JU Open Plus: The Train to Seoul

AUGUST 2023 ISSUE REVIEW The case report by Raheem et al1 is our first for our methods section called videos and manuscripts. The contents are primarily video-based surgical footage with related outcomes and a standard index searchable abstract. We hope to have a steady interest in this format of publishing, which is common in many other types of surgical journals, and now a first for our AUA family of journals. In this work, the authors demonstrate several problem-solving tips and tricks for a neophallus that were creating redundant skin, incontinence, and foul-smelling urine. Congrats to the team for getting this section started. In a case report for our rare conditions section, Schwartz et al2 describe a highly rare incidence of a lipoma of the upper urinary tract. The imaging shows a clear filling defect that would be urothelial carcinoma until proven otherwise vs a blood clot. The lesion was successfully biopsied, fulgurated, and removed with a wire basket—all endoscopic and nephron sparing. The lesion did not appear like urothelial nor have an associated positive cytology—2 good clues to avoid nephroureterectomy and consider rare incidence of benign pathology. Holdren et al3 report an in-depth look at the commonly encountered anatomic feature of adipose tissue covering the anterior prostate and bladder neck. This region is often labeled as periprostatic, anterior, or periurethral fat and may or may not contain histological lymph nodes. Surgeons often dissect this tissue to see the bladder neck plane better and may or may not submit the tissue for analysis. In this retrospective review, the cohort for analysis is a familiar flow of events: 1177 radical prostatectomy cases, with 786 containing lymph nodes, 340 with periurethral tissue submitted, and a final group of 58 that had periurethral lymph nodes on histological examination. Of the 58, 15.5% were positive for cancer, and only 1 patient had concomitant positive pelvic lymph nodes. They observed statistically significant higher average PSA, Gleason score, and staging. Personally, I would advise 2 scenarios: (1) if the patient has typical indications for a pelvic lymph node dissection, then add the periurethral to the submission and (2) if the patient will not have a pelvic lymph node dissection, it may be better to submit periurethral tissue if it is being dissected away and otherwise discarded. Some thin patients have only scant tissue in this plane, and I understand this step being omitted, as you can see from the flow of this cohort from overall population to the group studied with lymph node tissue submitted and demonstrated on histological examination. The study by Chughtai et al4 is essentially a pharmaceutical laboratory investigation into the highly practical question as to whether supplements, such as saw Palmetto, contain standardized active ingredients. It has been my longstanding impression that these categories of supplements that are not approved by the Food and Drug Administration will contain variable active ingredients. In the case of saw palmetto, the risk to the patient is low, but many studies have shown minimal to modest symptom relief compared with placebo. In this investigation, they tested 28 available products, defined a standardized metric of over 80% total fatty acid content, and found that only 1 of 28 products met such criteria. The authors provide several looks at the raw data, and it is a technical piece for much of the paper, but the punch line is highly useful for clinical practice—few products have a reliable active ingredient. The series by Xuan et al5 is from a very high-volume robotics center in Beijing, China, and reports a novel approach to using robotics for resection of adrenal metastases from kidney cancer among patients with previous partial or radical nephrectomy. The resections are performed in stages with 3 different setups for the camera and working arms—7 ports in total. The figures and intraoperative photographs are very well done, and the paper includes supplemental videos—highly valuable for surgeons planning this technique. The prospective study by Ma et al6 will be of interest to many robotic surgeons who perform radical prostatectomy. A common question is whether overall surgical skill performance and/or experience specifically drive functional outcomes. The authors setup an evaluation tool called dissection assessment for robotic technique (DART) and using independent evaluators, graded a large cohort of surgeons and cases, and correlated scores with outcomes. They chose to focus on the surgical evaluation of the neurovascular bundle as related to 1-year urinary continence outcome. Overall DART scores and 4 separate domains were predictive. The details of how DART scores could be improved and might be useful for surgeons for quality improvement. In fact, the authors found DART scores more useful than case experience. DART scores could also be a way to standardize a cohort of surgical cases that might be compared with other treatment domains that do not have such skill relationships. AUGUST 2023: PEOPLE PLACES AND THINGS The end of summer/early fall is usually the start of a busy meeting season, including international and national conferences. I was privileged to be on faculty at the 2023 joint meeting of the Korean Prostate Society and Asian Pacific Society of Uro-Oncology—Figures 1 and 2. I arrived a few days early to lecture and visit colleagues at Dong-A University and Changwon Hanmaeum hospital in the Busan area of coastal South Korea. Sightseeing included Haeundae beach (Figure 3A) and the Haedong Yonggungsa temple (Figure 3B). Then, it was time to move to Seoul for the next meeting. I traveled from Busan to Seoul on a high speed train—thinking there must be a nice play on words here. Famous sites included the Gyeongbokgung Palace (Figures 4A and 4B) and the National Folk Museum (Figure 5). I had photographed these sites in 2016, but it was very overcast that week and satisfying to be able to rephotograph them with perfect blue skies. For the matching “things” theme of our pictorial, I selected Korean barbeque (Figure 6) as a unique experience with tableside grilling. At this point, my chopsticks skills are reasonable for a non-native.Figure 1.: People. The Fall meeting season kicked off with the Korean Prostate Society joint meeting with the Asia Pacific Society of Uro-Oncology. The officers of the Korean Prostate Society hosted the international faculty for a welcome dinner in Seoul. Back row (left to right): Jae Heon Kim, Jong-Wook Park, Jae Young Joung, Sung Kyu Hong, and U Syn Ha. Front row: Renu Eapen (Australia), Peter Black (Canada), Houston Thompson (USA), and John Davis (USA).Figure 2.: People. Renu Eapen from Australia presents her experience and clinical trials work with PSMA PET scan and the progress made so far to support this imaging technology with high-quality clinical trials. Trials to date support its use in staging high-risk prostate cancer and recurrent disease, while ongoing trials are investigating its use to support disease screening.Figure 3.: Places. Busan, South Korea. The second largest city in South Korea is Busan, which sits at the junction of the Yellow Sea and Sea of Japan. It is famous as a port city and home to the U.N. Memorial Cemetery and Haedong Yonggungsa temple. Pictured in (A) the famous Haeundae Beach district. B, The Haedong Yonggungsa temple.Figure 4.: A and B, Places. The Gyeongbokgung Palace, Seoul, South Korea.Figure 5.: Places. The National Folk Museum of Korea—showcasing the history of the Korean people.Figure 6.: Things. Korean Barbeque—table side grilling at its best. For surgeons, it is like having a bovie and smoke evacuator at the table.

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