CD44 and CD133 protein expression might serve as a prognostic factor for early occurrence castration-resistant prostate cancer

BACKGROUND

The occurrence of castration-resistant prostate cancer (CRPC) varies in patients with advanced prostate cancer (PCa) undergoing androgen deprivation therapy (ADT). The rate of occurrence of CRPC may be related to the presence of prostate cancer stem cells (CSC). Thus, this study aims to evaluate the presence of CSC markers (CD44 and CD133) in histopathology tissue at the time of diagnosis and their correlation with the occurrence of CRPC in patients with advanced PCa within 2 years of ADT.

METHOD

A retrospective case-control study was conducted to evaluate the incidence of CRPC within 2 years. The inclusion criteria were patients with PCa who had received treatment with ADT and a first-generation anti-androgen (AA) for 2 years. We classified patients based on whether they developed CRPC within 2 years (CRPC) of the therapy or did not experience CRPC within 2 years (non-CRPC) of the therapy. We performed immunohistochemical (IHC) staining for CD44 and CD133 on the prostate biopsy tissue samples.

RESULTS

Data were collected from records spanning 2011-2019. We analyzed a total of 65 samples, including 22 patients with CRPC and 43 patients with non-CRPC who had received treatment with LHRH agonists and AA for up to 2 years. Our findings showed a significant H-score difference in CD44 protein expression between CRPC prostate adenocarcinoma samples 869 (200-1329) and non-CRPC 524 (154-1166) (p = 0.033). There was no significant difference in CD133 protein expression between the two groups (p = 0.554). However, there was a significant difference in the nonoccurrence of CRPC between the high expressions of both CD44 and CD133 groups with other expressions of CD44/CD133 groups (25% vs. 75%; p = 0.011; odds ratio = 4.29; 95% confidence interval [1.34, 13.76]).

CONCLUSION

This study found a low expression of at least one CD44/CD133 protein in the patients without early occurrence of CRPC. This result might suggest that CD44/CD133 may function as a potential prognostic marker for PCa, especially in a low expression, to identify patients who have a better prognosis regarding the occurrence of early CRPC.

Penile carcinoma: A retrospective analysis of 93 patients at a tertiary care center in Jakarta, Indonesia

OBJECTIVES

Penile carcinoma (PC) is a rare disease with considerable physical and psychological impact. To date, there is no data regarding PC prevalence and characteristics in Indonesia. This study aimed to analyze the characteristics of patients with PC in Indonesia and determine cumulative survival rates and time to disease progression.

METHODS

This was a retrospective study of all patients diagnosed with PC at Cipto Mangunkusumo General Hospital from 1995 to 2014, with a minimum of 1 year follow-up. The outcomes of the study were cumulative survival rates and time-to-disease progression.

RESULTS

Ninety-three subjects were recruited, with a mean age of 49.44 ± 13.62. Inguinal lymph node dissection (ILND) was performed in 49 (53%) patients. The mean survival in the ILND group was better compared to the non-ILND group (80.7 months vs. 67.1 months; p = 0.032). Time-to-progression in the ILND group was significantly longer than in the non-ILND group (71.7 months vs. 54.3 months; p = 0.022). No significant difference in survival between the total and partial penectomy (PP) groups was observed (p = 0.701). Time-to-progression in total penectomy (TP) was significantly longer than in PP (68 months vs. 56.0 months; p = 0.023). In Cox-regression analysis, after adjustment of other variables, history of ILND, higher stage of cancer, and older age were found to affect the survival of patients.

CONCLUSION

ILND in PC led to better survival and reduced disease progression. The type of penectomy is only associated with progression but not survival. TP had a longer time to disease progression compared to PP.

The expression of stem cells markers and its effects on the propensity for recurrence and metastasis in bladder cancer: A systematic review

Bladder cancer is one of the most frequent cancers of the urinary tract, associated with high recurrence rates and metastasis. Cancer stem cells (CSCs) are a subpopulation of cancer cells characterized by high self-renewal and differentiation capacities, resulting in increased cancer recurrence, larger tumor size, higher rates of metastasis, higher resistance to treatment, and overall poorer prognosis. This study aimed to evaluate the role of CSCs as a prognostic tool to predict the risks of metastasis and recurrence in bladder cancer. A literature search was conducted across seven databases from January 2000 to February 2022 for clinical studies investigating the use of CSCs to determine the prognosis of bladder cancer. The following keywords were used: ("Bladder Cancer" OR "Transitional Cell Carcinoma" OR "Urothelial Carcinoma") AND ("Stem Cell" OR "Stem Gene") AND ("Metastasis" OR "Recurrence"). A total of 12 studies were deemed eligible for inclusion. SOX2, IGF1R, SOX4, ALDH1, CD44, Cripto-1, OCT4, ARRB1, ARRB2, p-TFCP2L1, CDK1, DCLK1, and NANOG, which were all identified as CSC markers. Several of these markers have been implicated in the recurrence and metastasis of tumor in bladder cancer, which played a role as prognostic factor of bladder cancer. Given the pluripotent and highly proliferative properties of CSCs. CSCs may play a role in the complex biological behavior of bladder cancer, including, but not limited to, its high rates of recurrence, metastasis, and resistance to treatment. The detection of cancer stem cell markers offers a promising approach in determining the prognosis of bladder cancer. Further studies in this area are thus warranted and may contribute significantly to the overall management of bladder cancer.

Patency rate difference of the arteriovenous fistula with and without pre-anastomosis balloon dilatation in chronic kidney disease patients

Background: Arteriovenous fistula (AVF) failure rate in chronic kidney disease patients is relatively high due to inadequate feeding arteries and draining veins. The primary balloon angioplasty (PBA) dilatation technique is a way to mitigate AVF failure. There have not been many studies to determine the patency rate with and without PBA. This study analyzed the patency rate and the number of patency failures in Indonesia AVF patients with and without PBA. Methods: A retrospective cohort study was conducted in AVF surgery patients from 2019 to 2021 with or without PBA with a total sample technique. The patient was choosen without AVF surgery in the same arm with had follow-up every three months for three years. We excluded incomplete medical record data and unfollowed patients six weeks after surgery. The Kaplan–Meier method used the log-rank test to estimate each group's patency rate. The p-value<0.05 was considered significant. Results: There were 60 subjects, of which 29 were with PBA and 31 were without PBA. There was a significant difference between the two groups regarding venous diameter and postoperative venous flow volume (p<0.01). The log-rank test showed a significant difference in patency failure in the group without PBA (35.5%, mean patency rate 56.3 weeks) compared to the group with PBA (10.3%, mean patency rate 104.4 weeks) with p=0.028. The median duration showed that 50% of the group without PBA experienced patency failure at week 59.3. In contrast, until the observation's end, the PBA group experienced patency failure of less than 50%. Conclusion: Using the PBA technique can reduce the incidence of patency failure and maintain longer patency in patients with AVF.

