Feasibility, Safety, and Functional Outcomes of Pelvic Hypothermia Induced Using a Rectal Cooling Device During Robot-assisted Radical Prostatectomy: A Phase I/II Trial

Introduction: Radical prostatectomy (RP) is one of the standard treatments for localized prostate cancer. However, in terms of functional outcomes, there are aspects that still need improvements. We designed this prospective phase I/II clinical trial to assess the safety, clinical feasibility, and functional outcomes of hypothermic robot-assisted RP (RARP). Material and Methods: Twenty patients with preoperative total 5-item International Index of Erectile Function scores ≥12 points, scheduled for RARP, were enrolled in the study. Pelvic hypothermia was induced using an endorectal cooling device (BelloCool System). The primary outcome was the completion rate of the planned hypothermic RARP. Secondary outcomes included the drop in neurovascular bundle (NVB) temperature, adverse (including device-related) events, continence, and potency recoveries, and postoperative quality of life. Contemporaneous patients (propensity score-matched for baseline characteristics) who satisfied the inclusion criteria were included in the control group. Results: The completion rate of the planned hypothermic surgery was 100%. The nadir NVB temperature was 24.9 [22.4, 28.2]°C, which was 10.2 [7.0, 13.1]°C lower than the nadir core body temperature. There was no device-related adverse event, and bowel function was well preserved for the whole follow-up period. At 12 months postoperatively, potency and continence recovery rates were higher in the hypothermic group than in the control group (40% vs 15%, p = 0.027 and 95% vs 80%, p = 0.167, respectively). The Kaplan-Meier curve showed faster recovery rate of potency in the hypothermic group (hazard ratios = 3.46, log-rank p < 0.01). Conclusions: Hypothermic RARP using the BelloCool™ endorectal cooling system is safe and feasible. A large-population-based randomized controlled trial is needed to confirm the potential for a benefit in continence and potency recovery.

Association between decreased ipsilateral renal function and aggressive behavior in renal cell carcinoma

Background

To assess prognostic value of pre-operative ipsilateral split renal function (SRF) on disease-free survival (DFS) and its association with aggressive pathological features in renal cell carcinoma (RCC) patients. 

Methods

We examined patients registered in SNUG-RCC-Nx who underwent partial or radical nephrectomy at Seoul National University Hospital between January 1, 2010 and December 31, 2020. Patients with the following criteria were excluded from the study. 1) non-kidney origin cancer or benign renal tumor, 2) no pre-operative Tc 99 m-DTPA renal scan, 3) single kidney status or previous partial or radical nephrectomy, and 4) bilateral renal mass. Finally, 1,078 patients were included.

Results

Among 1,078 patients, 899 (83.4%) showed maintained ipsilateral SRF on DTPA renal scan; 179 patients (16.6%) showed decreased SRF. The decreased SRF group showed significantly large tumor size (maintained vs. decreased SRF; 3.31 ± 2.15 vs. 6.85 ± 3.25, p < 0.001), high Fuhrman grade (grade 3–4) (41.7% vs. 55.6%, p < 0.001), and high T stage (T stage 3–4) (9.0% vs. 20.1%, p < 0.001). Pathological invasive features, including invasion of the renal capsule, perirenal fat, renal sinus fat, vein, and collecting duct system, were associated with low SRF of the ipsilateral kidney. Univariate Cox regression analysis identified higher SSIGN (The stage, size, grade, and necrosis) score and decreased ipsilateral SRF as significant risk factors, while multivariate analysis showed SSIGN (5–7) (hazard ratio [HR] 11.9, p < 0.001) and SSIGN (8–10) (HR 69.2, p < 0.001) were significantly associated with shortened DFS, while decreased ipsilateral SRF (HR 1.75, p = 0.065) showed borderline significance. Kaplan–Meier analysis showed that decreased ipsilateral SRF (< 45%) group had shorter DFS than the other group (median DFS: 90.3 months vs. not reached, p < 0.001).

Conclusions

Among unilateral RCC patients, those with low ipsilateral SRF showed poor prognosis with pathologically invasive features. Our novel approach may facilitate risk stratification in RCC patients, helping formulate a treatment strategy.

