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Purpose To compare surgical outcomes between the lateral and the posterior approach for retroperitoneal laparoscopic adrenalectomy (RLA). Materials and methods We retrospectively reviewed the records of 130 patients who underwent RLA for adrenal tumors by a single surgeon between January 2015 and December 2018. Patient characteristics and perioperative outcomes were analyzed and compared between two surgical groups: lateral approach (n=56) and posterior approach (n=74). Results There were no significant differences in perioperative outcomes between the two groups except for operative time (lateral approach, 105.4±41.21 minutes vs. posterior approach, 71.5±31.51 minutes; p=0.001). In the lateral approach group, two patients (3.6%) underwent open conversion, but there were no major complications in either group (Clavien-Dindo classification ≥3). Male sex was associated with an operative time of ≥90 minutes in the univariate analysis (p=0.019), but this effect did not remain significant in the multivariate analysis. In the multivariate analysis, large tumor size (>5 cm; p=0.020) and preoperative diagnosis of malignancy (p=0.043) were significantly associated with an operative time of ≥90 minutes. Conclusions Both the lateral and posterior approaches for RLA were performed safely with similar operative outcomes and are therefore comparable options for the treatment of adrenal tumors. In addition, large tumor size and preoperative diagnosis of malignancy are associated with longer operative times.

Aim To elucidate the precise cellular and molecular mechanisms that underlie urethral fibrogenesis. Methods Endoluminal electrocautery injury (using Karl Storz 10 Fr. Pediatric urethroscope) was employed in male rabbits (n = 6) to create mucosal injury. Retrograde urethrogram (RUG) and endoluminal ultrasound techniques were used to assess severity and changes in luminal cross-sectional area. Six control rabbits were subjected to sham injury, in which the electrocautery was inserted but not powered. Urethral tissues were harvested 30 days postinjury and subjected to RNA sequencing and quantitative polymerase chain reaction (qPCR) to determine changes in gene expression. Histological, immunostaining, and Western blot studies were used to determine changes in protein expression of known markers of fibrosis (eg, collagen, Integrinαv, GIV/Girdin, transforming growth factor-β (TGF-β), and pSMAD1,2,3). Results Trichrome staining confirmed increased connective tissue in urethral scar tissues. Immunostaining revealed a potential role for epithelial to mesenchymal cell transition (EMT) and positive labeling for all fibrotic markers (eg, collagen-1, Integrin αv, GIV/Girdin, transforming growth factor-β (TGF-β), and SMAD1,2,3). Western blot analysis confirmed increased protein levels of these fibrotic markers. Conclusion Our RNA sequencing and qPCR studies, in conjunction with our protein data, suggest that urethral mucosal fibrogenesis may be mediated by novel fibrogenic signaling pathways involving Wnt-β catenin, TGF-β, GIV/Girdin, and EMT which lead to increased collagen deposition. Therapeutic strategies targeting these pathways may be beneficial in attenuating fibrogenesis and stricture progression.

PURPOSE This study aims to investigate the trend in medical travel by non-Seoul residents to Seoul for treatment of prostate cancer and also to investigate the possible factors affecting the trend. Materials and Methods This study represents a retrospective cohort study using data from theKoreanNationalHealth Insurance System from 2002 to 2015. Annual trends were produced for proportions of patients who traveled according to the age group, economic status and types of treatment. Multiple logistic analysiswas used to determine factors affecting surgeries at medical facilities in Seoul among the non-Seoul residents. RESULTS A total of 68,543 patients were defined as newly diagnosed prostate cancer cohorts from 2005 to 2014. The proportion of patients who traveled to Seoul for treatment, estimated from cases with prostate cancer-related claims, decreased slightly over 9 years (28.0 at 2005 and 27.0 at 2014, p=0.02). The average proportion of medical travelers seeking radical prostatectomy increased slightly but the increase was not statistically significant (43.1 at 2005 and 45.4 at 2014, p=0.26). Income level and performance ofrobot-assisted radical prostatectomy were significant positive factors for medical travel to medical facilities in Seoul. Combined comorbidity diseases and year undergoing surgery were significant negative factors for medical travel to medical facilities in Seoul. CONCLUSION The general trend of patients travelling from outside Seoul for prostate cancer treatment decreased from 2005 to 2014. However, a large proportion of traveling remained irrespective of direct distance from Seoul.

Objectives To estimate the prevalence of fluoroquinolone-resistant rectal flora in patients undergoing transrectal ultrasound-guided prostate needle biopsy and to identify the high-risk groups. Methods From January 2015 to March 2016, rectal swabs of 557 men who underwent transrectal ultrasound-guided prostate needle biopsy were obtained from five institutions. Clinical variables, including demographics, rectal swab culture results and infectious complications, were evaluated. Univariable and multivariable analyses were used to identify the risk factors for fluoroquinolone resistance of rectal flora and infectious complications. Results The incidence of fluoroquinolone-resistant and extended-spectrum beta-lactamase production was 48.1 and 11.8%, respectively. The most common fluoroquinolone-resistant bacteria was Escherichia coli (81% of total fluoroquinolone-resistant bacteria, 39% of total rectal flora), and 16 (2.9%) patients had infectious complications. Univariable and multivariable analysis of clinical parameters affecting fluoroquinolone resistance showed no factor associated with fluoroquinolone resistance of rectal flora. The clinical parameter related to infectious complications after prostate biopsy was a history of operation within 6 months (relative risk 6.60; 95% confidence interval 1.99-21.8, P = 0.002). Conclusions These findings suggest that a risk-based approach by history taking cannot predict antibiotic resistance of rectal flora, and physicians should consider targeted antibiotic prophylaxis or extended antibiotic prophylaxis for Korean patients undergoing transrectal ultrasound-guided prostate biopsy because of high antibiotic resistance of rectal flora.

