Nihon Hinyokika Gakkai zasshi. The japanese journal of urology最新文献

A 70-year-old man with prostate cancer (cT3aN0M0), with a prostate-specific antigen (PSA) level of 38.9 ng/mL, and a Gleason score of 4+4 = 8, was treated with maximum androgen blockade for 1 year, resulting in a PSA reduction to 0.1 ng/mL. He subsequently underwent robot-assisted laparoscopic radical prostatectomy (RARP). Pathological examination revealed pT3bN1with negative surgical margins. Postoperatively, without additional treatment, PSA levels were 0.007 ng/mL and 0.019 ng/mL at 2 and 5 months, respectively. Six months after surgery, the patient developed left hydronephrosis with upper ureteral urine leakage but no signs of ureteral cancer. However, PSA slightly increased to 0.055 ng/mL, whereas carcinoembryonic antigen (CEA) levels increased to 19.2 ng/mL. Despite this, gastro-colonoscopy failed to detect any evidence of cancer. Nine months after surgery, multiple lung tumors, a solitary hepatic tumor, intraperitoneal lymphatic swellings, and port site masses were identified. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan did not reveal any other malignancies. At that time point, PSA increased to 0.185 ng/mL, while neuron-specific enolase and pro-gastrin-releasing peptides levels were within normal limits. Subsequent gastro-colonoscopy did not detect any malignancies. Ten months after surgery, bilateral orchiectomy and docetaxel chemotherapy were initiated for recurrent prostate cancer with aggressive variants but without neuroendocrine differentiation. Immunohistochemistry (IHC) of a biopsy sample from the port site mass suggested enteric adenocarcinoma distinct from the prostatic tissue observed in the original RARP specimen. The metastases progressed, and CEA levels continued to rise despite three cycles of docetaxel chemotherapy. Genomic testing identified KRAS and other mutations, confirming the tumor's compatibility with enteric adenocarcinoma. Fourteen months after surgery, chemotherapy for colon cancer was initiated. Unfortunately, the patient succumbed to respiratory failure 19 months after surgery. In cases of unusual recurrence patterns, as observed in this case, IHC and genomic testing of the recurrent mass can be crucial for accurate diagnosis.

(Objective) Venous thromboembolism (VTE) is a significant complication during the perioperative period in urological cancer surgery. However, the study of perioperative VTE among Japanese patients remains insufficient. We conducted a retrospective investigation into the incidence of perioperative VTE in bladder cancer patients who underwent open radical cystectomy (ORC). (Materials and methods) From April 2020 to October 2023, 60 patients received ORC at our hospital. Of these, we included 57 patients in this retrospective study. Preoperatively, lower limb venous ultrasound was conducted to assess for deep vein thrombosis in patients with high D-dimer levels, and postoperatively, it was performed on all patients the day after surgery. We analyzed the incidence of perioperative VTE and the factors associated with it. (Results) Preoperatively, of 57 patients, 13 (22.8%) were diagnosed with VTE, and of these 13, 4 had pulmonary embolism (PE). Postoperatively, among the 44 patients without preoperative VTE, 7 (15.9%) developed new VTE immediately after surgery, and an additional 4 (9.1%) developed VTE during hospitalization. Of these 11 patients, 3 (6.8%) had concurrent PE. There were no fatal cases associated with VTE either before or after surgery. The patients with preoperative VTE had a significantly higher proportion of females who had undergone two or more courses of neoadjuvant chemotherapy (NAC) compared to the patients without preoperative VTE. Furthermore, both pre-and post-operatively, patients with VTE had significantly higher D-dimer levels. (Conclusion) In patients undergoing ORC, there was a connection between NAC and preoperative VTE. However, early intervention prevented fatal outcomes. As a result, we believe perioperative VTE screening is useful, particularly in patients treated with ORC.

A 79-year-old male patient with urothelial carcinoma with squamous differentiation, pT2N0M0, was referred to our hospital. A computed tomography (CT) scan showed left hydronephrosis associated with the bladder tumor and reticular shadows in the lung fields. After neoadjuvant chemotherapy with gemcitabine and cisplatin, the patient underwent robot-assisted radical cystectomy and cutaneous ureterostomy for bladder cancer on March X. On postoperative day 2, SpO₂ decreased with increased oxygen demand, and a CT scan revealed a diffuse reticular shadow in both lungs. The patient was diagnosed with acute exacerbation of interstitial pneumonia (IP). Steroid pulse therapy with 1,000 mg/day methylprednisolone (mPSL) was initiated immediately, and nasal high-flow (NHF) oxygen was introduced. After a positive response to mPSL was confirmed, the patient was weaned from NHF on postoperative day 9. As the IP did not worsen, he was discharged after receiving home oxygen therapy. Six months after the acute exacerbation of IP, CT showed no tumor recurrence or progression.

