(Purpose) To report our clinical experience regarding transurethral resection of bladder tumor (TUR-Bt) guided by photodynamic diagnosis (PDD) with intravesical instillations of 5-aminolevulinic acid (ALA) and to assess the usefulness of the therapeutic method. (Materials and methods) TUR-Bt guided by PDD was performed in 57 patients of which 47 were men and 10 women with a median age of 74.3 years (range 45-90), 36 were primary cases and 21 were recurrent cases with non-muscle invasive bladder cancer. Two to two and half hours prior to endoscopy 1.5 g ALA dissolved in 50 ml of 8.4% sodium hydrogen carbonate (NaHCO3) solution was instilled intravesically. For fluorescence excitation a blue light source (D-LIGHT System, Karl Storz Endoscopy Japan K.K.) was used. The tumorous lesions under white light guidance and the lesion with fluorescent excitation under blue (fluorescence) light guidance were taken by cold cup as a biopsy and also resected sequentially. To evaluate the accuracy of PDD, the levels in images of the ALA-induced fluorescence were compared with the pathological results. To evaluate the availability of TUR-Bt guided by PDD, survival Analysis regarding vesical recurrence was retrospectively examined compared to the cases underwent conventional TUR-Bt under white light guidance. Moreover, in these cases, multivariate analysis using Cox proportional-hazards model was performed to detect the clinico-pathological factor independently contribute to improving prognosis. (Results) In the 301 specimens obtained from 57 patients, the sensitivity and specificity of PDD were 92.5% and 60.1%, whereas the sensitivity and specificity of conventional endoscopic examination under white light guidance were 81.6% and 79.5%, respectively. Median follow-up period was 19.1 (range 8.6-49.9) months in 57 patients underwent TUR-Bt guided by PDD. Eight of 57 patients recurred and recurrence-free survival rate was 88.2±0.1% (at 12 months) and 76.2±0.1% (24-48 months). Median follow-up period was 49.9 (5.0-145.0) months in 149 patients underwent conventional TUR-Bt. Ninety-nine of 149 patients recurred and recurrence-free survival rate was 60.3±0.0% (12 months) and 31.6±0.0% (24-48 months). There was statistical significance in recurrence-free survival rate between these 2 therapeutic groups (p< 0.001). Moreover, multivariate analysis revealed the independent factor contribute to improving prognosis was only TUR-Bt guided by PDD (hazard ratio 0.279, p=0.001). (Conclusion) It was suggested that TUR-Bt guided by PDD might reduce the risk of vesical recurrence in the early stage after operation of non-muscle invasive bladder cancer.
(Purpose) In this retrospective study we reported the results of salvage external beam radiotherapy for patients with biochemical recurrence after radical prostatectomy. (Materials and methods) A total of 28 patients with biochemical recurrence after radical prostatectomy underwent salvage radiotherapy with (n=16) or without (n=12) hormonal therapy. Median radiation dose was 60 Gy. Biochemical recurrence after radiotherapy was defined as a single prostate-specific antigen (PSA) of at least 0.1 ng/ml. Potential risk factors were evaluated for significant associations with biochemical recurrence. (Results) The median follow-up period after salvage radiotherapy was 42 months. The actuarial biochemical recurrence free survival rate at 3 and 5 years was 81% and 74%, respectively. Addition of hormonal therapy to salvage radiotherapy did not alter biochemical recurrence rate (P=0.56). Univariate analysis revealed that Gleason score of 8 to 10 (P=0.026) and PSA before salvage therapy greater than 0.24 ng/ml (P=0.0016) were significant risk factors for biochemical recurrence. On multivariate analysis, PSA before salvage therapy greater than 0.24 ng/ml (P=0.017) maintained statistical significance. Of 28 patients 3 (11%) experienced late grade 3 toxicity of hematuria. (Conclusion) Our data suggest that early use of salvage radiotherapy is beneficial for patients with biochemical recurrence after radical prostatectomy.
(Objectives) In this study, we sought to define the incidence of benign renal tumors in our institute and to clarify the clinical factors associated with benign renal tumors, in order to assist in forming preoperative differential diagnoses. (Methods) From October 2002 to July 2007, we performed 157 nephrectomies in patients preoperatively diagnosed with renal cell carcinoma. We chose 81 tumors, all of which were less than 5 cm, for further study. We reviewed double-phase helical CT imaging retrospectively, specifically focusing on attenuation patterns and homogeneity. We also compared clinical factors, including age, sex and tumor size, between the benign and malignant renal tumors. (Results) The patient's median age was 67 years (mean age, 63 years), and the median tumor diameter was 3.0 cm (mean, 3.2 cm). Benign renal tumors were found in 10 (12%) of the 81 tumors; these included seven cases of oncocytoma and three cases of angiomyolipoma with minimal fat. Several factors were significant clinical determinants of differentiation between benign and malignant renal tumors: homogeneity in CT, female gender, and small tumor size all predominated in cases of benign tumors. Attenuation pattern in CT, however, was not a significant factor (p=0.344). (Conclusions) When a patient, especially a female, presents with a small and homogeneous renal tumor, careful consideration should be given to the possibility of a benign process, which needs further consideration before performing excessive surgery.