Increased urinary B2-microglobulin is associated with poor prognosis of upper tract urothelial carcinoma

Background

Kidney tubular damage markers are biomarkers of acute or chronic kidney injury. Hypothetically, upper tract urothelial cancer (UTUC), which induces obstructive uropathy or direct invasion of the renal parenchyma, may also induce increased excretion of urinary tubular damage proteins. Therefore, this study aimed to investigate the use of tubular damage biomarker as prognostic markers for UTUC.

Methods

The records of 417 surgically resected patients with UTUC were obtained from the Seoul National University Prospectively Enrolled Registry for urothelial cancer-upper tract urothelial cancer (SUPER-UC-UTUC) between January 2016 and December 2020. Patients with non-urothelial cancer or without urinary tubular injury marker measurement were excluded, and finally, 296 patients were finally included. B2-microglobulin (B2-MG) was an injury marker, and a value higher than 0.3 was considered abnormally elevated, according to previous studies.

Results

The mean age was 70.9 years, and the male sex was predominant (n = 211, 71.3%). The incidences of renal pelvis and ureter cancer were similar (50.7% vs. 49.3%). Most patients had high-grade diseases (n = 254, 88.8%). The high urine B2-MG group was older, had decreased renal function, and had a higher pathologic T stage than did the low group. Multivariate Cox regression analysis of disease-free survival (DFS), open surgical method (Hazard ratio (HR) 1.52, p = 0.027), large tumor size (HR 1.06, p = 0.017), tumor multifocality (HR 1.90, p = 0.038), lymphovascular invasion (HR 2.19, p < 0.001), and high urine B2-MG (HR 1.57, p = 0.021) were significantly associated with shortened metastasis-free survival (MFS). Kaplan–Meier curve analysis revealed short DFS (median survival 15.5 months vs. unattained, log-rank p = 0.001) and MFS (unattained median survival in both groups, log-rank p = 0.003) for the high urine B2-MG group compared to the low urine B2-MG group.

Conclusion

Patients with UTUC presenting with increased pre-operative urine B2-MG levels were associated with disease recurrence and metastasis. This biomarker may aid in performing pre-operative risk stratification and in assessing the individual prognosis of patients with UTUC.

Machine learning-based prediction model for late recurrence after surgery in patients with renal cell carcinoma

Background

Renal cell carcinoma is characterized by a late recurrence that occurs 5 years after surgery; hence, continuous monitoring and follow-up is necessary. Prognosis of late recurrence of renal cell carcinoma can only be improved if it is detected early and treated appropriately. Therefore, tools for rapid and accurate renal cell carcinoma prediction are essential.

Methods

This study aimed to develop a prediction model for late recurrence after surgery in patients with renal cell carcinoma that can be used as a clinical decision support system for the early detection of late recurrence. We used the KOrean Renal Cell Carcinoma database that contains large-scale cohort data of patients with renal cell carcinoma in Korea. From the collected data, we constructed a dataset of 2956 patients for the analysis. Late recurrence and non-recurrence were classified by applying eight machine learning models, and model performance was evaluated using the area under the receiver operating characteristic curve.

Results

Of the eight models, the AdaBoost model showed the highest performance. The developed algorithm showed a sensitivity of 0.673, specificity of 0.807, accuracy of 0.799, area under the receiver operating characteristic curve of 0.740, and F1-score of 0.609.

Conclusions

To the best of our knowledge, we developed the first algorithm to predict the probability of a late recurrence 5 years after surgery. This algorithm may be used by clinicians to identify patients at high risk of late recurrence that require long-term follow-up and to establish patient-specific treatment strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01964-w.

Efficacy and Safety of Udenafil Once Daily in Patients with Erectile Dysfunction after Bilateral Nerve-Sparing Robot-Assisted Laparoscopic Radical Prostatectomy: A Randomized, Double-Blind, Placebo-Controlled Study

PURPOSE

To evaluate the efficacy and safety of udenafil 75 mg once daily in patients with erectile dysfunction following bilateral nerve-sparing robot-assisted laparoscopic radical prostatectomy (BNS-RALP).

