan-Meier methods and factors related to OS and CSS using Cox regression models.Surgery group showed similar perioperative outcome and postoperative complications to those previously reported in UC patients without metastasis, and fewer urinary complications than non-surgery group. Surgery group showed better oncological outcomes than non-surgery group for median CSS (16.0 vs 10.0 months, P = 0.014) and median OS (14.0 vs 9.0 months, P = 0.043). Multivariate analysis showed Eastern Cooperative Oncology Group performance status and metastasis to liver as significant predictors of CSS and OS. Surgery was not related with OS, but a significant predictor of CSS.Extirpative surgery for primary tumor in metastatic UC can be feasible and it might have survival benefits, especially those patients with a tolerable general condition and no liver metastasis. In addition, LT reduces the possibility of a surgical procedure towing to urinary complications.ope

Prostate epithelial genes define therapy-relevant prostate cancer molecular subtype

Background and objectives: Transcriptomic landscape of prostate cancer (PCa) shows multidimensional variability, potentially arising from the cell-of-origin, reflected in serum markers, and most importantly related to drug sensitivities. For example, Aggressive Variant Prostate Cancer (AVPC) presents low PSA per tumor burden, and characterized by de novo resistance to androgen receptor signaling inhibitors (ARIs). Understanding PCa transcriptomic complexity can provide biological insight and therapeutic guidance. However, unsupervised clustering analysis is hindered by potential confounding factors such as stromal contamination and stress-related material degradation. Materials and methods: To focus on prostate epithelial cell-relevant heterogeneity, we defined 1,629 genes expressed by prostate epithelial cells by analyzing publicly available bulk and single- cell RNA sequencing data. Consensus clustering and CIBERSORT deconvolution were used for class discovery and proportion estimate analysis. The Cancer Genome Atlas Prostate Adenocarcinoma dataset served as a training set. The resulting clusters were analyzed in association with clinical, pathologic, and genomic characteristics and impact on survival. Serum markers PSA and PAP was analyzed to predict response to docetaxel chemotherapy in metastatic setting. Results: We identified two luminal subtypes and two aggressive variant subtypes of PCa: luminal A (Adipogenic/AR-active/PSA-high) (30.0%); luminal S (Secretory/PAP-high) (26.0%); AVPC-I (Immune-infiltrative) (14.7%), AVPC-M (Myc-active) (4.2%), and mixed (25.0%). AVPC-I and AVPC-M subtypes predicted to be resistant to ARI and have low PSA per tumor burden. Luminal A and AVPC-M predicted to be resistant to docetaxel and have high PSA/PAP Ratio. Metastatic PCa patients with high PSA/PAP ratio (>20) had significantly shorter progression-free survival than those with low ratio (≤20) following docetaxel chemotherapy. Conclusion: We propose four prostate adenocarcinoma subtypes with distinct transcriptomic, genomic, and pathologic characteristics. PSA/PAP ratio in advanced cancer may aid in determining which patients would benefit from maximized androgen receptor inhibition or early use of antimicrotubule agents.ope

Management of postoperative ileus after robot-assisted laparoscopic prostatectomy.

To compare different postoperative management methods on the recovery of bowel function after robot-assisted laparoscopic prostatectomy (RALP).This is a prospective study of 716 patients who underwent RALP at Severance Hospital in Seoul, South Korea, between March 2017 and February 2018. Instructions for the different postoperative management methods (mobilization, abdominal massage, hot pack therapy, and gum chewing) were presented to patients, who subsequently reported when these activities were performed as well as the time to first flatus on a designated form.There were no significant differences in age, height, weight, body mass index, body surface area, prevalence of hypertension and diabetes mellitus, and in American Society of Anesthesiologists (ASA) scores with respect to early bowel recovery. Prolonged times of surgery and anesthesia significantly caused delays in bowel recovery. The total number and time of mobilization, total time of hot pack therapy, and number of gum chewing were significantly and positively associated with bowel recovery. A Kaplan-Meier analysis showed that all of the postoperative management methods were positively associated with the mean time to first flatus.Methods of postoperative management (mobilization, abdominal massage, hot pack therapy, and gum chewing) have positive effect on bowel motility after RALP. Furthermore, reductions in the times of surgery and anesthesia could significantly decrease prolonged delays in bowel recovery.ope