E-cadherin expressions on bladder and its association with cancer progressivity: a retrospective cohort study

Background

Bladder cancer is characterized by high recurrence and progressivity. E-cadherin serves as one of the most important molecules involved in the epithelial cells’ cell-to-cell adherence, suggested to inhibit tumor cell progression. This study aims to investigate the association between the E-cadherin expressions with bladder cancer progressiveness in 3 years.

Methods

This study was a retrospective cohort study involving bladder cancer patients in Cipto Mangunkusumo Hospital, Jakarta. Diagnosis of bladder cancers was confirmed by histopathological and immunohistochemistry examination between 2011 and 2018, with both grading and staging determined by uropathologists and uro-oncologists. E-cadherin was examined through immunohistochemistry examination at the time of diagnosis. Data on demography, muscle invasion, clinical staging, grade, metastasis, multifocality, and recurrence were obtained from medical records and pathology reports. The association of E-cadherin expression to muscle invasion and non-muscle invasion bladder cancer was evaluated and statistically analyzed. Patients’ survival data were followed up by phone.

Results

Forty bladder cancer patients with a mean age of 60.05 ± 10.3 years were included. Most subjects had high E-cadherin expression (85%), muscle invasion (65%), high grade (65%), no metastasis (87.5%), multifocality (65%), and no recurrence (62.5%). Lower expression of E-cadherin was associated with the higher clinical stage (p < 0.02) and metastasis (p < 0.001). Patients with low E-cadherin expression showed worse cumulative survival than the high one (mean 32 months vs. 25 months, p = 0.13).

Conclusions

Low level of E-cadherin was associated with the higher risk of muscle invasion, clinical staging, histological grade, and risk of metastasis. Meanwhile, patients with the high level of E-cadherin showed a better three-year survival rate.

Retroperitoneoscopic proximal ureter resection and ureteroureterostomy as an alternative management for upper tract urothelial carcinoma: A case report

Radical nephroureterectomy (RNU) with bladder cuff removal is the treatment of choice for upper tract urothelial carcinoma (UTUC). Partial ureterectomy (PU) with ureteroureterostomy in this case has shown a good result. We herein report an elderly woman with adenocarcinoma colon complaining gross intermittent hematuria and solid ureteral mass on NCCT. Patient declined RNU, so we performed PU with ureteroureterostomy. Histology examination showed high-grade infiltrating urothelial carcinoma with negative margin. Four cycles of Gemcitabine and cisplatin were given. Routine follow up and evaluation were done without any mass progression. PU and ureteroureterostomy with adjuvant chemotherapy are an alternative procedure for UTUC.

Adenocarcinoma mucinosum of extrophy bladder: A rare case report

INTRODUCTION

Bladder exstrophy is a rare congenital anomaly while, bladder adenocarcinoma mucinous type is a rare type of bladder cancer, with aggressive behavior and inadequate response to radiation and chemotherapy. In extremely rare cases, untreated bladder exstrophy could transform into bladder mucinous adenocarcinoma.

CASE PRESENTATION

We report a case of a 41-year-old male with untreated bladder exstrophy that transformed into mucinous adenocarcinoma. The patient also had epispadias and a right inguinal hernia. Joint procedures were conducted to perform radical cystectomy, total penectomy and W-Pouch continent urostomy, inguinal hernia repair, osteotomy, and keystone and scrotal flap by split-thickness skin graft (STSG) for wound closure. The patient progressed well after surgery, two months after initial procedure, nephrostomies were conducted due to pouches stenosis. Due to the government's limited transportation and lockdown policy, as the Covid-19 pandemic occurred, the patient could not come to the hospital for routine follow-up and died nine-month after surgery.

CLINICAL DISCUSSION

Bladder exstrophy is one of the risk factors of bladder cancer. Transformation of bladder exstrophy into mucinous adenocarcinoma is extremely rare, as the case is the first case to be discovered in Indonesia. Surgery, followed with a strict follow-up regime, is mainstay of treatment in this type of malignancy.

CONCLUSION

Adenocarcinoma of mucinous type is a scarce type of bladder exstrophy malignancies. A multidiscipline approach is mandatory in these cases. Strict and regular follow up are suggested for these cases.

Impact of metabolic syndrome on lower urinary tract symptoms in patients with benign prostate hyperplasia

BACKGROUND Studies evaluating the relationship between metabolic syndrome (MetS) and lower urinary tract symptoms (LUTS) in men with benign prostate hyperplasia (BPH) are lacking in Indonesia. This study aimed to discover the association of LUTS and MetS in men with BPH. METHODS Subjects who underwent biopsy were recruited from Cipto Mangunkusumo Hospital, Jakarta, Indonesia from January 2014 to January 2018, but only men who had biopsy-proven BPH were included. Body mass index, waist circumference, fasting blood glucose, triglyceride, high-density lipoprotein, prostate volume (PV), and international prostate symptom score (IPSS) were collected before the biopsy. MetS criteria were based on the National Cholesterol Education Program Adult Treatment Panel III. IPSS was assessed for LUTS and consisted of irritative and obstructive symptoms and quality of life (QoL). Independent t-test or Mann–Whitney test was used to analyze numerical data. RESULTS Of 227 men with biopsy-proven BPH, 87 (38.3%) were diagnosed with MetS. PV was similar in men with or without MetS (54.4 [20.3–100] versus 49.9 [19.5–100] cm3, p = 0.239). Men with MetS generally had more LUTS (15 [1–30] versus 11 [0–35], p = 0.005), more irritative symptoms (8 [0–20] versus 6 [0–20], p = 0.007), and lower QoL (4 [0–6] versus 3 [0–6], p = 0.018). CONCLUSIONS BPH patients with MetS had greater LUTS, particularly irritative symptoms and QoL score.