Background A complete enumeration study was conducted to evaluate trends in national practice patterns and direct medical costs for prostate cancer (PCa) in Korea over a 10-year retrospective period using data from the Korean National Health Insurance Service. Methods Reimbursement records for 874,924 patients diagnosed between 2002 and 2014 with primary PCa according to the International Classification of Disease (ICD) 10th revision code C61 were accessed. To assess direct medical costs for patients newly diagnosed after 2005, data from 68,596 patients managed between January 2005 and 31 December 2014 were evaluated. Results From 2005 to 2014, the total number of PCa patients showed a 2.6-fold increase. Surgery and androgen deprivation therapy were the most common first-line treatment, alone or within the context of combined therapy. Surgery as a monotherapy was performed in 23.5% of patients in 2005, and in 39.4% of patients in 2014. From 2008, the rate of robot-assisted RP rose sharply, showing a similar rate to open RP in 2014. Average total treatment costs in the 12 months post-diagnosis were around 10 million Korean won. Average annual treatment costs thereafter were around 5 million Korean won. Out-of-pocket expenditure was highest in the first year post-diagnosis, and ranged from 12 to 17% thereafter. Conclusions Between 2005 and 2014, a substantial change was observed in the national practice pattern for PCa in Korea. The present data provide a reliable overview of treatment patterns and medical costs for PCa in Korea.

The aim of this study was to evaluate the effect of povidone-iodine rectal disinfection and targeted antimicrobial prophylaxis in men undergoing transrectal ultrasound-guided prostate biopsy based on rectal swab culture results. From January 2011 to December 2015, we studied differences in infectious complications in men who received povidone-iodine rectal disinfection with targeted antimicrobial prophylaxis and those who received empirical prophylaxis before transrectal ultrasound-guided prostate biopsy. Clinical variables including demographics, prior antibiotic, rectal swab culture results, povidone-iodine rectal cleansing, antibiotic prophylaxis, and infectious complications were evaluated. Patients were divided into three groups as follows: Group A received no povidone-iodine rectal cleansing but received empirical antimicrobial prophylaxis; group B received povidone-iodine rectal cleansing and empirical antimicrobial prophylaxis; and group C received povidone-iodine rectal cleansing and targeted antimicrobial prophylaxis. Patients were divided into group A (n = 192; 13.2 %), group B (n = 579; 39.9 %), or group C (n = 679; 46.8 %). In groups A and B, all patients received fluoroquinolone antimicrobial prophylaxis. Group C patients received targeted antimicrobial prophylaxis according to antibiotic resistance of rectal flora, and 71.1 % of these received fluoroquinolone antimicrobial prophylaxis. Infectious complication rates were 3.6, 2.9, and 1.3 % in group A, group B, and group C, respectively. Incidences of acute prostatitis and bacteremia were significantly lower in group C (p = 0.041 and p = 0.049, respectively) than in the other groups. In the era of quinolone resistance, the combination of povidone-iodine rectal cleansing and targeted antibiotic prophylaxis may reduce the rate of infectious complications.

Objective To investigate the effects of testosterone on cavernosal endothelial progenitor cells (EPCs) in a castrated rat model. Materials and methods In all, 45 male Sprague–Dawley rats (12-weeks old) were divided into control, surgical castration, and castration with testosterone replacement groups. The rats were castrated under ketamine anaesthesia, and testosterone was administered by daily subcutaneous injection of 3 mg/kg testosterone propionate. The corpus cavernosum was obtained after perfusion with 10 mL saline via the abdominal aorta 4 weeks later. The expression of EPC-specific markers [cluster of differentiation 34 (CD34), fetal liver kinase 1 (Flk1), and vascular endothelial (VE)-cadherin] was evaluated by flow cytometry analysis and immunofluorescence staining. Results CD34+/Flk1+ and CD34+/VE-cadherin+ cells were detected in the cavernosal sinusoidal endothelial space. Flow cytometry analysis showed that CD34 and Flk1 double positive cells (EPCs) comprised ≈3.79% of the corpus cavernosum in normal rats. The percentage of EPC marker-positive cells decreased significantly in the castration group (2.8%; P < 0.05) and was restored to 3.56% after testosterone supplementation. Confocal microscopy revealed that the numbers of CD34+/Flk1+ and CD34+/VE-cadherin+ cells decreased in castrated rats compared with controls, but were similar to control levels in rats receiving testosterone replacement. Conclusions The EPC markers were expressed in the cavernosal sinusoidal endothelial space, and the numbers of resident EPCs were regulated by testosterone. These results suggest that testosterone replacement therapy may improve erectile function by modulating EPCs in patients with hypogonadism.

Background: We investigated the efficacy of desmopressin in elderly patients with nocturnal polyuria (NP) to evaluate its effects on sleep quality. Methods: Patients with NP (defined as the nighttime urine production >33% of total 24-hour urine volume determined from a frequency-volume chart) were recruited. Desmopressin (0.2 mg) was treated orally at bedtime for 12 weeks. The participants completed the Medical Outcomes Study (MOS) Sleep Scale. Results: The mean patient age was 62.7 ± 13.0 (range 42-78 years). The mean symptom duration was 42.2 ± 39.7 months. The number of nocturia episodes (from 3.49 ± 1.83 to 2.03 ± 1.35, p = 0.01), nocturnal urine volume (p = 0.01), NP index (p = 0.01), and nocturia index (p = 0.01) decreased significantly after treatment with desmopressin. Among the MOS Sleep Scale categories, hours slept/night (p = 0.042), shortness of breath (p = 0.019), and adequacy of sleep (p = 0.001) changed significantly with a decrease in the number of nocturia episodes. Adverse events were mild. Conclusions: Desmopressin is an effective treatment for NP and improved sleep quality in elderly men.

Retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) are currently the gold standard imaging technique for diagnosis of urethral stricture and determination of stricture location. However, RUG and VCUG have multiple limitations. These techniques require exposure to ionizing radiation, the quality is operator and patient dependent, there is a moderate degree of invasiveness with urethral catheterization, can have artifacts because of patient positioning that underestimates stricture length. The development of novel imaging modalities without ionizing radiation to accurately evaluate the presence, location, length, and lumen cross-sectional area (CSA) of the urethral stricture would be of great value. The objective of this study was to develop a novel endoluminal ultrasound (ELUS) imaging technique that permits the accurate quantitation of urethral stricture.Urethral strictures were created in rabbits (n = 5) by electrocautery and an ELUS technique was developed for subsequent luminal imaging. A 3.2F 40 MHz ultrasound (US) probe was introduced transurethrally and infused with US contrast agent. Images were recorded as the catheter was pulled back at a constant speed to acquire tomographic images. Lumen CSA over the entire urethral length was calculated using a custom methodology and validated in our laboratory.Urethral luminal CSA over the entire length of urethra before and after experimental stricture development was quantified including the length of stenosis. Intra- and interobserver variability (r = 0.99 for both) was excellent.Feasibility of ELUS as a quantitative technique to determine healthy urethral lumen and stricture CSA was demonstrated. The translational potential for a nonionizing imaging modality to better describe CSA, length, location, and uninvolved urethral CSA of the stricture is a significant improvement over current methodology.

