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

A 70-years-old man with metastatic hormone-sensitive prostate cancer received the apalutamide, an oral androgen receptor signaling inhibitor. On day10 after drug initiation, fever and skin rash appeared on his whole-body surface. He stopped taking the drug on day18 and skin symptoms temporarily improved about 7 days after discontinuation. However, on day 38, symptoms recurred, and the patient was admitted to the hospital as an emergency due to suspicion of Stevens-Johnson syndrome. Steroid pulse therapy was administered, and gradual improvement of the skin lesions was observed. With the widespread use of apalutamide in daily clinical settings, severe drug eruptions such as the present case may potentially increase, and further additive experiences are awaited.

We present a case of retroperitoneal carcinosarcoma. A 48-year-old woman with left-sided abdominal pain and a 15 cm tumor in the lower left renal retroperitoneal region on computed tomography (CT) was referred to our hospital. Contrast-enhanced CT showed a well-defined tumor with contrast effect on the retroperitoneum. Magnetic resonance imaging (MRI) demonstrated a heterogeneous cystic mass and well-enhanced mural nodules in the tumor on T2-weighted images. Her levels of serum CA-125 and CA-19-9 were high at 44.7 and 143.0 U/mL, respectively. Although she was diagnosed with primary retroperitoneal mucinous cystadenocarcinoma and underwent surgical resection, the pathological diagnosis was a carcinosarcoma on the retroperitoneum. No adjuvant therapy was given. CT findings at 2 months revealed local recurrence and multiple pulmonary metastases. She received paclitaxel (175 mg/m² on day 1) and carboplatin (area under the curve of 6 on day 1) (TC) every 3 weeks. After two courses of TC therapy, some pulmonary metastases disappeared and shrank, but the progression of local recurrence was observed. However, after seven total courses of TC therapy, local recurrence further progressed, with the infiltration of the abdominal wall and lumbar pain, which was determined to be progressive disease (PD). A comprehensive genomic profiling test revealed no actionable genetic mutations. She died of cancer five months after the disease recurred. Carcinosarcoma is a rare tumor with poor prognosis, for which no established treatment exists beyond surgical resection. In this case, the therapeutic agent could not be determined; however, genomic analysis should be performed to guide the treatment of carcinosarcoma in advanced cases.

(Objective) We examined if the degree of preoperative hydronephrosis influences the occurrence of postoperative intravesical recurrence (IVR) in patients with upper tract urothelial cancer (UTUC). (Material and method) From January 2010 to March 2022, a total of 237 patients underwent total nephroureterectomy and partial cystectomy for UTUC at our hospital. For this study, 169 patients were selected after excluding 57 patients with a history of bladder cancer, 10 patients who received postoperative intravesical anticancer drug injection and 1 patient with inadequate data. Cases with Society for Fetal Urology (SFU) Grade 2 or higher (renal pelvis and several calyces observed) on preoperative computed tomography were considered to have hydronephrosis. Multivariate analysis was performed by selecting four known risk factors: tumor localization (ureter tumor), positive preoperative urine cytology, multiple upper tract ureteral carcinomas, and carcinoma in situ of UTUC. (Result) There were 120 male patients (71.0%) and 49 female patients (29.0%), with a median age of 71 years. The median observation period was 43 months. IVR was observed in 46 patients (27.2%) after surgery; 82 patients (49.1%) had SFU Grade 2 or higher (preoperative hydronephrosis) and 25 had SFU Grade 4 (dilatation of the renal pelvis and calyces and thinning of the renal parenchyma). There was a correlation between SFU Grade progression and an increase in IVR rate. Compared with patients without hydronephrosis, the presence of SFU Grade 4 hydronephrosis was found to be an independent associate factor after adjusting for known risk factors in multivariate analysis (p=0.02, hazard ratio 3.02, 95% confidence interval 1.18-7.75). (Conclusion) Patients with preoperative SFU Grade 4 hydronephrosis are more likely to have IVR. Postoperative intravesical anticancer drug injections and more frequent cystoscopies may be beneficial for these patients.

