Investigative and Clinical Urology最新文献

Recently, the combination of enfortumab vedotin and pembrolizumab has been recommended as the preferred first-line therapy for metastatic or locally advanced urothelial carcinoma owing to its substantial survival benefits. However, its high-cost limits accessibility, leading to many patients receiving cisplatin-based chemotherapy as a more practical alternative. Therefore, cisplatin-based combination chemotherapy remains a widely used first-line treatment for metastatic bladder cancer (MBC). Nonetheless, nearly half of the patients are ineligible for cisplatin owing to factors such as renal impairment, poor performance status, or other comorbidities. The definition of cisplatin ineligibility, which is often based on the Galsky criteria, lacks robust scientific validation, and limited pharmacokinetic data on the effects of cisplatin in patients with renal impairment are available. This review explored alternative treatment strategies for cisplatin-ineligible patients, including immune checkpoint inhibitors, carboplatin-based regimens, antibody-drug conjugates, and novel combination therapies. Notably, recent advancements, such as the combination of enfortumab vedotin and pembrolizumab, have shown promising survival benefits in this patient population. Additionally, emerging targeted therapies, such as fibroblast growth factor receptor inhibitors, are reshaping the treatment landscape of cisplatin-ineligible patients with MBC, emphasizing the need for personalized approaches that balance efficacy and safety.

Purpose: The prevalence of liver dysfunction among men has been steadily increasing in recent decades. Among the various non-invasive assessment tools available, the Fibrosis-4 (FIB-4) Index has emerged as a particularly valuable and widely adopted scoring system for evaluating liver fibrosis. This study investigated the relationship between liver fibrosis evaluated by the FIB-4 Index and male health care parameters.

Materials and methods: Participants were assessed using standardized questionnaires, including the International Prostate Symptom Score (IPSS) for lower urinary tract symptoms (LUTS), the Sexual Health Inventory for Men (SHIM) and EHS (Erection Hardness Score) for erectile function, and the AMS (Aging Males Symptoms rating scale) for late onset hypogonadism. Endocrinological parameters, including dehydroepiandrosterone sulfate (DHEA-S), insulin-like growth factor 1 (IGF-1), total testosterone and cortisol levels, as well as metabolic factors, including hemoglobin A1c (HbA1c) and triglyceride level, were evaluated as potential confounders.

Results: The patient age was 50.62±0.24 years. The analysis revealed significant associations between higher FIB-4 Index quintiles and worsening sexual function and LUTS. Among endocrine factors, DHEA-S and IGF-1 exhibited decreasing trends with higher FIB-4 Index values, whereas cortisol showed an increasing trend. Surprisingly, no significant association was observed between FIB-4 Index and testosterone levels. HbA1c increased, but triglycerides did not correlate with FIB-4. Multiple regression confirmed IPSS and SHIM scores were independently linked to the FIB-4 Index (p<0.05).

Conclusions: These findings highlight the importance of hepatic assessment in men with erectile dysfunction and LUTS, supporting a multidisciplinary approach to care.

Purpose: preclinical trial confirmed that Angelica gigas and Astragalus membranaceus had a curative effect on benign prostatic hyperplasia (BPH). Therefore, this study aimed to investigate the effects of this compound in patients with BPH symptoms.

Materials and methods: Subjects were divided into the treatment and control groups. They underwent four visits, and medication was initiated from the 2nd visit onwards, with a total of 12 weeks of intake. The endpoints were the International Prostate Symptom Score (IPSS), International Index of Erectile Function (IIEF), prostate-specific antigen level, testosterone, dihydrotestosterone, maximal urinary flow rate, residual urine volume, and subjective evaluation improvement. Safety tests included clinical pathology tests and checking for adverse reactions.

Results: A total of 39 patients from the treatment group and 45 from the control group were included in the efficacy analysis. After 12 weeks, a significant improvement was seen in IPSS total score (p=0.0219) and incomplete emptying score (p=0.0007). Furthermore, there were statistically significant improvements in the IIEF total score, erectile function, sexual desire, intercourse satisfaction, and overall satisfaction in the treatment group. The subjective improvement evaluation also showed a significant improvement (p=0.0143). Ten cases of mild adverse events were reported, including gastrointestinal problems, skeletal pain, dermatitis, and others. However, no severe adverse reactions were observed, and it was unlikely that these were related to the test product.

Conclusions: After taking the trial product (SHPro^®) for 12 weeks, the total and incomplete emptying IPSS improved, as did the IIEF, which indicated subjective improvements. And its safety was confirmed.

