RenseNet: A Deep Learning Network Incorporating Residual and Dense Blocks with Edge Conservative Module to Improve Small-Lesion Classification and Model Interpretation

Deep learning has become an essential tool in medical image analysis owing to its remarkable performance. Target classification and model interpretability are key applications of deep learning in medical image analysis, and hence many deep learning-based algorithms have emerged. Many existing deep learning-based algorithms include pooling operations, which are a type of subsampling used to enlarge the receptive field. However, pooling operations degrade the image details in terms of signal processing theory, which is significantly sensitive to small objects in an image. Therefore, in this study, we designed a Rense block and edge conservative module to effectively manipulate previous feature information in the feed-forward learning process. Specifically, a Rense block, an optimal design that incorporates skip connections of residual and dense blocks, was demonstrated through mathematical analysis. Furthermore, we avoid blurring of the features in the pooling operation through a compensation path in the edge conservative module. Two independent CT datasets of kidney stones and lung tumors, in which small lesions are often included in the images, were used to verify the proposed RenseNet. The results of the classification and explanation heatmaps show that the proposed RenseNet provides the best inference and interpretation compared to current state-of-the-art methods. The proposed RenseNet can significantly contribute to efficient diagnosis and treatment because it is effective for small lesions that might be misclassified or misinterpreted.

[Expression of endosialin in human hypertrophic scars and its regulation on fibroblast phenotype]

Objective: To explore the expression of endosialin, i.e., CD248 in human hypertrophic scars (HSs) and its regulatory effect on the phenotype of hypertrophic scar fibroblasts (HSFs). Methods: The method of experimental research was used. From March to May, 2023, 3 pediatric patients with HS were admitted to the Department of Burns and Cutaneous Surgery of the First Affiliated Hospital of Air Force Medical University, including 2 females and 1 male, aged one year ten months to two years. The HS tissue resected during the surgery and the remaining full-thickness skin graft, i.e., normal skin tissue after full-thickness skin grafting were collected from the aforementioned pediatric patients for subsequent experiments. Using the aforementioned two types of tissue, the histological structures were observed by hematoxylin-eosin staining, collagen distribution was observed by Masson staining, and the expression of CD248 was observed and measured by immunohistochemical staining. The primary HSFs were isolated from HS tissue using explant culture technique, and the 3rd to 5th passages of HSFs were used in subsequent experiments. According to the random number table, HSFs were divided into immunoglobulin G78 (IgG78)-treated group and IgG control group, which were treated with 200 nmol/L human CD248 monoclonal antibody IgG78 and human IgG control antibody for 24 h, respectively. The mRNA expressions of collagen type Ⅰ (Col Ⅰ) and α-smooth muscle actin (α-SMA) in HSFs were measured by real-time fluorescence quantitative reverse transcription polymerase chain reaction, the protein expressions of Col Ⅰ and α-SMA in HSFs were detected by Western blotting, and the intracellular location and protein expressions of Col Ⅰ and α-SMA were detected by immunofluorescence method. The number of samples in each experiment was 3. Data were statistically analyzed with paired sample t test and independent sample t test. Results: Compared with those in normal skin tissue, the epidermis and dermis in HS tissue were significantly thicker, with massive accumulation and disordered arrangement of collagen in the dermis. The expression of CD248 in HS tissue was significantly upregulated compared with that in normal skin tissue (t=5.29, P<0.05). At post treatment hour 24, the mRNA expressions of Col Ⅰ and α-SMA of HSFs in IgG78-treated group were 0.39±0.05 and 0.56±0.09, respectively, which were significantly lower than 1.00±0.07 and 1.00±0.08 in IgG control group, respectively (with t values of 11.87 and 6.49, respectively, P values all <0.05). The protein expressions of Col Ⅰ and α-SMA of HSFs in IgG78-treated group were 0.617±0.011 and 0.67±0.14, respectively, which were significantly lower than 1.259±0.052 and 1.23±0.16 in IgG control group, respectively (with t values of 20.92 and 4.52, respectively, P values all <0.05). At post treatment hour 24, immunofluorescence staining showed that Col Ⅰ and α-SMA mainly located in the cytoplasm of HSFs in the two groups, and the protein expressions of Col Ⅰ and α-SMA of HSFs in IgG78-treated group were obviously downregulated compared with those in IgG control group. Conclusions: The expression of CD248 is significantly upregulated in human HS. Targeted blockade of CD248 can significantly inhibit the collagen synthesis by HSFs and the transdifferentiation of HSFs into myofibroblasts.

Interpretation of SLC3A1 and SLC7A9 variants in cystinuria patients: The significance of the PM3 criterion and protein stability

Cystinuria is a genetic disorder caused by defects in the b0,+ transporter system, which is composed of rBAT and b0,+AT coded by SLC3A1 and SLC7A9, respectively. Variants in SLC3A1 and SLC7A9 follow autosomal recessive inheritance and autosomal dominant inheritance with reduced penetrance, respectively, which complicates the interpretation of cystinuria-related variants. Here, we report seven different SLC3A1 variants and six different SLC7A9 variants. Among these variants were two novel variants previously not reported: SLC3A1 c.223C > T and SLC7A9 c.404A > G. In silico analysis using REVEL correlated well with the functional loss upon SLC7A9 variants with scores of 0.8560-0.9200 and 0.4970-0.5239 for severe and mild decrease in transport activity, respectively. In addition, DynaMut2 was able to predict a decreased protein expression level resulting from the SLC7A9 variant c.313G > A with a ΔΔGStability -2.93 kcal/mol. Our study adds to the literature as additional cases of a variant allow applying the PM3 criterion with higher strength level. In addition, we suggest the clinical utility of REVEL and DynaMut2 in interpreting SLC3A1 and SLC7A9 variants. While a decreased protein expression level is not embraced in the current variant interpretation guidelines, we believe in silico protein stability predicting tools could serve as evidence of protein function loss.

Korean Society of Endourology and Robotics (KSER) recommendation on the diagnosis, treatment, and prevention of urolithiasis

This article provides evidence-based recommendations and expert opinions to aid urologists in making optimal decisions regarding managing urolithiasis in various clinical scenarios. The most frequently asked questions by urologists in their clinical practice have been collected and answered in the form of FAQs; based on the latest evidence and expert opinions. The natural history of urolithiasis is divided into active treatment and silent phases, with the active treatment stage divided into typical and special situations and peri-treatment management. The authors address 28 key questions, offering practical guidance for the proper diagnosis, treatment, and prevention of urolithiasis in clinical practice. This article is expected to be served as a valuable resource for urologists.

Inner surface modification of polyurethane ureteral stents using plasma-enhanced chemical vapor deposition to improve the resistance to encrustation in a pig model

PURPOSE

We developed a ureteral stent with a non-fouling inner surface using plasma micro-surface modification technology. This study aimed to evaluate the safety and efficacy of this stent in animal model.

MATERIALS AND METHODS

Ureteral stents were placed in five Yorkshire pigs. A bare stent was inserted on one side and an inner surface-modified stent was inserted on the other side. Two weeks after stenting, laparotomy was performed to harvest the ureteral stents. The changes in the inner surface were grossly evaluated using scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). In addition, if encrustation was observed, the components were analyzed using Fourier transform infrared spectroscopy. Urine cultures were used for safety assessment.

RESULTS

In all models, urine cultures did not show any bacterial growth before and after stenting, and stent-related complications were not identified. Hard materials were palpable in four bare models. Palpable material was not identified in the modified stent. Calcium oxalate dihydrate/uric acid stones were identified in two bare stents. In the SEM images with EDS, biofilm formation was confirmed in the bare stents. Biofilm formation was significantly less on the inner surface of the modified stent, and the intact surface of the modified stent was larger than that of the bare stent.

