Construction of a Retrospective Cohort to Observe 10-Year Urologic Cancer Treatment Trends at the Biggest Medical Center of South Korea

Purpose: To construct a urologic cancer database using a standardized, reproducible method, and to assess preliminary characteristics of this cohort.Materials and Methods: Patients with prostate, bladder, and kidney cancers who were enrolled with diagnostic codes in the electronic medical record (EMR) at Asan Medical Center from 2007–2016 were included. Research Electronic Data Capture (REDCap) was used to design the Asan Medical Center-Urologic Cancer Database (AMC-UCD). The process included developing a data dictionary, applying branching logic, mapping clinical data warehouse structures, alpha testing, clinical record summary testing, creating “standards of procedure,” importing data, and entering data. Descriptive statistics were used to identify rates of surgeries and numbers of patients.Results: Clinical variables (n=407) were selected to develop a data dictionary from REDCap. In total, 20,198 urologic cancer patients visited our institution from 2007–2016 (bladder cancer, 4,616; kidney cancer, 5,750; prostate cancer, 10,330). The overall numbers of patients and surgeries increased over time, with robotic surgeries rapidly growing over a decade. The most common treatment for urologic cancer was surgery, followed by chemotherapy and radiation therapy.Conclusions: Using a standardized method, the AMC-UCD fosters multidisciplinary research. This constructed database provides access to clinical statistics to effectively assist research. Preliminary data should be refined through EMR chart review. The successful organization of data from 2007–2016 provides a framework for future periods of investigation and prospective models.

Perioperative Outcomes of Different Surgical Methods Among Bladder Cancer Patients Undergoing Radical Cystectomy With Neobladder Urinary Diversion

Purpose: To compare perioperative outcomes according to surgical methods among bladder cancer patients who underwent radical cystectomy (RC) with neobladder urinary diversion.Materials and Methods: Between June 2007 and January 2020, 89 bladder cancer patients who received RC with neobladder urinary diversion were enrolled in this study. Patients were stratified into surgical methods – (1) open RC with neobladder (ONB) reconstruction, (2) robotassisted RC (RARC) with extracorporeal neobladder (ECNB) reconstruction, and (3) RARC with intracorporeal neobladder (ICNB) reconstruction. Perioperative outcomes were compared among the 3 groups, with major complications defined according to Clavien-Dindo grades III–V within 90 days. Logistic regression analysis was performed to identify significant factors for postoperative complications.Results: Of 89 patients, 28 (31%) had ONB, 31 (35%) had ECNB, and 30 (34%) had ICNB. The median operative time was 471 minutes, and the ICNB group (424.5 minutes) was significantly less than ONB (444.5 minutes) and ECNB groups (542.9 minutes) (p=0.001). Transfusion rate was also significantly less in the ICNB group (13%) (p=0.001). Complications were recorded in 67 patients (75%) and major complications in 22 of all patients (25%). The major complication rate was significantly less in ICNB (13.4%) than in ONB (25%) and ECNB (35%) (p=0.003). Multivariate analysis showed surgical methods (ICNB) (odds ratio [OR], 0.709; p=0.003) and age (OR, 1.150; p=0.001) were significant factors related to occurrence of major postoperative complications.Conclusions: RARC with ICNB reduces postoperative complications compared to ONB and ECNB.

Patient-Specific Tumor Microenvironment Models

The heterogeneity of cancer makes it difficult to predict the prognosis of treatment. There is still a lack of preclinical model systems that reflect the clinical characteristics of patients who have heterogenetic tumors. Advances in 3-dimentional (3D) cell culture are leading to discoveries that occur in the development and progression of cancer that has not been known. There are many models including patient-derived xenograft, patient-derived organoid and spheroid, patient-derived explant, scaffold-based model, and system-based model. Each 3D model has its strengths and limitations. One model cannot answer every question, so it seems most reasonable to approach multiple models when studying cancer heterogeneity. Hopefully, 3D tumor modeling will make tremendous progress on this path by fusion of innovative biomaterials and advanced modeling techniques that can partially mimic the heterogeneous environment of real tumors.

Risk Factors Leading to Radical Cystectomy in Patients Who Had Undergone Nephroureterectomy