To investigate whether histological inflammation detected in an initial prostate biopsy can predict the risk of prostate cancer on a repeat biopsy. This was a retrospective study of 171 patients who underwent repeat prostate biopsy for persistently elevated prostate-specific antigen after an initial negative biopsy result. The enrolled patients were divided into two groups according to the results of the repeat biopsy: the noncancer group (n = 126) and the cancer group (n = 45). Multivariate regression analysis was used to determine the effect of inflammation grade, aggressiveness, and prostate-related parameters on the detection of prostate cancer at the repeat biopsy. Prostate inflammation grade (p = 0.005) and aggressiveness (p = 0.001) in the initial biopsy were significantly different between the cancer and noncancer groups. Factors associated with the risk of prostate cancer at the repeat biopsy were age [odds ratio (OR) 1.08; 95 % confidence interval (CI) 1.03–1.14], prostate-specific antigen density (OR 24.30; 95 % CI 9.3–62.9), prostate-specific antigen velocity (OR 1.05; 95 % CI 1.01–1.09), and inflammation aggressiveness (OR 0.05; 95 % CI 0.01–0.27). A histological inflammatory finding at the initial prostate biopsy was negatively associated with prostate cancer detection in repeat biopsy. This result could be useful to determine the need for repeat prostate biopsy in patients with persistently elevated prostate-specific antigen.

Objectives To evaluate the surgical feasibility of laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of large pheochromocytomas, and to identify the preoperative risk factors for intraoperative hypertension. Methods We retrospectively reviewed 51 patients who underwent laparoscopic adrenalectomy using the lateral retroperitoneal approach for the treatment of pheochromocytomas. Patient characteristics and perioperative outcomes were analyzed and compared between the two study groups based on tumor size: group A (n = 27, ≤6 cm) and group B (n = 24, ˃6 cm). Results There was no significant difference in preoperative characteristics between the two groups except for tumor size (P = 0.001) and urinary metanephrine (P = 0.011). Group B patients required longer operating time (P = 0.008), had a greater estimated blood loss (P = 0.001) and hemoglobin change (P = 0.002). However, no significant differences were observed in perioperative complications and mortality. Multivariate analysis showed that symptomatic pheochromocytomas (P = 0.004) and tumor size (P = 0.007) were significant risk factors for intraoperative hypertension. Conclusions Laparoscopic adrenalectomy using the lateral retroperitoneal approach for pheochromocytomas can be regarded as a treatment option, even for tumors measuring >6 cm. Symptomatic pheochromocytomas and large tumor size seem to represent risk factors for intraoperative hypertension.

Purpose: Systemic inflammatory responses, which are defined in terms of the Glasgow prognostic score (GPS), have been reported to be independent predictors of unfavorable outcomes in various human cancers. We assessed the utility of the GPS as a predictor of intravesical recurrence after radical nephroureterectomy (RNU) in upper urinary tract carcinoma (UTUC). Materials and Methods: We collected data for 147 UTUC patients with no previous history of bladder cancer who underwent RNU from 2004 to 2012. Associations between perioperative clinicopathological variables and intravesical recurrence were analyzed by using univariate and multivariate Cox regression models. Results: Overall, 71 of 147 patients (48%) developed intravesical recurrence, including 21 patients (30%) diagnosed with synchronous bladder tumor. In the univariate analysis, performance status, diabetes mellitus (DM), serum albumin, C-reactive protein, GPS, and synchronous bladder tumor were associated with intravesical recurrence. In the multivariate analysis, performance status (hazard ratio [HR], 2.33; 95% confidence interval [CI], 1.41–3.85; p=0.001), DM (HR, 2.04; 95% CI, 1.21–3.41; p=0.007), cortical thinning (HR, 2.01; 95% CI, 1.08–3.71; p=0.026), and GPS (score of 1: HR, 6.86; 95% CI, 3.69–12.7; p=0.001; score of 2: HR, 5.96; 95% CI, 3.10–11.4; p=0.001) were independent predictors of intravesical recurrence. Conclusions: Our results suggest that the GPS as well as performance status, DM, and cortical thinning are associated with intravesical recurrence after RNU. Thus, more careful follow-up, coupled with postoperative intravesical therapy to avoid bladder recurrence, should be considered in these patients.

To evaluate the effect of bent distortion of the image of the prostate on the accuracy of 3-dimensional measurements during transrectal ultrasonography (TRUS).TRUS images were obtained prospectively from 60 patients with prostate cancer. The degree of rectal compression on the probe was varied in each case to obtain a typical bent distortion image (BDI) and a minimally bent image (MBI). Magnetic resonance imaging (MRI) served as the reference. Axial and midsagittal BDI, MDI, and MRI were selected. Three-dimensional prostate diameters (height, width, and length) and volume were obtained from all images by 2 independent observers. The data were analyzed by using a paired t test, intraclass correlation coefficients (ICCs), and Bland-Altman plots.The MBI and BDI diameters differed significantly (P .001). All ICCs for the MBI diameters and volume and the ICCs for BDI length and volume exceeded 0.9, which indicates high measurement reliability. However, the ICCs for BDI height and width were below 0.9. When the difference in MBI or BDI relative to MRI was calculated for each variable, the MBI differences were all significantly smaller than the BDI differences (P .001).Bent distortion during TRUS affects the accuracy of measurements. MBI is also morphologically more realistic than BDI. Therefore, to minimize prostatic image distortion, the rectal probe should be placed so that the posterior wall of the prostate is as flat as possible.