CONCLUSIONS

The application of a specialized, plasma-enhanced, chemical vapor deposition technology to the inner surface of ureteral stents was safe and showed resistance to biofilm formation and encrustation.

Effects of hormone therapy on the clinical outcomes of endoscopic intervention in patients with endometriosis-related ureteral obstruction

PURPOSE

We investigated whether endoscopic interventions, including laser endoureterotomy and balloon dilatation following hormone therapy, are a good choice to treat ureteral obstruction due to ureteral endometriosis instead of laparoscopic or open surgery.

MATERIALS AND METHODS

Patients with ureteral obstruction due to endometriosis who underwent endoscopic intervention between 2004 and 2021 were reviewed. Patients with other causes of ureteral obstruction or previous ureteral surgery were excluded from the study. The primary endpoint was the 3-month success rate of endoscopic intervention with or without hormone therapy. Secondary endpoints were the success rate of endoscopic intervention between the hormone-treated and hormone-untreated groups at 6 months and the success rate according to the hormone therapy response of endometriosis at 3 and 6 months.

RESULTS

Eighteen patients with 19 ureter units were evaluated in this study, including 12 patients receiving hormone therapy and six patients not receiving hormone therapy. Among patients receiving hormone therapy, one patient had bilateral ureteral obstruction. The success rate of endoscopic intervention was higher in patients who received hormone therapy than in those who did not receive hormone therapy three months after endoscopic intervention (76.9% vs. 0.0%, p=0.003). The same result was also found 6 months after endoscopic intervention (75.0% vs. 0.0%, p=0.005). In addition, the success rates were higher in the hormone-responsive group than in the non-responsive group (100.0% vs. 57.1%), although the difference was not statistically significant (p=0.122).

CONCLUSIONS

Ureteral obstruction caused by endometriosis can be effectively treated by endoscopic intervention with hormone therapy in select patients.

Anti-adhesion agent to prevent of post-operative adhesion and fibrosis after vasectomy: a study using a rat model

Background

Post-vasectomy pain syndrome (PVPS) is difficult to treat. Direct damage to the vas deferens, inflammation, compression of nerves through fibrotic adhesions, and congestion of the epididymis are known to cause PVPS. The purpose of this study was to evaluate whether the application of anti-adhesion agents after vasectomy can reduce the degree of adhesion and fibrosis in a rat model.

Methods

In the study, 11 Sprague-Dawley rats (22 vas deferens) from each group were evaluated. In the experimental group, surgery was terminated after applying the anti-adhesion agent; this was not applied in the control group. After 14 days of vasectomy, the scrotum was dissected to evaluate the degree of gross adhesion at the vasectomy site. Histological examination of the surrounding tissues, including the vas deferens and the spermatic cord, was also performed.

Results

Adhesions were not observed in 72.73% (16/22) rats from the experimental group, in which the anti-adhesion agent was applied; in contrast, the incidence of adhesions in the control group was 100%. There was a statistically significant relationship between the distribution of grades for adhesion and anti-adhesion agent (chi-square, P<0.001). On classification of fibrosis and inflammation, application of the anti-adhesion agent was significantly associated with lower grade inflammation and fibrosis compared to that of the control group (chi-square, P=0.001). The rate of intact muscle structure was 90.91% (20/22) in the experimental group, and 36.36% (8/22) in the control group, and the application of the anti-adhesion agent demonstrated significant association with preservation of intact muscle structure (chi-square, P<0.001).

Conclusions

The application of an anti-adhesion agent after vasectomy prevented the development of adhesion, fibrosis, and inflammation reaction and further reduced structural destruction.

Inner surface modification of ureteral stent polyurethane tubes based by plasma-enhanced chemical vapor deposition to reduce encrustation and biofilm formation

Encrustation and/or biofilm formation in ureteral stents are major causes of obstruction and reduce the lifetime of a ureteral stent. In this study, the inner surfaces of polyurethane (PU) tubes (inner and outer diameters of 1.2 and 2.0 mm, respectively) were reformed with Ar, O₂, and C₂H₂ gases using specialized plasma-enhanced chemical vapor deposition techniques for the first time. Then, the modified PU tubes were immersed in urine for 15 days, and the characteristics of the inner surfaces were analyzed. Depending on the modification procedure, the corresponding inner surface exhibited different chemical properties and different rates of encrustation and biofilm formation. For a hydrophilic surface treated with Ar and O₂, encrustation and biofilm formation increased, while for the C₂H₂ coating, the development of encrustation and biofilm reduced by more than five times compared with the untreated bare PU tube. This study demonstrated that inner plasma surface modification of ureteral stents greatly enhances resistance to encrustation and biofilm formation.

[Preliminary study on differentially expressed proteins in a mouse model of secondary cystic echinococcosis based on data independent acquisition proteomics]

OBJECTIVE

To identify the differentially expressed proteins in different liver tissues in the mouse model of cystic echinococcosis (CE), so as to provide insights into the research and development of therapeutic drugs targeting CE.

METHODS

Female Kunming mice at ages of 6 to 8 weeks were randomly assigned into the CE group and the control group. Mice in the CE group were intraperitoneally infected with 2 000 Echinococcus multilocularis protoscoleces, while mice in the control group were injected with the same volume of physiological saline. All mice in both groups were sacrificed after breeding for 350 d, and the lesions (the lesion group) and peri-lesion specimens (the peri-lesion group) were sampled from the liver of mice in the CE group and the normal liver specimens (the normal group) were sampled from mice in the control group for data independent acquisition (DIA) proteomics analysis, and the differentially expressed proteins were subjected to Gene Ontology (GO) term enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis.

RESULTS

A total of 26 differentially expressed proteins were identified between the lesion group and the normal group and between the peri-lesion group and the normal group, including 8 up-regulated proteins and 18 down-regulated proteins. GO term enrichment analysis showed that these differentially expressed proteins were predominantly enriched in endoplasmic reticulum membrane (biological components), oxidoreductase activity (molecular function) and oxoacid metabolic process and monocarboxylic acid metabolic process (biological processes). KEGG pathway enrichment analysis revealed that the differentially expressed protein Acyl-CoA oxidase 1 (Acox1), which contributed to primary bile acid biosynthesis during the fatty acid oxidation, was involved in peroxisome signaling pathway, and the differentially expressed protein fatty acid binding protein 1 (Fabp1), which contributed to fatty acid transport, was involved in the peroxisome proliferator-activated receptor (PPAR) signaling pathway.

CONCLUSIONS

Differentially expressed proteins are identified in the liver specimens between mouse models of CE and normal mice, and some differentially expressed proteins may serve as potential drug targets for CE.

[Preliminary study on differentially expressed proteins in a mouse model of secondary alveolar echinococcosis based on data independent acquisition proteomics]

OBJECTIVE

To identify the differentially expressed proteins in different liver tissues in the mouse model of alveolar echinococcosis using high-resolution mass spectrometry with data independent acquisition (DIA), and to identify the key proteins contributing to the pathogenesis of alveolar echinococcosis.