MATERIALS AND METHODS

A multi-center, prospective, randomized, controlled, double-blind study was conducted. Among patients with localized prostate cancer with international index of erectile function-erectile function domain (IIEF-EF) score of 18 or higher before BNS-RALP, those who developed postoperative erectile dysfunction (IIEF-EF score 14 or less at 4 weeks after BNS-RALP) were enrolled. Enrolled patients were randomly assigned to the udenafil 75 mg daily group or the placebo group in a 2:1 ratio. Each subject was followed up at 8 weeks (V2), 20 weeks (V3), and 32 weeks (V4) to evaluate the efficacy and safety of udenafil.

RESULTS

In all, 101 patients were screened, of whom 99 were enrolled. Of the 99 patients, 67 were assigned to the experimental group and 32 to the control group. Ten (14.93%) patients in the experimental group and 10 (31.25%) in the control group dropped out of the study. After 32 weeks of treatment, IIEF-EF score of 22 or higher was seen in 36.51% (23/63) of patients in the experimental group and 13.04% (3/23) patients in the control group (p=0.021). The proportion of patients with IIEF-EF improvement of 25% or more compared to the baseline was 82.54% (52/63) in the experimental group and 62.96% (17/27) in the control group (p=0.058).

CONCLUSIONS

Udenafil 75 mg once daily after BNS-RALP improved the erectile function without any severe adverse effects.

Phase I Clinical Trial of Prostate-Specific Membrane Antigen-Targeting 68Ga-NGUL PET/CT in Healthy Volunteers and Patients with Prostate Cancer

OBJECTIVE

68Ga-NGUL is a novel prostate-specific membrane antigen (PSMA)-targeting tracer based on Glu-Urea-Lys derivatives conjugated to a 1,4,7-triazacyclononane-N, N', N″-triacetic acid (NOTA) chelator via a thiourea-type short linker. This phase I clinical trial of 68Ga-NGUL was conducted to evaluate the safety and radiation dosimetry of 68Ga-NGUL in healthy volunteers and the lesion detection rate of 68Ga-NGUL in patients with prostate cancer.

MATERIALS AND METHODS

We designed a prospective, open-label, single-arm clinical trial with two cohorts comprising six healthy adult men and six patients with metastatic prostate cancer. Safety and blood test-based toxicities were monitored throughout the study. PET/CT scans were acquired at multiple time points after administering 68Ga-NGUL (2 MBq/kg; 96-165 MBq). In healthy adults, absorbed organ doses and effective doses were calculated using the OLINDA/EXM software. In patients with prostate cancer, the rates of detecting suspicious lesions by 68Ga-NGUL PET/CT and conventional imaging (CT and bone scintigraphy) during the screening period, within one month after recruitment, were compared.

RESULTS

All 12 participants (six healthy adults aged 31-32 years and six prostate cancer patients aged 57-81 years) completed the clinical trial. No drug-related adverse events were observed. In the healthy adult group, 68Ga-NGUL was rapidly distributed, with the highest uptake in the kidneys. The median effective dose coefficient was calculated as 0.025 mSv/MBq, and cumulative activity in the bladder had the highest contribution. In patients with metastatic prostate cancer, 229 suspicious lesions were detected using either 68Ga-NGUL PET/CT or conventional imaging. Among them, 68Ga-NGUL PET/CT detected 199 (86.9%) lesions and CT or bone scintigraphy detected 114 (49.8%) lesions.

CONCLUSION

68Ga-NGUL can be safely applied clinically and has shown a higher detection rate for the localization of metastatic lesions in prostate cancer than conventional imaging. Therefore, 68Ga-NGUL is a valuable option for prostate cancer imaging.

Acidic urine is associated with poor prognosis in patients with bladder cancer undergoing radical cystectomy

Purpose

To assess the prognostic value of acidic urine (low urine pH) in patients with bladder cancer undergoing radical cystectomy.

Materials and methods

We reviewed patients enrolled in the Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Cystectomy (SUPER-UC-Cx) who underwent radical cystectomy for bladder cancer between March 2016 and December 2020 at the Seoul National University Hospital. During this period, 368 patients were registered in our database. To eliminate confounding factors, we excluded patients diagnosed with non-urothelial cancer and end-stage renal disease.