Purpose: To identify the risk factors leading to radical cystectomy in patients who had undergone nephroureterectomy (NUx).Materials and Methods: We retrospectively reviewed the medical records of patients with upper tract urothelial carcinoma who underwent NUx during 2011–2019 and excluded patients with metastatic cancer. In total 646 patients were included in this study; of these, 532 had no previous bladder cancer history. Follow-up was performed every 3 months for 2 years after NUx was administered, and recurrence was confirmed using cystoscopy, urine cytology, computed tomography, and chest radiography. Bladder recurrence was confirmed through biopsy, urine cytology, or radiologic examination. Univariate and multivariate Cox regression analyzes were performed for statistical analysis of risk factors leading to radical cystectomy in patients undergoing NUx.Results: Lymphovascular invasion (LVI) (hazard ratio [HR], 4.728; 95% confidence interval [CI], 1.463–15.570; p=0.011), previous transurethral resection of bladder tumor history (HR, 3.825; 95% CI, 1.164–12.571; p=0.027), and intravesical recurrence (IVR) within 6 months (HR, 3.733; 95% CI, 1.091–12.778; p=0.036) in patients undergoing NUx are predictors of radical cystectomy implementation. In a multivariate analysis of patients without bladder cancer history, bladder recurrence was identified as a predictor of radical cystectomy implementation, if it occurred within 6 months of NUx (HR, 8.608; 95% CI, 1.545–47.976; p=0.014).Conclusions: LVI and IVR within 6 months and previous bladder cancer history are factors that can predict the need for radical cystectomy after NUx. Even in patients without bladder cancer history, early bladder recurrence within 6 months is a major predictor of radical cystectomy.

Double Retroperitoneal Hydatid Localization: A Case Report

The hydatid cyst is a parasitic pathology which is endemic in Tunisia and presents a public health problem. Hydatid cysts located in the retroperitoneum, especially around or in the kidney, are rare and only represent 5% of visceral locations. The kidney is the most commonly affected organ of the urinary tract. The psoas muscle is an uncommon location and not less than 70 cases have been cited. We report the case of an unusual presentation of a right kidney hydatid cyst associated with a psoas muscle location. To our knowledge, this association of double retroperitoneal location has not been reported in the literature.

Utility of Urinalysis as a Follow-up Surveillance Tool in Nonmuscle Invasive Bladder Cancer

Purpose: To evaluate the association between microscopic hematuria (MH) detected by surveillance urinalysis and cancer recurrence in nonmuscle invasive bladder cancer (NMIBC) patients.Materials and Methods: A total of 1,082 NMIBC patients who underwent transurethral resection of bladder tumor (TURB) procedures at Asan Medical Center between January 2017 and December 2019 were included. We retrospectively reviewed the follow-up data for these cases including cystoscopy, urinalysis, and urine cytology. The association between urine testing and cancer recurrence was assessed by both univariable and multivariable logistic regression analysis.Results: The study patients had a median age of 68 years (interquartile range, 60–75 years) and comprised 898 men and 184 women. Among the 1,428 TURB procedures conducted in this series, 548 of the lesions (38.4%) were diagnosed as low-grade and 880 (61.6%) as highgrade cancers. A total of 3,309 follow-up cystoscopies were conducted during the study period and were divided into high-grade (HG) (2,011 cases) and low-grade (LG) (1,298 cases) groups according to the latest TURB pathology. MH was found to have a statistically significant association with NMIBC recurrence in both the LG (odds ratio [OR], 1.57; 95% confidence interval [CI], 1.107–2.223; p=0.011) and HG (OR, 1.90; 95% CI, 1.434–2.517; p<0.001) groups.Conclusions: Urinalysis during follow-up may provide important information on cancer recurrence in NMIBC patients.

Subcutaneous Interleukin-2 Monotherapy for Metastatic Renal Cell Carcinoma in Korean Patients

Purpose: This study was a prospective single-arm clinical trial aimed at assessing the efficacy and toxicity of subcutaneous interleukin (IL)-2 monotherapy in patients with metastatic renal cell carcinoma (RCC).Materials and Methods: We enrolled 26 patients with metastatic RCC in this multicenter controlled trial. The patients received subcutaneous injections of recombinant IL-2 (BMI-rh-IL2, an aldesleukin biosimilar, BMIKOREA Co., Ltd.) in 5-week cycles. In the first week, the patients received a subcutaneous IL-2 loading dose of 18×106 IU once on treatment days 1–5, followed by 2 days of rest. In the following 3 weeks, they received a dose of 18×106 IU via subcutaneous injection once on treatment days 1 and 2. Then, the patients received a dose of 9×106 IU via subcutaneous injection once on treatment days 3, 4, and 5, followed by 2 days of rest. The primary end point was the objective response rate; the secondary end points were progressionfree survival (PFS) and safety.Results: Overall, 22 patients were included in the final per-protocol analysis. The objective response and the disease control rates were 13.64% (3 of 22), and 90.9% (20 of 22), respectively. The mean PFS was 5.55 months (95% confidence interval, 2.71–8.4). The proportion of patients who experienced a treatment-related grade 3 or 4 adverse event was 3.85% (1 of 26). There were no treatment-related deaths.Conclusions: In this study, the subcutaneous IL-2 monotherapy regimen demonstrated efficacy and safety comparable to those reported in previous studies of subcutaneous IL-2 monotherapy and was effective in Korean patients with metastatic RCC.