Silent Hypertensive Crisis in an Adolescent: First Case Report of Pediatric Pheochromocytoma from Indonesia

Secondary hypertension in children, to the rare extent, can be caused by endocrine factors such as pheochromocytoma, an adrenal tumor that secretes catecholamine. Only a few cases have been reported in the past 3 decades. To the best of our knowledge, this is the first case report of pediatric pheochromocytoma from Indonesia. We reviewed a case of a 16-year-old Indonesian boy with history of silent hypertensive crisis who was referred from a remote area in an island to the pediatric nephrology clinic at Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Despite medications, his symptoms persisted for 14 months. At the pediatric nephrology clinic, pheochromocytoma was suspected due to symptoms of catecholamine secretion presented, which was palpitation, diaphoresis, and weight loss. However, as the urine catecholamine test was unavailable in Indonesia, the urine sample was sent to a laboratory outside the country. The elevated level of urine metanephrine, focal pathological uptake in the right adrenal mass seen on ¹³¹I-MIBG, and histopathology examination confirmed the suspicion of pheochromocytoma. Following the tumor resection, he has been living with normal blood pressure without antihypertensive medications. This case highlights that pheochromocytoma should always be included in the differential diagnoses of any atypical presentation of hypertension. In limited resources setting, high clinical awareness of pheochromocytoma is required to facilitate prompt referral. Suspicion of pheochromocytoma should be followed by measurement of urine metanephrine levels. Early diagnosis of pheochromocytoma would fasten the optimal cure, alleviate the symptoms of catecholamine release, and reverse hypertension.

The Role of 3D-Printed Phantoms and Devices for Organ-specified Appliances in Urology

Urology is one of the fields that are always at the frontline of bringing scientific advancements into clinical practice, including 3D printing (3DP). This study aims to discuss and presents the current role of 3D-printed phantoms and devices for organ-specified applications in urology. The discussion started with a literature search regarding the two mentioned topics within PubMed, Embase, Scopus, and EBSCOhost databases. 3D-printed urological organ phantoms are reported for providing residents new insight regarding anatomical characteristics of organs, either normal or diseased, in a tangible manner. Furthermore, 3D-printed organ phantoms also helped urologists to prepare a pre-surgical planning strategy with detailed anatomical models of the diseased organs. In some centers, 3DP technology also contributed to developing specified devices for disease management. To date, urologists have been benefitted by 3D-printed phantoms and devices in the education and disease management of organs of in the genitourinary system, including kidney, bladder, prostate, ureter, urethra, penis, and adrenal. It is safe to say that 3DP technology can bring remarkable changes to daily urological practices.

Meta-analysis of neoadjuvant chemotherapy compared to radical cystectomy alone in improving overall survival of muscle-invasive bladder cancer patients

BACKGROUND

Most patients with muscle-invasive bladder cancer (MIBC) developed metastasis within 2 years, even after radical cystectomy (RC). The recurrence rate of MIBC was more than 50% of the cases. A meta-analysis conducted by Yin et al. showed that neoadjuvant chemotherapy (NAC) + RC improves overall survival in MIBC compared with RC only. However, a new meta-analysis by Li et al. concluded that NAC + RC was not superior to RC only in improving overall survival. The inconsistencies of these studies required further comprehensive analysis to recommend NAC use in bladder cancer treatment. Therefore, this meta-analysis aims to analyze previous studies that compare the efficacy of NAC + RC versus RC only to improve overall survival of MIBC.

METHODS

The articles were searched using Pubmed with keywords "muscle-invasive bladder cancer", "neoadjuvant chemotherapy", "cystectomy", and "overall survival". The articles that were published until June 2020 were screened. The overall survival outcome was analyzed as hazard ratio (HR) and presented in a forest plot.

RESULT

Seventeen studies were included in meta-analysis with a total sample of 13,391 patients, consist of 2890 received NAC followed by RC and 10,418 underwent RC only. Two studies used methotrexate/vinblastine/doxorubicin/cisplatin (MVAC), two studies used gemcitabine/cisplatin (GC), one study used Cisplatin-based regimen, one study used MVAC or GC, one study used gemcitabine/carboplatin (GCarbo) or GC or MVAC, one study used Cisplatin/Gemcitabine or MVAC, one study used Cisplatin only, one study used Cisplatin-based (GC, MVAC) or non-Cisplatin-based (combined paclitaxel/gemcitabine/carboplatin), one study used GC, MVAC, Carboplatin, or Gemcitabine/Nedaplatin (GN), and five studies did not mention the regimen The overall survival in the NAC + RC only group was significantly better than the RC only group (HR 0.82 [0.71-0.95], p = 0.009).

CONCLUSION

NAC + RC is recommended to improve overall survival in MIBC patients. A further study assessing side effects and quality of life regarding NAC + RC is needed to establish a strong recommendation regarding this therapy.

Cross-continental comparison of safety and protection measures amongst urologists during COVID-19

Objectives

To determine the well‐being of urologists worldwide during the coronavirus disease 2019 pandemic, and whether they have adequate personal protective equipment knowledge and supplies appropriate to their clinical setting.

Methods

Urologists worldwide completed a Société Internationale d’Urologie online survey from 16 April 2020 until 1 May 2020. Analysis was carried out to evaluate their knowledge about protecting themselves and others in the workplace, including their confidence in their ability to remain safe at work, and any regional differences.

Results

There were 3488 respondents from 109 countries. Urologists who stated they were moderately comfortable that their work environment offers good protection against coronavirus disease 2019 showed a total mean satisfaction level of 5.99 (on a “0 = not at all” to “10 = very” scale). A large majority (86.33%) were confident about protecting themselves from coronavirus disease 2019 at work. However, only about one‐third reported their institution provided the required personal protective equipment (35.78%), and nearly half indicated their hospital has or had limited personal protective equipment availability (48.08%). Worldwide, a large majority of respondents answered affirmatively for testing the healthcare team (83.09%). Approximately half of the respondents (52.85%) across all regions indicated that all surgical team members face an equal risk of contracting coronavirus disease 2019 (52.85%). Nearly one‐third of respondents reported that they had experienced social avoidance (28.97%).

Conclusions

Our results show that urologists lack up‐to‐date knowledge of preferred protocols for personal protective equipment selection and use, social distancing, and coronavirus disease 2019 testing. These data can provide insights into functional domains from which other specialties could also benefit.