Results

A total of 351 patients with a mean age of 69.8 ± 10.5 years and median follow-up of 16.0 months were eligible for the analysis. The mean preoperative urine pH was 6.0. The patients were divided into low (pH ≤ 5.5) and high (pH≥6.0) urine pH groups for comparison. All clinicopathological features, including the tumor size, grade, and stage were comparable between the low and high urine pH groups. A Cox regression analysis was performed to assess the independent effect of acidic urine on patient survival. A multivariate analysis showed that high T stage (T3-4) (hazard ratio (HR) 5.18, P<0.001), decreased renal function (estimated glomerular filtration rate <60 mL/min/1.73 m²) (HR 2.29, P=0.003), and low urine pH (≤5.5) (HR 1.69, P=0.05) were associated with shortened recurrence-free survival (RFS). Regarding the overall survival (OS), high T stage (T3-4) (HR 7.15, P<0.001) and low urine pH (≤5.5) (HR 2.66, P=0.029) were significantly associated with shortened survival. A Kaplan–Meier analysis demonstrated that the acidic urine group showed shorter RFS (P=0.04) and OS (P=0.028) than the other groups.

Conclusions

Acidic urine was independently associated with reduced RFS and OS in patients with bladder cancer undergoing radical cystectomy. Acidic urine contributing to an acidic tumor environment may promote aggressive behavior in bladder cancer.

High Carbohydrate Antigen 19-9 Levels Indicate Poor Prognosis of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinoma (UTUC) occurs in urothelial cells from the kidney and the ureters. Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker for pancreatic and gastrointestinal cancers, and its high levels are associated with poor prognosis in bladder cancer. In this study, prospective patients enrolled in the registry of Seoul National University were retrospectively examined to determine the clinical significance of CA 19-9 in UTUC. In 227 patients, high serum CA 19-9 levels reflected a high tumor burden represented by high T and N stages, leading to adverse prognosis in metastasis-free or overall survival. Subsequently, propensity score matching analysis showed that the CA 19-9 level is an independent prognostic factor of UTUC.

Clinical determinants of recurrence in pTa bladder cancer following transurethral resection of bladder tumor

BACKGROUND

Non-muscle invasive bladder cancer can be controlled by transurethral resection of bladder (TURB), but suffers from frequent recurrences in 60-70% of cases. Although, recurrence interval after TURB influences treatment course and prognosis, its implication and risk factors have not been fully elucidated. We evaluated the risk factors of early (within 1 yr) and late (after 1 yr) recurrence of pTa bladder cancer and clinical significance of recurrence interval on disease progression and overall survival.

METHODS

In this study, pTa bladder cancer patients enrolled in prospective patient registry system of Seoul National University, SUPER-UC, were retrospectively examined to determine the clinical risk factors for recurrence and its significance regarding to recurrence interval. A total of 1067 bladder cancer patients who underwent TURB between March 20 and June 2021 were included and classified into three groups of no recurrence, early, or late recurrence to be comparatively analyzed.

RESULTS

Early recurrence was associated with poorer cystectomy-free survival and overall survival than late recurrence. Risk factors for early recurrence included a high number of previous TURB, tumor multiplicity, tumor location, tumor shape, incompleteness of TURB, and high tumor grade. Otherwise, late recurrence was associated with low-grade tumors with insufficient TURB depth.

CONCLUSION

Patients with risk factors for early recurrence should be closely followed up with special cautions.

Safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy for extremely severe autosomal dominant polycystic kidney disease: Techniques and outcome

PURPOSE

To demonstrate the safety and feasibility of synchronous unilateral nephrectomy and contralateral heminephrectomy in extremely severe autosomal dominant polycystic kidney disease (ADPKD), which corresponds to the Mayo imaging classification classes 1D and 1E.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent unilateral nephrectomy and contralateral heminephrectomy at the Seoul National University Hospital (Seoul, Korea) between May 1, 2016 and August 1, 2021. The preoperative kidney volume was calculated using the ellipsoid equation (length×width×thickness×π/6). The Mayo imaging classification was determined by height-adjusted total kidney volume and age. Using a midline vertical incision, heminephrectomy was performed first by horizontal transection, followed by contralateral nephrectomy. Hilar vessel clamping or resection-bed suturing was not required.

