Impact of Cerebrovascular Disease on Survival Benefits from Local Treatment in Patients with De Novo Metastatic Hormone-Sensitive Prostate Cancer

PURPOSE: Local treatment has become a treatment option for patients with de novo metastatic hormone-sensitive prostate cancer (mHSPC). Subgroup analyses based on a history of cerebrovascular disease (CVD) were performed to evaluate the impact thereof on overall survival (OS) after local treatment. MATERIALS AND METHODS: A retrospective analysis was performed for 879 patients with de novo mHSPC between August 2003 and November 2016. Patients were stratified according to prior CVD history and the type of initial treatment: androgen-deprivation therapy (ADT) alone versus local treatment consisting of radical prostatectomy (RP) or radiation therapy (RT) with ADT, with or without metastasis-directed therapy. The primary outcome was OS assessed by Kaplan-Meier analysis and Cox-regression models. RESULTS: Of 879 patients, 660 (75.1%) men underwent ADT alone, and 219 (24.9%) men underwent RP or RT with ADT, with or without metastasis-directed therapy. The median follow-up was 38 months. Multivariable analysis showed CVD history to be associated with a higher risk of overall mortality (p=0.001). In the overall cohort and in patients without a history of CVD, patients who underwent local treatment exhibited higher OS than men who received ADT alone (all p<0.001). However, the survival benefit conferred by local treatment was not seen in patients with a history of CVD (p=0.324). OS was comparable between patients who received RP and RT (p=0.521). CONCLUSION: Local treatment with or without metastasis-directed therapy may provide OS advantages for mHSPC patients without a history of CVD. Further prospective studies are needed to address these important concerns.ope

Prostate Volume Variation with Age Community-based Survey in Namhae Region

Purpose: The size of prostate increases with age, but there has been few Korean data on the prostate size in the general population. We thereby report the size of prostate with respect to age in Korean men residing in Namhae, Korea. Materials and Methods: To determine the prostate size, 1421 men from Namhae, Korea underwent transrectal ultrasonography. Size of the prostate was estimated as a weight by the elliptical method. Results: The mean prostate weight was 33.5⁑10.6 ml. The relationship between prostate volume and age was statistically significant in 1421 men(Pearson correlation coefficient=0.156, p=0.0001). Also, between the normal group and the groups of men with lower urinary tract symptoms(LUTS), there was significant correlation with age(Pearson correlation coefficient=0.162, p=0.0001), while results were insignificant with size(Pearson correlation coefficient= 0.170, p=0.0001). Conclusions: Size and rate of growth of the prostate were smaller compared to the Western society, nevertheless, prostate size increased with age. For accurate and reasonable age-specific size of the prostate of Korean male, more community based multicenter study will be needed with more refined measurement techniques such as step-section planimetry for the prostatic volume estimation.ope

Effectiveness of Percutaneous Nephrolithotomy, Retrograde Intrarenal Surgery, and Extracorporeal Shock Wave Lithotripsy for Treatment of Renal Stones: A Systematic Review and Meta-Analysis

Background and objectives: To perform a updated systematic review and meta-analysis comparing effectiveness of percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), and extracorporeal shock wave lithotripsy (ESWL) for treatment of renal stones (RS). Materials and Methods: A total of 37 studies were included in this systematic review and meta-analysis about effectiveness to treat RS. Endpoints were stone-free rates (SFR), incidence of auxiliary procedure, retreatment, and complications. We also conducted a sub-analysis of ≥2 cm stones. Results: First, PCNL had the highest SFR than others regardless of stone sizes and RIRS showed a higher SFR than ESWL in <2 cm stones. Second, auxiliary procedures were higher in ESWL than others, and it did not differ between PCNL and RIRS. Finally, in <2 cm stones, the retreatment rate of ESWL was higher than others. RIRS required significantly more retreatment procedures than PCNL in ≥2 cm stones. Complication was higher in PCNL than others, but there was no statistically significant difference in complications between RIRS and PCNL in ≥2 cm stones. For ≥2 cm stones, PCNL had the highest SFR, and auxiliary procedures and retreatment rates were significantly lower than others. Conclusions: We suggest that PCNL is a safe and effective treatment, especially for large RS.ope

Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy

This study aimed to investigate the effect of intraoperative fluid volume on the postoperative ileus (POI) recovery period. A retrospective review of the Korean robot-assisted radical cystectomy database identified 718 patients who underwent robot-assisted radical cystectomy (RARC). Regression analyses were performed to identify the associations between the amount of intraoperative fluid administration (crystalloid/colloid/total), POI period (time to flatus/bowel movements), and length of hospital stay (LOS) after adjusting for covariates. In addition, we analyzed the risk factors for gastrointestinal complications and prolonged POI using a logistic regression model. An increasing volume of the administered crystalloid/total fluid was associated with prolonged POI (crystalloid R2 = 0.0725 and P < 0.0001; total amount R2 = 0.0812 and P < 0.0001), and the total fluid volume was positively associated with the LOS (R2 = 0.099 and P < 0.0001). The crystalloid amount was a risk factor for prolonged POI (P < 0.001; odds ratio, 1.361; 95% confidence interval, 1.133-1.641; P < 0.001). In the context of RARC, increased intravenous fluids are associated with prolonged POI and longer LOS.ope

Clinical outcomes and costs of robotic surgery in prostate cancer: a multiinstitutional study in Korea