We investigated the value of the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) as markers of mortality in patients with Fournier's gangrene.Records from 62 patients treated for Fournier's gangrene between 2003 and 2014 were reviewed retrospectively. Data were collected regarding medical history, symptoms, physical examination findings, admission laboratory tests, and the extent of body surface area involved (%). Fournier's Gangrene Severity Index score, NLR, and PLR were calculated. The data were assessed separately for surviving and deceased patients.Of the 62 patients, 36 survived (58%, group 1) and 26 died (42%, group 2). Parameters that were statistically different between the two groups (p 0.05) were the NLR, PLR, Fournier's Gangrene Severity Index score, and admission laboratory parameters, including body temperature, heart rate, bicarbonate, albumin, and serum calcium. The average body surface area affected in group 2 was statistically different from that of group 1 (6.0% versus 2.3%, p = 0.001). A high Fournier's Gangrene Severity Index score (9), high NLR (8), and high PLR (140) were associated more frequently with group 2 patients. Multivariable regression analysis showed that high NLR (adjusted odds ratio [OR], 4.66; 95% confidence interval [CI], 1.25-17.3; p = 0.022) and high PLR (adjusted OR, 11.6; 95% CI, 2.7-49.5; p = 0.001) were independent prognostic factors for poor prognosis from Fournier's gangrene. However, the Fournier's Gangrene Severity Index score did not shown any statistically significant effect on mortality (p = 0.086).The Fournier's Gangrene Severity Index scoring system was not associated with determining poor prognosis, however, high NLR and high PLR were associated with predictors of mortality in patients with Fournier's gangrene.

PURPOSE The purpose of this study is to evaluate the effect of diabetes mellitus (DM) and preoperative glycemic control on prognosis in Korean patients with upper tract urothelial carcinoma (UTUC) who underwent radical nephroureterectomy (RNU). MATERIALS AND METHODS A total of 566 patients who underwent RNU at six institutions between 2004 and 2014 were reviewed retrospectively. Kaplan-Meier and Cox regression analyses were performed to assess the association between DM, preoperative glycemic control, and recurrence-free, cancer-specific, and overall survival. RESULTS The median follow-up period was 33.8 months (interquartile range, 41.4 months). A total of 135 patients (23.8%) had DM and 67 patients (11.8%) had poor preoperative glycemic control. Patients with poor preoperative glycemic control had significantly shorter median recurrence-free, cancer-specific, and overall survival than patients with good preoperative glycemic control and non-diabetics (all, p=0.001). In multivariable Cox regression analysis, DM with poor preoperative glycemic control showed association with worse recurrence-free survival (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.31 to 3.90; p=0.003), cancer-specific survival (HR, 2.96; 95% CI, 1.80 to 4.87; p=0.001), and overall survival (HR, 2.13; 95% CI, 1.40 to 3.22; p=0.001). CONCLUSION Diabetic UTUC patients with poor preoperative glycemic control had significantly worse oncologic outcomes than diabetic UTUC patients with good preoperative glycemic control and non-diabetics. Further investigation is needed to elucidate the exact mechanism underlying the impact of glycemic control on UTUC treatment outcome.

To evaluate the effect of the prostatic urethral angle (PUA) on the peak flow rate (Qmax) and urinary symptoms in the clinical setting.The records were obtained from a prospectively maintained database for first-visit men with lower urinary tract symptoms. Uroflowmetric measurements, postvoid residual urine volume, and International Prostate Symptom Score were assessed. The prostate-related parameters, including prostate volume, PUA, and intravesical prostatic protrusion, were measured using transrectal ultrasonography. Patients with comorbidities that can affect voiding function or in whom the PUA could not be measured were excluded.A total of 316 patients were included. On multivariate linear regression analysis, the PUA (P = .002) was independently associated with the International Prostate Symptom Score. However, the International Prostate Symptom Score was not influenced by patient age, prostate volume, or intravesical prostatic protrusion. The mean PUA was significantly different according to symptom severity. The mean PUA was 42.2° ± 7.0°, 45.5° ± 9.1°, and 47.3° ± 8.6° in patients with mild, moderate, and severe symptoms, respectively (P = .004, analysis of variance). Although the PUA (P.001) and patient age (P.001) were independent predictors of Qmax, the prostate volume and intravesical prostatic protrusion did not affect the Qmax. The mean PUA was 52.2° ± 7.3° in patients with a Qmax10 mL/s, 45.0° ± 7.9° in those with a Qmax ≥10 mL/s but20 mL/s, and 39.8° ± 7.9° in those with a Qmax of ≥20 mL/s (P.001, analysis of variance).The results of our study has shown that the PUA is significantly associated with the Qmax and symptom scores in men with lower urinary tract symptoms. Our findings suggest that the PUA should be considered in the treatment of male patients with lower urinary tract symptoms.

Objective: Our intent was to investigate the impact of specific parameters—clinical status, performance status (Eastern Cooperative Oncology Group (ECOG)), C-reactive protein, serum albumin, and inflammation (Glasgow Prognostic Score)—on progression-free survival and overall survival in patients given systemic chemotherapy as the first-line treatment of advanced bladder cancer. Methods: A total of 67 patients treated for advanced bladder cancer in a 7-year period (2004‐ 10) were reviewed. Prior to administration of first-line chemotherapy (gemcitabine plus cisplatin), baseline ECOG performance status, C-reactive protein, albumin, Glasgow Prognostic Score and clinical status were assessed. Patients with both elevated C-reactive protein (.1.0 mg/dl) and low albumin (,3.5 mg/dl) were assigned a Glasgow Prognostic Score of 2, while lesser scores were set when one (Glasgow Prognostic Score 1) or both levels (Glasgow Prognostic Score 0) were within the normal range. To evaluate relationships to progressionfree survival and overall survival, univariate and multivariate analyses were conducted. Results: By multivariate analysis, ECOG performance status (hazard ratio ¼ 3.48, 95% confidence interval 1.87‐6.45, P ¼ 0.001) and hypoalbuminemia (hazard ratio ¼ 2.04, 95% confidence interval 1.10‐3.78, P ¼ 0.023) were found to be factors independently associated with reduced progression-free survival. Factors independently associated with shortened overall survival were ECOG performance status (hazard ratio ¼ 5.32, 95% confidence interval 2.22‐ 12.71, P ¼ 0.001) and Glasgow Prognostic Score 2 (hazard ratio ¼ 7.00, 95% confidence interval 2.53‐19.36, P ¼ 0.001). Conclusions: These outcomes indicate that a systemic inflammatory response coupled with hypoalbuminemia (Glasgow Prognostic Score 2) correlates significantly with shortened overall survival and may thus be useful as a prognostic index in this setting.

