(Purpose) To evaluate prostate specific antigen (PSA) bounce that may occur as a time PSA rise phenomenon during follow up period after brachytherapy (BT) with permanent seed implantation for prostate cancer. (Materials and methods) Seven hundred and forty-six patients had undergone BT from November 2003 to April 2007 in a single institute, and of 130 patients who did not receive hormone therapy and had minimal 3-year follow up are analyzed. PSA bounce was defined as a rise of at least 0.4ng/ml with spontaneous return to pre-bounce level or lower. (Result) Among the 130 patients, 40 patients (30.8%) developed PSA bounce, and median time to PSA bounce was 18 months after the BT. With univariate analysis, younger patients (P=0.027) and larger prostate (P=0.030) had statistically significant correlation with PSA bounce. With multivariate analysis, younger patients were identified as only independent factor for predicting PSA bounce. Eight patients out of 130 patients (6.2%) triggered the Phoenix definition (nadir+2ng/ml) of PSA failure, however, clinical failure was seen only in 3 patients, and other 5 patients were considered as PSA bounce. (Conclusion) PSA bounce is likely to occur in younger patients within 3 years after BT. It is clinically important to distinguish PSA bounce from PSA failure during following period after BT.
(Objective) We examined the relationship between morcellation efficiency and enucleated tissue weight in holmium laser enucleation of the prostate (HoLEP) for patients with benign prostatic hyperplasia (BPH) retrospectively. (Methods) From January to December 2010, 140 patients with BPH were treated by HoLEP combined with mechanical morcellation with up side down technique by a single surgeon. (Results) The mean age was 70.6 years, and the mean enucleated tissue weight was 46.8g. The mean morcellation time was 9.9 min, and the mean rate of morcellation was 6.7g/min. No complications were reported relating to morcellation such as bladder injury. Although morcellation time and enucleated tissue weigh were proportionally related (Estimate equation: Y=-1.186+0.813*X, R^2: 0.814), larger glands with more than 80g of tissue enucleated did not match this distribution map. Five cases with more than 100g of enucleated tissue weight required much longer operation time (range 66-90 min) and were disproportioned to tissue weight. Morcellation efficiency tended to decrease when enucleated tissue weight exceeds 80g and less than average in almost all cases. Morcellation efficiency significantly worsen when enucleated tissue weight exceeds more than 100g. (Conclusions) Morcellation efficency may decrease in larger gland exceeds 80g.
(Objectives) For the management of patients with small renal tumor, laparoscopic partial nephrectomy (LPN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease (CKD). The challenge of LPN is to resect a tumor in a bloodless field within a limited warm ischemia time (WIT), followed by hemostatic renorrhaphy under restricted movement of laparoscopic forceps. Therefore, LPN still remains challenging to even experienced laparoscopic surgeon. DaVinci device improved the movability of forceps in LPN and provided three-dimensional visualization. We evaluated outcome and safety of our first series of robot-assisted laparoscopic partial nephrectomy (RALPN) for localized kidney tumor. There was no previous report of RALPN undertaken in our country. (Patients and methods) Since August 2010, our team carried out RALPN for a total of five cases of renal tumor. There were four males and one female with an age range of 41 to 65 years-old. Size of tumor ranged from 15 to 28mm, located in exophytic region, and four cases in right side and one in left. RALPN was undertaken by single surgeon through transperitoneal approach in two cases and retroperitoneal in tree. (Results) RALPN was completed in all patients without conversion to open or hand-assisted surgery. The median operative time and the estimated blood loss were 189 minutes, ranged from 150 to 264, and 29ml, from 10 to 50, respectively. The median volume of removed tumor and the length of WIT were 7g, ranged from 4 to 13g, and 18 minutes, from 13 to 26 minutes, respectively. No complications or reoperations were associated during or post our RALPN cases. Pathological examination of removed tumor showed renal cell carcinoma with negative surgical margin in all cases. (Conclusions) Introduction of daVinciTM device to LPN made this procedure, RALPN, a secured and promising one, which leading to shorten the WIT and to achieve satisfied renorrhaphy. Even for the complex and technically challenging renal tumors, robotic assistance is expected to provide patients the benefit of minimally invasive surgery with safety and satisfactory renal function.
