Obesity has been suggested as a risk factor for worse perioperative outcomes, especially in radical prostatectomy, in several studies. However, the impact of obesity on perioperative outcomes has not yet been well elucidated for robot-assisted laparoscopic radical prostatectomy (RALP). We evaluated whether obesity had an adverse effect on outcomes following RALP compared with retropubic radical prostatectomy (RRP).
Materials and Methods
From April 2008 to May 2011, 181 patients underwent radical prostatectomy (RALP, 111; RRP, 70). These patients were subdivided into two groups according to body mass index (BMI): the nonobese group (BMI, 25 kg/m2 or less) and the obese group (BMI, greater than 25 kg/m2). Perioperative outcomes in RALP and RRP were retrospectively compared between the two groups.
In RRP, patients in the obese group (n=20) showed greater blood loss and a higher complication rate than did those in the nonobese group (n=50). However, in RALP, no statistically significant differences in perioperative outcomes were observed between the obese (n=37) and the nonobese (n=74) groups. RALP showed less blood loss and a lower complication rate in both the obese and nonobese groups than did RRP.
RALP is thought to be a more effective and safer procedure in obese patients compared with traditional open radical prostatectomy. In the management of obese patients with localized prostate cancer, RALP should be considered as a primary choice for treatment.
Obesity; Prostatectomy; Robotics
Prostate biopsy is used to confirm the prostate cancer. Although first biopsy result was benign, repeat biopsy is recommended for the patient who has higher risk of prostate cancer. In this study, we investigated the PSA change ratio (post-biopsy PSA to baseline PSA) whether it could be predictive factor of prostate cancer and helpful when decided to perform repeat biopsy.
Materials and Methods
151 patients, first diagnosed as benign, but underwent repeat biopsy due to clinical suspicion of prostate cancer were included. Post-biopsy PSA was checked 60 minutes later after biopsy. PSA change ratio was defined as post-biopsy PSA to baseline PSA. According to results of repeat biopsy, patients were divided into benign group (group A) and cancer groups (group B). Between two group baseline PSA, PSA density, post-biopsy PSA and PSA change ratio were compared, and most effective cut-off value was analyzed using receiver operating characteristic (ROC).
129 men were benign, 22 men were prostate cancer according to results of repeat biopsy. Between two groups, post-biopsy PSA and PSA change ratio were statically significant differences. (p<0.001, <0.001) The effective cut-off value was 3.0, 3.5 and 4.0 according to ROC. At ROC curve, PSA change ratio was statistically significant for diagnosis of prostate cancer. (AUC 0.800, p<0.001).
PSA change ratio is thought be a predictive factor for prostate cancer. If the PSA change ratio was less than 3.0-4.0, repeat biopsy should be considered to confirm the diagnosis.
Prostate-specific antigen; Prostatic hyperplasia; Prostatic neoplasms
We report a rare case of testicular metastasis from prostate cancer. A 68-year-old patient presented with a right testicular mass with discomfort. He had a history of robot-assisted laparoscopic radical prostatectomy and had received adjuvant radiation therapy and had been treated with androgen deprivation therapy continuously at another institution. We performed a right inguinal orchiectomy. The testicular mass was diagnosed as a metastasis from prostate carcinoma.
Neoplasm metastasis; Prostate neoplasms; Testicular neoplasms
Laparoscopic radical nephrectomy (LRN) is more challenging with increases in body mass index (BMI). Several recent studies have shown, however, that LRN can be safely performed even in obese patients. The influence of obesity on the perioperative outcomes of LRN has not been well elucidated for large renal tumors (>7 cm), however. We estimated the impact of obesity on LRN for stage T1 and T2 renal cell carcinoma (RCC).
Materials and Methods
From January 2004 to March 2011, 266 patients underwent LRN (T1: 195, T2: 71). These patients were subdivided into the following two groups according to BMI: the nonobese group (BMI less than 25 kg/m2) and the obese group (BMI greater than 25 kg/m2). Perioperative outcomes were retrospectively compared between these two groups in T1 and T2 RCC patients.