Effects of low versus standard pressure pneumoperitoneum on renal syndecan-1 shedding and VEGF receptor-2 expression in living-donor nephrectomy: a randomized controlled study

Background

Laparoscopic nephrectomy is a preferred technique for living kidney donation. However, positive-pressure pneumoperitoneum may have an unfavorable effect on the remaining kidney and other distant organs due to inflamed vascular endothelium and renal tubular cell injury in response to increased systemic inflammation. Early detection of vascular endothelial and renal tubular response is needed to prevent further kidney injury due to increased intraabdominal pressure induced by pneumoperitoneum. Transperitoneal laparoscopic living donor nephrectomy represented a human model of mild increasing intraabdominal pressure. This study aimed to assess the effect of increased intraabdominal pressure on vascular endothelium and renal tubular cells by comparing the effects of low and standard pressure pneumoperitoneum on vascular endothelial growth factor receptor-2 (VEGFR-2) expression and the shedding of syndecan-1 as the early markers to a systemic inflammation.

Methods

We conducted a prospective randomized study on 44 patients undergoing laparoscopic donor nephrectomy. Subjects were assigned to standard (12 mmHg) or low pressure (8 mmHg) groups. Baseline, intraoperative, and postoperative plasma interleukin-6, syndecan-1, and sVEGFR-2 were quantified by ELISA. Syndecan-1 and VEGFR-2 expression were assessed immunohistochemically in renal cortex tissue. Renal tubule and peritubular capillary ultrastructures were examined using electron microscopy. Perioperative hemodynamic changes, end-tidal CO₂, serum creatinine, blood urea nitrogen, and urinary KIM-1 were recorded.

Results

The low pressure group showed lower intra- and postoperative heart rate, intraoperative plasma IL-6, sVEGFR-2 levels and plasma syndecan-1 than standard pressure group. Proximal tubule syndecan-1 expression was higher in the low pressure group. Proximal-distal tubules and peritubular capillary endothelium VEGFR-2 expression were lower in low pressure group. The low pressure group showed renal tubule and peritubular capillary ultrastructure with intact cell membranes, clear cell boundaries, and intact brush borders, while standard pressure group showed swollen nuclei, tenuous cell membrane, distant boundaries, vacuolizations, and detached brush borders.

Conclusion

The low pressure pneumoperitoneum attenuated the inflammatory response and resulted in reduction of syndecan-1 shedding and VEGFR-2 expression as the renal tubular and vascular endothelial proinflammatory markers to injury due to a systemic inflammation in laparoscopic nephrectomy.

Trial registration

ClinicalTrials.gov NCT:03219398, prospectively registered on July 17th, 2017.

TUR-P phantom for resident surgical training: food-based design as a human mimicking model of the prostate

PURPOSE

This study would like to develop a novel model similar to human prostate in terms of its texture profile, sensation upon resection, and anatomical hallmarks for resident transurethral resection of the prostate (TUR-P) training.

METHODS

Ten phantom designs were proposed, using broadly available ingredients and a homemade protocol. Three steps of evaluation and development were done: objective measurement measuring texture profile (e.g. hardness, elasticity, cohesiveness/consistency, and adhesiveness/stickiness) using TA-XT2i Texture Analyzer (Llyod Instruments, Ametek Inc) to compare the designs with human prostate, finding the most similar design to prostate; expert consensus by a panel of urologist/senior residents comparing the simulation of TUR-P on the selected design with pre-existing control phantom; and anatomical design development using 3D printing for molding.

RESULTS

Texture profile analysis for mean hardness, elasticity, cohesiveness/consistency, and adhesiveness/stickiness of human prostate was 3753.4 ± 673.4, 85 ± 1.9, 0.7 ± 0.03, and 0, respectively, and design IX was the most similar to human prostate (3660.7 ± 465.6, 87.0 ± 2.5, 0.6 ± 0.05, 0). Furthermore, expert consensus showed superiority of design IX compared with pre-existing control phantom (16.95 ± 1.36 vs 8.86 ± 3.10; P < 0.001). Most of the respondents agreed that the texture, consistency, and phantom ability to mimic human prostate upon resection were similar with human prostate, though hallmarks of the prostate e.g. veromontanum, and lobes were lacking. We used these feedbacks to develop a mold, designed to produce these important anatomical hallmarks.

CONCLUSION

This study developed a cost-effective prostate model from a food-based design that is similar to human prostate in terms of its texture and sensation upon TUR-P resection provided with important anatomical hallmarks.

A randomized controlled trial on analgesic effect of repeated Quadratus Lumborum block versus continuous epidural analgesia following laparoscopic nephrectomy

BACKGROUND

Epidural analgesia as the effective pain management for abdominal surgery has side effects such as paresthesia, hypotension, hematomas, and impaired motoric of lower limbs. The quadratus lumborum block (QLB) has potential as an abdominal truncal block, however, its analgesic efficacy has never been compared to epidural analgesia on laparoscopic nephrectomy. This prospective randomized controlled study compared the effectiveness of QLB with the epidural analgesia technique in relieving postoperative pain following transperitoneal laparoscopic nephrectomy.

METHODS

Sixty-two patients underwent laparoscopic donor nephrectomy and were randomized to receive QLB (n = 31) or continuous epidural (n = 31). The QLB group received bilateral QLB using 0.25% bupivacaine and the epidural group received 6 ml/h of 0.25% bupivacaine for intraoperative analgesia. As postoperative analgesia, the QLB group received repeated bilateral QLB with the same dose and the epidural group received 6 ml/h of 0.125% bupivacaine for 24 h after surgery completion. The primary outcome was the 24-h cumulative morphine requirement after surgery. The secondary outcome was the postoperative pain scores. Sensory block coverage, hemodynamic changes, Bromage score, postoperative nausea-vomiting (PONV), paresthesia, and duration of urinary catheter usage were recorded and analyzed.

RESULT

The 24-h cumulative morphine requirement and pain scores after surgery were comparable between the QLB and epidural groups. The coverage of QLB was extended from T9 to L2 and the continuous epidural block was extended from T8 to L3 dermatomes. The mean arterial pressure (MAP) measured at 24 h after surgery was lower in the epidural group (p = 0.001). Bromage score, incidence of PONV, and paresthesia were not significantly different between the two groups. Duration of urinary catheter usage was shorter (p < 0.001) in the QLB group.

