Purpose: To analyze the degree of psychological distress experienced pre- and postoperatively in patients who underwent radical prostatectomy after being diagnosed with prostate cancer. Materials and Methods: Patients diagnosed with prostate cancer who underwent radical prostatectomy without history of psychiatric disorders were included in this study. The degree of psychological distress was evaluated using hospital anxiety and depression scale (HADS) and distress thermometer (DT) questionnaires preoperatively and at 1, 3, 6, and 12 months postoperatively. Results: Distress was high preoperatively and decreased over the entire period. In addition, HADS-anxiety and HADS-depression scores showed an improved severity, shifting from an abnormal state to a borderline state in some patients. However, the DT score, including emotional problems, spiritual concerns, physical problems, family problems, and practical problems, was slightly higher at 1 month postoperatively compared to preoperatively. Furthermore, even at 12 months postoperatively, about one fifth of patients surveyed had a DT score of 4 or higher, requiring psychiatric intervention. Conclusions Before and after radical prostatectomy, a significant number of patients complained of distress such as anxiety, depression, and insomnia, and they needed help from a specialist because of psychological distress even 12 months postoperatively.Therefore, a close evaluation of the patient’s psychological distress and supportive treatment are needed during the entire pre- and postoperative period.

Cytoreductive nephrectomy (CN) has long been the standard of care for patients with metastatic renal cell carcinoma (mRCC) since 2 clinical trials revealed its role during the cytokines era. With discovery of novel and effective drugs, such as vascular endothelial growth factor-targeted therapies, the role of CN started to be challenged. The 2 recent prospective randomized trials Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques (CARMENA) and Immediate Surgery or Surgery After Sunitinib in Treating Patients with Metastatic Kidney Cancer trial (SURTIME) have changed the therapy paradigm for patients with mRCC. The CARMENA trial was performed to reveal whether CN is required in the targeted therapy, whereas SURTIME evaluated whether initial sunitinib can aid in the selection of patients who are most likely to benefit from subsequent CN or identify patients with innate resistance to targeted therapy. These trials suggest that CN does not provide a survival benefit for patients with poor‑risk disease. Especially, current evolutions in systemic therapies have demonstrated improved oncological outcomes from immunotherapy (IO) such as immune checkpoint inhibitor, particularly in its combination or combination with tyrosine kinase inhibitor. Accordingly, the role of CN continues to be questioned. Taken together, these findings reinforce the concept that the ultimate impact of CN on oncologic outcomes of mRCC patients in the era of IO still needs further investigation to represent a key for unmet clinical need.

Background: There is no clear consensus on the optimal treatment with curative intent for patients with positive surgical margins (PSMs) following radical prostatectomy (RP). The aim of this study was to investigate the perceptions and treatment patterns of Korean urologists regarding the resection margin after RP. Methods: A preliminary questionnaire was prepared by analyzing various studies on resection margins after RP. Eight experienced urologists finalized the 10-item questionnaire.In July 2019, the final questionnaire was delivered via e-mail to 105 urologists in Korea who specialize in urinary cancers. Results: We received replies from 91 of the 105 urologists (86.7%) in our sample population.Among them, 41 respondents (45.1%) had performed more than 300 RPs and 22 (24.2%) had completed 500 or more RPs. In the question about whether they usually performed an additional biopsy beyond the main specimen, to get information about surgical margin invasion during surgery, the main opinion was that if no residual cancer was suspected, it was not performed (74.7%). For PSMs, the Gleason score of the positive site (49.5%) was judged to be a more important prognostic factor than the margin location (18.7%), multifocality (14.3%), or margin length (17.6%). In cases with PSMs after surgery, the prevailing opinion on follow-up was to measure and monitor prostate-specific antigen (PSA) levels rather than to begin immediate treatment (68.1%). Many respondents said that they considered postoperative radiologic examinations when PSA was elevated (72.2%), rather than regularly (24.4%). When patients had PSMs without extracapsular extension (pT2R1) or a negative surgical margin with extracapsular extension (pT3aR0), the response ‘does not make a difference in treatment policy’ prevailed at 65.9%. Even in patients at high risk of PSMs on preoperative radiologic screening, 84.6% of the respondents said that they did not perform neoadjuvant androgen deprivation therapy. Most respondents (75.8%) indicated that they avoided nerve-sparing RP in cases with a high risk of PSMs, but 25.7% said that they had tried nerve-sparing surgery. Additional analyses showed that urologists who had performed 300 or more prostatectomies tended to attempt more nerve-sparing procedures in patients with a high risk of PSMs than less experienced surgeons (36.6% vs. 14.0%; P = 0.012). Conclusion The most common response was to monitor PSA levels without recommending any additional treatment when PSMs were found after RP. Through this questionnaire, we found that the perceptions and treatment patterns of Korean urologists differed considerably according to RP resection margin status. Refined research and standard practice guidelines are needed.