Background: This study compared the surgical, functional, and oncologic outcomes of robot-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and retropubic radical prostatectomy (RRP) in Korean men. Methods: The study population included 864 patients who underwent radical prostatectomy for prostate cancer in the departments of urology of five tertiary hospitals between 2010 and 2011. RALP, LRP, and RRP perioperative, oncological, and functional outcomes as well as complications were assessed. Medical cost data were analyzed for 682 of 864 patients. Results: No significant differences were found among the three groups regarding the length of stay, biochemical recurrence, complications, and metastasis. The RALP group had a significantly higher rate of pelvic lymph node dissection (64.6% vs. 35.3% or 53.3%, P value <0.0001) and bilateral nerve-sparing procedures (15.7% vs. 10.0% or 8.9%, P value <0.0001) and less blood loss (median 250 mL vs. 300 mL or 700 mL, P value <0.0001) than the LRP and RRP groups. The 12-month continence recovery rate was higher in the RALP group (92.1%) than in the LRP (86.5%) and RRP (84.4%) groups (P value <0.0001). Medical costs for RALP were approximately twofold to threefold higher than those for LRP or RRP. Conclusions: Our findings suggest that surgical and functional outcomes are better with robot-assisted surgery than with laparoscopic or open surgery in terms of estimated blood loss and urinary continence; however, no differences were found among groups in terms of biochemical recurrence and the rate of complications.ope

Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence

Introduction: The definition of the safest width of healthy renal margin to achieve oncological efficacy and therefore of the safest resection technique (RT) during partial nephrectomy (PN) continues to be widely debated. The aim of this study is to evaluate the prevalence of positive surgical margins (PSM), loco-regional recurrence (LRR) and renal recurrence (RER) rates after simple enucleation (SE) and standard partial nephrectomy (SPN) for malignant renal tumors. Evidence acquisition: A systematic review of the English-language literature was performed through August 2016 using the Medline, Web of Science and Embase databases according to the PRISMA criteria. A systematic review and meta-analysis was performed in those studies that defined the exact anatomical location of recurrence after PN. Evidence synthesis: Overall, 33 studies involving 11,282 patients were selected for quantitative analysis. At a median follow-up of 43 (SE) and 52 (SPN) months, the pooled estimates of the prevalence of PSMs, LRR and RER were 2.7% (95% CI: 1.5-4.6%, P<0.001) and 0.4% (95% CI: 0.1-2.2%, P=0.018), 2.0% (95% CI: 1.4-2.8%, P<0.001) and 0.9% (95% CI: 0.5-1,7%, P=0.04), 1.5% (95% CI: 0.9-2.3%, P=0.001) and 0.9% (95% CI: 0.5-1,7%, P=0.40) in patients undergoing SPN and SE, respectively. Conclusions: Our systematic analysis and meta-analysis demonstrates that SE is noninferior to SPN regarding PSM, LRR and RER rates in patients undergoing PN for malignant renal tumors. Further studies using standardized reporting tools are needed to evaluate the role of resection techniques for oncologic outcomes after PN.restrictio

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.ope

Comparison of bone mineral loss by combined androgen block agonist versus GnRH in patients with prostate cancer: A 12 month-prospective observational study

The multi-centre, prospective, observational study was designed to examine the efficacy of continuous combined androgen block (CAB) vs. GnRH agonist monotherapy in terms of bone mineral density (BMD) change during 12 months post-androgen deprivation therapy (ADT) in Asian prostate cancer patients. Multiple regression analysis and estimated the 10-year probability of major fractures among the patients with Fracture Risk Assessment Tool were conducted to investigate the underlying factors affecting BMD. Paired t-test to evaluate the change of BMD from baseline to 12 month, and two sample t-test to examine the difference of BMD changes were used between two groups. BMD significantly decreased in both the CAB and GnRH groups, with no group wise differences. The proportion of osteopenia or osteoporosis was slightly increased after the 12-month post-ADT. Ten-year probability of hip fracture and major osteoporotic fracture was approximately 3% and 5%, respectively. In conclusion, a significant decrease of BMD by 12-month ADT was observed without any differences between the two groups, whereas ADT-related BMD loss did not induce detrimental effects on bone health in terms of increased bone fracture risk. This was the first prospective study on BMD changes as a predictor of fracture during ADT in an Asian population.ope

Robotic surgery an evolution of future direction

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The Present and Future of Robotic Surgery

Since the beginning of the 21st century, the emergence of innovative technologies has made further advances in minimal access surgery possible. Robotic surgery and telepresence surgery effectively addressed the limitations of laparoscopic procedures, thus revolutionizing minimal access surgery. Surgical robots provide surgeons with technologically advanced vision and hand skills. As a result, such systems are expected to revolutionize the field of surgery. In that time, much progress has been made in integrating robotic technologies with surgical instrumentation. However, robotic surgery will not only require special training, but it will also change the existing surgical training pattern patters and reshape the learning curve by offering new solutions, such as robotic surgical simulators and robotic telementoring. This article provides an introduction to medical robotic technologies, describesdevelops a possible classification, reviews the evolution of a surgical robot, and discusses future prospects for innovation. In the future, surgical robots should be smaller, less expensive, easier to operate, and should seamlessly integrate emerging technologies from a number of different fields. We believe that, in the near future Aas robotic technology continues to develop in the near future, we believe that almost all kinds of endoscopic surgery will be performed by this technologyope