METHODS

Protoscoleces were isolated from Microtus fuscus with alveolar echinococcosis and the experimental model of alveolar echinococcosis was established in female Kunming mice aged 6 to 8 weeks by infection with Echinococcus multilocularis protoscoleces. Mice were divided into the experimental and control groups, and animals in the experimental group was injected with approximately 3 000 protoscoleces, while mice in the control group were injected with the same volume of physiological saline. Mouse liver specimens were sampled from both groups one year post-infection and subjected to pathological examinations. In addition, the lesions (the lesion group) and peri-lesion specimens (the peri-lesion group) were sampled from the liver of mice in the experimental group and the normal liver specimens (the normal group) were sampled from mice in the control group for DIA proteomics analysis, and the differentially expressed proteins were subjected to bioinformatics analysis.

RESULTS

A total of 1 020 differentially expressed proteins were identified between the lesion group and the normal group, including 671 up-regulated proteins and 349 down-regulated proteins, and 495 differentially expressed proteins were identified between the peri-lesion group and the normal group, including 327 up-regulated proteins and 168 down-regulated proteins. The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis revealed that these differentially expressed proteins were involved in peroxisome, peroxisome proliferator-activated receptor (PPAR) and fatty acid degradation pathways, and the peroxisome and PPAR signaling pathways were found to correlate with liver injury. Several differentially expressed proteins that may contribute to the pathogenesis of alveolar echinococcosis were identified in these two pathways, including fatty acid binding protein 1 (Fabp1), Acyl-CoA synthetase long chain family member 1 (Acsl1), Acyl-CoA oxidase 1 (Acox1), Enoyl-CoA hydratase and 3-hydroxyacyl CoA dehydrogenase (Ehhadh) and Acetyl-Coenzyme A acyltransferase 1B (Acaa1b), which were down-regulated in mice in the experimental group.

CONCLUSIONS

A large number of differentially expressed proteins are identified in the liver of the mouse model of alveolar echinococcosis, and Fabp1, Acsl1, Acox1, Ehhadh and Acaa1b may contribute to the pathogenesis of alveolar echinococcosis.

Feasibility of a deep learning-based diagnostic platform to evaluate lower urinary tract disorders in men using simple uroflowmetry

Purpose

To diagnose lower urinary tract symptoms (LUTS) in a noninvasive manner, we created a prediction model for bladder outlet obstruction (BOO) and detrusor underactivity (DUA) using simple uroflowmetry. In this study, we used deep learning to analyze simple uroflowmetry.

Materials and Methods

We performed a retrospective review of 4,835 male patients aged ≥40 years who underwent a urodynamic study at a single center. We excluded patients with a disease or a history of surgery that could affect LUTS. A total of 1,792 patients were included in the study. We extracted a simple uroflowmetry graph automatically using the ABBYY Flexicapture^® image capture program (ABBYY, Moscow, Russia). We applied a convolutional neural network (CNN), a deep learning method to predict DUA and BOO. A 5-fold cross-validation average value of the area under the receiver operating characteristic (AUROC) curve was chosen as an evaluation metric. When it comes to binary classification, this metric provides a richer measure of classification performance. Additionally, we provided the corresponding average precision-recall (PR) curves.

Results

Among the 1,792 patients, 482 (26.90%) had BOO, and 893 (49.83%) had DUA. The average AUROC scores of DUA and BOO, which were measured using 5-fold cross-validation, were 73.30% (mean average precision [mAP]=0.70) and 72.23% (mAP=0.45), respectively.

Conclusions

Our study suggests that it is possible to differentiate DUA from non-DUA and BOO from non-BOO using a simple uroflowmetry graph with a fine-tuned VGG16, which is a well-known CNN model.

Clinical effectiveness of house dust mite immunotherapy in mono- versus poly-sensitised patients with allergic rhinitis: a systematic review and meta-analysis

Selecting an appropriate allergen-specific immunotherapy (AIT) regimen for polysensitised allergic rhinitis (AR) patients is challenging for clinicians. Although previous studies showed comparable effectiveness of single-allergen AIT with house dust mite (HDM) extract between monosensitised and polysensitised AR patients, there is no systematic review and meta-analysis demonstrating the comparable effectiveness of HDM AIT. In this meta-analysis, we analysed nine studies to compare the clinical effectiveness of HDM AIT. The primary outcome was nasal symptom score and secondary outcomes were medication and quality of life scores. The changes in nasal symptom score after HDM AIT did not significantly differ between monosensitised and polysensitised patients. The clinical effectiveness of HDM AIT regarding medication and quality of life score was not significantly different between monosensitised and polysensitised patients). In conclusion, single-allergen AIT with HDM extract showed comparable clinical effectiveness between polysensitised and monosensitised patients with AR.

The Feasibility of Pop-Dusting Using High-Power Laser (2 J × 50 Hz) in Retrograde Intrarenal Surgery for Renal Stones: Retrospective Single-Center Experience

Objective: Recently, retrograde intrarenal surgery (RIRS) using laser lithotripsy has become popular. However, the optimal laser energy setting for pop-dusting has not been established. In this study, we report our experiences of RIRS using the high-power (up to 100 W) pop-dusting (HPPD) technique. Methods: This study retrospectively assessed 82 cases with RIRS using HPPD. Patients who underwent abdominal CT or mercaptoacetyltriglycine (MAG3) diuretic renal scan at 3 months postoperatively were included in this study. Patient and stone characteristics and perioperative and postoperative outcomes were evaluated. Results: The average number of renal stones was 3.67 ± 4.11, and the average length of the largest stones was 13.30 ± 6.41 mm. The mean Hounsfield units was 959.99 ± 384.73. The operation time was 58.10 ± 26.67 minutes. The mean HPPD time was 11.93 ± 9.48 minutes, with settings of 1.97 ± 0.25 J and 48.78 ± 3.29 Hz. The stone-free rate was 89%. The mean hospital stay was 1.68 ± 1.29 days. Pelvicaliceal and ureter injuries were observed in 9.8% and 32.9% of the study population, respectively. However, there was no transfusion, subcapsular hematoma, persistent urinary leakage, ureteral or infundibular stricture, or renal functional deterioration. There was transient postoperative fever in 12.2% of the study population. Conclusions: HPPD could be performed safely during RIRS for renal stones without significant complications such as collecting system injury or bleeding. High-power laser mode (up to 100 W) can be a safe and effective choice for pop-dusting during RIRS, especially for large and hard stones.

Transvesicoscopic Politano-Leadbetter ureteral reimplantation in children with vesicoureteral reflux: A novel surgical technique

Purpose

We introduce our novel procedure for transvesicoscopic ureteral reimplantation using the Politano-Leadbetter technique (TVUR-PL). We describe the detailed surgical procedure and report operative outcomes.

Materials and Methods

We report a retrospective analysis of operative outcomes of TVUR-PL performed in children with vesicoureteral reflux (VUR) from January 2017 to July 2018. The analyzed operative outcomes included patient demographics, operative times, intra- and postoperative complications, indwelling duration of urethral Foley catheter, hospital length of stay, and treatment success.

Results

A total of 47 patients (17 males, 30 females) underwent TVUR-PL during the study period, including 18 unilateral and 29 bilateral cases (76 ureters). All operations were successfully completed without open conversion. The median operative time was 121 minutes for unilateral cases and 178 minutes for bilateral cases. The median duration of placement of a urethral Foley catheter was 2 days. There were no intra- or postoperative complications. Only one patient (1/47 patients, 2.1%), who had no postoperative VUR on voiding cystourethrography, experienced febrile urinary tract infection during the follow-up period.

Conclusions

Our novel TVUR-PL technique is a safe and effective minimally invasive surgical treatment option for children with VUR. The main advantage of our new operation is that it allows us to maintain the natural direction of the ureter after surgery.