Objective To introduce a novel method to successfully remove organized hematoma. Endoscopic evacuation can be troublesome in some patients with a large amount of blood clots or organized hematoma. Methods We retrospectively reviewed medical records of 15 patients who were treated with a so-called “suction and fishing method” for severe clot retention. A large-bore catheter connected with a wall suction unit was inserted into the bladder through the resectoscope sheath, and subsequently a large volume of urine retention and quite a substantial amount of soft clots were removed (suction step). After awhile, negative pressure could not work when the catheter met large and organized fragments of blood clots. In this situation, large blood clots hanging on the catheter tip were removed by gently removing the catheter (fishing step). Results In all patients, clot retention was successfully managed with this method. Clot evacuation was performed without anesthesia in 9 patients when electrocauterization was not planned, and opioid analgesics were sufficient for pain control. In the other 6 patients, clot evacuation and fulguration were performed under anesthesia. Median time for clot evacuation was 20 minutes (range 5–55) and median estimated volume of clot evacuated was 200 mL (range 50–600). There was no procedure-related complication such as bladder rupture. Conclusion The suction and fishing method is a simple, safe, and successful way to evacuate severe organized clot retention. It can resolve intractable clot retention and rapidly relieve related symptoms without anesthesia.

Purpose: Few studies have explored the treatment of isolated communicating hydroceles via scrotal incision. We prospectively evaluated the surgical outcomes of such treatment in boys with hydroceles compared with that using traditional, inguinal incision hydrocelectomy. Materials and Methods: Of 347 boys aged 0–12 years who were diagnosed as hydrocele on ultrasonography, 173 boys were assigned to the scrotal incision hydrocelectomy group (group I, n=173) and 172 boys were assigned to the traditional inguinal incision hydrocelectomy group (group II, n=172), and finally 156 boys in group I and 156 boys in group II were included in this study. Surgical outcomes, including postoperative complications and hydrocele relapse rates, were compared between groups. Results: The overall success rates were similar in both groups (group I, 96.8%; group II, 89.1%; p=0.740). The operation time and hospital stay were significantly shorter in group I (30.94±3.95 minutes and 3.94±0.30 days) than in group II (38.02±7.12 minutes and 4.24±0.99 days; p

We compared the efficacy and safety of multiple session 99% ethanol sclerotherapy to single session OK-432 sclerotherapy for the treatment of simple renal cysts.Between September 2004 and November 2006, 41 patients (50 cysts, group 1) underwent sclerotherapy with 99% ethanol at least twice and 48 (61 cysts, group 2) underwent a single session of OK-432 sclerotherapy. Followup was performed with ultrasound or computerized tomography every 3 months for 1 year. Complete regression of the renal cyst or more than 70% reduction with no symptoms was considered successful treatment.There was no significant difference in the mean size of renal cysts between the 2 treatment groups. The overall success rate was 84.0% in group 1 and 98.4% in group 2. For cysts smaller than 500 ml there was a similar complete regression rate between the 2 groups whereas in cysts 500 ml or larger the complete regression ratio of group 2 was higher than group 1. The symptom relief rate of group 2 was higher than group 1. In group 1 there were 2 patients with a recurrent cyst but in group 2 there was no enlargement of the aspirated cysts. For cysts smaller than 200 ml neither treatment group had complications whereas in cysts 200 ml or larger the frequency of complications was higher in group 1.Single session OK-432 sclerotherapy is simpler, safer and more effective than multiple session 99% ethanol sclerotherapy for the treatment of simple renal cysts, especially large cysts.

Objectives An analysis of differentially expressed genes (DEGs) between bladder transitional cell carcinoma (TCC) and the surrounding urothelium to help identify what lies behind the mechanism of multifocal tumor development has not yet been performed. We sought to find a new DEG related to the development of bladder TCC. Methods Thirty-nine bladder TCC tissues paired with normal-appearing urothelium tissues obtained from the same patient were used as subjects. Initially, we compared the messenger RNA (mRNA) profiles between normal-appearing urothelium and TCC tissue of 1 patient by using annealing control primer (ACP)-based GeneFishing polymerase chain reaction (PCR) and selective amplification of family members (SAFM) PCR to identify potential DEGs. To validate the results of the ACP data, reverse transcriptase-polymerase chain reaction (RT-PCR) was performed on those of all 39 patients. Results Among the several DEGs discovered in the ACP data, 1 DEG was chosen as the candidate for the RT-PCR, that is present or markedly upregulated in normal-appearing urothelial tissue compared with TCC tissue. Gene sequence searching revealed that this DEG is chicken ovalbumin upstream promoter-transcription factor I (COUP-TFI). Downregulation of COUP-TFI mRNA expression in TCC tissue compared to normal-appearing urothelium tissue of the same patient, irrespective of tumor stage and grade, was confirmed by RT-PCR in 39 patients. Conclusions Our results suggest that the loss of COUP-TFI may play a role in the transition from normal epithelium to TCC. Further characterization of the COUP-TFI gene is expected to give us informations about bladder TCC tumorigenesis.