The patient was a 79-year-old man who underwent right extrapleural lucite ball plombage for pulmonary tuberculosis at aged 19. He was followed BPH with medication from May 2008 at our hospital. He presented with macrohematuria in January 2010, but cystoscopy and CT scan showed no significant abnormalities. He was admitted to complaining of general fatigue and anemia in February 2010. TURBT was performed 10 days after admission, and showed the bleeding sites with oozing in mucosa at the bilateral and posterior wall of the bladder. Neither CT nor cytological examinations were helpful in diagnosing this disease, although histological observation implied a possibility of malignant vasoformative tumor. He died one month after admission. Autopsy revealed a huge bloody mass at the right upper thoracic wall and same metastatic tumors of both adrenals, the bone, the stomach and the urinary bladder. Microscopic examination revealed that atypical cells had proliferated and formed vascular structures, which were stained positively with CD31, and vimentin. Finally, the diagnosis was made of pleural angiosarcoma and multiple metastasis. Metastatic angiosarcoma of the bladder is very rare and difficult to make definite diagnosis, however we have to keep in mind the presence of this disease.
A 49-year man, with past history of right total nephroureterectomy due to urothelial carcinoma of the right renal pelvis in September 2006 and left partial ureterectomy due to contralateral ureteral recurrence in October 2007, underwent TUR-BT due to superficial high-grade recurrent bladder cancer. After TUR-Bt, he was treated with intravesical Bacillus Calmette-Guérin (BCG) instillation at weekly intervals. Just after 5th instillation, he suffered a continuous high fever up to 38°C and complained of general fatigue. Chest CT showed diffuse micronodular shadows in both lungs, and serum liver enzyme was markedly elevated. All cultures from his sputum and urine were negative for mycobacterium tuberculosis. TB-PCR test and quantiferon were also negative. These findings together with no improvement of the symptoms with anti-tuberculous treatment finally made us to judge that this was due to a hypersensitivity reaction to BCG. Soon after pulse steroid therapy, body temperature was normalized and the abnormal findings of the lung and liver disappeared.
A 55-year-old man who presented himself with gross hematuria and right back pain was found to have a right renal mass with evidence of metastasis to the lymph nodes, bone and lung (cT1bN1M1). He underwent a transperitoneal right nephrectomy. Tumor expressed markers of CD10, P504S and CK19 immunohistochemically, so histopathological examination revealed tubulocystic carcinoma of the right kidney (pT3a). After the patient received sunitinib therapy, computed tomography revealed reduction in the size of the metastatic lung nodule and lymph nodes, indicating a partial response. He is alive without disease progression at 12 months after nephrectomy. Tubulocystic carcinoma has been referred to by Amin et al as low-grade collecting duct carcinoma and is not yet included in the World Health Organization (WHO) 2004 classification of renal tumors. The cells lining the tumor range from cuboidal to columnar and have large nuclei with low-grade changes and abundant eosinophilic or amphophilic cytoplasm. Hobnail cells are commonly seen. Immunohistochemically, tubulocystic carcinomas are strongly positive for markers of the proximal nephron (CD10, P504S) and the distal nephron (parvalbumin, CK19). Despite a low nuclear grade, tubulocystic carcinomas occasionally show progressive behavior clinically. Although there is no established salvage therapy, sunitinib was found to be effective for this patient.
Three patients who had metastatic urothelial carcinoma have been administered gemcitabine monotherapy (GEM). A 78-year-old male who underwent nephroureterectomy for right ureteral cancer presented with liver and retroperitoneal lymph node metastases postoperatively. GEM was administered because of severe renal insufficiency. Although 8 cycles of this therapy were done, we discontinued it because of progressive disease. A 68-year-old male who underwent nephroureterectomy for left ureteral cancer presented with retroperitoneal lymph node metastasis postoperatively. GEM for the purpose of maintenance therapy was administered after first-line chemotherapy. He maintained a stable disease after 9 cycles. A 70-year-old female who underwent transurethral resection of a bladder tumor presented with neck lymph node metastasis postoperatively. She was administered GEM for second-line chemotherapy as an outpatient because she did not want hospital treatment. However, it failed due to progressive disease after 3 cycles. There were few adverse events that forced the patient to be admitted into the hospital, although bone marrow suppression of grade 3 or 4 occurred in 2 patients. GEM for metastatic urothelial carcinoma may be adapted for patients who have severe renal insufficiency and need maintenance therapy.
A 21-year-old female patient underwent emergency cesarean section and a postoperative hematoma occurred at the site of the uterine incision. The patient underwent laparotomy for hemostasis. An 3cm perforation at the posterior wall of the bladder was identified. The bladder was repaired in two layers with an absorbable suture. Three days later she developed a fever of over 38°C. Despite therapy with several antimicrobial agents, her fever persisted and the wound was opened. Computed tomography scan revealed an abscess at the site where the hematoma had formed. We present a case of severe wound infection that was caused by Mycoplasma hominis infection after cesarean section. Bladder perforation associated with cesarean section is uncommon. Mycoplasma hominis should be considered as a causative organism if an antimicrobial resistant infection occurs at the surgical site after a cesarean section.