Long-term outcomes of two types of metal stent for chronic benign ureteral strictures

BACKGROUND

We aimed to compare the results of long-term use of two types of metal stent for chronic benign ureteral strictures.

METHODS

Our study included 46 ureter units (UUs) that underwent metal stent placement from 2010 to 2017. We included benign ureteral strictures causes by variety reasons that could not be solved by other treatment and malignant obstructions were excluded. Covered mesh stent (Uventa™) and a thermo-expandable stent (Memokath 051™) were used. Primary success was defined as maintaining patency without procedures and overall success was defined as maintaining patency with additional procedures.

RESULTS

We placed covered mesh stents in 25 UUs and thermo-expandable stents in 21 UUs. The mean follow-up duration of each stent was 41.4 ± 23.1 and 34.4 ± 16.5 months (p = 0.250). In the first year of stent insertion, primary success was achieved in 54.9 and 70.4% (p = 0.204). Overall success was achieved in 78.7 and 75.4% in same duration, respectively (p = 0.586). Longer stent placement had positive predictive value on both success rates (HR = 0.185, p = 0.047 and HR = 0.111, p = 0.018). Prior radiation therapy and non-pelvic ureter stricture both adversely affected the overall success rate (HR = 5.412, p = 0.048 and HR = 4.203, p = 0.030). Previous PCN status had negative predictive value for both success rates (HR = 4.014, p = 0.003 and HR = 3.064, p = 0.035).

CONCLUSIONS

The treatment outcomes of two types of metal stent were comparable, especially in the first year of stent insertion.

A randomized, double-blind, placebo-controlled trial to evaluate the role of curcumin in prostate cancer patients with intermittent androgen deprivation

BACKGROUND

The anti-cancer activities of curcumin are well-documented from preclinical studies using prostate cancer models. Our objective was to evaluate the anti-cancer activity of oral curcumin in patients with prostate cancer.

METHODS

This randomized, double-blind, placebo-controlled trial was performed on patients with prostate cancer who received intermittent androgen deprivation (IAD). Participants who finished the first on-treatment period of IAD were randomized into a curcumin or placebo group. The patients took oral curcumin (1440 mg/day) or placebo for six months and were followed up until the beginning of the second on-treatment. The primary end-point was duration of the first off-treatment. The secondary end-points were change in PSA and testosterone levels during 6 months, PSA progression rate, and health-related quality of life (HRQOL) scores at 6 months. Safety assessments included adverse event, adverse drug reaction, and serious adverse event.

RESULTS

A total of 97 participants were randomized 1:1 to curcumin (n = 49) and placebo (n = 48) groups. Among them, 82 patients (84.5%) were evaluable for the analysis (39 and 43 patients in the curcumin and placebo groups, respectively). The median off-treatment duration was 16.3 months (95% confidence interval [CI] 12.3-20.3 months) and 18.5 months (95% CI 12.5-23.0 months) in the curcumin and placebo groups, respectively. There was no significant difference in the curve of off-treatment duration between the two groups (P = 0.4816). The proportion of patients with PSA progression during the active curcumin treatment period (6 months) was significantly lower in the curcumin group than the placebo group (10.3% vs 30.2%, P = 0.0259). The change of PSA, testosterone levels during 6 months, and HRQOL scores at 6 months were not different between curcumin and placebo groups. Adverse events were higher in the placebo group (16 of 46 vs 7 of 45 patients, P = 0.0349). No significant differences in the adverse drug reaction were found between the two groups.

CONCLUSIONS

Six months' intake of oral curcumin did not significantly affect the overall off-treatment duration of IAD. However, PSA elevation was suppressed with curcumin intake during the curcumin administration period. Curcumin at this dose was well tolerated and safe.

Clinical Impact of a Protocolized Kidney Donor Follow-up System

BACKGROUND

Adequate kidney donor management after donation is increasingly emphasized due to concerns of renal function impairment after nephrectomy with increasing life expectancy. In this study, the clinical impact of a protocolized kidney donor follow-up system by nephrologists was evaluated.

METHODS

A total of 427 living kidney donors underwent nephrectomy from January 2010 to December 2014 and were followed for at least 2 years at the Samsung Medical Center. Donors were followed-up by nephrologists after the establishment of a donor clinic with systemized protocols in January 2013. The primary outcomes were incidence of post-donation low estimated glomerular filtration rate (eGFR) and renal function adaptability. Secondary outcomes were changes in compliance and incidence of hyperuricemia and microalbuminuria.

RESULTS

The patients were divided into 2 groups according to the time of nephrectomy: the pre-donor clinic period (n = 182) and the donor clinic period (n = 172). Preoperative eGFR in patients in the pre-donor clinic period was higher than that in patients in the donor clinic period. After donation, poor renal adaptation was less frequent in the donor clinic period compared to the pre-donor clinic period. Low eGFR tended to be less common during the donor clinic period. Shorter mean outpatient clinic visit intervals with more visits within 6 months after donation and earlier detection of de novo hyperuricemia were found during the donor clinic period.

CONCLUSION

A protocolized donor clinic run by nephrologists may improve post-nephrectomy renal outcomes and compliance and facilitate better management of potential risk factors of chronic kidney disease in donors.

Comparison of outcomes in totally tubeless percutaneous nephrolithotomy according to nephrostomy tract sealing with fibrin versus gelatin matrix: a propensity score matching study

To investigate and compare surgical outcomes in totally tubeless percutaneous nephrolithotomy (ttPCNL) patients according to the type of sealant during nephrostomy tract closure, the records of 158 patients who underwent ttPCNL were retrospectively reviewed. Fibrin sealant [Tisseel^®; n = 107, fibrin-only sealant (FS)] or gelatin matrix hemostatic sealant [FloSeal^®; n = 51, gelatin matrix sealant (GS)] was applied during tract closure according to surgeon's preference. On the first postoperative day, computed tomography (CT) was scanned for all patients. Unsatisfactory radiological outcome (URO) was defined as any postoperative hematoma or urinoma (≥ 2 cm) on the CT. Unsatisfactory clinical outcome (UCO) was defined as any adverse event requiring additional intervention. Both UROs and UCOs were sub-classified as either hemorrhage or drainage related. 2:1 propensity score matching was applied according to clinical parameters. Median age was 58 (19-78) years and a mean stone size was 2.1 ± 1.1 cm. The treatment success rate (stone free or < 4 mm residual) among all patients was 91.1% (144/158). UROs and UCOs occurred in 35.4% (86/158) and 11.4% (18/158) of all cases, respectively. Neither of the frequency of URO nor hemorrhage-related UCO was different according to sealant type. However, drainage-related UCOs were more prevalent among the GS group, mainly due to the higher postoperative ureter stenting rate. The postoperative pain severity and the length of hospitalization were comparable between groups. In summary, using GS rather than FS during tract closure did not worsen hemorrhage-related outcomes. However, the clinical risk of ureter occlusion requiring additional temporary ureteral stenting was increased.

Clinical Usefulness of a Self-Retaining Internal Organ Retractor for Laparoendoscopic Single-Site Adrenalectomy

INTRODUCTION

Although laparoendoscopic single-site adrenalectomy (LESS-A) is feasible, it is still considered as a challenging procedure because of technical limitations. Making an optimal retraction is one of major obstacles in LESS-A, and it sometimes requires additional ports or needlescopic devices. Internal organ retractor (IOR) is a novel retraction device that is applied intracorporeally without additional port. In this study, we investigated the clinical usefulness of IOR in LESS-A.