Purpose The bladder outlet obstruction index (BOOI), also known as the Abrams-Griffiths (AG) number, is the most widely used index for predicting BOO. However, the obstructed prostatic urethra determined by the BOOI is often inconsistent with endoscopically-proven obstruction. We assessed abdominal straining pattern as a novel parameter for improving the prediction of BOO. Materials and Methods We retrospectively reviewed the pressure-flow studies (PFS) and cystourethroscopy in 176 BPH/LUTS patients who were unresponsive to medical therapy. During PFS, some groups of patients tried to urinate with abdominal straining, which can increases intravesical pressure and underestimate BOOI theoretically. Accordingly, the modified BOOI was defined as (PdetQmax+ΔPabd)-2Qmax. Results Ultimately, 130 patients were eligible for the analysis. In PFS, ΔPabd (PabdQmax-initial Pabd) was 11.81±13.04 cmH2O, and it was 0–9 cmH2O in 75 (57.7%), 10–19 cmH2O in 23 (17.7%) and ≥20 cmH2O in 32 (24.6%) patients. An endoscopically obstructed prostatic urethra in 92 patients was correctly determined in 47 patients (51.1%) by the original BOOI versus 72 patients (78.3%) based on the modified BOOI. Meanwhile, an “unobstructed” urethra according to the original BOOI was present in 11 patients (12.0%), whereas according to the modified BOOI, only 2 (2.1%) would be labeled as “unobstructed”. In receiver operating characteristic curves, the area under the curve was 0.906 using the modified BOOI number versus 0.849 in the original BOOI (p

Background Epididymal anomalies and patent processus vaginalis are frequently found in boys with cryptorchidism or hydrocele. We conducted this study to evaluate the association between epididymal anomalies and testicular location or patent processus vaginalis in boys with undescended testis or hydrocele. Methods Children undergoing surgery with undescended testis (group A, 136 boys and 162 testes) or communicating hydrocele (group B, 93 boys and 96 testes) were included. Testicular locations and epididymal anomalies were investigated prospectively. An anomalous epididymis was defined as anomalies of epididymal fusion that consisted of loss of continuity between the testis, the epididymis, and the long looping epididymis. The epididymis was considered normal when a normal, firm attachment between the testis, the caput, and the cauda epididymis was present. Results The mean ages of groups A and B were 24.6 ± 19.7 (range, 8–52 months) and 31.4 ± 20.6 months (range, 10–59 months). The incidence of epididymal anomalies was significantly higher in group A than that in group B (65.4 % vs. 13.5 %, P

The appearance of extended-spectrum beta-lactamase (ESBL)-producing gram-negative bacteria in urinary tract infection (UTI) constitutes an important therapeutic challenge. The aim of this study was to describe drug susceptibility profiles of ESBL-producing bacteria isolated from urine samples. We also determined the antimicrobial co-resistance to several agents, including fosfomycin.The computerized database was used to identify ESBL-positive urine samples. We analyzed E. coli and Klebsiella isolates obtained from urine cultures, and duplicate isolates and isolates not tested against fosfomycin were excluded. The cases were further categorized according to UTI definition [community-acquired (CoA) UTI, community-onset health care-associated (HCA) UTI, and hospital-acquired (HA) UTI]. ESBL isolates were stratified according to their origin into two groups: urology and non-urology isolates.Antimicrobial susceptibilities of the strains to fosfomycin were tested in 277 ESBL-positive strains, 217 ESBL-EC strains, and 60 ESBL-KP strains. The most effective agents were carbapenems, such as imipenem and meropenem. The least active substances were ciprofloxacin (20.7 %), levofloxacin (22.7 %), trimethoprim-sulfamethoxazole (34.3 %), and ampicillin-clavulanate (42.9 %). Overall, 243 out of the 277 (87.7 %) isolates tested were susceptible to fosfomycin. Higher fosfomycin sensitivity was observed in E. coli (94.9 %) compared to Klebsiella (61.7 %) (p = 0.001). ESBL-positive isolates from urological (68 isolates) and non-urological patients (209 isolates) showed similar susceptibility profiles. Other than carbapenems, isolates from CoA-UTI showed higher sensitivity to fosfomycin (100 %) and nitrofurantoin (93.1 %), isolates from HCA-UTI showed higher sensitivity to amikacin (94.1 %), and isolates from HA-UTI showed overall poor sensitivity to antibiotics.Fosfomycin could be an alternative treatment option for UTIs related to ESBL-producing E. coli spp. and CoA-UTI, but not for UTIs related to ESBL-producing Klebsiella spp. Antimicrobial susceptibilities of ESBL-producing strains were different according to the UTI classification. Fosfomycin showed decreased activity against isolates from HCA-UTI and HA-UTI. However, further clinical verification is required to assess the clinical efficacy of fosfomycin for the treatment of UTIs caused by ESBL-producing E. coli isolates.

This study was conducted to introduce a simple modification that can facilitate microsurgical subinguinal varicocelectomy (MSV) especially for surgeons inexperienced in microsurgical technique. A single surgeon performed microsurgical intermediate subinguinal varicocelectomy (MISV) on 52 patients with 61 cases between September 2010 and August 2012. Patient age, varicocele grade, operation time, intraoperative findings, postoperative complications, and 3-month follow-up results were analyzed. Patient mean age was 28 years (range, 15–69 years), and there were 9 bilateral cases. The mean operative time was 51 minutes (range, 34–109 minutes). We compared the first 31 cases to the second 30 cases, to assess investigator experience on operating times. The mean number of ligated veins was 5 (range, 3–10) in internal spermatic vein, 1 (range, 0–4) in external spermatic vein, and 1 (range, 0–3) in gubernacular vein. In 28 patients, the average postoperative sperm concentration at the 3-month follow-up was significantly higher than the preoperative sperm concentration (28.5 ± 18.2 × 106/mL versus 10.5 ± 23.0 × 106/mL; P = 0.003). Mean motility improved after MSIV (65.7% ± 18.2% versus 47.2% ± 21.7%; P = 0.004). In conclusion, MISV appears comparable with MSV in terms of the high success rate, low complication rate, and low postoperative pain; and it can be easily accomplished by inexperienced surgeons.