RESULTS

In all, nine patients with ADPKD of the highest severity (Mayo class 1D/1E) underwent unilateral heminephrectomy and contralateral nephrectomy for the most common cause of severe abdominal discomfort and malnutrition. All nine patients had end-stage renal disease with hypertension and anemia. The median preoperative total kidney volume was 10,905.8 mL (interquartile range [IQR], 8,170.4-16,227.6 mL). The median operation time was 140 minutes (IQR, 125-185 min) and the median estimated blood loss was 250 mL (IQR, 200-425 mL). Eight of the nine patients were discharged without ICU care or any complications. Delayed pseudoaneurysm occurred in one case and was successfully managed by embolization. All patients were symptom-free for a median follow-up period of 2 years.

CONCLUSIONS

Synchronous unilateral nephrectomy and contralateral heminephrectomy are safe and feasible treatment options for severe bilateral ADPKD.

Isolation and Genomic Analysis of Single Circulating Tumor Cell Using Human Telomerase Reverse Transcriptase and Desmoglein-2

As epithelial cells in the circulation are considered to originate from the tumor, the epithelial cell adhesion molecule has been commonly used as a standard marker for circulating tumor cells (CTCs) isolation. However, it seems to disappear after the epithelial-mesenchymal transition that most cancer cells undergo for intravasation. Thus, more advanced techniques for CTC detection are needed to better understand the clinical significance of CTCs. A cancer cell-specifically-infecting or replicating virus that codes a fluorescent monitor gene can be a solution to efficiently detect CTCs. Thus, the authors designed an adenovirus to bind to desmoglein-2, which is highly expressed in most cancer cells. A cancer-specific human telomerase reverse transcriptase promoter is inserted to control a viral E1 region. The adenovirus is utilized to compare the number of CTCs from renal cell carcinoma and prostate cancer patients before and after surgery. The isolated two or three CTCs are eligible for whole genome sequencing. The genomic analysis proves the difference of variants between primary tumors and CTCs. Taken together, it is a fast and exact serial method for CTC isolation and the enriched genome sequencing may be used to determine the prognosis and as a point-of-care system for patients with cancer.

Acidic Urine Is Associated With Poor Prognosis of Upper Tract Urothelial Carcinoma

Purpose

To assess the prognostic role of acidic urine (low urine pH) in upper tract urothelial cancer (UTUC).

Materials and Methods

We reviewed patients enrolled in Seoul National University Prospectively Enrolled Registry for Urothelial Cancer-Upper Tract Urothelial Cancer (SUPER-UC-UTUC) who underwent surgical resection from March 2016 to December 2020 in Seoul National University Hospital (SNUH). Patients with non-urothelial cancer or those who are in condition at end-stage renal disease were excluded. Acidic urine was defined as urine pH ≤ 5.5.

Results

A total of 293 patients with a mean age of 70.7 ± 9.5 years were enrolled in this study. Pre-operative laboratory results showed a mean estimated glomerular filtration rate (eGFR) of 64.1 ± 19.2 mL/min/1.73m² and a mean urine pH of 5.86 ± 0.66. Patients were subdivided into low (pH ≤ 5.5) and high (pH > 5.5) urine pH for comparison. As a result, all variables were comparable except for the T stage, which was significantly higher in the low urine pH group (p = 0.017). Cox regression analysis was performed to assess the clinical impact of acidic urine on patient survival. Multivariate Cox regression analysis revealed that tumor multifocality (HR 2.07, p = 0.015), higher T stage (HR 1.54, p = 0.036), lymphovascular invasion (HR 1.69, p = 0.033), eGFR < 60 mL/min per 1.73 m² (HR 1.56, p = 0.017), and acidic urine (HR 1.63, p < 0.01) independently decreased disease-free survival (DFS), while multifocality (HR 9.50, p < 0.01), higher T stage (HR 9.51, p = 0.001) and acidic urine (HR 10.36, p = 0.004) independently reduced the overall survival (OS).

Conclusions

Acidic urine is independently associated with reduced DFS and OS in UTUC. Acidic urine contributing to acidic environment may promote acquisition of agressive behavior of UTUC.