MATERIALS AND METHODS

Medical records of 73 consecutive patients who underwent LESS-A from March 2009 to December 2014 were reviewed. Twenty-two patients underwent LESS-A with IOR and 51 patients without IOR.

RESULTS

Mean age, body mass index, tumor size, operation time, estimated blood loss, and hospital stay were not significantly different between two groups. In IOR group, median number of applied IOR was 2.0 (1.0-3.0) per single operation. Mean time for application and removal was 80.0 and 46.5 seconds for a single IOR, respectively. There were no complications related to the IOR. In without IOR group, there were nine cases that needed needlescopic trocars, six cases that needed 5 mm or larger trocars, and one case that was converted to hand-assisted laparoscopy. However, we did not use any needlescopic instrument or additional trocar in IOR group. There was no case of open conversion in both groups.

CONCLUSION

LESS-A could be done effectively and safely using IOR. IOR system maintained optimal retraction throughout the operation. Its application and removal are intuitive and take only a few minutes. We think IOR system is an attractive retraction method in LESS-A.

Efficacy and safety of tamsulosin 0.4 mg single pills for treatment of Asian patients with symptomatic benign prostatic hyperplasia with lower urinary tract symptoms: a randomized, double-blind, phase 3 trial

OBJECTIVE

To verify the efficacy and safety of tamsulosin 0.4 mg and tamsulosin 0.2 mg compared with those of placebo in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH).

METHODS

A total of 494 patients from multiple centers participated in this double-blind, randomized, phase 3 trial. Eligible patients were randomly assigned to the tamsulosin 0.4 mg group, tamsulosin 0.2 mg group or placebo group. The International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual (PVR) urine volume, blood pressure, heart rate and adverse events were compared among the three groups at 4, 8 and 12 weeks.

RESULTS

A total of 494 BPH patients were analyzed. There were no differences in the baseline characteristics among the three groups. After 12 weeks of treatment, total IPSS was improved in the 0.2 mg and 0.4 mg tamsulosin groups; however, the extent of improvement was greater in the 0.4 mg group than in the 0.2 mg group (0.4 mg: -9.59 vs. 0.2 mg: -5.61; least-squares mean difference [95% confidence interval]: -3.95 [-5.01, -2.89], p < .0001). In addition, in the patients with severe symptoms (IPSS ≥20), total IPSS was improved the most in the 0.4 mg group (-11.27 ± 5.00, p < .0001). Qmax and PVR were improved in the 0.4 mg and 0.2 mg groups; however, the differences were not statistically significant between treatment groups. No patients experienced any serious adverse effects in any of the three groups.

CONCLUSIONS

Tamsulosin 0.4 mg and 0.2 mg appear to be superior to placebo treatment, and tamsulosin 0.4 mg is more effective than 0.2 mg in terms of total IPSS improvement. Tamsulosin 0.4 mg has favorable efficacy and tolerability in Asian men with symptomatic BPH. ClinicalTrials.gov Identifier: NCT02390882.

Long-Term Outcomes of Laparoendoscopic Single-Site Nephrolithotomy for Caliceal Diverticular Calculi: A Case Series

OBJECTIVE

To evaluate the outcomes of laparoendoscopic single-site nephrolithotomy (LESS-NL) for symptomatic caliceal diverticular calculi.

PATIENTS AND METHODS

From November 2009 to March 2014, 11 cases of LESS-NL with a homemade single-port device for caliceal diverticular calculi were performed by a single experienced laparoscopic surgeon. All patients were assessed at postoperative 1 month, 1 year, and 3 years for symptom-free status and by CT for stone-free and caliceal diverticular obliteration status. All complications were categorized by the Clavien-Dindo classification. Demographic parameters and postoperative outcomes were retrospectively analyzed.

RESULTS

All procedures were effectively performed without conversion to open or conventional laparoscopic surgery. Median patient age was 53 years (range 22-73), and median diverticular size was 26 mm (range 15-58). Six patients (54.5%) had multiple stones, and five patients (45.5%) had a single stone; median stone size was 20.6 mm (range 12.1-66.4). The transperitoneal approach was used in seven patients (63.6%) and retroperitoneal approach in four patients (36.4%). Median operative time was 161 minutes (range 110-250), median estimated blood loss was 50 mL (range 20-400), and median hospital stay was 4 days (range 3-6). An additional needlescopic instrument was used in five cases (45.5%). There were three cases (27.3%) of grade I complications (two postoperative fever, one ileus), and no intraoperative or major complications. Median visual analog scale score significantly improved by discharge day (from 4.9 preoperatively to 1.4; p = 0.003). After a median follow-up of 38 months (range 36-41), all patients were symptom free with no evidence of stone or caliceal diverticulum on imaging.

CONCLUSIONS

LESS-NL is a safe, feasible, and definitive treatment option for symptomatic caliceal diverticular calculi.

Predictive Factors of Renal Adaptation After Nephrectomy in Kidney Donors

BACKGROUND

Despite compensatory hyperfiltration in remaining nephrons following donor nephrectomy, some donors show impaired renal adaptation and low estimated glomerular filtration rate (eGFR). We investigated the factors predicting early renal adaptation after nephrectomy and identified kidney donors at risk of inadequate renal adaptation.

METHODS

A total of 265 living kidney donors from 2010 to 2013 were retrospectively analyzed. Renal function was serially followed for 6 months after the operation. Regression analyses were performed to identify the independent predictors of low eGFR (eGFR <60 mL/min/1.73 m²) and impaired renal adaptation (%Modification of Diet in Renal Disease [MDRD] <66% of baseline eGFR).

RESULTS

A total of 148 donors belonged to the low eGFR group, and changes in eGFR (ΔeGFR) at postoperative (PO) 1 day and 1 month were identified as independent predictors of low eGFR. Impaired renal adaptation was related to age, ΔeGFR PO 2-3 days, and ΔeGFR PO 1 month. Early renal adaptation was associated with age, male gender, and residual kidney computerized tomography angiography (CTA) volume. The best sensitivity and specificity were obtained with a cutoff value of ΔeGFR 31 at PO 1 day and 1 month for predicting low eGFR and with a value of ΔeGFR 27 at PO 2-3 days and 1 month for predicting impaired renal adaptation.

CONCLUSIONS

Our study showed that the degree of early renal adaptation determines subsequent renal function in kidney donors. Closer monitoring and management may be required in old or male donors with small residual CTA kidney volume as well as donors with persistent ΔeGFR >27 within 1 month of nephrectomy.

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

IMPORTANCE

Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.

OBJECTIVES

To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.

EXPOSURES

Robotic-assisted vs laparoscopic radical nephrectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.

RESULTS

Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).

CONCLUSIONS AND RELEVANCE

Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

The incidence of unsuccessful partial nephrectomy within the United States: A nationwide population-based analysis from 2003 to 2015

PURPOSE

Partial nephrectomy (PN) remains underutilized within the United States and few reports have attempted to explain this trend. The aim of this study is to evaluate the nationwide incidence of unsuccessful PN and factors that predict its occurrence.

METHODS

Using the Premier Healthcare Database, we retrospectively analyzed a weighted sample of 66,432 patients undergoing curative surgery for renal mass between 2003 and 2015. PN intent was denoted by presence of insurance claims for the administration of mannitol. Unsuccessful PN was defined as an event in which patients were administered mannitol but received radical nephrectomy. A multivariate logistic regression model was generated to identify factors predicting unsuccessful PN.