Patients with lower urinary tract symptoms (LUTS) have a higher prevalence of cardiovascular disease. We evaluated the correlation between LUTS and cardiovascular risk factors in men presenting with benign prostatic hyperplasia (BPH).We retrospectively reviewed the medical records of 295 men with transurethral resection of the prostate for the treatment of BPH and LUTS. Risk factors for cardiovascular disease included: hypertension, diabetes mellitus (DM), smoking, and dyslipidemia. The severity of LUTS measured by the International Prostatic Symptom Score (IPSS), prostate volume, prostate specific antigen (PSA), maximal urinary flow rate (Qmax), and postvoid residual urine (PVR) in subjects with or without cardiovascular risk factors were compared.IPSS-total (22.9 ± 7.8 vs. 21.2 ± 7.3, P = 0.01) and obstructive symptom score (13.3 ± 5.2 vs. 11.9 ± 4.7, P = 0.01) was significantly different between men with hypertension and without cardiovascular risk factors. There was no significant difference of variables between subjects with DM, smoking or dyslipidemia and without cardiovascular risk factors. In the Pearson correlation, the systolic and diastolic blood pressure (BP) were related with prostate volume (r = 0.138, P = 0.040; r = 0.163, P = 0.020), IPSS-total (r = 0.139, P = 0.043; r = 0.138, P = 0.043), and an obstructive symptom score (r = 0.168, P = 0.014; r = 0.143, P = 0.037), respectively.Men with hypertension are more likely to have a higher IPSS and large prostate volume than men without hypertension. This finding implicates a pathophysiological association between hypertension and LUTS, and the need to manage comorbid symptoms simultaneously.

Studies of predictive factors of extracorporeal shockwave lithotripsy (ESWL) failure in patients with ureteral stones have not yielded results sufficient to prevent ESWL failure. The present study investigated patients with ureteral stone and analyzed the predictive factors of ESWL failure. Ninety patients with ureteral stone treated from January 2006 to June 2012 using ESWL for ureteral stone were enrolled. Patient's demographic data including age, gender, body mass index (BMI), symptoms and calculous characteristics including location, size, episode and the grade of hydronephrosis were recorded. Statistical results were performed using univariate and multivariate analyses for the predictive factors of ESWL failure. In univariate analysis, calculous location, size, and grade of hydronephrosis between two groups displayed significant differences (p0.05). The predictive factors of ESWL failure were BMI25 kg/m(2) [Odds ratio (OR) = 3.5, 95% confidence interval (CI) 1.1-11.0], calculous size ≥ 1 cm (OR = 10.5, 95% CI 3.0-36.2), calculous location (mid-ureter; OR = 8.49, 95% CI 1.5-45.7) and severe grade of hydronephrosis (OR = 12.3, 95% CI 1.9-79.5). In conclusions, ESWL failure can be predicted in cases of obesity, calculous size exceeding 1 cm, mid-ureteral stone and severe hydronephrosis. When we consider calculous management in patients with these risk factors, initial surgical approach is recommended instead of ESWL.

Objective: We compared renal function before and after pyeloplasty in children with unilateral ureteropelvic junction obstruction (UPJO) according to the children's age. Methods: We reviewed the medical records of 36 children with UPJO who had undergone pyeloplasty and showed improved urine drainage on postoperative diuretic renal scan. The children were divided into two groups according to their age at the time of surgery: group I, ≤1 year of age (n = 15), and group II, >1 year of age (n = 21). Parenchymal thickness (PT) and pelvic anteroposterior diameter measured by ultrasonography and renal function measured by 99mTc-MAG3 renal scan were compared before and after surgery. Results: Group I patients, who underwent pyeloplasty within 1 year of birth, showed significant recovery of the PT ratio at follow-up evaluation (from 0.50 ± 0.13 preoperatively to 0.83 ± 0.23 postoperatively; p = 0.029) compared with that in group II (from 0.74 ± 0.23 preoperatively to 0.75 ± 0.18 postoperatively; NS). The mean differences in the PT ratio before and after surgery were 0.29 ± 0.25 and 0.02 ± 0.18 in groups I and II, respectively. Conclusion: This result suggests that early surgery improves subsequent parenchymal growth of the involved renal unit.

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.

To determine landmarks for stent positioning in both ureteral orifices (UOs) and the gender differences in their location in men and women. The location of the UO and the bladder neck (BN) was measured fluoroscopically by the intravesical distal location of an open-ended catheter marked with radiopaque materials. We compared the location in men (n = 12) and women (n = 12) with a full bladder (hydrostatic pressure of 50 cmH2O) or an empty bladder. The mean distances from BN to UO in men and women were significantly different both in an empty bladder (2.5 ± 0.4 and 2.1 ± 0.3 cm, respectively) and in a full bladder (2.9 ± 1.0 and 2.3 ± 0.6 cm, respectively). The location of UO was changed by bladder filling in women but not in men. In women, most UOs were found superior to the symphysis pubis (SP) in empty bladder (66.6 %). Most of this location was observed at behind the upper boarder of SP in full bladder of women (75 %). The BN of women was located at the lower level in basal state compared to men. Also, the location of BN was markedly changed by bladder fulling in women (p = 0.04) but not in men. Significant gender differences were observed in the location of UO and BN. Clinicians should keep in mind the anatomical differences between men and women during fluoroscopic-guided procedure.

The aim of this study is to evaluate the efficacy of alfuzosin with methylprednisolone on expulsion and pain control of lower ureteral stones

Purpose To assess the clinical utility of laparoendoscopic single-site surgery (LESS) nephrectomy using a modified umbilical incision and home-made transumbilical port in cases requiring extirpative surgery. Materials and Methods Initial consecutive 18 patients underwent LESS nephrectomies that were performed by a single surgeon. A home-made port was placed through a modified umbilical incision, the length of which had preoperatively been determined. The laparoscopic transperitoneal nephrectomy procedures were performed with various combinations of standard and articulating laparoscopic instruments. Patient characteristics and perioperative outcomes, including pathologic results, were recorded prospectively. Results All 18 extirpative surgeries, including simple nephrectomy (eight cases), radical nephrectomy (nine cases), and nephroureterectomy (one case), were completed successfully. The median operation time was 167 min (range 82-220), and the median blood loss was 250 mL (range 0-1050). All specimens were extracted intact through a modified umbilical incision (median length 2.5 cm, range 1.5-6.0). Final pathological analysis revealed a nonfunctioning kidney in five cases, a dysplastic kidney in three cases, a mixed epithelial and stromal tumor in one case, renal cell carcinoma in eight cases (T1: five cases, T3: three cases), and Ta ureter transitional cell carcinoma in one case. Conclusion LESS nephrectomy using a home-made port and modified umbilical incision is feasible with both minimal incision and cost-effective. Our technique may be more useful for extirpative procedures in which a specimen needs to be removed intact, because incision length can be freely adjusted. Prospective comparisons are warranted to more clearly elucidate the utility of this surgical technique.