There were no significant differences in perioperative outcomes between the obese and nonobese groups of T1 RCC patients. However, in T2 RCC patients, operative time and complication rate were significantly increased in the obese group.
Our results suggest that LRN can be safely performed in Korean patients with T1 RCC regardless of obesity. In T2 RCC patients, however, LRN may become more difficult with increasing BMI considering a longer operation time as well as a higher complication rate. We suggest that LRN for obese patients with T2 RCC be carefully considered.
Laparoscop; Obesity; Renal cell carcinoma
In the past several decades there has been a remarkable development of small-caliber, flexible ureteroscopes and various ancillary instruments for stone manipulation and retrieval. Percutaneous antegrade ureteroscopy can be substituted in select cases for retrograde ureteroscopy. We report a case of a 60-year-old man with severe ankylosis in both hip joints who was diagnosed with bilateral ureteral stones. The patient underwent antegrade flexible ureteroscopy and laser lithotripsy. This case illustrates the role of antegrade flexible ureteroscopy combined with the holmium:YAG laser as a minimally invasive, safe, and effective technique for the management of stones in a patient who cannot undergo a retrograde approach.
Lasers; Ureteroscopy; Urinary calculi
Mesenteric fibromatosis is a rare benign disease characterized by proliferating fibrous tissue in the bowel mesentery. We report a case of aggressive mesenteric fibromatosis with ureteral stenosis arising in a 46-year-old woman who suffered from intermittent right abdominal pain. Computed tomography revealed a right retroperitoneal mass with right ureteral stenosis at the level of the right common iliac vessel. The mass was excised with resection of the affected segment of the ileum, ascending colon, and ureter, and end-to-end ureter anastomosis was performed. Pathological examination confirmed mesenteric fibromatosis.
Aggressive fibromatosis; Retroperitoneal neoplasms
We aimed to evaluate the safety and clinical responses in Korean ankylosing spondylitis (AS) patients after three months of etanercept therapy. AS patients satisfying the Modified New York Criteria were enrolled. They were assessed for safety and clinical responses at enrollment and after three months of etanercept therapy. A total of 124 patients completed the study. After three months, the rate of ASsessment in AS International Working Group 20% improvement (ASAS 20) response was 79.8%. The rates of ASAS 40 and ASAS 5/6 responses were 58.5 and 62.8%, respectively. Significant improvement of Korean version of Bath AS Disease Activity Index (KBASDAI) (p<0.0001), Bath AS Functional Activity Index (BASFI) (p<0.0001), and Bath AS Metrology Index (BASMI) (p=0.0009) were achieved after three months. Quality of life was also significantly improved after three months, as demonstrated by scores for SF-36 (p<0.0001) and EQ-5D (p<0.0001). Erythrocyte sedimentation rate and C-reactive protein were significantly decreased (p<0.0001, p<0.0001, respectively). None of the patients developed tuberculosis and there were no serious adverse event. AS patients with inadequate response to conventional therapy showed significant clinical improvement without serious adverse events after three months of etanercept therapy.
Spondylitis, Ankylosing; TNFR-Fc Fusion Protein; Clinical Effectiveness; Safety
Severe systemic manifestations of adult onset Still's disease (AOSD) are often fatal and occasionally related to hemophagocytic syndrome (HS). We describe the case of a 49-yr-old woman with AOSD presenting with non-remitting high fever, confusion, jaundice, hepatosplenomegaly, serositis, azotemia, pancytopenia, coagulopathy with disseminated intravascular coagulation (DIC), hyperferritinemia, acute acalculous cholecystitis and ileocolitis noted in computed tomographic images. The patient had a history of herpes zoster developed prior to the admission, but there is no history of diarrhea or abdominal pain. Although bone marrow examination was not performed due to hemorrhagic diathesis, we suspected AOSD-associated HS on the basis of clinical course without detectable infectious agents in cultures or serologic studies. Intravenous immunoglobulin, pulse methylprednisolone, oral cyclosporine A (CsA) and ceftriaxone brought about transient improvement of fever and confusion, but the disease progressed. After increasing CsA dose, all previously mentioned abnormalities disappeared rapidly. Accordingly, we believe that DIC and multiple organ dysfunctions might have been the complications of HS but not that of sepsis, and that CsA can be used as a first-line therapy in case of life-threatening situations.
