근치적 방광적출술을 시행한 방광암 환자에서 임파 혈관 침윤의 예후적 중요성: 체계적 고찰과 메타분석

학위논문 (석사)-- 서울대학교 대학원 : 의학과(비뇨기과학), 2015. 8. 구자현.Purpose: The objective of the present study was to conduct a systematic review and meta-analysis of published literature to appraise the prognostic value of lymphovascular invasion (LVI) in radical cystectomy specimens. Materials and Methods: Following the PRISMA statement, PubMed, Cochrane Library, and SCOPUS database were searched from the respective dates of inception until June 2013. According to inclusion criteria, 21 articles were included from the 389 articles initially identified. Methodological assessment for the included studies was performed. The log-Hazard Ratios (HR) and their 95% Confidence intervals (CI) were obtained from each study and the meta-analysis was performed subsequently using a random-effect model. Subgroup analyses were performed to examine if our pooled estimate of the prognostic value was influenced by data parameters. Sensitivity analyses were performed by removing one study at a time. A test of heterogeneity of the combined HRs was carried out using the Chi-square test and Higgins I-squared statistic. Publication bias was evaluated using the funnel plot. Results: A total of 21 articles met the eligibility criteria for this systematic review, which included a total of 12,527 patients ranging from 57 to 4,257 per study. LVI was detected in 34.6% in radical cystectomy specimens. LVI was associated with higher pathological T stage and tumor grade, as well as lymph node metastasis. The pooled HR was statistically significant for recurrence-free survival (pooled HR, 1.6195% CI, 1.26?2.06), cancer-specific survival (pooled HR, 1.6795% CI, 1.38?2.01), and overall survival (pooled HR, 1.8495% CI, 1.27?2.66), despite the heterogeneity among included studies. On sensitivity analysis, the pooled HRs and 95% CIs were not significantly altered when any one study was omitted. The funnel plot for overall survival demonstrated a certain degree of asymmetry, which showed slight publication bias. Conclusions: This meta-analysis indicates that LVI is significantly associated with poor outcome in patients with bladder cancer who underwent radical cystectomy. Adequately designed prospective studies are required to provide the precise prognostic significance of LVI in bladder cancer.Abstract i Table of contents iii Table and figure legends iv Introduction 1 Materials and Methods 2 Results 5 Discussion 8 Conclusions 12 References 13 국 문 초 록 32Maste

Effect of Diabetes Mellitus on Symptomatic Improvement After Surgery for Benign Prostatic Hyperplasia in Patients With Lower Urinary Tract Symptom and its Relations With Prostatic Urethral Angulation

Purpose To compare improvement of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia in diabetic versus nondiabetic patients after transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP). Methods The medical records of 437 patients who underwent TURP or HoLEP at a tertiary referral center from January 2006 to January 2022 were retrospectively analyzed. Among them, 71 patients had type 2 diabetes. Patients in the diabetic mellitus (DM) and non-DM groups were matched 1:1 according to age, baseline International Prostate Symptom Score (IPSS), and ultrasound measured prostate volume. Changes in LUTS were assessed at 3 months after surgery using IPSS and evaluated by categorizing patients according to prostatic urethral angulation (PUA; <50° vs. ≥50°). Medication-free survival after surgery was also investigated. Results No significant differences were noted between the DM and non-DM groups in baseline characteristics except for comorbidities (i.e., hypertension, cerebrovascular disease, and ischemic heart disease, P=0.021, P=0.002, and P=0.017, respectively) and postvoid residual urine volume (115±98 mL vs. 76±105 mL, P=0.028). Non-DM patients showed significant symptomatic improvement regardless of PUA, while DM patients demonstrated improvement in obstructive symptoms only in those with large PUA (≥51°). Among patients with small PUA, DM patients had worse medication-free survival after surgery compared to controls (P=0.044) and DM was an independent predictor of medication reuse (hazard ratio, 1.422; 95% confidence interval, 1.285–2.373; P=0.038). Conclusions DM patients experienced symptomatic improvement after surgery only in those with large PUA. Among patients with small PUA, DM patients were more likely to reuse medication after surgery

Evaluation of functional outcome of bilateral kidney tumors after sequential surgery