A 47-year-old male had previously undergone internal urethrotomy three times for bulbar urethral stricture. During the third internal urethrotomy, the iatrogenic rectal injury occurred and resulted in the rectourethral fistula. Subsequently, the urethral stricture became obliterative, and the patient voided through the fistula via the rectum. Twelve years after the initial diagnosis of bulbar urethral stricture, he was referred to our hospital for urethral reconstruction. We performed excision and primary anastomosis along with fistula closure. However, shortly after initiating voiding, stricture recurred at the anastomosis site. Six years after the initial surgery, we performed a re-do excision and primary anastomosis, but stricture recurred again. He was managed with intermittent self-dilation, but the stricture progressed to involve a longer urethral segment. Five years after the second surgery, we performed salvage penile skin flap tube urethroplasty. A 3 cm circumferential incision was made to harvest the foreskin flap, which was transferred to the perineum and tubularized. After complete excision of the scarred bulbar urethra, the tubularized foreskin flap was interposed to the urethral defect. The patient could void on postoperative day 24 and remains stricture-free with good voiding sixteen months postoperatively. While transurethral treatment is a simple and widely used for urethral strictures, it is essential to recognize that repeated procedures can lead to increase stricture complexity and negatively impact subsequent urethroplasty outcome.

We performed robot-assisted radical prostatectomy (RARP) for 221 patients from December 2015 to May 2023. In 218 patients, the prostatic anterior fat pad was submitted separately for histopathological evaluation. Fourteen patients (6.4%) had lymph nodes in the prostatic anterior fat pad, and three (1.4%) had lymph node metastasis in the prostatic anterior fat pad. The details of three cases are presented here.Case 1 was a 63-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial prostate-specific antigen (PSA) concentration of 24.522 ng/ml and a Gleason score of 3+4. The pathological results indicated adenocarcinoma, pT3a, Gleason score: 3+4. The postoperative PSA nadir was 0.205 ng/ml, and the patient was diagnosed with biochemical recurrence. Subsequently, the patient underwent hormone therapy and salvage radiation therapy, with no recurrence to date.Case 2 was a 62-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial PSA of 10.418 ng/ml and a Gleason score of 4+4. The pathological results indicated adenocarcinoma, pT2c, Gleason score: 4+4. The postoperative PSA nadir was 0.401 ng/ml, and the patient was diagnosed with biochemical recurrence. The patient subsequently underwent hormone therapy.Case 3 was a 76-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial PSA of 4.676 ng/ml and a Gleason score of 4+3. The pathological results indicated adenocarcinoma, pT2c, Gleason score: 3+4. The postoperative PSA nadir was 0.031 ng/ml, and the patient has not experienced recurrence to date.

We performed a urodynamic study (UDS) and voiding cystourethrography (VCUG) or videourodynamics for three female patients with urinary dysfunction to differentiate between bladder outlet obstruction (BOO) and detrusor underactivity (DU). Case 1: A 72-year-old woman with a history of urinary retention and chief complaint of dysuria. UDS showed detrusor contraction (detrusor pressure at maximum flow: PdetQmax 86.6 cmH₂O) and low urinary flow (maximum flow rate: Qmax 2.2 ml/s). VCUG showed poor bladder neck opening and bilateral vesicoureteral reflux and we diagnosed BOO due to bladder neck dysfunction. Case 2: A 74-year-old woman with dysuria. UDS showed detrusor contraction (PdetQmax 27.7 cmH₂O) and low urinary flow (Qmax 5.3 ml/s). VCUG showed the open bladder neck and narrowing of the middle urethra during voiding. We diagnosed BOO due to abnormal urethral function during voiding. Case 3: An 85-year-old woman with a chief complaint of nocturia. UDS showed weak detrusor contraction (PdetQmax 18.3 cmH₂O) and low urinary flow (Qmax 3.8 ml/s). VCUG revealed urethral dilatation. We diagnosed DU. The combination of UDS and VCUG for female urinary dysfunction may be a useful tool for the differential diagnosis of DU and BOO.

(Objective) Patient characteristics and treatment outcomes of a rare histologic type of bladder neuroendocrine carcinoma were evaluated. (Methods) 2,133 cases of bladder cancer treated by transurethral resection of bladder tumor from August 2005 to August 2022 were histopathologically reevaluated, and clinicopathological factors, treatment methods, and prognosis of cases with a confirmed diagnosis of bladder neuroendocrine cancer were analyzed. (Results) Of 2,133 cases, 12 (0.56%) were diagnosed as neuroendocrine carcinoma. Immunohistochemical staining revealed small cell carcinoma in 10 cases (83.3%) and large cell carcinoma in 2 cases (16.7%). The median age was 79 years, and performance status 2 or higher was reported in 3 cases. Seven cases had localized cancer at the time of diagnosis, five cases had distant metastasis, and radical cystectomy was performed in four cases. Of the 3 cases who received chemotherapy, first-line platinum-based chemotherapy achieved disease control in two cases. After second-line treatment, no cases responded to pembrolizumab or enfortumab vedotin. The median overall survival (OS) of all cases was 12.5 months. The median OS of cases who underwent total cystectomy was 26 months, and that of cases who did not undergo total cystectomy was 8.2 months, showing a significant difference (p=0.05). (Conclusion) Neuroendocrine carcinoma of the urinary bladder often develops in older patients and has a poor prognosis. In cases of localized cancer, total cystectomy should be performed if possible.