Muscle Characteristics Obtained Using Computed Tomography as Prognosticators in Patients with Castration-Resistant Prostate Cancer

Limited studies have investigated the correlation between body composition and prostate cancer outcomes. We analyzed the effect of muscle mass and quality on castration-resistant prostate cancer (CRPC) outcomes. Skeletal muscle index (SMI) and skeletal muscle attenuation (SMA) were measured for 411 patients at the L3 vertebral level using computed tomography at CRPC diagnosis and were dived to low and high groups at the value of median. Analysis of the skeletal phenotypes and age (70 years) was performed to evaluate the effect of SMI and SMA. The median survival rates for patients with low and high SMI were 19 and 24 months (p = 0.015), and those with low and high SMAs were 15 and 26 months (p 70 years. Patients with low SMA + low SMI had the worst prognosis. Muscle characteristics seems to be a prognosticator in survival of CRPC patients and may be considered in treatment planning.ope

Phosphodiesterase-5 Inhibitor Use in Robot Assisted Radical Prostatectomy Patients Is Associated with Reduced Risk of Death: A Propensity Score Matched Analysis of 1,058 Patients

Purpose: We investigated whether the use of a phosphodiesterase-5 inhibitor (PDE5i) after robot assited radical prostatectomy has a survival benefit over non-use patients because there are controversial results on the association between PDE5i use and survival outcomes for prostate cancer patients in literature. Materials and methods: We designed a retrospective, matched, large-sample cohort study of 5,545 patients who underwent robot assisted radical prostatectomy (RARP) during 2013-2021 in a single institute. The exclusion criteria was patients who were aged >70 years at surgery, American Society of Anesthesiologists (ASA) physical status classification grade 4 or 5, history of other malignancies, patients who started PDE5i 6 months after survery and patients with follow up period less than 24 months after surgery. Among the 1,843 included patients, 1,298 were PDE5i users, and 545 were PDE5i non-users. We performed propensity score matching (PSM) of PDE5i users (n=529) with non-users (n=529) by adjusting for the variables of age, Gleason grade group, pathological T stage, preoperative ASA physical status grade, and International Index of Erectile Function score. Results: There were no significant difference in patient characteristics according to PSM. Kaplan-Meier curve revealed the difference of overall survival for PDE5i users and non-users (clustered log-rank test p<0.05). In a stratified Cox regression analysis, PDE5i use after RARP was associated with improved overall survival and reduced risk of death (hazard ratio 0.43; confidence interval 0.24-0.79; p=0.007). The limitation of this study was that the indication for the prescription of PDE5i was not given. Conclusions: PDE5i administration after RARP were associated with overall survival of patients with prostate cancer. A further randomized control trial may reveal whether routine use of PDE5i after prostatectomy can improve survival of prostate cancer patient.ope

Prostate-Specific Antigen Kinetics Following 5alpha-Reductase Inhibitor Treatment May Be a Useful Indicator for Repeat Prostate Biopsy

PURPOSE: To evaluate parameters for determining repeat prostate biopsy in patients with 5alpha-reductase inhibitor (5ARI) treatment after initial negative biopsy. MATERIALS AND METHODS: From January 2007 to December 2015, patients who underwent a repeat prostate biopsy after an initial negative biopsy were enrolled from multiple institutions. Serial prostate-specific antigen (PSA) levels after the initial biopsy were analyzed for PSA kinetics. Clinicopathologic variables were evaluated according to the use of 5ARIs after the initial negative biopsy. RESULTS: Of 419 patients with initial negative biopsies (median age=67.0 years, median PSA=6.31 ng/mL), 101 patients (24.1%) were diagnosed with prostate cancer at the repeat biopsy. An increase in PSA level at 18 months, compared to that at 6 months, was a predictor of a positive repeat biopsy. However, the use of 5ARIs was not identified as a predictor. Of 126 patients receiving 5ARI treatment after the initial biopsy, 30 (23.8%) were diagnosed with prostate cancer at the repeat biopsy. Increase in PSA level at more than two time points after 6 months of 5ARI treatment (odds ratio=4.84, p=0.005) was associated with cancer detection at the repeat biopsy. There were no significant 5ARI group-related differences in the detection rates of prostate and high-grade cancers (Gleason score >/=7). CONCLUSION: The effects of 5ARIs on prostate cancer detection and chemoprevention remain uncertain. However, more than two increases in PSA level after 6 months of 5ARI treatment may indicate the presence of prostate cancer.ope