Background There are limited data concerning patients treated with sequential bilateral kidney surgery. Current guidelines still lack an optimal surgical sequencing approach. We evaluated renal functional outcomes after sequential partial nephrectomy (PN) and radical nephrectomy (RN) in patients with bilateral renal cell carcinoma (RCC). Methods A propensity score matched cohort of 267 patients (synchronous bilateral RCCs, N = 44 [88 lesions]; metachronous bilateral, N = 45 [90 lesions]; unilateral, N = 178) from two tertiary institutions were retrospectively analyzed. Synchronous bilateral RCCs were defined as diagnosis concomitantly or within 3 months of former tumor. Renal functional outcomes were defined as estimated glomerular filtration rate (eGFR) changes and de novo chronic kidney disease (CKD, stage ≥3) after surgery. Renal functional outcomes and clinical factors predicting de novo CKD were assessed using descriptive statistics and Cox regression analysis. Results In subgroup of bilateral RCCs, patients underwent sequential PN (N = 48), PN followed by RN (N = 8), or RN followed by PN (N = 25). Final postoperative estimated glomerular filtration rates (eGFRs) were 79.4, 41.4, and 61.2 ml/minute/1.73 m2, respectively (p = 0.003). There were significant differences in eGFR decline from baseline and de novo chronic kidney disease (CKD stage ≥ III) among groups, with PN followed by RN group showing the worst functional outcomes (all p <  0.05). Moreover, sequential PN subgroup in bilateral RCC showed significantly higher rate of de novo CKD than unilateral RCC group (13.8% vs. 6.9%, p = 0.016). On multivariate analysis, hypertension (p = 0.010) and surgery sequence (PN followed by RN, p <  0.001) were significant predictors of de novo CKD. Conclusions The surgery sequence should be prudently determined in bilateral renal tumors. PN followed by RN showed a negative impact on renal functional preservation. Nephron-sparing surgery should be considered for all amenable bilateral RCCs

Blood transfusion had no influence on the 5-year biochemical recurrence after robot-assisted radical prostatectomy: a retrospective study

Background Although red blood cells (RBC) transfusion is known to be significantly associated with biochemical recurrence in patients undergoing open prostatectomy, its influence on biochemical recurrence after robot-assisted laparoscopic radical prostatectomy remains unclear. Therefore, this study aimed to validate the effect of RBC transfusion on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy. Methods This study retrospectively analyzed the medical records of patients who underwent robot-assisted laparoscopic radical prostatectomy at single tertiary academic hospital between October 2007 and December 2014. Univariate and multivariate Cox proportional hazard regression analysis was performed to identify any potential variables associated with 5-year biochemical recurrence. Results A total of 1311 patients were included in the final analysis. Of these, 30 patients (2.3%) were transfused with RBC either during robot-assisted laparoscopic radical prostatectomy or during their hospital stay, which corresponded to 5-year biochemical recurrence of 15.7%. Multivariate Cox proportional hazard regression analysis showed that RBC transfusion had no influence on the 5-year biochemical recurrence. Variables including pathologic T stage (Hazard ratio [HR] 3.5, 95% confidence interval [CI] 2.4–5.1 p < 0.001), N stage (HR 2.3, 95% CI 1.5–3.7, p < 0.001), Gleason score (HR 2.4, 95% CI 1.8–3.2, p < 0.001), and surgical margin (HR 2.0, 95% CI 1.5–2.8, p < 0.001) were independently associated with the 5-year biochemical recurrence. Conclusions RBC transfusion had no significant influence on the 5-year biochemical recurrence in patients undergoing robot-assisted laparoscopic radical prostatectomy

Mid-term results of ReMEEX sling system in female stress urinary incontinence with various indications and feasibility of readjustment

Purpose: To examine efficacy and safety of ReMEEX implantation in patients with female stress urinary incontinence (SUI) associated with detrusor underactivity (DU), recurrence, or intrinsic sphincter deficiency (ISD). Materials and Methods: Retrospective cohort study included 303 females who underwent ReMEEX system (March 2008 to May 2021). Patients were stratified into three groups by purpose of surgery (SUI with DU, reoperation, and SUI with ISD) and evaluated with following criteria: cure (absence of subjective complaint of leakage and objective leakage in the stress test), improvement (rare leakage subjectively, but satisfaction regardless of stress test), and failure. Primary outcome was success rate of surgery assessed through patient interviews and a stress test. Surgical outcomes and complications were evaluated. Results: Mean follow-up was 34.4 months (range, 6.0–145.0 months). At the final follow-up visit, 42.9% and 49.2% of patients were cured and improved. Twenty-one point five percent required tension readjustment (mean number, 1.2). The total complication rate was 19.5% (none for grade ≥4). Preoperative Qmax was significantly higher in the ISD group (p<0.001) and preoperative total International Prostate Symptom Score (IPSS) score was significantly higher in the DU group (p=0.044). Moreover, at postoperative 1 year, both total IPSS score and IPSS quality of life score were significantly higher in the DU group (both p=0.001). Conclusions: The success rate of ReMEEX system was 92.1% at mean follow-up of 34.4 months in female SUI with DU, reoperation, or ISD. It also enabled postoperative readjustment of sling tension, as needed, up to 130 months after surgery

Clinical Implication of Adherent Perinephric Fat in Robot-Assisted Partial Nephrectomy: Validation With Video Review