Purpose: To investigate whether estramustine phosphate (EMP) monotherapy is applicable to castration-resistantprostate cancer (CRPC) patients who cannot receive cytotoxic chemotherapy. Materials and Methods: This retrospective single-arm study was conducted in CRPC patients who had notexperienced cytotoxic chemotherapy and received EMP monotherapy (560 mg/day) at 2 institutions from 2008to 2017. We analyzed prostate-specific antigen (PSA) responses, overall survival, and adverse effects of EMPtreatment. Results: A total of 28 patients were analyzed. A reduction in serum PSA was observed in 11 patients (39.3%).Seven cases (25.9%) achieved more than 25% reduction of PSA, and 5 of them (18.5%) experienced more than50% reduction. Median overall survival was 23 months (interquartile range, 10–60 months). Multivariable analysesdemonstrated that low level of PSA at diagnosis of CRPC and long duration of prior androgen deprivation therapywere independent favorable factors predicting long-term overall survival. Adverse effects were edema (n=2; grade2), nausea/vomiting (n=1; grade 2), gynecomastia (n=1; grade 2), and dyspnea (n=1; grade 1). Neither thromboembolicevent nor grade 3–5 toxicity was observed. There was no discontinuation caused by side effects ofEMP. Conclusions EMP monotherapy could be considered as a safe treatment option with some effectiveness for CRPCpatients who did not undergo cytotoxic chemotherapy. EMP is not generally recommended anticancer drug in thecurrent guidelines for CRPC, but EMP monotherapy is thought to have an alternative role when a standard treatmentcannot be selected due to patient's age, health condition, or comorbidity.

Anomalies of the aortoiliac arteries are rarely reported and are generally discovered incidentally on imaging performed mostly for investigation of other medical concerns. While aortic bifurcation is typically reported at the fourth lumbar vertebra, variations are possible. We present a case with very low aortic bifurcation, almost at the level of S2, with various other anomalies including a corkscrew left common iliac artery passing just anterior to the bladder dome with pulsation noted during cystoscopy. An ectopic right kidney was also noted. To our knowledge, these vascular anomalies have not been reported previously.

Increasingly many studies have presented robotic simple prostatectomy (RSP) as a surgical treatment option for large benign prostatic hyperplasia (BPH) weighing 80–100 g or more. In this review, some frequently used RSP techniques are described, along with an analysis of the literature on the efficacy and complications of RSP and differences in treatment results compared with other surgical methods. RSP has the advantage of a short learning curve for surgeons with experience in robotic surgery. Severe complications are rare in patients who undergo RSP, and RSP facilitates the simultaneous treatment of important comorbid diseases such as bladder stones and bladder diverticula. In conclusion, RSP can be recommended as a safe and effective minimally invasive treatment for large BPH.

There is no clear consensus for the best treatment of men with locally advanced prostate cancer. As a first step, radiation therapy or primary hormone therapy or radical prostatectomy with extended pelvic lymph node dissection is used. But it seems impossible to have a good oncologic result with single treatment modality. Traditionally, external beam radiation therapy with adjuvant hormone therapy is most preferred treatment method in locally advanced prostate cancer and radical prostatectomy has not been routinely used because of high rates of margin positive and lymph node metastasis. But, recently published articles showed that surgery in multimodal setting is effective treatment modality and not inferior to radiation therapy in oncologic outcomes. Perioperative morbidities of surgery and incontinence rates are similar to surgery of organ confined diseases, and patients with primary radiotherapy seem to have high rate of lower urinary tract symptoms and radiation related complications compared with radical prostatectomy with adjuvant radiotherapy. There is still controversy in regard to performing surgery for locally advanced prostate cancer. We review the studies with surgery in locally advanced prostate cancer and compare with radiation therapy in multimodal setting, and review the studies with surgery in oligometastatic prostate cancer.
Consensus ; Humans ; Lower Urinary Tract Symptoms ; Lymph Node Excision ; Lymph Nodes ; Male ; Methods ; Neoplasm Metastasis ; Prostate* ; Prostatectomy ; Prostatic Neoplasms* ; Radiotherapy ; Radiotherapy, Adjuvant

Prostate cancer is the most common type of male cancer worldwide. Although radical prostatectomy (RP) is advised for prostate cancer in patients with a life expectancy of more than 10 years by various guidelines, most elderly men still do not undergo the procedure regardless of increasing life expectancy. This study aimed to determine whether RP is suitable for patients with prostate cancer aged 75 years or older. A retrospective study of patients who underwent RP at 6 institutions between 2005 and 2012 was conducted. Patients were divided into 2 groups at the time of surgery: 65-69 years (younger group) and 75 years or older (older group). We compared clinical characteristics, pathological results, complication rates, and recurrence-free survival between the two groups. Compared with the younger group, the older group had significantly higher preoperative serum prostate-specific antigen level, pre- and postoperative Eastern Cooperative Oncology Group (ECOG) performance status grade, hypertension prevalence, and Gleason score at biopsy and RP. However, except urinary incontinence, there were no statistically significant differences in the peri- and post-operative complications. After median follow-up periods of 36 months (younger group) and 40 months (older group), the biochemical recurrence-free survival rates were not significantly different (P = 0.581). Although the urinary incontinence rate was higher in the older group, RP was a suitable option for selected Korean men aged 75 years or older with limited complication rates and excellent outcomes similar to those for patients aged 65-69 years.
Age Factors ; Aged ; Biopsy ; Disease-Free Survival ; Humans ; Hypertension/epidemiology ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Grading ; Prostate-Specific Antigen/blood ; Prostatectomy ; Prostatic Neoplasms/mortality/pathology/*surgery ; Republic of Korea ; Retrospective Studies