A Study on Metabolic Health Status as a Risk Factor for Female Bladder Cancer Incidence: Analysis From the National Health Checkups Database of Korea

Purpose: This study investigated metabolic health status as a risk factor for female bladder cancer using the National Health Checkups databases of Korea.Materials and Methods: We defined obesity if body mass index was ≥25 kg/m2 and normal weight as <25 kg/m2. Metabolic unhealthiness was defined when 3 or more criteria of metabolic syndrome were met. A total of 11,461,618 women who took National health Checkups between 2009 and 2012 were categorized as metabolic healthy normal weight (MHNW), metabolic unhealthy normal weight (MuHNW), metabolic health obese (MHO), and metabolic unhealthy obese (MuHO). Multivariable-adjusted Cox regression was done to analyze the hazard ratio of bladder cancer.Results: The mean age was 48±11.55 years and body mass index was 23.19±2.13 kg/m2. During 5.4±1.1 years of follow-up, 3,893 patients were newly diagnosed with bladder cancer. Compared to MHNW group, the hazard ratio of MuHNW group and MuHO group were 1.237 and 1.288, respectively, while 0.997 in the MHO group. As the number of metabolic unhealthy criteria increased, the cumulative incidence of bladder cancer increased.Conclusions: As a result of a large-scale study conducted on the female population in Korea, the risk of bladder cancer increased with metabolic unhealthiness. Even with normal weight, if metabolically unhealthy, the risk of bladder cancer increased. The greater the degree of metabolic unhealthiness, the higher the risk of bladder cancer. Education on metabolic healthiness concerning female bladder cancer is necessary.

Perioperative and Oncological Outcomes of 1,002 Consecutive Patients With Localized Renal Cell Carcinoma Treated by Robotic Partial Nephrectomy at a Single Center

Purpose: To analyze and compare the results of robotic partial nephrectomy (RPN) at a single center with the previous large-scale studies in terms of perioperative and oncological outcomes.Materials and Methods: We retrospectively evaluated 1,013 cases of RPN in our center database from December 2008 to August 2018. Total 11 cases were excluded in final analysis. We evaluated perioperative outcomes as the Trifecta achievement, which is defined as no positive surgical margin (PSM), no perioperative complications greater than Clavien-Dindo classification I and a warm ischemia time of <25 minutes. In addition, we analyzed pathological and oncological outcomes; recurrence, metastasis, all-cause deaths, cancer-specific deaths, and 5-year survival rates.Results: In 1,002 cases, the Trifecta achievement was 61.1% (n=612). The postoperative complication was 18.4% (n=184) but most were grade 2 or less (14.9%, n=145). Ninety-three cases (9.28%) had benign and 907 cases (90.5%) had malignant pathologies. A local recurrence were 14 cases (1.54%) and distant metastasis were 20 cases (2.2%) during follow-up periods. Allcause death rate was 1.2% (n=11) and cancer-specific death rate was 0.2% (n=2). The median follow-up period was 39 months. A 5-year recurrence-free survival rate, cancer-specific survival rate, and overall survival rate were 95.2%, 99.7%, and 98.4%.Conclusions: In summary, our data shows comparable perioperative outcomes to other largescale studies of RPN in terms of the Trifecta achievement with similar baseline characteristics. In terms of oncological outcomes, there was lower rate of PSM and similar recurrence free survival rate.

Usefulness of Prostate-Specific Antigen Density as an Indicator for Recommending Prebiopsy Magnetic Resonance Imaging to Prevent Missed Prostate Cancer Diagnoses

Purpose: To identify the indication for recommending prebiopsy magnetic resonance imaging (MRI) to prevent prostate cancer missed diagnoses in cases without prebiopsy MRI.Materials and Methods: Between January 2017 and September 2020, 585 patients suspected with prostate cancer underwent prostate biopsy after MRI. For patients with visible lesions, MRI-targeted biopsy using an image-based fusion program was performed in addition to the 12- core systematic biopsy. Patients for whom MRI was performed in other institutions (n=4) and patients who underwent target biopsy alone (n=7) were excluded.Results: Of 574 patients (median prostate-specific antigen [PSA] level, 6.88 ng/mL; mean age, 68.2 years), 342 (59.6%) were diagnosed with prostate cancer (visible lesions=312/449 [69.5%]; nonvisible lesions=30/123 [24.0%]). The detection rates of visible lesions stratified using the Prostate Imaging Reporting and Data System score (3 vs. 4 vs. 5) were 30.9% (54 of 175), 61.2% (150 of 245), and 90.1% (127 of 141), respectively. Multivariate analysis showed that PSA density was a significant factor for presence of visible lesions, prostate cancer, and significant prostate cancer diagnosis. Among patients with positive lesions, 27 (8.2%) were diagnosed with prostate cancer concomitant with negative systematic biopsy results. A PSA density of 0.15 ng/mL/cm³ was identified as the significant cutoff value for predicting positive target biopsy in groups with negative systematic biopsy. Sixty of the negative target lesions (26.1%) were diagnosed using systematic biopsy.Conclusions: To maximize cancer detection rates, both targeted and systematic biopsies should be implemented. PSA density was identified as a useful factor for recommending prebiopsy MRI to patients suspected with prostate cancer.