A 75-year-old man was hospitalized for acute pyelonephritis. Seven months earlier, he had undergone radical cystoprostatectomy and ileal conduit urinary diversion. On the second day of hospitalization, he experienced a stroke in the right cerebral hemisphere. No significant residual effects were identified. On the fifth day of hospitalization, he suffered cardiopulmonary arrest. Fortunately, he was quickly rescued by cardiopulmonary resuscitation. Blood analysis revealed severe hyperchloremic metabolic acidosis and a marked decrease in urinary chloride levels. Hyperchloremic metabolic acidosis and his physical condition quickly improved with continuous hemodiafiltration and antimicrobial treatment. The patient was discharged after stroke rehabilitation. He experienced pyelonephritis twice more, but no cancer recurrence was reported.

Osteomyelitis pubis is rare among the various complications following radical prostate cancer surgery. A 70-year-old man with type 2 diabetes mellitus was diagnosed with prostate cancer (cT2aN0M0) based on a transrectal prostate biopsy performed after an elevated PSA revealed at an examination. Subsequently, we performed a retroperitoneoscopic radical prostatectomy to resect the localized prostate cancer. No intra- or postoperative complications were observed, and the patient was discharged 10 days postoperatively. The patient visited the outpatient clinic 76 days postoperatively presenting with lower abdominal pain and difficulty walking. He had played tennis two days earlier, and thus, was presenting the symptoms. A pelvic MRI revealed inflammation in the bilateral pubic bone marrow centered on the pubic symphysis after which a diagnosis of osteomyelitis pubis was made. A urine culture revealed Pseudomonas aeruginosa and the patient was started on levofloxacin hydrate medication. Although his symptoms were ameliorated, the treatment was discontinued because of taste disturbance followed by repeated flare-ups. Consequently, the patient was switched to inpatient antibiotic treatment and was administered intravenous tazobactam piperacillin hydrate for 2 weeks, which improved his symptoms. He was discharged from the hospital after an additional 2-week course of the antibiotic treatment. One and a half years after discharge, there was no evidence of recurrent osteomyelitis pubis, urinary incontinence, and recurrent prostate cancer.

A 70-year-old man was referred to our institution because of a left seminal vesicle tumor revealed by computed tomography (CT) for postoperative follow-up of malignant melanoma. The prostate-specific antigen level (1.03 ng/mL) was not elevated. We performed transrectal ultrasound-guided seminal biopsy, and the pathological diagnosis was schwannoma. We decided to do follow-up because it was a benign tumor. However, the maximum diameter of the tumor increased over time from 21 mm to 47 mm during 7 years of follow-up. Since malignant potential could not be denied by image diagnosis, we decided to resect the tumor radically. The patient received robot-assisted laparoscopic left seminal vesicle resection. The pathological diagnosis was schwannoma with no malignant features. In such cases, robot-assisted surgery has great advantages in terms of expansion of the operative field and understanding of the three-dimensional structure.

(Objectives) Trans-umbilical laparo-endoscopic single-site surgery for a urachal remnant (LESSU) enables an aesthetically outcome as the scar is concealed within the umbilical fold. We performed trans-umbilical LESSU using the glove port to minimize interference between surgical instruments and evaluated its efficacy. (Materials and methods) LESSU was performed by a single surgeon in our institute in 13 patients between August 2020 and April 2023. GelPOINT Mini™ (Applied Medical Corporation) or Free access XS (TOP^® Corporation) were used in the first two cases, followed by the glove port method from the third case onward. We retrospectively collected clinical data by using medical records. (Results) Five males and six females, with a median age of 33 years (23-74 years), underwent surgery with the glove method. The median operating time was 126 minutes (84-153 minutes), and minimal blood loss was observed in all cases. Perioperative complications occurred in one case (forcal peritonitis, Clavien-Dindo II). The median postoperative hospital stay was 3 days (2-5 days). Fixation using a rubber band attached to a camera port from the fifth case onwards, contributed to reduced average operating time. The surgical cost of surgery using the glove method was lower than using standard surgical platforms for single-port surgery. (Conclusion) LESSU using the glove method has several benefits such as offering better flexibility of each surgical instrument, better surgical imaging near the umbilicus, and treatment at a lower surgical cost.