CONCLUSION

The repeated QLB had a similar 24-h cumulative morphine requirement, comparable postoperative pain scores and sensory blockade, higher postoperative MAP, a similar degree of motoric block, no difference in the incidence of PONV and paresthesia, and shorter urinary catheter usage, compared to the continuous epidural analgesia following transperitoneal laparoscopic nephrectomy.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03520205 retrospectively registered on May 9th 2018.

Comparison of Three-Quadrant Transversus Abdominis Plane Block and Continuous Epidural Block for Postoperative Analgesia After Transperitoneal Laparoscopic Nephrectomy

Background

Postoperative pain management is important for the early recovery of the living donor patient. Patient-controlled opioid analgesia, epidural analgesia, or a combination of both is the preferred pain management after abdominal surgery although these approaches have serious side effects. The transversus abdominis plane (TAP) block has been increasingly used for postoperative pain management and the addition of dexamethasone to local anesthetic can prolong the duration of action.

Objectives

This study evaluated the efficacy of ultrasound-guided three-quadrant TAP block analgesia with the addition of dexamethasone, compared to the continuous epidural analgesia in postoperative cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic living donor nephrectomy.

Methods

A prospective randomized control study was conducted on 50 patients with ASA I-II, 18 - 65 years old, BMI 18 - 30, and undergoing transperitoneal laparoscopic donor nephrectomy under general anesthesia. The patients were randomly assigned into either a three-quadrant TAP block group (n = 25) with 20 mL of 0.25% bupivacaine plus dexamethasone 8 mg or a continuous epidural group (n = 25) using 0.125% bupivacaine postoperatively. The morphine consumption and the numerical rating scale (NRS) at rest and movement were evaluated at 2, 6, 12, and 24 hours postoperatively. The postoperative first-time mobilization and duration of urinary catheter usage were recorded.

Results

Patients demographic characteristics were similar in the two groups. During 24 hours after the surgery, cumulative morphine consumption (P = 0.232), the NRS at rest and movement (P > 0.05), and the first-time mobilization (P = 0.075) were not significantly different between the groups, except that the NRS during movement at 12 hours was significantly lower in the TAP block group (P = 0.004). The duration of urinary catheterization was significantly longer as a side effect in the continuous epidural group (P < 0.001).

Conclusions

The three-quadrant TAP block with the addition of dexamethasone showed comparable analgesic effects as the continuous epidural analgesia in cumulative opioid consumption and pain scale in the first 24 hours following transperitoneal laparoscopic donor nephrectomy.

Prostate specific antigen (PSA) kinetic as a prognostic factor in metastatic prostate cancer receiving androgen deprivation therapy: systematic review and meta-analysis

Aim: Metastatic prostate cancer (mPCa) has a poor outcome with median survival of two to five years. The use of androgen deprivation therapy (ADT) is a gold standard in management of this stage.  Aim of this study is to analyze the prognostic value of PSA kinetics of patient treated with hormonal therapy related to survival from several published studies Method: Systematic review and meta-analysis was performed using literature searching in the electronic databases of MEDLINE, Science Direct, and Cochrane Library. Inclusion criteria were mPCa receiving ADT, a study analyzing Progression Free Survival (PFS), Overall Survival (OS), or Cancer Specific Survival (CSS) and prognostic factor of survival related to PSA kinetics (initial PSA, PSA nadir, and time to achieve nadir (TTN)). The exclusion criteria were metastatic castration resistant of prostate cancer (mCRPC) and non-metastatic disease. Generic inverse variance method was used to combine hazard ratio (HR) within the studies. Meta-analysis was performed using Review Manager 5.2 and a p-value <0.05 was considered statistically significant. Results: We found 873 citations throughout database searching with 17 studies were consistent with inclusion criteria. However, just 10 studies were analyzed in the quantitative analysis. Most of the studies had a good methodological quality based on Ottawa Scale. No significant association between initial PSA and PFS. In addition, there was no association between initial PSA and CSS/ OS. We found association of reduced PFS (HR 2.22; 95% CI 1.82 to 2.70) and OS/ CSS (HR 3.31; 95% CI 2.01-5.43) of patient with high PSA nadir. Shorter TTN was correlated with poor result of survival either PFS (HR 2.41; 95% CI 1.19 - 4.86) or CSS/ OS (HR 1.80; 95%CI  1.42 - 2.30) Conclusion: Initial PSA before starting ADT do not associated with survival in mPCa.  There is association of PSA nadir and TTN with survival.

Adherence of Indonesian urologists to practice guidelines for the management of benign prostatic hyperplasia

Background

Clinical guideline is built to provide consistent, efficient, and high quality of medical care based on recent evidence. This study aimed to investigate the adherence of Indonesian urologists to clinical guidelines for the management of benign prostatic hyperplasia (BPH).

Materials and methods

This was a cross-sectional study using questionnaire conducted between January and June 2017. Respondents were Indonesian urologists registered as members of Indonesia Urological Association and had already practice in urology for at least 6 months. Questionnaires were sent via e-mail and Google Form. The level of adherence was measured using scoring system decided by authors' agreement. All data were processed using SPSS, version 23, and presented in descriptive fashion.

Results

Of 352 urologists who fulfilled inclusion and exclusion criteria, 209 (59.4%) respondents returned the questionnaire. Most of respondents (95.2%) used Indonesia Urological Association BPH guidelines as their clinical practice guidance. Routinely performed recommended examination, such as symptom scoring system, digital rectal examination, urinalysis, uroflowmetry, postvoid residual urine, and prostate imaging were used by 89.9%, 92.5%, 70.4%, 50.8%, 53.3%, and 98.6% respondents, respectively. After patient is diagnosed with BPH, most of respondents considered medical therapy (99%), surgical therapy (93%), and watchful waiting (78.4), with alpha-blocker as the drugs most preferred by respondents. For indication to perform surgery for BPH, only bladder stones, decreased renal function, and trial without catheter failure were considered by more than 85% of respondents. Open prostate surgery was performed by 54.8% respondents for the following reasons: large prostate volume, presence of bladder stone, unavailability of endourology equipments, abnormality of bladder, and residency training program. At last, this study found median (minimum–maximum) of Indonesian urologists adherence level toward BPH guidelines is 78.5% (28.6%–100%).