RESULTS

Overall rates of unsuccessful PN declined from 33.5% to 14.5% since 2003. Conversion to radical nephrectomy occurred most frequently during laparoscopic (34.7%) and least frequently during robotic approach (13.6%). There was significant difference in the rate of unsuccessful PN between very high and very low volume surgeons (open: 39.4% vs. 13.3%, laparoscopic: 51.2% vs. 32.2%, and robot assisted: 27.1% vs. 9.4%, all P<0.001). After adjustment for patient- and hospital-related factors, surgical approach (laparoscopic vs. open, odds ratio = 1.74, 95% CI: 1.31-2.30, P<0.001) and annual surgeon volume (very high vs. very low, odds ratio = 0.27, 95% CI: 0.21-0.34 P<0.001) were associated with unsuccessful PN.

CONCLUSIONS

Although the rate of unsuccessful PN appears to be declining, it still remains common for low volume surgeons and with the laparoscopic surgical approach. Further evaluation of its effect on health care outcomes is necessary.

Effects of eupatilin on the contractility of corpus cavernosal smooth muscle through nitric oxide-independent pathways

Eupatilin (5,7-dihydroxy-3,4,6-trimethoxyflavone) is one of the main compounds present in Artemisia species. Eupatilin has both antioxidative and anti-inflammatory properties and a relaxation effect on vascular contraction regardless of endothelial function. We evaluated the relaxant effects of eupatilin on the corpus cavernosum (CC) of rabbits and the underlying mechanisms of its activity in human corpus cavernosum smooth muscle (CCSM) cells. Isolated rabbit CC strips were mounted in an organ bath system. A conventional whole-cell patch clamp technique was used to measure activation of calcium-sensitive K⁺ -channel currents in human CCSM cells. The relaxation effect of eupatilin was evaluated by cumulative addition (10^-5  m ~ 3 × 10^-4  m) to CC strips precontracted with 10^-5  m phenylephrine. Western blotting analysis was performed to measure myosin phosphatase targeting subunit 1 (MYPT1) and protein kinase C-potentiated inhibitory protein for heterotrimeric myosin light chain phosphatase of 17-kDa (CPI-17) expression and to evaluate the effect of eupatilin on the RhoA/Rho-kinase pathway. Eupatilin effectively relaxed the phenylephrine-induced tone in the rabbit CC strips in a concentration-dependent manner with an estimated EC₅₀ value of 1.2 ± 1.6 × 10^-4  m (n = 8, p < 0.05). Iberiotoxin and tetraethylammonium significantly reduced the relaxation effect (n = 8, p < 0.001 and p = 0.003, respectively). Removal of the endothelium or the presence of L-NAME or indomethacin did not affect the relaxation effect of eupatilin. In CCSM cells, the extracellular application of eupatilin 10^-4  m significantly increased the outward currents, and the eupatilin-stimulated currents were significantly attenuated by treatment with 10^-7  m iberiotoxin (n = 13, p < 0.05). Eupatilin reduced the phosphorylation level of MYPT1 at Thr853 of MLCP and CPI-17 at Thr38. Eupatilin-induced relaxation of the CCSM cells via NO-independent pathways. The relaxation effects of eupatilin on CCSM cells were partially due to activation of BK_Ca channels and inhibition of RhoA/Rho-kinase.

Change of Ultrasound Estimated Bladder Weight and Bladder Wall Thickness After Treatment of Bladder Outlet Obstruction With Dutasteride

OBJECTIVES

To investigate the change of bladder wall hypertrophy to relieve bladder outlet obstruction (BOO) by treatment with 5α-reductase inhibitor.

METHODS

Men who have BOO confirmed by urodynamic study (BOO index ≥40) were treated with dutasteride 0.5 mg once a day for 6 months. We measured ultrasound estimated bladder weight (UEBW), UEBW divided by body surface area (UEBW/BSA), and bladder wall thickness (BWT) before and after treatment. Changes in LUTS parameters were assessed by using the International Prostate Symptom Score, uroflowmetry, residual urine volume, prostate volume, serum prostate-specific antigen (PSA), and LUTS outcome scores (LOS). Correlation between the change of LUTS parameters and UEBW, UEBW/BSA, and BWT were evaluated. We assessed the changes of bladder wall hypertrophy according to the results of benefit, satisfaction, and willingness to continue (BSW) questionnaire.

RESULTS

Thirty patients completed the 6-month study. The mean UEBW was 47.10 ± 7.79 g before and 50.07 ± 5.39 g after dutasteride treatment (P = 0.259). The mean UEBW/BSA was 26.47 ± 4.30 g/m² before and 28.2 ± 3.53 g/m² after treatment (P = 0.253), and there was no definite change in mean BWT after treatment (P = 0.301). Most LUTS parameters including LOS significantly improved. Increased BOO index value was related to decreased BWT (ρ = 0.361, P = 0.049). There was no definite change in mean UEBW, UEBW/BSA, and BWT according to the results of the BSW questionnaire.

CONCLUSIONS

There was no change in UEBW, UEBW/BSA and BWT despite improving most clinical parameters suggesting BOO. The changes of bladder wall hypertrophy parameters still have limitations to directly reflect the relief of BOO.

Surgical Outcomes of Primary and Recurrent Female Urethral Diverticula

OBJECTIVE

To evaluate the surgical outcomes of female urethral diverticulectomy.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of 68 patients with symptomatic urethral diverticula (UD) with at least 1 year of follow-up data following transvaginal urethral diverticulectomy conducted by a single surgeon. The presence of UD was confirmed by a preoperative magnetic resonance imaging (MRI). According to MRI findings, the UDs were classified as simple, U-shaped, or circumferential. Cure was defined as the absence of residual diverticulum on a postoperative MRI with a resolution of symptoms.

RESULTS

There were 27 cases (39.7%) of simple, 16 cases (23.5%) of U-shaped, and 25 cases (36.8%) of circumferential diverticula. The initial cure rate for UD was 77.9%. According to configuration, the cure rates for simple, U-shaped, and circumferential diverticula were 100%, 75.0%, and 64.0%, respectively (P = .043). Of the 15 patients with UD recurrence, 4 did not require reoperation because of symptom resolution. Of the 11 cases that underwent a second operation, 8 patients were cured: 7 via a Martius labial fat pad interposition (MLFI) procedure and 1 via simple excision without MLFI. The overall cure rate was 92.6%. The circumferential configuration was an independent factor for a lower cure rate (odds ratio, 7.97; 95% confidence interval, 1.14-55.69).

CONCLUSION

Transvaginal diverticulectomy is an effective treatment for female UD. The success rate of an initial surgery was significantly lower for UDs with circumferential configurations than for simple or U-shaped UDs. Regardless of the initial configuration, MLFI is a good treatment option for recurrent or persistent diverticula.

The effect of contralateral kidney volume on renal function after radical nephroureterectomy: Implications for eligibility for neoadjuvant chemotherapy for upper tract urothelial cancer

PURPOSE

We investigated the effect of preoperative contralateral kidney (CK) volume on renal function after radical nephroureterectomy (RNU).

METHODS

We reviewed 630 patients who underwent RNU between September 1994 and December 2013. Of these 630 patients, 135 patients with advanced upper tract urothelial cancer were ultimately included. Preoperative CK volume was measured from computed tomography images of the venous phase using a specialized volumetric program. Glomerular filtration rate (GFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations and checked preoperatively, 7 days, 1, 3, and 12 months postoperatively.