ObjectiveTo assess the impact of adherent perinephric fat (APF) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). MethodsA total of 562 Asian patients with kidney tumors received RAPN and their Mayo adhesive probability (MAP) scores were evaluated. APF was determined intraoperatively and confirmed by a second surgical video review and perioperative data were compared according to the MAP score. The associations of APF with clinical factors were examined using logistic regression analyses. Subgroup (classified according to who performed the surgery) analysis was conducted to assess if the perirenal dissection time is significantly correlated with APF. ResultsA total of 118 consecutive patients were classified into two groups according to APF. Patients in the APF group needed significantly longer perirenal fat dissection time (p &lt; 0.001) and longer hospital stay (p = 0.028). MAP score (Odds ratio [OR]: 2.71, 95% Confidence interval [CI]: 1.56-4.71, p &lt; 0.001), body mass index (OR: 1.24, 95% CI: 1.04-1.47, p = 0.016), and perirenal fat dissection time (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004) were significantly associated with the presence of APF. Perirenal fat dissection time was significantly correlated with APF presence in two of three surgeon subgroups (ss = 8.117, p = 0.023; ss = 7.239, p = 0.011). ConclusionsPreoperative MAP score and perirenal fat dissection time were significantly associated with APF during RAPN.N

A Novel Acoustic Uroflowmetry-Based Mobile App Voiding Diary: Comparison with Conventional Paper-Based Voiding Diary

Objectives. To evaluate the usefulness of a novel acoustic uroflowmetry-(UFM-) based mobile application (app) voiding diary (VD) focusing on the (1) compliance and (2) correlation with a conventional paper-based VD. Materials and Methods. A total of 78 patients were included between December 2019 and June 2020, and a subsequent review of all data was performed. The analyzed data were as follows: (1) survey of convenience/satisfaction/preference comparing the two methods, (2) compliance regarding the completeness of both methods, and (3) correlation of each metric (24-hour urine volume, nocturnal urine volume, nocturnal polyuria index, total number of voids, number of daytime voids, number of nocturnal voids, and maximal bladder capacity) between the two methods. Results. The survey results of convenience, satisfaction, and preference were as follows. With regard to convenience and satisfaction area, higher scores are reported in the mobile app VD (mean +/- standard deviation (SD); convenience: 7.47 +/- 2.19 [app] vs. 4.20 +/- 2.49 [paper]; satisfaction: 7.36 +/- 2.17 [app] vs. 5.07 +/- 2.65 [paper]). The median score of the overall preference for using the mobile app instead of the paper-based VD was 9 out of 10 (mean +/- SD7.82 +/- 2.68). We also found a good correlation between the two methods for nocturnal urine volume (r = 0.55, p = 0.04), nocturnal polyuria index (r = 0.66, p = 0.23), total number of voids (r = 0.9, p = 0.02), number of nocturnal voids (r = 0.83, p = 0.02), and maximal bladder capacity (r = 0.89, p = 0.04). Conclusion. The acoustic UFM-based mobile app VD demonstrated favorable findings compared to the conventional paper-based VD.N

Prognostic Significance of Lymphovascular Invasion in Radical Cystectomy on Patients with Bladder Cancer: A Systematic Review and Meta-Analysis

<div><p>Purpose</p><p>The objective of the present study was to conduct a systematic review and meta-analysis of published literature to appraise the prognostic value of lymphovascular invasion (LVI) in radical cystectomy specimens.</p><p>Materials and Methods</p><p>Following the PRISMA statement, PubMed, Cochrane Library, and SCOPUS database were searched from the respective dates of inception until June 2013.</p><p>Results</p><p>A total of 21 articles met the eligibility criteria for this systematic review, which included a total of 12,527 patients ranging from 57 to 4,257 per study. LVI was detected in 34.6% in radical cystectomy specimens. LVI was associated with higher pathological T stage and tumor grade, as well as lymph node metastasis. The pooled hazard ratio (HR) was statistically significant for recurrence-free survival (pooled HR, 1.61; 95% confidence interval [CI], 1.26–2.06), cancer-specific survival (pooled HR, 1.67; 95% CI, 1.38–2.01), and overall survival (pooled HR, 1.67; 95% CI, 1.38–2.01), despite the heterogeneity among included studies. On sensitivity analysis, the pooled HRs and 95% CIs were not significantly altered when any one study was omitted. The funnel plot for overall survival demonstrated a certain degree of asymmetry, which showed slight publication bias.</p><p>Conclusions</p><p>This meta-analysis indicates that LVI is significantly associated with poor outcome in patients with bladder cancer who underwent radical cystectomy. Adequately designed prospective studies are required to provide the precise prognostic significance of LVI in bladder cancer.</p></div

Flow chart of the literature search used in this meta-analysis.

<p>Flow chart of the literature search used in this meta-analysis.</p

Begg’s Funnel plots for publication bias test.

<p>Each point represents a separate study for the indicated association. Vertical line represents the mean effects size. (A) Recurrence-free survival. (B) Cancer-specific survival. (C) Overall survival.</p