Conclusions

In general, Indonesian urologists have a good adherence toward guidelines. However, there is still wide variation of their adherence to it.

Prostate cancer detection rate in Indonesian men

PURPOSES OF THE STUDY

To evaluate the overall detection rate of prostate cancer in biopsies according to serum prostate-specific antigen levels, determine the number of cores biopsied in Indonesian men, and provide a correlated staging of prostate cancer patients at varying intervals of prostate-specific antigen levels.

METHODS

We retrospectively analyzed the data from Indonesian men who had undergone prostate biopsy at two national referral medical centers in Jakarta from January 1995 to December 2014. Prostate biopsy was performed when levels of prostate-specific antigen were>4.0 ng/mL or malignancy was suspected upon digital rectal examination.

RESULTS

Of 2942 men who underwent biopsies, 844 (28.7%) were diagnosed with prostate cancer. When patients were stratified into five subgroups by serum prostate-specific antigen levels (< 4.0, 4.0-9.9, 10.0-19.9, 20.0-100.0, and>100.0 ng/mL), the overall detection rate of prostate cancer was 21.0%, 9.3%, 13.1%, 35.4%, and 92.9%, respectively. The detection rate was significantly higher in patients who underwent 10-core biopsies than in patients who underwent 6-core biopsies (31.6% vs. 22.4%, p<0.001). The receiver operating characteristic analysis to detect locally advanced/metastatic prostate cancer found that serum prostate-specific antigen levels of 42.7 ng/mL had a sensitivity of 74%, specificity of 73%, positive predictive value of 85.2%, and negative predictive value of 57.5%, with area under the curve of 0.81 (95% confidence interal 0.78 to 0.84).

CONCLUSION

The overall detection rate of prostate cancer in Indonesian men was 28.7%. The prostate cancer detection rate appeared to be lower than that observed in white men.

Expression of the Bcl-2 family genes and complexes involved in the mitochondrial transport in prostate cancer cells

Alteration of molecular pathways triggering apoptosis gives raise to various pathological tissue processes, such as tumorigenesis. The mitochondrial pathway is regulated by both the genes of the Bcl-2 family and the genes encoding mitochondrial transport molecules. Those proteins allow a release of cyctochrome c through the outer mitochondrial membrane. This release activates the caspase cascade resulting in death of cells. There are at least two main transport systems associated with the family of Bcl-2 proteins that are involved in transport of molecules through the outer mitochondrial membrane, i.e., the voltage dependent anion channels (VDACs) and translocases of the outer mitochondrial membrane proteins (TOMs). We investigated the expression of genes of the Bcl-2 family, i.e., pro-apoptotic Bak and Bid, and anti-apoptotic Bcl-2; VDAC gene, i.e., VDAC1, VDAC2 and VDAC3; and TOMM genes, i.e., TOMM20, TOMM22 and TOMM40. This study was performed at the mRNA and the protein level. Fourteen paraffin embedded prostate cancer tissues and five normal prostate tissues were analyzed by the quantitative PCR array and immunohistochemistry. We found a significant increase in both mRNA expression of the anti-apoptotic Bcl-2 gene and VDAC1 gene in prostate cancer tissue in comparison with their normal counterparts. Translation of the anti-apoptotic Bcl-2 and VDAC1 genes in prostate cancer tissue was slightly increased. We observed no significant differences in the mRNA expression of the pro-apoptotic Bak and Bid genes, VDAC2 or VDAC3 genes or the three TOMM genes in these tissues. The pro-apoptotic Bax protein was downtranslated significantly in secretory cells of prostate cancer as compared to normal prostate. We suggest that this protein is a good candidate as biomarker for prostate cancer.

Outcomes and predictors of localized or locally-advanced prostate cancer treated by radiotherapy in Indonesia

Purpose:

Presently there is no published data on the outcomes of localized or locally-advanced prostate cancer (PCa) treated by external-beam radiotherapy (RT) in Indonesia.

Methods:

This study retrospectively analyzed 96 patients with localized or locally-advanced PCa treated by RT from year 1995 to 2009, at the national referral hospital and the national cancer hospital of Indonesia. Cumulative prostate and pelvic radiation dose/type was <70 Gy conventional RT in 84.4% patients, and ≥70 Gy Three dimensional-conformal or intensity modulated RT in 15.6% patients. Overall survival (OS) and biochemical progression-free survival (BFS) were estimated by Kaplan-Meier. Predictors of OS and biochemical recurrence were analyzed by multivariate Cox regressions.

Results:

The median follow-up was 61 months (range, 24 to 169 months). There were 3.1% low-risk, 26% intermediate-risk, and 70.8% high-risk cases. More than half of the patients (52.1%) had pretreatment prostate-specific antigen (PSA) >20 ng/mL. The 5-year survival outcome of low-risk, intermediate-risk, and high-risk patients were: OS, 100%, 94.7%, and 67.9% (P=0.297); and BFS, 100%, 94.1%, and 57.1% (P=0.016), respectively. In the high-risk group, the 5-year OS was 88.3% in patients who received adjuvant hormonal androgen deprivation therapy (HT), compared to 53% in RT only, P=0.08. Significant predictors of OS include high-risk group (hazard Ratio [HR], 9.35; 95% confidence interval [CI], 1.52 to 57.6; P=0.016), adjuvant therapy (HR, 0.175; 95% CI, 0.05 to 0.58; P=0.005), detection by transurethral resection of the prostate (TUR-P) (HR, 6.81; 95% CI, 2.28 to 20.33; P=0.001), and pretreatment PSA (HR, 1.003; 95% CI, 1.00 to 1.005; P=0.039). The sole predictor of biochemical failure was pretreatment PSA (P=0.04), with odds ratio of 4.52 (95% CI, 1.61 to 12.65) for PSA >20 ng/mL.

Conclusions:

RT is an effective treatment modality for localized or locally-advanced PCa in Indonesian patients, with outcomes and predictors consistent to that reported elsewhere. Predictors of poorer outcomes include high-risk group, higher pretreatment PSA, incidental detection by TUR-P, and lack of adjuvant HT. Adjuvant hormonal therapy significantly improve the survival of high risk patients.

