Purpose: Enhanced recovery after surgery (ERAS) protocol has proven to lower both length of stay and recovery time, while being cost-effective at the same time. There are three ERAS protocols implemented for radical cystectomy (RC). All of those were published by different institutions, such as the European Association of Urology, the Société Internationale d'Urologie, and the American Urological Association. We modified and proposed ERAS components from preoperative care until postoperative care to evaluate the implementation of ERAS for RC. Standard ERAS protocol is not fully applicable in Hasan Sadikin General Hospital due to financial factors and the limited list of drugs available to choose from our universal health coverage prescription system; thus, we had to make some modifications. This study aims at evaluating the preliminary results of an implementation of modified ERAS protocol in RC at our hospital. Materials and Methods: A cohort retrospective study of 21 consecutive patients who underwent RC (9 ERAS vs. 12 non-ERAS). The primary outcomes were the reduced length of stay (LOS) and hospitalization cost. The secondary outcomes included less intraoperative blood loss, faster bowel movement, lower transfusion rates, and decreased readmission rates. Results: Patients with ERAS had lower blood loss (ERAS median [range]: 1100 [500–2000] ml vs. 1650 [100–3000] ml for non-ERAS, P = 0.219), lower transfusion rates (ERAS: 55.6% vs. 91.7% for non-ERAS, P = 0.119), and fewer readmissions (ERAS: 0% vs. 8.3% for non-ERAS, P = 1.000). Bowel movement was faster in ERAS group (ERAS mean [range]: 6.11 ± 2.977 [3.00–12.00] h vs. 12.50 ± 5.385 [6.00–24.00] h for non-ERAS, P = 0.005). Duration of hospitalization was shorter with ERAS (5 [3–7] days) than without ERAS (8 [5–20] days, P = 0.003). The total mean costs were significantly higher in the non-ERAS group compared to the ERAS group ($1529 ± 346 for ERAS vs. $2580 ± 1415 for non-ERAS, P=0.028). Conclusion: Modified ERAS protocols for RC at our institution reduced the LOS and hospitalization cost and lead to faster bowel movement and no readmission.

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Purpose: We compared tamsulosin, silodosin, and alfuzosin in catheter-free trials after acute urinary retention (AUR) due to benign prostatic hyperplasia (BPH). This study aims at assessing the efficacy of tamsulosin, silodosin, and alfuzosin, and the factors affecting the success of catheter-free trials. Materials and Methods: An observational, prospective, randomized study of 49 men with AUR due to BPH was performed from July 2015 to August 2017. Participants were catheterized after the assessment of prevoid urine volume. The prostate size was measured, and IPSS at presentation was calculated. The participants were divided into tamsulosin, silodosin, and alfuzosin groups and were given a catheter-free trial after administration of alpha-blockers for three doses. Descriptive analysis, independent t-test, and Chi-square test were used for data analysis. Univariate and multivariate analyses were done using STATA software version 14.2. P < 0.05 was considered to indicate statistical significance. Results: The overall success of trial without catheter (TWOC) was 62.5% (30 out of 49). There was no difference in the efficacy of tamsulosin, silodosin, and alfuzosin in catheter-free trials after AUR due to BPH. The success of TWOC was affected by median lobe enlargement, and patients with Grade 3 intravesical protrusion of prostate were less likely to have a successful TWOC. Conclusion: TWOC after administration of three doses of alpha-blockers was shown to be useful in most patients irrespective of prostate size. There was no difference in the efficacy of tamsulosin, silodosin, and alfuzosin in catheter-free trials.