Still's Disease, Adult-onset; Hemophagocytic Syndrome; Cyclosporins
Khz is a compound derived from the fusion of Ganoderma lucidum and Polyporus umbellatus mycelia that inhibits the growth of cancer cells. The results of the present study show that Khz induced apoptosis preferentially in transformed cells and had only minimal effects on non-transformed cells. Furthermore, Khz induced apoptosis by increasing the intracellular Ca2+ concentration ([Ca2+]i) and activating JNK to generate reactive oxygen species (ROS) via NADPH oxidase and the mitochondria. Khz-induced apoptosis was caspase-dependent and occurred via a mitochondrial pathway. ROS generation by NADPH oxidase was critical for Khz-induced apoptosis, and although mitochondrial ROS production was also required, it appeared to occur secondary to ROS generation by NADPH oxidase. Activation of NADPH oxidase was demonstrated by the translocation of regulatory subunits p47phox and p67phox to the cell membrane and was necessary for ROS generation by Khz. Khz triggered a rapid and sustained increase in [Ca2+]i, which activated JNK. JNK plays a key role in the activation of NADPH oxidase because inhibition of its expression or activity abrogated membrane translocation of the p47phox and p67phox subunits and ROS generation. In summary, these data indicate that Khz preferentially induces apoptosis in cancer cells, and the signaling mechanisms involve an increase in [Ca2+]i, JNK activation, and ROS generation via NADPH oxidase and mitochondria.
Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis.
Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear.
All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable.
We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.
Spondylodiscitis; Curettage; Drainage; Surgery; Transpedicular
The study was designed to investigate the effect of serum glucose, insulin and insulin resistance on the risk of prostate cancer (CaP) and on the clinicopathological characteristics in Korean men. Subjects were retrospectively recruited from 166 CaP patients underwent radical prostatectomy and 166 age-matched benign prostatic hyperplasia (BPH) patients. The serum was taken on the morning of the day of operation and insulin resistance was assessed by homeostasis model assessment insulin resistance index (HOMA-IR). Men in highest tertile of insulin was associated with 55% reduced odds of CaP than those with the lowest tertile (OR = 0.45, 95% CI = 0.23-0.89, P = 0.022). The patients in highest tertile of insulin had a more than 5.6 fold risk of locally advanced stage than those in the lowest tertile (OR = 5.62, 95% CI = 1.88-16.83, P = 0.002). Moreover, the patients in the highest tertile HOMA-IR group was associated with an increased risk of locally advanced stage than the lowest tertile group (OR = 3.10, 95% CI = 1.07-8.99, P = 0.037). These results suggest that elevated insulin and insulin resistance are associated with the advanced pathological stage of prostate cancer in Korean patients.
Glucose; Insulin; Insulin Resistance; HOMA-IR; Prostatic Neoplasms
Several studies have demonstrated the superiority of endorectal coil magnetic resonance imaging (MRI) over pelvic phased-array coil MRI at 1.5 Tesla for local staging of prostate cancer. However, few have studied which evaluation is more accurate at 3 Tesla MRI. In this study, we compared the accuracy of local staging of prostate cancer using pelvic phased-array coil or endorectal coil MRI at 3 Tesla.
Materials and Methods
Between January 2005 and May 2010, 151 patients underwent radical prostatectomy. All patients were evaluated with either pelvic phased-array coil or endorectal coil prostate MRI prior to surgery (63 endorectal coils and 88 pelvic phased-array coils). Tumor stage based on MRI was compared with pathologic stage. We calculated the specificity, sensitivity and accuracy of each group in the evaluation of extracapsular extension and seminal vesicle invasion.