PRELIMINARY REPORT: LAPAROSCOPIC RADICAL PROSTATECTOMY IN JAKARTA

Objective: To report initial experience of laparoscopic radical prostatectomy (LRP) in Jakarta and evaluate the functional and oncology outcome. Material & Method: Between June 2007 until September 2008, we had done 9 times LRP surgery. All data is retrospectively taken and divided in three groups, i.e. pre-operative data (patient demography, pre-operative PSA, prostate volume, Gleason Score, clinical and functional staging), intra-operative data (intra-operative complication, conversion to open surgery, bleeding volume, and operating time), and post-operative data (post-operative complication, duration of urine catheter usage, duration of hospitalization, functional and oncology status). Results: Among nine subjects who underwent LRP, five subjects (55,55%) did not converted into open surgery. There are 2 subjects who gain their sexual potency and urine continence in one year post op. Only one subject is proven without biochemical failure in 1 year. Conclusion: We confirmed that radical prostatectomy can be performed with transperitoneal laparoscopic technique by a team that has been experienced in laparoscopic. Keywords: Laparoscopic radical prostatectomy, functional result, oncological result.

The value of prostate-specific antigen in Asia

One of the most important diagnostic tools used to detect prostate cancer is prostate-specific antigen (PSA), yet increased PSA alone does not reflect the presence of prostate cancer. Other pathological prostatic conditions such as prostatitis and benign prostatic hyperplasia (BPH) may also increase the level of PSA. However, unlike in other prostate diseases, PSA has a key role in the diagnosis and management of prostate cancer. The incidence of prostate cancer varies from country to country, with the highest incidence being found in the Western world and the lowest in Asian countries. Owing to the low incidence of prostate cancer, there could be different views regarding the use of PSA in Asian countries, especially for the early detection/screening of prostate cancer. The purpose of this article is to review the use and value of PSA in the diagnosis of prostate diseases (especially prostate cancer) in Asian countries/populations. A literature search was performed in 'MEDLINE' (PubMed) and Google Scholar using main keywords such as 'PSA', 'PSA usage', 'PSA sensitivity and specificity', 'Asia', and various countries in Asia. Articles that provide population/community-based PSA data, together with the characteristics, distribution, and indications for PSA testing in the respective countries, were selected. Eleven papers were finally selected for inclusion in this review. Five studies found that PSA, by its 95th percentile value, have an age-referenced tendency in Asian males, similarly to the West. The predictive values of PSA in detecting prostate cancer are also quite similar to those in Western countries. With the exponential growth of the aging population in the world, especially in Asia, the incidence of prostate cancer will follow this upward trend. Therefore, PSA testing for screening or diagnostic purposes would increase with time in Asia.

The Bell-Shaped Nitinol Prostatic Stent in the Treatment of Lower Urinary Tract Symptoms: Experience in 108 Patients

OBJECTIVES

To assess the efficacy, safety, and durability of the bell-shaped nitinol prostatic stent in the treatment of moderate to severe lower urinary tract symptoms caused by benign prostatic enlargement in otherwise healthy patients.

METHODS

Stents were inserted in an outpatient setting under local anaesthesia. Assessments included maximum urinary flow (Qmax), postvoid residual (PVR) urine volume, International Prostate Symptom Score (IPSS), including quality of life (QoL) item, at baseline and follow-up visits.

RESULTS

108 men were enrolled in the trial. Stents were successfully inserted in 97% of the patients. Spontaneous voiding was achieved in all patients. After one month Qmax (+3.7 ml/s), PVR (-99 ml), IPSS (-12) and QoL (-1.7) all showed statistically significant improvements compared to baseline. Substantial improvements, however, were maintained for only one to two months. The main complications were haematuria (19%), urge incontinence (22%), and migration (15%). The median indwelling time was 105 days. The main reason for removal of stents was worsening of symptoms, which might be attributable to the tilting of stents within the prostatic urethra, found upon removal.

CONCLUSIONS

Insertion of the bell-shaped nitinol prostatic stent temporarily improves voiding parameters and symptom scores. Because of the limited durability, however, the bell-shaped prostatic stent is not suitable for clinical practice.

Construct Validity of the Chicken Model in the Simulation of Laparoscopic Radical Prostatectomy Suture

BACKGROUND AND PURPOSE

For a simulation to be valid, it has to be close to reality, correlate with the performance in a real case, and be able to discriminate between individuals with different degrees of experience. We explored the construct validity (ability to discriminate between experienced and inexperienced subjects) of a simulation for the urethrovesical anastomosis during laparoscopic radical prostatectomy (LRP).

MATERIALS AND METHODS

Dead chickens were used. After partial emptying of the corporal cavity, an 18F catheter was placed through the esophagus to the stomach. In the Pelvic Trainer, a laparoscopic section of the esophago-glandular-stomach junction and a suture between the two edges were performed in the same fashion as for a urethrovesical suture in LRP. Five subjects with different levels of experience in laparoscopy, ranging from nil to more than 250 LRPs, tested two types of suture. One-way ANOVA was used to detect differences in suturing time among the operators. A multiple comparison test was used to detect specific differences between operators.

RESULTS

Although suturing time had a strong negative correlation with the operator's experience, significant statistical differences in suturing time were found only between the least experienced operator and the other ones. Qualitative differences in the suture were found among operators.

CONCLUSION

This simulation correlates well with the laparoscopic (LRP) subject's experience. It can discriminate between inexperienced and experienced subjects, exhibiting moderate construct validity, but failed to reflect the different levels of experience among the most experienced subjects.

Post-Void Residual Urine Volume is Not a Good Predictor of the Need for Invasive Therapy Among Patients With Benign Prostatic Hyperplasia

PURPOSE

We assessed the value of baseline PVR as predictor of the need for invasive therapy during long-term followup of patients with clinical BPH treated initially with alpha1-blockers or WW.

MATERIALS AND METHODS

The records of a cohort of 942 patients with BPH treated with alpha(1)-blockers or WW were reviewed. Baseline I-PSS scores, PSA, prostate volume, uroflowmetry, pressure flow parameters and followup data were collected prospectively. Correlations between PVR and other baseline parameters were calculated. The 5-year cumulative risks of invasive therapy were calculated with the Kaplan-Meier method. After stratification of PVR by various cutoff levels (50, 100 and 300 ml), rate ratios between large and small PVRs were calculated using proportional hazards analyses.