Vesicourethral anastomotic stenosis (VUAS) is a challenging complication following radical prostatectomy with incidence ranging between, and sometimes exceeding, 1.4%-4.8%. While endoscopic management remains the first-line approach, refractory cases often necessitate open or robotic reconstruction. This review examines contemporary surgical options, including newer reconstructive techniques and salvage procedures for recalcitrant stenoses. A comprehensive review of all relevant literature was conducted to evaluate surgical options for VUAS. Techniques assessed included endoscopic procedures, YV- and T-plasty, transvesical reconstruction, robotic-assisted approaches, and salvage techniques such as bladder flaps and intestinal substitution. A novel endoscopic procedure, the transurethral incision with transverse mucosal realignment, may offer higher success with decreased morbidity. Open and robotic techniques are often utilized in recalcitrant stenosis. The most comprehensive cohort to date looking at robotic repair of refractory VUAS by the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) demonstrated a 75% success rate at 3 months. Patients with a history of radiation may suffer from higher complication rates. Salvage options, including intestinal substitution for extensive stenoses, have been described but remain a last resort due to potential for greater morbidity. Urinary diversion is an option for patients with refractory disease, often leading to improved quality of life despite initial hesitancy. The management of VUAS requires an individualized approach based on degree of stenosis, prior treatments, and patient goals. While newer techniques such as robotic reconstruction show promise, long-term studies are needed to determine their efficacy and complication rates. Continued advancements will refine treatment algorithms for this complex condition.

Purpose: After radical cystectomy (RC), the pathologic complete response (pT0) among muscle-invasive bladder cancer (MIBC) is considered a favorable oncological result. The objective of this study was to evaluate the effect of neoadjuvant chemotherapy (NAC) among the pT0 patients using a large-scale multicenter study.

Materials and methods: This study included 3,972 patients who underwent RC at 11 tertiary medical centers. Analysis was conducted on patients with MIBC who achieved a pT0, with a focus on comparing results between those who received NAC and those who did not. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were analyzed in these groups.

Results: Among 252 eligible pT0 patients, 121 were categorized in the non-NAC group while the remaining 131 were in the NAC group. As compared to the non-NAC group, the NAC group demonstrated significantly better survival outcomes, with 5-year RFS rates of 89% vs. 80% (p=0.043), OS rates of 84% vs. 69% (p=0.011), and CSS rates of 95% vs. 80% (p=0.007). Multivariable Cox proportional hazards analyses demonstrated that NAC independently improved RFS (hazard ratio [HR] 0.192, p=0.002) and CSS (HR 0.200, p=0.020), but not OS (HR 0.672, p=0.263).

Conclusions: In patients with MIBC who achieved a pT0, NAC administration prior to RC has a positive impact on oncological prognosis. Although further prospective studies are needed for validation, the results of this study will confirm the importance of NAC in MIBC.

Purpose: Antimicrobial-resistant (AMR) Mycoplasma genitalium has become a global concern. To assess AMR patterns in Korea, we analyzed the genetic diversity of the AMR-determining sites (ARDS) in M. genitalium across in 285 samples collected over two decades.

Materials and methods: Mycoplasma-positive samples were collected from various groups: males at one referral center (ORC) from 2014 to 2019 (G1; 43) and from 2020 to 2023 (G2; 54), males at primary care clinics (PCCs) in 2018-2019 (G3; 84), female sex workers at a regional healthcare center in 2004 (G4; 51), and females at PCCs in 2018-2019 (G5; 53). Sanger sequencing was performed at positions 2058/2059 in the 23S rRNA gene and positions GyrA95, GyrA99, ParC83, and ParC87 of topoisomerase IV genes in M. genitalium.

Results: In 2004, mutations were rare with S83I (0.0%), M95I (3.4%), and A2059G (10.5%). By 2020-2023, ARDS mutations had become common, peaking at S83I (83.3%) and A2059G (70.4%). No sex differences were observed in ARDS mutations between G3 and G5. A comparison of mutations in males at the ORC showed significant differences in A2059G and S83I between pre-2020 (G1) and post-2020 (G2). Males at the ORC (G1) had higher mutation rates in A2059G, GyrA95, and GyrA99 compared to males at PCCs (G3).

Conclusions: Currently, referred males exhibit a rapid increase in AMR, and the synergy between A2059G and S83I/R/N mutations raises concerns regarding the emergence of pan-drug-resistant M. genitalium, potentially leading to an irreversible crisis in treatment options in Korea.

Purpose: Consensus is lacking among South Korean urologists on the appropriate treatment of metastatic hormone-sensitive prostate cancer (mHSPC). A modified, Delphi-based consensus on managing mHSPC patients was developed to support clinical decision-making.