Both endorectal coil and pelvic phased-array coil MRI achieved high specificity, low sensitivity and moderate accuracy for the detection of extracapsular extension and seminal vesicle invasion. There were statistically no differences in specificity, sensitivity and accuracy between the two groups.
Overall staging accuracy, sensitivity and specificity were not significantly different between endorectal coil and pelvic phased-array coil MRI.
Prostatic neoplasms; magnetic resonance imaging; neoplasm staging; comparative study
The osteoporosis and lumbar canal stenosis, in elderly patients are under diagnosed and under reported. We report a cross sectional study to demonstrate the osteoporotic profile in patients with lumbar spinal stenosis (LSS) and to determine the proportion of patients with LSS who need to be treated for osteoporosis.
Materials and Methods:
One hundred and six postmenopausal patients with symptomatic LSS were evaluated for osteoporotic profile, which included lumbar and hip bone mineral density (BMD), serum vitamin D concentration, bone resorption and formation markers. Demographic and disease related variables were analyzed to identify the association with the risk of osteoporosis or osteopenia. Statistical analysis used were multivariate logistic regression with a forward stepwise procedure.
Twenty-four patients (22.6%) had osteoporosis and 60 (56.6%) had osteopenia. Overall, 84 patients (79.2%) with symptomatic LSS had osteoporosis or osteopenia. Fifty-nine patients (55.6%) had hypovitaminosis D. All bone turnover makers [alkaline phosphatase, osteocalcin, urinary-N-terminal telopeptide (u-NTx)] were demonstrated to be within normal range. Only age was associated with the risk of osteoporosis or osteopenia in the hip region. In the lumbar spine, all variables were not associated with osteoporosis or osteopenia. 44 patients (41.5%) required treatment for osteoporosis as per risk factors for osteoporosis. According to the guidelines from the Health Insurance Review Agency, however, only 20 patients (18.8% required) qualified for reimbursement for osteoporosis medications.
LSS is associated with osteopenia, osteoporosis, and hypovitaminosis D, which should prompt careful screening and treatment in cases of osteoporosis and osteoarthritis.
Bone mineral density; bone turnover marker; hypovitaminosis D; lumbar spinal stenosis; osteoporosis
The objective of this study was to evaluate of prevalence of co-existing spine and hip disease using initial screening kidney–ureter–bladder (KUB) radiograph in patients over 50 who underwent spinal surgery.
Materials and Methods:
The study subjects were 388 patients (male: female=117:271; mean age 62.0 years) who underwent spinal surgery between 2008 and 2010. We retrospectively reviewed the initial KUB radiographs used to diagnose the spine and hip disease. Depending on the extent of acetabular and hip joint visualization in KUB, we divided the subjects into three groups: Acetabulum, hip joint, and femoral neck visualization. The hip visualization rate was also assessed with respect to patient height. χ2 and logistic regression test were used for statistical analysis.
126 (32.5%) cases had significant hip pathology including hip osteoarthritis (Kellgren/Lawrence grade 3 in 123 cases, grade 4 in 3 cases) and avascular necrosis (1 case each of Ficat stage IIA and IIB), and 8 cases had other morphologic abnormalities. Regarding acetabulum–hip visualization in KUB, 7 (1.8%) cases had acetabulum visualization only, 16 (4.1%) had hip joint visualization, and 365 (94.1%) had femoral neck including lesser trochanter visualization. Patients were categorized into four groups according to height (less than 150 cm, 150–159 cm, 160–169 cm, greater than 170 cm). The hip visualization rates differed significantly among these four groups (P<0.05).
The prevalence of discernible hip pathology in patients who underwent spinal surgery was 32.5%. Hip joint visualization was excellent (98.2%) in KUB radiographs. Hence, spinal surgeons should pay attention to hip pathology in surgically indicated spinal patients.