RESULTS

PVR has weak (-0.2<R <0.2) correlations with other baseline parameters. With increasing PVR cutoff levels, the 5-year cumulative risk of invasive therapy for the large PVR subgroup, increases from 45% to 64% and from 15% to 21% in the alpha1-blockers and WW group, respectively. Large PVR yields a significant 2-fold up to a 4-fold increased risk of invasive therapy compared to small PVR in both treatment groups. In multivariate models these significant risk differences largely disappear, although a statistically not significant higher risk remains for the large PVR (greater than 300 ml) patients.

CONCLUSIONS

In general, baseline PVR has little prognostic value for the risk of BPH related invasive therapy in patients on alpha1-blocker and WW. Only patients with large PVR have a 2-fold increased risk of invasive therapy compared to patients with smaller PVR.

Prognostic role of prostate-specific antigen and prostate volume for the risk of invasive therapy in patients with benign prostatic hyperplasia initially managed with alpha1-blockers and watchful waiting

OBJECTIVES

To investigate the prognostic role of prostate-specific antigen (PSA) level and prostate volume (PV) for the need for benign prostatic hyperplasia (BPH)-related invasive therapy among patients initially treated with an alpha1-blocker or watchful waiting (WW) in real-life clinical practice.

METHODS

Data were collected from 2264 consecutive patients with clinical BPH. Patients initially treated with an alpha1-blocker or WW were included in this study. They were stratified by baseline PSA level (less than 1.5, 1.5 to less than 3.0, 3.0 to 10.0 ng/mL) and PV (less than 30 and 30 to 200 cm3), and analyzed for the time to BPH-related invasive therapy.

RESULTS

Of the 2264 patients, 389 treated with alpha1-blockers and 553 who chose WW were included. Across the PSA and PV strata, the alpha1-blocker group had worse symptoms, peak flow, postvoid residual urine volumes, and obstruction than did the WW group. Increasing PSA levels produced an increase in the 5-year cumulative risk of invasive treatment: 20%, 34%, and 44% in the alpha1-blocker and 8%, 9%, and 15% in the WW group for a PSA level of less than 1.5, 1.5 to less than 3.0, and 3.0 to 10.0 ng/mL, respectively. The hazard ratio for the highest compared with the lowest PSA strata was 2.8 for alpha1-blocker and 2.7 for WW patients. An increasing PV increased the 5-year cumulative risk from 21% to 35% in the alpha1-blocker group and 8% to 11% in the WW group. The hazard ratio for the large versus small prostates in the alpha1-blocker group was 1.8 and in the WW group was 1.0.

CONCLUSIONS

A higher PSA level and larger PV resulted in a greater risk of BPH-related invasive therapy that was more pronounced in the alpha1-blocker than in the WW patients. However, symptom severity, flow parameters, and obstruction grade may have contributed to the difference in risk between the two treatment groups.

Prostate-Specific Antigen as an Estimator of Prostate Volume in the Management of Patients with Symptomatic Benign Prostatic Hyperplasia

OBJECTIVES

To assess the ability of serum prostate specific antigen (PSA) to estimate prostate volume (PV) to aid in the management of patients with benign prostatic hyperplasia (BPH).

METHODS

From 1989 to 2002, data were collected from 2264 patients complaining of lower urinary tract symptoms (LUTS) who visited the Department of Urology of the University Medical Centre Nijmegen, The Netherlands. Baseline PV and serum PSA was determined using standard techniques. All patients who had a baseline PV < or =200 ml, as well as a baseline serum PSA 0-10 ng/ml, were included. Patients with a history of prostate surgery, prostate cancer and conditions other than BPH at baseline were excluded. A log-transformed linear regression model was used to estimate PV. Receiver-operating characteristic (ROC) curves were constructed to evaluate the ability of serum PSA to estimate threshold PVs in men with BPH, and to select the optimal serum PSA cut-off values.

RESULTS

The analyses included 1859 patients with a mean age of 63.5 years, mean baseline PV 43.9 ml, and mean baseline PSA value 3.1 ng/ml. PV as well as serum PSA increases with age. Linear regression analyses showed that PV and serum PSA have an age-dependent log-linear relationship, where 42% of the variance of PV can be explained by PSA and age. ROC's area under the curves (AUC) reveal that PSA has a good predictive value for assessing 'prostate enlargement', with AUC around 82% in the overall age groups irrespective of the PV cut-off values. Optimal serum PSA cut-off values for the overall study population irrespective of age are 2.0 ng/ml to detect PV >30 ml and 2.5 ng/ml to detect PV >40 ml.

CONCLUSIONS

This study suggests that serum PSA can estimate prostate enlargement sufficiently accurately to be useful for therapeutic, especially medical, management. It is well accepted that the outcome of pharmacotherapy for BPH depends on baseline PV. Therefore, in the absence of reliable direct measurement of PV, serum PSA determination may be used to optimise patient management.

A higher PSA-density cut-off level in patients with intermediate PSA values for the early detection of prostate cancer

The use of PSA-density (PSAD) as an indicator for prostate biopsy at intermediate PSA values has generated controversy. There are investigators who consider that the determination of PSAD is futile, and that it is better to do a prostate biopsy based on PSA values alone, TRUS (Transrectal Ultrasound) findings and/or DRE examinations. Asian countries, especially in the Far East, are considered to have a low incidence of prostate cancer (PCa). However, based on western references, we still measure PSA-density with a cut-off level of 0.15 to promote prostate biopsy in patients with intermediate PSA values (4.1-10.0 ng/ml). Our study aims to evaluate the usefulness of PSAD as an indication for biopsy in patients with intermediate serum PSA values. To evaluate the usefulness of this indicator, we conducted a retrospective study of 132 uncatheterized (to minimize potential bias) BPH and PCa cases that were hospitalized in our department between 1995-1997 (3 years). This group comprised 127 BPH and 5 PCa patients. Mean age was 66.1 +/- 7.69 years; mean PSA was 7.92 +/- 9.289 ng/ml; mean prostate volume was 54.1 +/- 26.72 cc; mean PSAD was 0.15 +/- 0.185. More specifically, there were 49 patients with intermediate PSA values (47 BPH & 2 PCa). The receiver operator characteristic (ROC) curve revealed an optimum cut-off level of 0.19. At this level of PSA density, the measured sensitivity was 100% with a specificity of 79%. We concluded that, in our uncatheterized patients (without retention) series, the PSAD cut-off level for prostate biopsy (0.19) was higher than that in the western world (0.12 or 0.15).