RESULTS

The mean age at surgery was 62.1 (10.1) years and the mean CKD-EPI GFR was 73.8 (75.5) ml/min/1.73m². After RNU, new-onset CKD was identified in 69 (51.1%) patients. On multivariate logistic regression analysis, high body mass index (95% CI: 1.08-1.51, P = 0.005), low preoperative CKD-EPI GFR (95% CI: 0.92-0.98, P = 0.037), and low CK volume (95% CI: 0.96-0.99, P<0.001) were associated with new-onset CKD at 1 month after RNU. There was a positive correlation between CK volume and CKD-EPI GFR at 1 month after RNU (Spearman ρ = 0.495, P<0.001). When stratified according to CK volume, CK volume less than 150ml was significantly associated with new-onset CKD after RNU (95% CI: 2.49-26.29, P = 0.001).

CONCLUSIONS

High body mass index, low preoperative CKD-EPI GFR, and low CK volume are significantly associated with new-onset CKD. Therefore, they could be used to identify patients eligible for neoadjuvant chemotherapy in upper tract urothelial cancer.

Laparoendoscopic single-site simple nephrectomy using a magnetic anchoring system in a porcine model

Purpose

Magnetic anchoring devices may reduce the number of port sites needed in laparoscopic surgery. In this study, we prospectively assessed the feasibility of using a magnetic anchoring and guidance system (MAGS) in laparoendoscopic single-site (LESS) surgery performed by novices.

Materials and Methods

A total of 10 LESS simple nephrectomies were performed with or without MAGS in a nonsurvival porcine model by 6 operators with no previous LESS surgery experience. After installation of the homemade single port, an intra-abdominal magnet was fixed to the renal parenchyma with suturing and stabilized by an external magnet placed on the flank so that the position of the kidney could be easily changed by moving the external handheld magnet. The length of the procedure and any intraoperative complications were evaluated.

Results

Operative time (mean±standard deviation) was shorter in the group using the magnetic anchoring device (M-LESS-N) than in the group with conventional LESS nephrectomy (C-LESS-N) (63±20.8 minutes vs. 82±40.7 minutes, respectively). Although all nephrectomies were completed uneventfully in the M-LESS-N group, renal vein injury occurred during dissection of the renal hilum in two cases of C-LESS-N and was resolved by simultaneous transection of the renal artery and vein with an Endo-GIA stapler.

Conclusions

LESS-N using MAGS is a feasible technique for surgeons with no LESS surgery experience. Taking into account the 2 cases of renal vein injury in the C-LESS-N group, the application of MAGS may be beneficial for overcoming the learning curve of LESS surgery.

Comparison of preoperative adaptive enlargement of the contralateral normal kidney in patients nephrectomized for benign non-functioning kidney versus renal cell carcinoma

OBJECTIVES

To investigate the potential effects of preoperative volumetric compensation of the contralateral normal kidney on renal function after simple nephrectomy or radical nephrectomy.

METHODS

A total of 306 patients (80 simple nephrectomy patients and 226 radical nephrectomy patients) with 1:3 propensity score matching were included between October 1996 and December 2013. Preoperative three-dimensional kidney volume was estimated from computed tomography images using a specialized volumetric program. Glomerular filtration rate assessed using the Chronic Kidney Disease Epidemiology Collaboration equations was checked preoperatively, 1 week, 3 months and 1 year after nephrectomy.

RESULTS

Preoperative mean Chronic Kidney Disease Epidemiology Collaboration glomerular filtration rate was 76.5 mL/min/1.73 m(2) in the simple nephrectomy group and 89.2 mL/min/1.73 m(2) in the radical nephrectomy group. In simple nephrectomy patients, mean Chronic Kidney Disease Epidemiology Collaboration glomerular filtration rate showed a stable pattern up to 3 months (75.5 mL/min/1.73 m(2) at 7 days and 76.2 mL/min/1.73 m(2) at 3 months), and decreased slightly to 72.6 mL/min/1.73 m(2) at 1 year. However, in radical nephrectomy patients, mean Chronic Kidney Disease Epidemiology Collaboration glomerular filtration rate decreased immediately to 63.4 mL/min/1.73 m(2) at 7 days after surgery, and then increased gradually to 64.6 mL/min/1.73 m(2) at 3 months and 65.9 mL/min/1.73 m(2) at 1 year. Preoperative mean contralateral normal kidney volume was 225.7 mL in the simple nephrectomy group and 180.1 mL in the radical nephrectomy group (P < 0.001). The contralateral normal kidney volume to total normal kidney volume ratio was 0.74 in the simple nephrectomy group and 0.51 in the radical nephrectomy group (P < 0.001).

CONCLUSIONS

Preoperative volumetric compensation of the contralateral normal kidney is important to maintain postoperative renal function in patients undergoing nephrectomy.

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology

OBJECTIVE

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.

METHODS

A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.

RESULTS

Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.

CONCLUSIONS

Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

Multiple cores of high grade prostatic intraepithelial neoplasia and any core of atypia on first biopsy are significant predictor for cancer detection at a repeat biopsy

Purpose

To investigate the differences in the cancer detection rate and pathological findings on a second prostate biopsy according to benign diagnosis, high-grade prostatic intraepithelial neoplasia (HGPIN), and atypical small acinar proliferation (ASAP) on first biopsy.

Materials and Methods

We retrospectively reviewed the records of 1,323 patients who underwent a second prostate biopsy between March 1995 and November 2012. We divided the patients into three groups according to the pathologic findings on the first biopsy (benign diagnosis, HGPIN, and ASAP). We compared the cancer detection rate and Gleason scores on second biopsy and the unfavorable disease rate after radical prostatectomy among the three groups.

Results

A total of 214 patients (16.2%) were diagnosed with prostate cancer on a second biopsy. The rate of cancer detection was 14.6% in the benign diagnosis group, 22.1% in the HGPIN group, and 32.1% in the ASAP group, respectively (p<0.001). When patients were divided into subgroups according to the number of positive cores, the rate of cancer detection was 16.7%, 30.5%, 31.0%, and 36.4% in patients with a single core of HGPIN, more than one core of HGPIN, a single core of ASAP, and more than one core of ASAP, respectively. There were no significant differences in Gleason scores on second biopsy (p=0.324) or in the unfavorable disease rate after radical prostatectomy among the three groups (benign diagnosis vs. HGPIN, p=0.857, and benign diagnosis vs. ASAP, p=0.957, respectively).

Conclusions

Patients with multiple cores of HGPIN or any core number of ASAP on a first biopsy had a significantly higher cancer detection rate on a second biopsy. Repeat biopsy should be considered and not be delayed in those patients.

Diagnostic Ureterorenoscopy Is Associated with Increased Intravesical Recurrence following Radical Nephroureterectomy in Upper Tract Urothelial Carcinoma

Diagnostic ureterorenoscopy is powerful tool to confirm upper tract urothelial cancer (UTUC). However, URS and associated manipulation may be related to the risk of intravesical recurrence (IVR) following radical nephroureterectomy (RNU). We aimed to investigate whether preoperative ureterorenoscopy would increase IVR after RNU in patients with UTUC. We performed a retrospective analysis of 630 patients who had RNU with bladder cuff excision due to UTUC. Diagnostic URS was performed in 282 patients (44.7%). Patients were divided into two groups according to the URS. Survival analysis and multivariate Cox regression model were performed to address risk factors for the IVR. The interval from URS to RNU was measured. During URS, manipulation such as biopsy and resection was determined. The median age was 64 (IQR 56–72) years with follow-up duration of 34.3 (15.7–64.9) months. Median time from URS to RNU was 16 (0–38) days. The IVR developed in 42.5% (n = 268) patients at 8.2 (4.9–14.7) months. The five-year IVR-free survival rate was 42.6 ± 8.0% and 63.6 ± 6.9% in patients with and without preoperative URS, respectively (P < 0.001). In multivariate analysis, previous history of bladder tumour, extravesical excision of distal ureter, multifocal tumour, and URS (HR, 95% CI; 1.558, 1.204–2.016, P = 0.001) were independent predictors for higher IVR. The IVR rate in patients without manipulation during URS was not different to those with manipulation (P = 0.658). The duration from URS to RNU was not associated with IVR (P = 0.799). Diagnostic URS for UTUC increased IVR rate after RNU. However, the lessening of interval from URS to radical surgery or URS without any manipulation could not reduce the IVR rate.