Materials and methods: Thirty-six questions on mHSPC treatment were developed by an expert committee (five urologists). Nine questions required achievement of consensus (key questions). Twenty-three urologists participated in two rounds of a Delphi survey. Consensus was defined as ≥75% agreement among panelists, with ≥90% agreement representing strong consensus.

Results: Eighteen questions (50.0%) reached strong consensus, 15 (41.7%) reached consensus, and three (8.3%) reached no consensus. Eight key questions (88.9%) reached strong consensus and one (11.1%) reached consensus. Consensus was reached on recommending androgen-deprivation therapy (ADT) intensification, irrespective of disease volume or type, with an androgen receptor pathway inhibitor (ARPI) as the preferred option. Not using docetaxel alone with ADT when an ARPI is available for treatment intensification was recommended (strong consensus). For high-volume mHSPC patients with a pathogenic, speckle-type poxvirus and zinc finger protein mutation, ADT+ARPI was recommended over triplet therapy (strong consensus). Panelists recommended regular imaging every 6-12 months if no ARPI reimbursement restrictions exist, but a 3-month interval (per current reimbursement guidelines) otherwise. ADT+ARPI was the most recommended systemic treatment (strong consensus).

Conclusions: This Delphi consensus established local consensus on controversial areas of mHSPC management. The findings offer meaningful perspectives that may help shape future treatment strategies and encourage thoughtful reconsideration of reimbursement criteria to align evidence and clinical practice in South Korea.

This corrects the article on p. 219 in vol. 64, PMID: 37341002.

Purpose: This study aimed to compare the clinical outcomes of Aquablation and Holmium Laser Enucleation of the Prostate (HoLEP) for the treatment of benign prostatic hyperplasia (BPH), with emphasis on functional improvement, ejaculatory preservation, and perioperative safety.

Materials and methods: We retrospectively analyzed data from January 2023 to March 2024, excluding patients with follow-up shorter than 3 months. Propensity score matching was performed using age, prostate volume, and preoperative prostate-specific antigen (PSA). Pre- and postoperative outcomes included International Prostate Symptom Score, Overactive Bladder Symptom Score, maximum flow rate (Qmax), post-void residual urine volume (PVR), PSA, and MSHQ-EjD (Male Sexual Health Questionnaire-Ejaculatory Dysfunction)-based ejaculatory grading (0-3). Paired t-tests, Wilcoxon signed-rank tests, McNemar's test, and Mann-Whitney U test were applied as appropriate.

Results: A total of 104 patients were included, with 34 matched pairs. Both procedures significantly improved lower urinary tract symptoms, with no significant differences in symptom score changes or PVR. HoLEP resulted in greater improvements in Qmax and PSA (p=0.011 and p<0.001, respectively). Aquablation demonstrated significantly better preservation of ejaculation (p=0.002). Although transient incontinence was more frequent in HoLEP and gross hematuria and urinary retention were more common in Aquablation, none of the complication rates showed statistically significant differences.

Conclusions: Aquablation and HoLEP are both effective surgical options for BPH. Aquablation offers comparable symptom relief with significantly superior ejaculation preservation, making it particularly suitable for sexually active patients. HoLEP provides greater deobstructive efficacy, as evidenced by superior Qmax and PSA outcomes. These findings support individualized, patient-centered decision-making.

Urothelial carcinoma, the most common malignancy of the urinary tract, presents a significant challenge, particularly in its metastatic stage, where prognosis remains poor despite advancements in treatment. Historically, platinum-based chemotherapy has been the standard first-line therapy, achieving moderate response rates but limited long-term survival. Recent breakthroughs have introduced immune checkpoint inhibitors, antibody-drug conjugates (ADCs), and targeted therapies as more effective alternatives. Enfortumab vedotin plus pembrolizumab has demonstrated superior efficacy as a first-line treatment, improving overall survival (OS) and objective response rates compared to chemotherapy. Maintenance therapy with avelumab has further prolonged survival in patients responding to initial platinum-based chemotherapy. Additionally, sacituzumab govitecan, an ADC targeting Trop-2, and erdafitinib, a fibroblast growth factor receptor (FGFR) inhibitor, have provided promising options for patients with refractory disease or FGFR alterations. The evolving treatment paradigm now prioritizes biomarker-driven, personalized approaches over traditional chemotherapy-based regimens. However, challenges remain in optimizing treatment sequencing and managing toxicity. Future research should focus on refining patient selection criteria and exploring novel combination therapies to enhance efficacy and durability of response.