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Purpose: Few studies have reported the value of the diameter-axial-polar (DAP) score in robot-assisted partial nephrectomy (RaPN) for renal cell carcinoma (RCC) and sequentially compare DAP and RENAL nephrometry score to predict long-term surgical, oncological, and functional outcomes of RaPN for renal cancer. This study demonstrated that the DAP score is effective enough to predict long-term trifecta outcomes of RaPN. Materials and Methods: We retrospectively collected clinical data of 108 patients with pathologically confirmed RCC who received RaPN by a single surgeon during 2012–2017. The patients were stratified into low, intermediate, and high complexities according to the RENAL and DAP scoring systems. We analyzed warm ischemia time (WIT), cancer-specific survival, radiographic progression-free survival, positive rate of surgical margin, renal function from the preoperative period to postoperative 1^st/6^th month, and postoperative complications. Results: The median follow-up period was 36 months. The 3-year cancer-specific survival rate and 3-year radiographic progression-free survival were 98.4% and 95.2%, respectively. Four patients (3.6%) had positive surgical margins. The largest decrease of renal functions from pre- to postoperative 6^th month was noted in the intermediate DAP score group. No difference was observed between the DAP and RENAL scores in terms of WIT in 25 min, positive margin, complication, 3-year radiographic local recurrence, and chronic kidney disease (CKD) change, but a significant difference was observed in WIT in 20 min (area under the curve of DAP vs. RENAL = 0.81 vs. 0.54, P = 0.03). Age is an independent factor for progression to CKD after RaPN (odds ratio = 1.054, 95% confidence interval = 1.008–1.102, P = 0.022). Complications occurred in 22 patients (20.4%), and the most common postoperative complications were bleeding (12.2%), postoperative fever (0.5%), and urinary leakage (0.3%). Conclusion: The DAP score is an easy and effective tool for predicting perioperative outcomes of RaPN, especially in WIT in 20 min.

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Purpose: Whether the predictive utility of prostate-specific antigen-age volume (PSA-AV) score can surpass serum total PSA, age-adjusted PSA, or PSA density (PSAD) has remained unclear based on previous reports. The aims of this study were to assess the predictive value of PSA-AV score in a Taiwanese population. Materials and Methods: We retrospectively reviewed the medical data of patients who underwent transrectal ultrasound-guided prostate biopsy between 2007 and 2013 at our institution. The ability of serum PSA, age-adjusted PSA, PSAD, and PSA-AV to predict prostate cancer was tested using receiver operating characteristic (ROC) curves. Results: A total of 415 biopsy specimens were included in the study, of which 75 (18.1%) were diagnosed with prostate cancer. The discriminative performance of serum PSA, age-adjusted PSA, PSAD, and PSA-AV for predicting prostate cancer was evaluated in the study cohort. The areas under ROC curve were determined for the four tests as follows: for serum PSA (95% confidence interval [CI]: 0.723–0.852), for age-adjusted PSA (95% CI: 0.719–0.888), for PSAD (95% CI: 0.673–0.877), and for the formula PSA-AV (95% CI: 0.783–0.884), they were 0.787, 0.804, 0.775, and 0.834, respectively. Comparing other tests, the novel formula PSA-AV was significantly better than the other three PSA-derived tests and reached statistical significance (P < 0.05). At this cutoff value (PSA-AV <200), the sensitivity was 74.7% and the specificity was 77.4%. Conclusion: The use of the formula PSA-AV in Taiwan was superior in the prediction of prostate biopsy findings compared to serum PSA, age-adjusted PSA, and PSAD according to our data, particularly in older patients or patients with a larger prostate volume.

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Smoking is a major risk factor that plays a role in the incidence of bladder cancer. Carcinogens from cigarettes are excreted through the urine, so direct contact with the urinary tract occurs and increases the risk of malignancy. Literature is obtained from the search results of PubMed, Medscape, and Science Direct electronic databases with some keywords used. Starting in 2009, 88 literature results were collected through the electronic databases of PubMed, Medscape, and Science Direct. After applying the exclusion criteria, 12 articles are included in this literature review with 536,989 bladder cancer patients and 52,753 controls in total. High clove cigarette smoking intensity (>40 cigarettes/day) is a risk of causing urothelial carcinoma bladder cancer. Clove cigarettes pose the highest risk of bladder cancer. Compared to clove cigarette, cigars, and tobacco pipes have relatively lower risk of causing bladder cancer. Meanwhile, other types of cigarettes, such as shisha and electronic cigarettes, do not eliminate the risk of bladder cancer. Smoking is a modifiable risk factor for bladder cancer. The current smoking history was associated with a higher risk of bladder cancer compared to the former history of smoking. Different types of smoking have different risks of bladder cancer.