(Purpose) The efficacy of α1-adrenoceptor (α1-AR) antagonist and anticholinergic agent combined therapy for patients with benign prostatic hyperplasia (BPH) together with overactive bladder (OAB) has been controversial. The purpose of this study was to evaluate the effect of tolterodine combined with α1-AR antagonist for patients with BPH and OAB after insufficient efficacy by monotherapy with α1-AR antagonist. The adverse event of this combined therapy was also assessed. (Materials and methods) The study included 47 patients with BPH, whose OAB symptom persisted (OAB symptom score; OABSS≥3) after monotherapy with α1-AR antagonist for more than 4 weeks. The mean age was 72.9 years and the mean prostate volume was 29.8 ml. Four mg/day of tolterodine with α1-AR antagonist was administered for 8 weeks to patients. International prostate symptom score (IPSS), quality of life (QOL) index, OABSS, King’ s Health Questionnaire (KHQ) and residual urine volume (RUV) were assessed before and after combined therapy. (Results) Six patients were dropped out from this study because of dry mouth, constipation, onset of other disease and insufficient efficacy by self-judgment. IPSS (from 15.1±6.8 to 11.0±7.9; P< 0.01), QOL index (from 4.3±1.1 to 3.6±1.3; P< 0.01) and OABSS (from 7.0±3.0 to 5.4±2.9; P< 0.01) of 41 patients improved significantly by combined therapy. The storage symptom of IPSS subscore improved significantly (from 8.0±2.9 to 6.5±2.8; P< 0.01), whereas the voiding symptom did not improve. Regarding KHQ, the score of 3 domains (impact on life, role limitation, and physical limitation) improved significantly (P< 0.05). RUV did not change and no serious adverse event including urinary retention was found in this study. (Conclusions) This study reveals that the combined therapy of α1-AR antagonist and tolterodine represents an effective and safe treatment modality for patients with BPH and OAB, whose OAB symptom was not improved by antecedent monotherapy with α1-AR antagonist.
56-year-old woman was admitted to our hospital due to gross hematuria. Cystoscopy and contrast-enhanced abdominal CT scan revealed a solid tumor at the right terminal ureter. She underwent transurethral resection of the right ureteral tumor. The ureteral tumor included proliferative endometrial stroma and glands under urothelial cells, and the histopathological diagnosis was ectopic endometriosis. Before the surgery, the patient had underwent hormone replacement therapy using estrogen patches to treat menopausal disorders, however, the dose of estrogen was five times higher than regular dose. Therefore, in this case, the serum level of estrogen was elevated over the normal value. Ectopic endometriosis is rare in urinary tract especially ureter. Furthermore, endometriosis is an uncommon disease in women during postmenopausal period. Our case suggests that an excessive hormone replacement therapy might cause endometriosis in postmenopausal women.
A 68-year-old-man was referred to our hospital with complaints of palpation, hematemesis and melena. Esophagogastroduodenoscopy revealed a huge ulcer in the stomach, and based on biopsy findings, he was pathologically diagnosed as having diffuse large B-cell type malignant lymphoma. A computed tomographic scan demonstrated prostatic enlargement and swelling of the left external iliac lymph nodes. Since his serum PSA level was 13.0 ng/ml, prostatic needle biopsy was performed. Histological findings revealed diffuse large B-cell type malignant lymphoma and moderately differentiated adenocarcinoma of the prostate. The patient achieved complete response after eight cycles of combination chemotherapy with rituximab cyclophosphamide, adriamycin, vincristine and predonisolone. At the same time of chemotherapy, androgen deprivation therapy was initiated. The current his PSA level is 0.2 ng/ml or less.
A 72-years-old male visited our hospital with a complaint of perineal and voiding pain. An elastic hard mass was palpated by rectal examination in the cranial lesion of prostate. On CT scan and MRI it was located at the site of the right seminal vesicle. Trans-rectal needle biopsy specimen showed leiomyosarcoma. Radical cystoprostatectomy with pelvic lymph node dissection was performed at Hokkaido University Hospital. Microscopic examination of the resected specimen revealed the tumor arose from the right seminal vesicle without involvement of the bladder and the prostate gland. Three months after the operation the tumor recurred at lung and pelvic lymph node. He died 10 month postoperatively. Autopsy finding showed many visceral organs metastases without local recurrence. In the past, nine cases of leiomyosarcoma of seminal vesicle were published in the literature. Including our case, pathological diagnosis by core needle biopsy was attempted in five cases, though accurate diagnosis was made in only two cases. In our case, Immunohistological study by SMA and desmin was useful for histological diagnosis preoperatively.
A 62-year-old male underwent resection of malignant melanoma of left breast skin in 2006. In 2007, he underwent lymph node dissection and chemotherapy (DAV-feron therapy) for left axillary lymph nodes metastasis. In Aug 2008, he was referred to our department with chief complaint of macrohematuria. Two non-papillary bladder tumors were detedted on cystoscopy and CT/MRI showed multiple lymph node swelling, including left inguinal, paraaortic, and right cervical regions. As malignant melanoma cells were found on urinary cytology, a diagnosis of metastatic malignant melanoma of the urinary bladder was made. It was thought that tumor resection would not contribute to prognostic improvement because of multiple lymph node metastases. Therefore, tumor resection was not performed. The patient is currently receiving chemotherapy. This is the eleventh case of metastatic malignant melanoma of the urinary bladder to be reported in the Japanese literature. There have been no previous reports of cases in which urinary cytology was positive for malignant melanoma cells.