To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy.From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed.Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group.The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomy.

We developed a nomogram to predict the probability of extracapsular extension (ECE) in localized prostate cancer and to determine when the neurovascular bundle (NVB) may be spared. Total 1,471 Korean men who underwent radical prostatectomy for prostate cancer between 1995 and 2008 were included. We drew nonrandom samples of 1,031 for nomogram development, leaving 440 samples for nomogram validation. With multivariate logistic regression analyses, we made a nomogram to predicts the ECE probability at radical prostatectomy. Receiver operating characteristic (ROC) analyses were also performed to assess the predictive value of each variable alone and in combination. The internal validation was performed from 200 bootstrap re-samples and the external validation was also performed from the another cohort. Overall, 314 patients (30.5%) had ECE. Age, Prostate specific antigen (PSA), biopsy Gleason score, positive core ratio, and maximum percentage of biopsy tumor were independent predictors of the presence of ECE (all P values

Purpose Endoscopic urethrotomy is an alternative method in treatment of urethral stricture. However, it have high recurrence rate because of the remained fibrotic tissue. Removal of the fibrotic tissue can maintain the patency of the urethral lumen after the procedure. We report the therapeutic efficacy of our initial experience using pediatric resectoscope for treating anterior urethral stricture in 16 cases. Materials and Methods From January 2009 to April 2011, transurethral resection with pediatric resectoscope was primarily performed on 16 patients with anterior urethral stricture. Retrograde urethrography, uroflowmetry, postvoid residual volume, IPSS score and QoL score were performed preoperatively. We used 11.5Fr pediatric resectoscope (Wolf) and monopolar electrosurgical generator. The stricture was incised under vision at the 12 o'clock location or the site of maximum scar tissue or narrowing in asymmetric strictures for working space. After incision, transurethral resection with pediatric resectoscope was performed to all scar tissues. Monopolar cutting current was set on 45 watt and coagulation current was set on 30 watt, fulgurate mode. Postoperatively, drainage of the bladder was performed for 7 days using an 18F latex catheter. Patients were followed up by IPSS score, QoL score, uroflowmetry and postvoid residual volume. Results Successful results without recurrence were achieved in 11 of 16patients. Postoperative urethral dilation had been performed average 2.4 times (0∼6 times). When we classified the results by etiology, the number of successful results in strictures with a trauma, iatrogenic, or unknown cause was 5 (7/11), 3 (3/4) and 1 (1/1), respectively. In 5 patients who failed treatment, we repeated transurethral resection with pediatric resectoscope in 1 patient, and periodic urethral dilation in 4 patients. No operative complications occurred in any patients. Conclusions Transurethral resection with pediatric resectoscope is an effective therapeutic method for anterior urethral stricture. More long-term follow-up and large scale studies are needed to confirm the efficacy of this procedure.

Purpose Due to the availability of serum prostate specific antigen (PSA) testing, the detection rate of insignificant prostate cancer (IPC) is increasing. To ensure better treatment decisions, we developed a nomogram to predict the probability of IPC. Materials and Methods The study population consisted of 1,471 patients who were treated at multiple institutions by radical prostatectomy without neoadjuvant therapy from 1995 to 2008. We obtained nonrandom samples of n = 1,031 for nomogram development, leaving n = 440 for nomogram validation. IPC was defined as pathologic organ-confined disease and a tumor volume of 0.5 cc or less without Gleason grade 4 or 5. Multivariate logistic regression model (MLRM) coefficients were used to construct a nomogram to predict IPC from five variables, including serum prostate specific antigen, clinical stage, biopsy Gleason score, positive cores ratio and maximum % of tumor in any core. The performance characteristics were internally validated from 200 bootstrap resamples to reduce overfit bias. External validation was also performed in another cohort. Results Overall, 67 (6.5%) patients had a so-called "insignificant" tumor in nomogram development cohort. PSA, clinical stage, biopsy Gleason score, positive core ratio and maximum % of biopsy tumor represented significant predictors of the presence of IPC. The resulting nomogram had excellent discrimination accuracy, with a bootstrapped concordance index of 0.827. Conclusion Our current nomogram provides sufficiently accurate information in clinical practice that may be useful to patients and clinicians when various treatment options for screen-detected prostate cancer are considered.

Purpose We report herein 119 patients with pheochromocytoma at our institute over the last 23 years. Materials and methods Between 1986 and 2009, 119 patients were diagnosed with pheochromocytoma at our institute. We reviewed the medical records of these patients. Results Of 119 patients, 45 were male and 74 were female, and mean age was 43.83 ± 13.49 years. Forty-three patients (36.1%) were diagnosed incidentally, and 8 patients (6.7%) were found to have familial pheochromocytoma. The mean dimension of the tumors was 5.89 ± 3.18 cm. 4 patients had bilateral tumors; three of these patients were found to have familial pheochromocytoma and 1 patient was diagnosed with malignant pheochromocytoma. A total of eight patients (6.7%) were found to have malignant pheochromocytoma. In 1 patient, metastasis to a lymph node was found at the time of diagnosis. Metastases were found at a mean of 49 ± 25.83 (6-75) months after surgery in the other seven patients. 6 patients died of malignant pheochromocytoma at a mean of 31 ± 28.71 months (1-81) after diagnosis, and the other 2 patients survived for 15 and 24 months, respectively. Conclusion Approximately 35% of patients with pheochromocytoma are diagnosed incidentally, and the number of detected cases is increasing. Although familial pheochromocytoma was found only in 6.7% of the patients, genetic testing should be considered in all patients, especially in patients with a family history, young age, or multifocal, bilateral, extra-adrenal, or malignant tumors. Given that malignant pheochromocytomas are frequently diagnosed during the follow-up period, long-term follow-up is necessary to confirm the absence of recurrence or metastasis.

Recently, increasing numbers of robotic-assisted laparoscopic radical prostatectomy have been performed at many centers. Although uncommon, malfunction of the da Vinci Surgical system represents a new and unique problem in urologic surgery. In this study, we report a rare case of a disassembled surgeon's console hand piece because of a loose screw during robotic-assisted laparoscopic radical prostatectomy.