Effect of Tamsulosin in Lower Urinary Tract Symptom Patients With Metabolic Syndrome

OBJECTIVE

To investigate the efficacy of tamsulosin, a selective alpha-1 blocker, in lower urinary tract symptoms (LUTS) patients with metabolic syndrome (MS).

PATIENTS AND METHODS

This prospective, multicenter clinical trial included men and women (20-75 years old) with LUTS, with or without MS. Patients were categorized as MS+ or MS-, respectively, and all of them were administered tamsulosin 0.2 mg per oral once daily for 24 weeks. Patients were assessed based on the International Prostate Symptom Score, King's Health Questionnaire (KHQ), Overactive Bladder Questionnaire, uroflowmetry with postvoid residuals, and MS factors (blood pressure, waist-to-hip ratio, and serum levels of fasting blood glucose, triglyceride, and high-density lipoprotein cholesterol) at baseline and at 4, 12, and 24 weeks of treatment.

RESULTS

Ninety-two patients were enrolled in this study (53/92 were MS- [57.6%]; 39/92 were MS+ [42.4%]). After 24 weeks of tamsulosin treatment, fasting blood glucose (P = .02) and triglyceride (P < .001) levels of changes were significantly greater in the MS+ group than in the MS- group. Total International Prostate Symptom Score, total Overactive Bladder Questionnaire score, and the scores of each question on the KHQ showed significant improvement after treatment without intergroup differences. In KHQ, although improvements in emotional status, sleep quality, fatigue, and personal distress were greater in the MS+ group (P = .05), the difference between the groups did not reach statistical significance.

CONCLUSION

Tamsulosin was effective in both LUTS patients with and without MS. Furthermore, tamsulosin had beneficial effects on some of the factors associated with MS.

Interventions do not enhance medication persistence and compliance in patients with overactive bladder: a 24 weeks, randomised, open-label, multi-center trial

OBJECTIVES

Anticholinergics are currently the mainstay for the management of overactive bladder (OAB). However, low drug adherence has been noted with these medications. The aim of this study was to determine whether a health education intervention (HEI) could improve drug persistence with anticholinergics in OAB patients.

METHODS

We enrolled 682 OAB patients who were randomly distributed into either the HEI plus fesoterodine (HEI) group or the fesoterodine alone (control) group. The HEI consists of four education sections: understanding OAB disease, dietary control, bladder training and understanding anticholinergics. The primary end-point was the difference in drug persistence between the HEI and control groups at 24 weeks. Persistence was defined as a gap ≤ 30 days between successive prescription pills.

RESULTS

Among the 682 patients, 210 (30.8%) completed 24 weeks of study. Persistence of the HEI group at 6 months was not statistically higher than that of the control group (40.4% vs. 34.9%, p = 0.181). Compliance at 6 months was also similar between the two groups (38.5% vs. 32.5%, p = 0.128). Using OAB symptom score questionnaire, the efficacy of the two groups was not different at each follow-up (p > 0.05). The global response was similar between the two groups. However, the HEI group was more satisfied with treatment than the control group (p = 0.034). The most common reason for discontinuation was satisfaction with the treatment so that they did not need to follow-up, followed by inadequate efficacy in both groups. Adverse events were reported in 12.3% of patients.

CONCLUSIONS

The health education intervention was not effective to increase drug persistence in OAB patients on anticholinergics.

New Methodology for Investigating Ejaculation Dysfunction: Measuring Intraluminal Seminal Vesicle Pressure in Rats with a Telemetric Device

INTRODUCTION

Ejaculation dysfunction is one of the most common male sexual disorders. Despite its prevalence and adverse impact on patients, little attention has been given to investigating ejaculation dysfunction.

AIM

We introduce a new method for evaluating ejaculation dysfunction in rats with a telemetric device.

METHODS

A pressure transducer was surgically implanted in the seminal vesicles of 7-week-old male Sprague-Dawley rats. One week later, the rats were subcutaneously administered tamsulosin 3 μg/kg, and intra-seminal vesicle pressure (ISVP) was recorded in freely moving rats after an injection of apomorphine (80 μg/kg). Same rats repeated experiment with tamsulosin 10 μg/kg, silodosin 1 mg/kg, and normal saline with 3-day intervals.

MAIN OUTCOME MEASURE

Sexual events were visually identified and recorded. Ejaculation was confirmed by visualization of a copulatory plug in the tip of the penis. We compared the maximal ISVP and area under the curve (AUC) of the ISVP.

RESULTS

Adequate ISVP data were easily recorded and available in 66.6% rats (10/15) over a 6-week telemetric recording period (12 recordings). The mean number of ejaculations during an inspection time of 30 minutes was 1.5 ± 0.1. The maximal ISVP values in rats receiving 3 μg/kg (30.0 ± 5.2 mm Hg) and 10 μg/kg tamsulosin (15.1 ± 1.6 mm Hg) and 1 mg/kg silodosin (12.9 ± 2.2 mm Hg) were significantly lower than that in control rats (61.4 ± 13.4 mm Hg, P < 0.05). The AUC values in rats receiving 3 μg/kg (72.7 ± 18.9 mm Hg × s) and 10 μg/kg tamsulosin (23.5 ± 6.1 mm Hg) and 1 mg/kg silodosin (23.9 ± 8.0 mm Hg) were also lower than that of control rats (162.6 ± 34.3 mm Hg, P < 0.05).

CONCLUSIONS

Telemetric ISVP assessment is reliable and feasible for investigating apomorphine-induced ejaculation in rats. Tamsulosin (3 μg/kg and 10 μg/kg) and silodosin 1 mg/kg decreased the ISVP during ejaculation.

Associations between serotonin transporter gene (SLC6A4) methylation and clinical characteristics and cortical thickness in children with ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a common, highly heritable psychiatric disorder. Additionally, environmental factors such as perinatal stress and early adversities contribute to the occurrence and severity of ADHD. Recently, DNA methylation has emerged as a mechanism that potentially mediates gene-environmental interaction effects in the aetiology and phenomenology of psychiatric disorders. Here, we investigated whether serotonin transporter gene (SLC6A4) methylation patterns were associated with clinical characteristics and regional cortical thickness in children with ADHD.

METHOD

In 102 children with ADHD (age 6-15 years), the methylation status of the SLC6A4 promoter was measured. Brain magnetic resonance imaging was obtained and ADHD symptoms were evaluated.

RESULTS

A higher methylation status of the SLC6A4 promoter was significantly associated with worse clinical presentations (more hyperactive-impulsive symptoms and more commission errors). Additionally, a negative correlation was observed between SLC6A4 methylation levels and cortical thickness values in the right occipito-temporal regions.

CONCLUSIONS

Our results suggest that the SLC6A4 methylation status may be associated with certain symptoms of ADHD, such as behavioural disinhibition, and related brain changes. Future studies that use a larger sample size and a control group are required to corroborate these results.