Hip pathology; spinal surgery; elderly
To evaluate the prevalence and risk factors of peripheral neuropathy in patients with rheumatoid arthritis (RA) treated with leflunomide (LEF) by quantitative sensory testing (QST).
A total of 94 patients were enrolledin this study, out of which 47 patients received LEF. The other 47 patients received alternative disease-modifying antirheumatic drugs and served as the control group. The demographic characteristics, laboratory findings, concomitant diseases, and medication history were evaluated at the time of QST. The cooling (CDT) and vibratory detection threshold (VDT) as the representative components of QST were measured.
Age, gender, RA duration, ESR, and CRP did not show any significant differences between the two groups. VDT did not demonstrate any significant difference in both groups. However, CDT in LEF group was significantly higher than that of the control group (8.6±2.7 in LEF vs. 5.6±3.8 in control). The proportion of RA patients in the LEF group showing abnormally high CDT was over 2 times greater than that of the control group, but these findings were not statistically significant. Age, RA duration (or LEF medication in LEF group), ESR, and CRP did not show significant correlation with CDT in both groups. VDT significantly correlated with age in both groups.
LEF treatment in patients with RA may lead to abnormal CDT in QST. CDT value was not affected by age, RA duration, disease activity, or LEF duration. It remains to be determined whether QST may be a valuable non-invasive instrument to evaluate the early sensory changes in patients with RA taking LEF.
Rheumatoid arthritis; Polyneuropathy; Leflunomide; Quantitative sensory testing
IL-1β is a key mediator of bone resorption in inflammatory settings, such as rheumatoid arthritis (RA). IL-1β promotes osteoclastogenesis by inducing RANKL expression on stromal cells and synergizing with RANKL to promote later stages of osteoclast differentiation. Because IL-1Rs share a cytosolic Toll–IL-1R domain and common intracellular signaling molecules with TLRs that can directly inhibit early steps of human osteoclast differentiation, we tested whether IL-1β also has suppressive properties on osteoclastogenesis in primary human peripheral blood monocytes and RA synovial macrophages. Early addition of IL-1β, prior to or together with RANKL, strongly inhibited human osteoclastogenesis as assessed by generation of TRAP+ multinucleated cells. IL-1β acted directly on human osteoclast precursors (OCPs) to strongly suppress expression of RANK, of the costimulatory triggering receptor expressed on myeloid cells 2 receptor, and of the B cell linker adaptor important for transmitting RANK-induced signals. Thus, IL-1β rendered early-stage human OCPs refractory to RANK stimulation. Similar inhibitory effects of IL-1β were observed using RA synovial macrophages. One mechanism of RANK inhibition was IL-1β–induced proteolytic shedding of the M-CSF receptor c-Fms that is required for RANK expression. These results identify a homeostatic function of IL-1β in suppressing early OCPs that contrasts with its well-established role in promoting later stages of osteoclast differentiation. Thus, the rate of IL-1–driven bone destruction in inflammatory diseases, such as RA, can be restrained by its direct inhibitory effects on early OCPs to limit the extent of inflammatory osteolysis.
Laparoscopic radical nephrectomy (LRN) has become the standard technique for radical nephrectomies for T1 renal tumors (7 cm or less). We extended our experience with LRN to T2 renal tumors (greater than 7 cm) and compared the efficacy and long-term oncologic outcomes with those of open radical nephrectomy (ORN) for T2 clear renal cell carcinoma (RCC) in the same period.
Materials and Methods
We retrospectively analyzed the data from 33 patients who underwent LRN and 35 patients who underwent ORN in our institution from January 2003 to June 2006 for T2N0M0 RCC. We compared long-term oncologic outcomes between the two groups.
The median follow-up periods were 60.0 months (range, 48.0-77.0 months) and 65.6 months (range, 56.0-77.0 months) in the LRN and ORN groups, respectively. There were no statistically significant differences between the two groups in the patients' demographic data. There were no significant differences in the 5-year overall survival rate, the cancer-specific survival rate, or the recurrence-free survival rate.