Immunotherapy for prostate cancer: Requirements for a successful regime transfer

Despite the revolutionary progress in cancer treatment using immune checkpoint inhibitors (ICIs), remarkable responses in prostate cancer treatment have not yet been achieved. The disappointing previous results of ICIs have required further studies towards combined treatment targeting other pathways and restricted the eligibility criteria for patients with high mutation burdens, especially those with mismatch repair deficiency. Cancer immunotherapies activate adaptive immune systems, rather than directly attack tumor cells with their own cytotoxicity. Therefore, refractoriness to ICIs can not only be derived from the intractable nature of tumor cells per se , but also from their hostile milieu. Here, we reviewed the prostate cancer immunotherapies exploring clinical trials to date, along with the molecular characteristics of prostate cancer and its microenvironment.

Comparison of functional and oncological outcomes between uterus-sparing radical cystectomy and standard radical cystectomy in females: A retrospective study

Purpose

This study aimed to compare the functional and oncological outcomes of females who underwent uterus-sparing radical cystectomy (USRC) and standard radical cystectomy (SRC).

Materials and Methods

Between February 2009 and December 2020, 90 female patients who underwent radical cystectomy with urinary diversion were included in this study, comprising the USRC and SRC groups. Functional outcomes were assessed in 63 patients who only underwent radical cystectomy with neobladder formation. Questionnaire scores, clean intermittent catheterization (CIC) rate, and urinary continence rate were analyzed. Oncological outcomes were assessed in 86 patients, regardless of the urinary diversion type. Overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) were compared.

Results

CIC rate was significantly lower in the USRC group than in the SRC group (14.7% vs. 48.0%; p=0.005). The continence rate was significantly higher in the USRC group than in the SRC group (85.3% vs. 40.0%; p=0.001). There were no significant differences in OS (p=0.890), CSS (p=0.700), or RFS (p=0.270) between the two groups. In multivariate analysis, uterine preservation did not significantly increase the hazard ratio (HR) of OS (HR, 0.62; 95% CI, 0.18–2.11; p=0.450), CSS (HR, 0.99; 95% CI, 0.22–4.40; p=0.990), or RFS (HR, 0.46; 95% CI, 0.19–1.11; p=0.840).

Conclusions

USRC resulted in higher continence rates and lower CIC rates than SRC without negatively affecting oncological outcomes. Hence, with thorough deliberation, USRC should be considered for females undergoing radical cystectomy.

Kidney VISTA prevents IFNγ-IL-9 axis-mediated tubulointerstitial fibrosis after acute glomerular injury

Severe glomerular injury ultimately leads to tubulointerstitial fibrosis that determines patient outcome, but the immunological molecules connecting these processes remain undetermined. The present study addressed whether V-domain Ig suppressor of T cell activation (VISTA), constitutively expressed in kidney macrophages, plays a protective role in tubulointerstitial fibrotic transformation after acute antibody-mediated glomerulonephritis. After acute glomerular injury using nephrotoxic serum, tubules in the VISTA-deficient (Vsir–/–) kidney suffered more damage than those in WT kidneys. When interstitial immune cells were examined, the contact frequency of macrophages with infiltrated T cells increased and the immunometabolic features of T cells changed to showing high oxidative phosphorylation and fatty acid metabolism and overproduction of IFN-γ. The Vsir–/– parenchymal tissue cells responded to this altered milieu of interstitial immune cells as more IL-9 was produced, which augmented tubulointerstitial fibrosis. Blocking antibodies against IFN-γ and IL-9 protected the above pathological process in VISTA-depleted conditions. In human samples with acute glomerular injury (e.g., antineutrophil cytoplasmic autoantibody vasculitis), high VISTA expression in tubulointerstitial immune cells was associated with low tubulointerstitial fibrosis and good prognosis. Therefore, VISTA is a sentinel protein expressed in kidney macrophages that prevents tubulointerstitial fibrosis via the IFN-γ/IL-9 axis after acute antibody-mediated glomerular injury.

Next-generation Proteomics-Based Discovery, Verification, and Validation of Urine Biomarkers for Bladder Cancer Diagnosis

Purpose

We aimed to identify, verify, and validate a multiplex urinary biomarker-based prediction model for diagnosis and surveillance of urothelial carcinoma of bladder, using high-throughput proteomics methods.