PURPOSE: To compare the current management of benign prostatic hyperplasia (BPH) by urologists and nonurologists by use of Korean nationwide health insurance data. MATERIALS AND METHODS: We obtained patient data from the national health insurance system. New patients diagnosed with BPH in 2009 were divided into two groups depending on whether they were diagnosed by a urologist (U group) or by a nonurologist (NU group). RESULTS: A total of 390,767 individuals were newly diagnosed with BPH in 2009. Of these, 240,907 patients (61.7%) were in the U group and 149,860 patients (38.3%) were in the NU group. The rate of all initial evaluation tests, except serum creatinine, was significantly lower in the NU group. The initial prescription rate was higher in the U group, whereas the prescription period was longer in the NU group. Regarding the initial drugs prescribed, the use of alpha-blockers was common in both groups. However, the U group was prescribed combination therapy of an alpha-blocker and 5-alpha-reductase inhibitor as the second choice, whereas the NU group received monotherapy with a 5-alpha-reductase inhibitor. During the 1-year follow-up, the incidence of surgery was significantly different between the U group and the NU group. CONCLUSIONS: There are distinct differences in the diagnosis and treatment of BPH by urologists and nonurologists in Korea. These differences may have adverse consequences for BPH patients. Urological societies should take a leadership role in the management of BPH and play an educational role for nonurologists as well as urologists.
5-alpha Reductase Inhibitors/therapeutic use ; Adrenergic alpha-Antagonists/therapeutic use ; Adult ; Age Distribution ; Aged ; Aged, 80 and over ; Databases, Factual ; *Disease Management ; Humans ; Insurance, Health ; Linear Models ; Male ; Middle Aged ; Physicians ; Prostatic Hyperplasia/*diagnosis/*therapy ; Republic of Korea ; Urology/*methods ; Young Adult

PURPOSE: Heat shock protein (HSP) 27 protects the cell by controlling apoptosis and immune reactions, and c-FLIP (cellular-FLICE inhibitory protein) inhibits apoptosis by inhibiting caspase-8 activity. We investigated the relationship of HSP27 and c-FLIP expression to prostate-specific antigen, Gleason score sum (GSS), and pathologic stage. MATERIALS AND METHODS: Samples from 163 patients between May 2004 and April 2010 were analyzed: 83 from patients that had underwent a radical prostatectomy, and 80 from those that underwent transurethral resection of the prostate to alleviate urinary symptoms from benign prostate hyperplasia. c-FLIP and HSP27 expression were observed by immunohistochemistry staining. Samples with less than 5% expression-positive cells were scored as 1, with 5%-50% were scored as 2, and with more than 50% were scored as 3. Local reactions were identified as 0.5 and evaluated. RESULTS: Both the presence of HSP27 within the tumor and the number of cancer cells positive for HSP27 were significantly correlated to GSS and pathologic stage (p<0.001, p=0.001, p<0.001, p<0.001). The same was true for c-FLIP expression (p<0.001). GSS was more highly correlated to HSP27 expression than to c-FLIP expression (r=0.814 for HSP27, r=0.776 for c-FLIP), as was pathologic stage (r=0.592 for HSP27, r=0.554 for c-FLIP). CONCLUSIONS: In prostate cancer, higher GSS and a more advanced pathologic stage were associated with a higher likelihood of having a HSP27-positive tumor and more HSP27-positive tumor cells. HSP27 expression was correlated with GSS and prostate cancer stage. A more advanced pathologic stage corresponded to a higher likelihood of having a c-FLIP-positive tumor and more c-FLIP-positive tumor cells. HSP27 expression had a higher correlation with prostate cancer stage and GSS than c-FLIP expression did.
Aged ; Biomarkers, Tumor/*metabolism ; CASP8 and FADD-Like Apoptosis Regulating Protein/*metabolism ; HSP27 Heat-Shock Proteins/*metabolism ; Humans ; Lymphatic Metastasis ; Male ; Middle Aged ; Neoplasm Grading ; Neoplasm Proteins/metabolism ; Neoplasm Staging ; Prostatectomy/methods ; Prostatic Hyperplasia/metabolism/surgery ; Prostatic Neoplasms/*metabolism/pathology/surgery ; Transurethral Resection of Prostate