Our results suggest that LRN for the management of T2 RCC is feasible and efficacious and that the long-term oncologic outcomes of LRN are comparable to those of ORN.
Laparoscopy; Nephrectomy; Renal cell carcinoma; Survival
To evaluate the efficacy and tolerability of tamsulosin 0.4 mg once daily in Korean patients with symptomatic benign prostatic hyperplasia (BPH) and investigate whether tamsulosin 0.4 mg can improve symptoms in patients with refractory lower urinary tract symptoms (LUTS) who were previously receiving tamsulosin 0.2 mg once daily.
Materials and Methods
A total of 116 patients from 3 urology centers participated. All study subjects entered a nonblind phase consisting of 8 weeks of tamsulosin 0.2 mg monotherapy followed by an additional 8 weeks of tamsulosin 0.2 mg (0.2 mg group) or 8 weeks of tamsulosin 0.4 mg (0.4 mg group). At week 8, we chose the 0.4 mg group on the basis of International Prostate Symptom Score (IPSS), quality of life (QoL), maximal urinary flow rate (Qmax), and adverse effects. At week 16, we compared the efficacy and tolerability of tamsulosin between the 0.2 and 0.4 mg groups.
A total of 26 patients (22.4%) were escalated to tamsulosin 0.4 mg at week 8. There were significant differences in IPSS, QoL, and Qmax at week 8 in both groups. There were significant differences in improvement in IPSS, QoL, Qmax, and postvoid residual urine volume from baseline to week 16 in both groups. There were no significant differences in efficacy or tolerability between the groups at week 16.
Our trial demonstrated that tamsulosin 0.4 mg has favorable efficacy and tolerability in Korean patients with symptomatic BPH refractory to tamsulosin 0.2 mg. No patients experienced any serious adverse effects when we escalated the dose of tamsulosin to 0.4 mg.
Prostatic hyperplasia; Tamsulosin
To evaluate the effectiveness of laparoscopic assisted total gastrectomy (LATG), we compared its early surgical outcomes with those of conventional open total gastrectomy (OTG) in patients who were diagnosed as having early gastric cancer preoperatively.
We retrospectively analyzed early surgical outcomes in 190 consecutive patients who underwent total gastrectomy for early gastric cancer between January 2009 to April 2010. The patients were divided into those who underwent LATG and those who underwent OTG. Their early surgical outcomes were analyzed to evaluate the effectiveness of LATG.
There was no significant difference in postoperative complication rates (P = 0.291). But in the analysis of other early surgical outcomes, we found that LATG could improve time to first flatus (P < 0.001), time to commencement of soft diet (P = 0.034), administration of analgesics (P = 0.024), pain score (Numeric Rating Scale), and hospital discharge (P = 0.045).
Although LATG didn't show better results for postoperative complications than those of OTG, LATG contributes to the improvement of early surgical outcomes, including bowel movement, pain score and hospital discharge. Therefore, we suggest that LATG could be a method to improve early surgical outcomes in patients who need total gastrectomy.
Early gastric cancer; Laparoscopic assisted total gastrectomy; Open total gastrectomy
Patients with ankylosing spondylitis (AS) achieve early bone union compared to those with other spinal diseases. This study compared the time to bone union after surgery between AS patients and degenerative spinal disease patients.
Patients with degenerative spinal diseases (control group) and AS (experimental group) underwent pedicle subtraction osteotomy followed by posterolateral fusion, and decompression and posterolateral fusion, respectively. There were 10 patients in the experimental group. The control group included 26 patients who were less than 50 years of age and underwent two-level autogenous grafting after decompression and spinal fusion. Autogenous grafts and a range of bone substitutes were used in the experimental group, whereas only autogenous grafts were used in the control group. Bone union was determined on the radiographs and 3-dimensional CT scan images. The level of union was assessed using the Lenke's and Christensen's classification systems.