Pure single-site robot-assisted pyeloplasty with the da Vinci SP surgical system: Initial experience

Purpose: Laparoendoscopic single-site surgery (LESS) reduces the limited invasiveness of conventional laparoscopy while providing superior cosmetic results. However, LESS remains a challenging surgical technique, even in robotic surgery, primarily due to the lack of triangulation and limited instrument movement. The da Vinci SP surgical system (Intuitive Surgical) was recently introduced to overcome these limitations. We describe our initial experience with pure single-site robot-assisted pyeloplasty (RAP) for ureteropelvic junction obstruction (UPJO) using the da Vinci SP surgical system. Materials and Methods: Three consecutive patients who were diagnosed with UPJO underwent RAP with the da Vinci SP surgical system from December 2018 to February 2019 at our institution. The surgical technique involved reproducing the steps of multi-port RAP. A 30-mm umbilical incision was made and the GelPOINT was inserted. The multichannel robotic port and the assistant's port were placed through the GelSeal cap. In all patients, Anderson-Hynes dismembered pyeloplasty was performed. The ureteral double J stent was inserted antegrade, and the drain was not placed. Results: The procedures were successfully completed using a pure single-site approach. There was no need for additional port placement or conversion to laparoscopic or open surgery. Total operative time in the three patients was 139, 180, and 213 minutes, respectively. No intraoperative complications occurred, and blood loss was minimal. The postoperative course of all patients was uneventful with no complications greater than Clavien-Dindo grade I surgical complications. Conclusions: Pure single-site RAP using the da Vinci SP surgical system is feasible and safe.ope

Neutrophil-to-Lymphocyte Ratio Predicts Pathological Renal Sinus Fat Invasion in Renal Cell Carcinomas of ≤7 cm with Presumed Renal Sinus Fat Invasion

PURPOSE: Computed tomography (CT) is the most useful diagnostic modality for staging renal cell carcinoma (RCC). However, CT is limited in its ability to predict renal sinus fat invasion (SFI). Here, we aimed to evaluate whether preoperative neutrophil-to-lymphocyte ratio (NLR) could predict pathological SFI in patients with RCC of ≤7 cm for whom preoperative imaging reveals potential renal SFI. MATERIALS AND METHODS: We reviewed the medical records of 1311 patients who underwent extirpative renal surgery for non-metastatic RCC of ≤7 cm between November 2005 and December 2014. After excluding patients with no SFI in preoperative imaging, unavailable preoperative data, and morbidity affecting inflammatory markers, a total of 476 patients were included in this study. Multivariate logistic regression analysis was used to evaluate predictors of pathological SFI. RESULTS: We implemented a cut-off value of 1.98, which was calculated by ROC analysis to obtain high (≥1.98) and low (<1.98) NLR groups. A total of 93 patients with pathological SFI had larger clinical tumor size, higher preoperative NLR, larger pathological tumor size, more frequent renal vein involvement, and higher Fuhrman nuclear grade. Multivariate analysis indicated that high NLR [odds ratio (OR) 2.032, p=0.004], clinical tumor size (OR 1.586, p<0.001), and collecting system involvement on preoperative imaging (OR 3.957, p=0.011) were significantly associated with pathological SFI in these tumors. CONCLUSION: Preoperative high NLR was associated with pathological SFI in patients with RCC of ≤7 cm and presumed SFI on preoperative imaging. Greater surgical attention is needed to obtain negative margins during partial nephrectomy in these patients.ope