(Objective) To evaluate prognostic factors of metastatic urothelial carcinoma treated with immunotherapy. (Materials and methods) Fifty patients treated with pembrolizumab at Osaka Rosai hospital during 2017-2022 were examined. The treatment efficacy was evaluated using Response Evaluation Criteria in Solid Tumors, Version 1.1. (Results) Radical surgery was performed in 40 of 50 patients. According to the Bellmunt risk classification, which considers the performance status, presence of anemia, presence of liver metastasis, and interval from previous chemotherapy, 10 cases had risk 0; 23, risk 1; 13, risk 2; and 4, risk 3. The objective response rate (complete and partial remission) during immunotherapy was achieved in 15 cases. The median times of overall survival (OS) from first-line treatment initiation and immunotherapy initiation were 18.7 and 10.9 months, respectively. Multivariate analysis revealed lower platelet counts (<200,000/μL), increased C-reactive protein levels (≥0.75 mg/dL), and NLR (elevated neutrophil-lymphocyte rate) (≥6) to be poor prognostic factors for OS. Considering these three factors, the median OS of the low-risk (0 or 1) and high-risk (2 or 3) groups was significantly different, at 13.8 and 3.5 months, respectively (p<0.001). (Conclusion) Early switching from immunotherapy to the next treatment should be considered for high-risk patients.

The patient was a male in his 60s who underwent a retroperitoneoscopic right nephrectomy for a diagnosis of right renal cell carcinoma (cT3aN0M0). During surgery, the patient was positioned in the left lateral recumbent, jackknife position. A blood test of the day after surgery showed an abnormally high CK level of 23,038 U/L. However, because his only symptom was mild pain in the left lower back, the patient was placed under follow-up observation. Two days postoperatively, the patient had worsening left lumbago, swelling, stiffness, and paresthesias in the left lumbar region. A simple CT scan showed internal hypo-absorption and increased volume of the left erector spinae muscle. With a diagnosis of left erector spinae compartment syndrome, the patient underwent an emergency decompressive fasciotomy by an orthopedic surgeon. The patient's postoperative course was uneventful with no sequelae, and he was discharged on postoperative day 22.In this case, the increased pressure on the lumbar region due to the cushion inserted into the lumbar flexion to reinforce the jackknife position was thought to have contributed significantly to the development of erector spinae compartment syndrome.Although erector spinae compartment syndrome is very rare after lateral recumbency surgery, taking thorough precautions is necessary, including the decompression of as much pressure as possible in the preoperative position and appropriate intraoperative blood pressure control, and to deal with it promptly, including fasciotomy in case of postoperative low back pain that coincides with the surface of the operating table.

A 14-year-old boy developed hydronephrosis and worsening renal function due to fibroepithelial polyps of the bladder and left ureter at the age of 12 years. The endoscopic treatment of ureteral polyps was attempted by his previous doctor; however urethral stricture and ureteral stricture developed and was untreatable. Therefore, he was referred to our hospital for further reconstructive treatment. He underwent Palminteri urethroplasty with penile skin graft for urethral stricture at the age of 13 years, followed by ureteroplasty at the age of 14 years. The stenotic ureter was minimally resected, with only complete obstruction and residual polyps, and augmented onlay ureteroplasty with a buccal mucosa graft was performed. Nephrostomy was removed 13 days after surgery, followed by the ureteral stent 4 months after surgery. Retrograde pyelography and ureteroscopy were performed 1 year and 2 years postoperatively, and neither recurrent strictures nor polyps were observed. The patient is doing well 3 years postoperatively.