In the experimental group, the mean age was 41.3 years (range, 30 to 67 years), the mean follow-up period was 21.7 months (range, 12 to 43 months), and bone union was confirmed at an average of 3.5 months (range, 3 to 5 months) after surgery. In the control group, the mean age was 43.1 years (range, 35 to 50 years), the mean follow-up period was 21.8 months (range, 12 to 74 months), and bone union was observed at an average of 5.6 months (range, 4 to 12 months) after surgery. The difference in the time to bone union between the two groups was significant (p = 0.023).
The union of grafted bone was obtained earlier in patients with AS than in those with degenerative spinal diseases. Therefore, future studies should examine the factors affecting the early union in AS patients.
Ankylosing spondylitis; Degenerative spinal disease; Bone graft
Recently, several studies have suggested that distal ureteral dilatation is an important factor influencing the spontaneous resolution of primary vesicoureteral reflux (VUR). We evaluated the relationship between distal ureteral dilatation and the spontaneous resolution of primary VUR.
Materials and Methods
The medical records of 114 patients with primary VUR maintained on prophylactic antibiotics from April 1999 to August 2008 were retrospectively reviewed. The patients' mean age was 24.2 months (range, 6-108 months). There were 66 male patients and 48 female patients. The mean follow-up was 37.6 months (range, 12-102 months). We analyzed various factors including age, gender, grade of reflux, laterality, and ureteral diameter ratio (UDR; the largest ureteral diameter was divided by the distance from the L1-4 vertebral body to minimize the differences in diameter by age) to determine whether these factors influenced the spontaneous resolution of primary VUR.
Unilateral, low-grade reflux and low UDR were significantly associated with the spontaneous resolution of reflux (p=0.048, p<0.001, and p<0.001, respectively). The multivariate analysis revealed that the spontaneous resolution rate of primary reflux was significantly higher in patients with low UDR than in patients with high UDR (p<0.001).
The degree of distal ureteral dilatation is expected to be another important factor in determining therapeutic course and predicting the spontaneous resolution of VUR.
Ureter; Vesico-ureteral reflux
Laparoscopic donor nephrectomy is associated with less postoperative pain and faster recovery times in living kidney donors. However, pneumoperitoneum, which is required in laparoscopic donor nephrectomy, can result in adverse effects on renal function in donors and recipients. We compared renal function in donors and recipients after hand-assisted laparoscopic donor nephrectomy (HALDN) and open donor nephrectomy (ODN).
Materials and Methods
Between January 1997 and January 2008, 241 live donor nephrectomies were performed by either HALDN (n=118) or ODN (n=123). Preoperative patient characteristics were not significantly different between the donors and recipients. We monitored the changes in serum creatinine levels of the donors and recipients preoperatively and on postoperative days 1, 5, 28, 84, and 365.
The mean operative times of HALDN and ODN were 171 and 163 minutes (p=0.284), and the mean warm ischemic times were 292 and 236 seconds (p=0.207), respectively. The mean serum creatinine level in the recipients on postoperative day 1 was significantly higher after HALDN than after ODN (3.48 vs. 2.62 mg/dl, p=0.003). However, from postoperative day 5 to 1 year, there was no significant difference between the two groups. The mean serum creatinine level in the donors was not significantly different between the HALDN and ODN groups throughout the study period.
Renal function recovery in the donors was similar with both HALDN and ODN. Graft renal function recovery after HALDN was comparable with that after ODN, except immediately after surgery (postoperative day 1).
Creatinine; Laparoscopy; Living donors; Transplant recipients
Robot-assisted laparoscopic radical cystectomy (RLRC) is a new option for the treatment of muscle-invasive bladder cancer, and case series for RLRC have been increasing recently. We report our operative technique and initial experiences with RLRC with extracorporeal urinary diversion.
Materials and Methods
Between October 2008 and November 2009, 17 consecutive patients with muscle-invasive bladder cancer underwent RLRC, pelvic lymph node dissection, and extracorporeal urinary diversion. Urinary diversion included 13 ileal conduits and 4 orthotopic neobladders (Studer method). Data were collected prospectively on patient demographics, intraoperative parameters, pathologic staging, and postoperative outcomes.