Materials and Methods

Label-free quantification of data-dependent and data-independent acquisition of 12 and 24 individuals was performed in each of the discovery and verification phases using mass spectrometry, simultaneously using urinary exosome and proteins. Based on five scoring system based on proteomics data and statistical methods, we selected eight proteins. Enzyme-linked immunosorbent assay on urine from 120 patients with bladder mass lesions used for validation. Using multivariable logistic regression, we selected final candidate models for predicting bladder cancer.

Results

Comparing the discovery and verification cohorts, 38% (50/132 exosomal differentially expressed proteins [DEPs]) and 44% (109/248 urinary DEPs) are consistent at statistically significance, respectively. The 20 out of 50 exosome proteins and 27 out of 109 urinary proteins were upregulated in cancer patients. From eight selected proteins, we developed two diagnostic models for bladder cancer. The area under the receiver operating characteristic curve (AUROC) of two models were 0.845 and 0.842, which outperformed AUROC of urine cytology.

Conclusion

The results showed that the two diagnostic models developed here were more accurate than urine cytology. We successfully developed and validated a multiplex urinary protein-based prediction, which will have wide applications for the rapid diagnosis of urothelial carcinoma of the bladder. External validation for this biomarker panel in large population is required.

Comparison of radical prostatectomy and external beam radiotherapy in high-risk prostate cancer

Purpose

We evaluated clinical outcomes of high-risk prostate cancer patients receiving external beam radiotherapy (EBRT) or radical prostatectomy (RP).

Materials and Methods

Patients were classified as high-risk prostate cancer and received definitive treatment between 2005 and 2015. Patients with previous pelvic radiotherapy, positive lymph node or distant metastasis were excluded. The primary outcomes were prostate cancer-specific survival (PCSS) and distant metastasis-free survival (DMFS).

Results

Of 583 patients met the inclusion criteria (77 EBRT and 506 RP), the estimated 10-year PCSS was 97.0% in the RP and 95.9% in the EBRT (p = 0.770). No significant difference was seen in the DMFS (p = 0.540), whereas there was a trend in favor of RP over EBRT in overall survival (OS) (p = 0.068). Propensity score matching analysis with confounding variables was done, with 183 patients (66 EBRT and 117 RP) were included. No significant difference in DMFS, PCSS or OS was found.

Conclusion

Our data demonstrated similar oncologic PCSS, OS, and DMFS outcomes between EBRT and RP patients.

Head-to-Head Comparison of 68Ga-NOTA (68Ga-NGUL) and 68Ga-PSMA-11 in Patients with Metastatic Prostate Cancer: A Prospective Study

68Ga-NOTA Glu-Urea-Lys (NGUL) is a novel prostate-specific membrane antigen (PSMA)-targeting tracer used for PET/CT imaging. This study aimed to compare performance in the detection of primary and metastatic lesions and to compare biodistribution between 68Ga-NGUL and 68Ga-PSMA-11 in the same patients with prostate cancer. Methods: Eleven patients with metastatic prostate cancer were prospectively recruited. The quantitative tracer uptake was determined in normal organs and in primary and metastatic lesions. Results:68Ga-NGUL showed significantly lower normal-organ uptake and rapid urinary clearance. The number and sites of detected PSMA-positive primary and metastatic lesions were identical, and no significant quantitative uptake difference was observed. 68Ga-NGUL showed a relatively lower tumor-to-background ratio than 68Ga-PSMA-11. Conclusion: In a head-to-head comparison with 68Ga-PSMA-11, 68Ga-NGUL showed lower uptake in normal organs and similar performance in detecting PSMA-avid primary and metastatic lesions. 68Ga-NGUL could be a valuable option for PSMA imaging.