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Renal cell carcinoma (RCC) comprises only 3% of adult cancer cases. In most cases, patient is asymptomatic and the tumor mass is incidentally detected during radiological imaging for other medical conditions. Only one-third of patients with RCC present with hematuria, palpable tumor mass, or flank pain. Most of the cases of RCC are with clear or papillary cells, but a small subset of cases have demonstrated clear cell RCC with leiomyomatous stroma. The World Health Organization classification of tumors of the urinary system and male genital organs 2016 and the International Society Urological Pathology 2012 Vancouver classification have identified RCC with leiomyomatous stroma (RCCLMS) as an emerging entity of RCC. RCCLMS has been seen with inherited renal cancer syndromes such as tuberous sclerosis complex and von Hippel-Lindau disease. Here, we present a rare case of RCC with morphological and histopathological findings of the RCCLMS subset but showed noninherited mutational traits.

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Purpose: The aim of our study was to analyze the outcomes and predictive factors in patients with an initial biopsy grade group 1 (GG1) prostate cancer (PCa) at risk of GG upgrading. Materials and Methods: We performed a retrospective review of patients who had GG1 PCa at biopsy and were managed with robotic-assisted laparoscopic radical prostatectomy (RaLRP) from January 2012 to December 2018 and collected their clinical characteristics and pathological data. The primary outcomes were GG upgrading at RaLRP and biochemical recurrence-free survival (BCRFS) in these patients. The secondary outcome was to analyze the risk factors of pathological upgrades. Results: Among the 159 patients with initial prostate biopsy of GG1, 122 patients (76.7%) had GG upgrading based on the final pathology at RaLRP. Multivariable analysis showed that transrectal ultrasound (TRUS)-measured prostate volume <30 mL (odds ratio [OR] 4.727, P = 0.011), prostate-specific antigen density [PSAD] ≥0.2 ng/mL² (OR 3.201, P = 0.019), magnetic resonance imaging (MRI)-measured prostate volume <30 mL (OR 3.892, P = 0.007), and PSAD ≥ 0.2 ng/mL² (OR 2.65, P = 0.019) were independent predictive factors of GG upgrading. During 5 years of follow-up, patients who upgraded to GG3-5 had a significantly shorter time to biochemical recurrence than those who remained as GG1 (P = 0.001) or upgraded to GG2 (P = 0.008). Conclusion: The final pathology grading was underestimated in 76.7% of initial biopsy GG1 and may influence the BCRFS after RaLRP. Prostate volume <30 mL and PSAD ≥0.2 ng/mL², measured by either MRI or TRUS, were significant predictive factors of biopsy GG1 upgrading.

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Purpose: We aim at investigating the relationship between lower urinary tract symptoms (LUTSs) and intrapelvic blood flow. Conventionally, intrapelvic blood flow is assessed using a Doppler blood flowmeter. In this study, the penile brachial pressure index (PBI), which is a simpler tool, was used. Materials and Methods: The participants of this study were 103 male outpatients with LUTS whose PBI was measured using the form pulse wave velocity/ankle-brachial index with a toe blood pressure cuff. Data including age, body mass index (BMI), penile blood pressure, PBI, complications (hypertension, dyslipidemia, and diabetes mellitus), International Prostate Symptom Score (IPSS), and Erection Hardness Score (EHS) were retrospectively examined. LUTS positivity was defined as an IPSS score ≥8 and LUTS negativity as an IPSS score <8. Results: The PBI and EHS scores were significantly higher in the LUTS-negative participants than in the LUTS-positive participants. Furthermore, a multivariate analysis showed a significant difference only in PBI. However, age, BMI, EHS, or previous history of complications did not significantly differ. Conclusion: PBI was found to be an independent factor of LUTS. Recent studies have shown that LUTS and erectile dysfunction are associated with lifestyle-related diseases, and that these conditions are caused due to impaired blood flow in the intrapelvic arteries due to arteriosclerosis. Therefore, LUTS should be treated as a vascular disease.

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