The mean patient age was 63.7 years. The mean body mass index was 22.6 kg/m2. No patients had a history of previous abdominal surgery. The mean operative time was 379.1 minutes, including 32.6 minutes for pelvic lymph node dissection, 185.2 minutes for RLRC, and 159.4 minutes for urinary diversion. The mean estimated blood loss was 210.5 ml. The mean hospital stay was 20.7 days and the mean time to oral intake and ambulation was 5.0 and 1.3 days, respectively. There were no major perioperative complications. The pathologic reports showed urothelial cell carcinomas in all cases.
Our initial clinical experiences indicate that RLRC with pelvic lymph node dissection and extracorporeal urinary diversion is a safe and feasible procedure with minimal blood loss and rapid recovery. Long-term follow up in a larger patient population is needed to determine the true oncological and functional benefit of this procedure.
Robotics; Urinary bladder neoplasms; Cystectomy
To evaluate the accuracy of radiologic tumor size for making decisions regarding nephron-sparing surgery of localized renal cell carcinomas (RCCs), we compared tumor size measured by a preoperative radiologic modality with that measured in the pathologic specimen.
Materials and Methods
Between January 2003 and December 2007, a total of 186 patients with pT1 or pT2 RCC underwent radical or partial nephrectomy at our institute. We excluded 11 patients who had preoperative arterial embolization (n=9) or positive surgical margins (n=2), and a total of 175 patients were included in this study. Radiologic size was defined as the largest diameter on computed tomography (CT), and pathologic size was defined as the largest diameter of the surgical specimen of the tumor. We retrospectively analyzed the difference between radiologic and pathologic tumor size.
The radiologic and pathologic tumor sizes did not significantly differ (4.98±2.82 cm vs. 4.55±2.70 cm, respectively, p=0.152). In the subgroup analysis, the size difference was statistically significant only for tumor sizes of less than 6 cm. The size difference was largest in tumors of 3 to 4 cm, for which mean the radiologic size was 0.63±1.19 cm larger than the mean pathologic size (p=0.002). Histologic type had no significant influence on the difference between radiologic and pathologic size.
The tumor size of RCCs in preoperative CT seems to correlate well with pathologic tumor size. However, CT imaging may overestimate the size of a tumor in the small mass group (less than 6 cm). These results should be considered when making decisions about nephron-sparing surgery.
Renal cell carcinoma; Nephrectomy; Radiology
Forkhead box O-class 1 (FOXO1) is a key regulator of glucose homeostasis, cell-cycle progression, and apoptosis. Its functions are modulated by forkhead box G1 (FOXG1), which acts as a transcriptional repressor with oncogenic potential. Real-time PCR and immunohistochemical staining were performed in 174 primary bladder cancer specimens and 21 normal bladder mucosae to evaluate these genes. FOXO1 and FOXG1 mRNA expression in cancer tissues were higher than in normal mucosae (each P<0.001). FOXO1 mRNA levels were significantly higher in samples of non-progressed patients (P<0.001), but FOXG1 were enhanced in those of progressed patients (P=0.019). On univariate analysis, FOXO1 mRNA expression was significantly associated with grade, stage, recurrence, progression and survival (each P<0.05). On multivariate analysis, increased FOXO1 mRNA expression was associated with both reduced disease progression (odds ratio [OR], 0.367; 95% confidence interval [CI], 0.163-0.826, P=0.015) and enhanced disease-free survival (OR, 3.262; 95% CI, 1.361-7.820, P=0.008). At a median follow-up of 33 months (range 2 to 156), the patients with a high FOXO1 mRNA expression had a significantly prolonged survival (P=0.001). Immunohistochemical findings of FOXO1 were generally concordant with mRNA expression levels. In conclusion, FOXO1 may be a promising marker for predicting progression in human bladder cancers.
FOXO1; FOXG1; Urinary Bladder Neoplasms; Prognostic Factor; Real Time PCR; Immunohistochemistry