(Purpose) Enfortumab vedotin has been available as a third-line treatment for advanced urothelial carcinoma in Japan since December 2021. While the treatment is expected to improve the outcome of advanced urothelial carcinoma, concerns regarding adverse events do exist. We report here our initial experience of the use of enfortumab vedotin as a third-line therapy in patients with advanced urothelial carcinoma. (Patients and Methods) We retrospectively evaluated the efficacy and adverse events of enfortumab vedotin treatment, as a third line therapy, in patients who had failed platinum-containing chemotherapy and immune checkpoint inhibitor therapy in our institution from January 2022 to January 2023. Efficacy was evaluated using the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 for progression-free survival (PFS), overall response rate (ORR), disease control rate (DCR), and duration of response (DOR). Safety was evaluated for treatment-related adverse events using the Common Terminology Criteria for Adverse Events (CTCAE) ver. 4.0. (Results) In this study, sixteen patients were investigated. The median age was 70 years (45-93 years); all patients had previously received platinum-containing chemotherapy with cisplatin or carboplatin, eleven having been treated with pembrolizumab, and 5 with avelumab, as sequential immune checkpoint inhibitors. As for efficacy, the median observation period was 9.27 months (4.03-16.6 months). The treatment response rate included 2 complete response (CR) (12.5%), 5 partial response (PR) (31.3%), and 5 stable disease (SD), out of 16 patients. The ORR and DCR were 43.8% and 75.0%, respectively. The median PFS was 7.77 months (3.67-not reached). The median time to response was 1.87 months (0.47-2.80 months) and the median DOR was 7.93 months (0.73-13.1 months). Eight patients (50%) discontinued treatment due to disease progression. As for safety, the incidence of treatment-related adverse events (TRAE) was 93.8%, and that of Grade 3 or higher TRAE was 56.3%. Four out of 16 patients (25%) underwent dose reduction due to TRAE. Among all grades, skin reactions were the most common in 12 patients (75%), followed by dysgeusia, alopecia, neutropenia, and anorexia. Neutropenia (including febrile neutropenia) was the most common Grade 3 or higher TRAE in five patients (31.3%), followed by skin reactions, anorexia, and anemia. Two of the patients, who observed skin reactions, developed severe rash and Stevens-Johnson syndrome, which eventually led to treatment discontinuation. The median time from enfortumab vedotin administration to onset of skin reaction was 9 days (5-18 days), with most cases occurring in the first cycle. (Conclusions) Enfortumab vedotin is an effective treatment option in real clinical practice. However, adverse events, including skin reactions, should be carefully monitored.

(Purpose) We performed a clinical retrospective study on the evaluation of pembrolizumab treatment results for advanced urothelial cancer in our hospital. (Materials and Methods) Twenty-seven patients diagnosed with advanced or metastatic urothelial carcinoma who received pembrolizumab between April 2018 and December 2021 were included. We retrospectively reviewed medical records to examine treatment outcomes, immune-related adverse event (irAE), and prognostic factors. (Results) The median age of patients was 76 years, and the median number of pembrolizumab doses was 6. The median overall survival was 8.8 months, and the best treatment response according to RECIST version 1.1 was complete response 1, partial response 7, stable disease 5, and progression disease 14. Pre-pembrolizumab risk factors related to overall survival include the presence of liver metastasis, LDH ≥200 IU/L, and TSH <4 μIU/mL in univariate analysis. Grade 3 irAE was type 1 diabetes in only 1 case, and grade 2 were hypothyroidism in 4 cases, type 1 diabetes in 1 case, interstitial pneumonia in 1 case, and skin disorder in 1 case. Nine patients had a TSH of 4 μIU/mL or higher at the start of pembrolizumab, and four of them had hypothyroidism requiring oral levothyroxine, and none of the patients in the low TSH group required hormone replacement (p =0.013). (Conclusion) High TSH level before pembrolizumab administration for advanced urothelial cancer was associated with hypothyroidism, suggesting the possibility of improved prognosis.

A 72-year-old man was referred to our hospital because of right renal tumors. Ultrasound examination revealed two masses in the right renal hilum. Contrast-enhanced computed tomography (CT) scan showed 25 mm and 10 mm soft tissue density nodules with poor contrast effect in the right renal hilum. Positron emission tomography-CT scan showed an accumulation of SUVmax of 6.65 in the same area. A CT-guided biopsy was performed, and immunostaining revealed the presence of IgG4-positive plasma cell clusters and a high serum IgG4 level of 658 mg/dL. A definitive diagnosis of IgG4-related disease was made, and the patient was placed under observation.A CT-guided biopsy is helpful for the diagnosis of IgG4-related disease and should be considered when masses are found in the unilateral renal hilum.