Estimated Glomerular Filtration Rate as a Prognostic Factor in Urothelial Carcinoma of the Upper Urinary Tract: A Systematic Review and Meta-Analysis

Preoperative renal function is associated with worse outcomes in patients undergoing radical nephroureterectomy (RNU). The purpose of this systemic review and meta-analysis was to determine the association of preoperative renal function with oncological outcome in patients who underwent RNU. We searched articles published up to March 2021 in PubMed, Scopus, and Embase by combining "urothelial carcinoma", "radical nephroureterectomy", and "estimated glomerular filtration rate". We also manually screened the reference list for publications following general guidelines recommended by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The relationship between preoperative renal function and survival was expressed as overall survival (OS), progression-free survival (PFS), and cancer-specific survival (CSS). This review and meta-analysis included 13 studies involving a total of 4668 patients who received RNU. Pooled analysis showed significant negative association of preoperative renal function with PFS (HR: 1.51, 95% CI: 1.23-1.80, p < 0.00001), CSS (HR: 1.63, 95% CI: 1.38-1.92, p < 0.00001), and OS (HR: 1.22, 95% CI: 1.10-1.35, p < 0.00001). Patients with upper tract urothelial carcinoma (UTUC) who received RNU showed a significant negative association of preoperative renal function with survival.

Pyuria as a Predictive Marker of Bacillus Calmette-Guérin Unresponsiveness in Non-Muscle Invasive Bladder Cancer

This study aims to investigate the clinical role of preoperative pyuria for predicting bacillus Calmette-Guérin (BCG) unresponsiveness in non-muscle invasive bladder cancer (NMIBC). We performed a logistic regression analysis on 453 patients with NMIBC who were treated with BCG immunotherapy after a transurethral resection of bladder tumours, to evaluate predictive factors of BCG unresponsiveness. We also analysed univariate and multivariable survival data to estimate the prognostic impact of pyuria. Of the total study population, 37.6% (170/453) of patients had BCG unresponsiveness. A multivariable logistic regression analysis revealed that a history of upper urinary tract cancer (odds ratio (OR): 1.86, 95% confidence interval (CI): 1.04-3.32, p-value = 0.035) and the presence of pyuria (OR: 1.51, 95% CI: 1.01-2.27, p = 0.047) and tumour multiplicity (OR: 1.80, 95% CI: 1.18-2.75, p-value < 0.001) were significant predictors of BCG unresponsiveness. A Cox proportional hazards analysis model showed that pyuria was a significant prognostic factor for progression-free survival (hazard ratio: 4.51, 95% CI: 1.22-16.66, p = 0.024). A history of upper urinary tract cancer and the presence of pyuria and tumour multiplicity are predictive markers of BCG unresponsiveness. For patients with NMIBC who have preoperative pyuria, treatment using BCG should be considered cautiously.

Prognostic factors for overall survival in patients with clear cell metastatic renal cell carcinoma: Model development and external validation with Memorial Sloan Kettering Cancer Center model and the international metastatic renal cell carcinoma database consortium model

To develop a new prognostic model for the overall survival of patients with clear cell metastatic renal cell carcinoma (mRCC) using Korean Renal Cancer Study Group (KRoCS) database and compared it with 2 renowned prognostic models: the Memorial Sloan Kettering Cancer Center (MSKCC) and the international metastatic renal cell carcinoma database consortium (IMDC) models.Data of 790 patients diagnosed with mRCC and receiving targeted therapy as their first-line treatment were pooled to this study. Data from 4 hospitals (n = 619) were used to develop the new model and those from other 5 hospitals (n = 171) were used for external validation. After detecting prognostic factors in multivariable Cox proportional-hazards regression analysis, patients were classified into 3 risk groups, favorable (0), intermediate (1-2), and poor (3 and more) by the number of prognostic factors.Seven variables such as more than 2 metastasis sites, no prior nephrectomy, Eastern Cooperative Oncology Group performance status ≥2, low hemoglobin, high serum corrected calcium, high neutrophil, high serum alkaline phosphatase were identified as prognostic factors for poor overall survival. Also, risk groups were categorized into 3 groups; median overall survival was 61.1 months in favorable, 26.5 months in intermediate, and 6.8 months in poor group. KRoCS ranked the first in all 3 statistical parameters including akaike information criterion (AIC), concordance index and generalized R2 among other prognostic models.We developed the KRoCS model and validated it externally with demonstrating its superiority over MSKCC and IMDC models. The KRoCS model can provide useful information for counseling patients with clear cell mRCC regarding life-expectancy.