(Objectives) To identify risk factors for developing recurrent bladder cancer in patients who underwent surgical resection for urothelial carcinoma of the upper urinary tract.
(Methods) We retrospectively analyzed 322 patients who underwent surgical resection for urothelial carcinoma of the upper urinary tract at the Jikei University Hospital and our affiliated hospitals between January 2005 and July 2011. Univariate and multivariate analyses by using the Cox proportional hazards model were performed to determine the risk factors for intravesical recurrence after nephroureterectomy in these 322 patients.
(Results) Of the 322 patients, 111 patients (34.5%) developed recurrent bladder cancer after a median interval of 8.0 months. On multivariate analysis, the presence of a superficial tumor and the presence of a ureteral tumor were independent predictors for intravesical recurrence.
(Conclusion) The risk factors for developing recurrent bladder cancer were the presence of a superficial tumor and the presence of a ureteral tumor. Further investigation is required to evaluate the efficacy of perioperative intravesical therapy for the prevention of intravesical recurrence.
Reiter's syndrome is one of the rare complications following intravesical bovis Bacillus Calmette-Guerin (BCG) treatment. In this study we have reviewed and discussed 101cases including our own 6 cases over the past 13years in Japan (2000-2013). The patients comprised 70 males and 25 females (6 cases were unknown), mean age of 63.1 (range 42-91). Arthritis occured 4-5 days after conjunctivitis. Thirty five (55%) of 68 patients needed corticosteroid treatment to control their arthritis. HLA-B27 is known as a risk factor of Reiter's syndrome, however, positive rate was only 2.4% (n=41).
(Objectives) Recently, laparoscopic surgery is the standard procedure in urological field. We report the experience of laparoscopic renal biopsy for 4 patients who have contraindication of ultrasound-guided percutaneous renal biopsy.
(Patients and methods) We retrospectively reviewed the patients who underwent laparoscopic renal biopsy (LRB) from March 2010 to June 2013 in our hospital. Four female with mean age of 54.5 years old underwent LRB. Two patients had solitary kidney and the other 2 patients had bleeding tendency. All the biopsy was performed retroperitoneal approach. We used 18-gauge biopsy needle to take renal cortical tissue in all cases. In addition, one patient underwent small wedge biopsy with a cold knife.
(Results) Mean operative time, pneumoperitoneal time, and estimated blood loss was 63.0 min (range 48-92 min), 37.5 min (range 22-75), and 11.25 ml (range 0-30 ml), respectively. No perioperative complication was observed. In all cases, we can diagnose pathologically by LRB.
(Conclusions) LRB is safe, effective, and feasible procedure for the patients in whom ultrasound-guided percutaneous renal biopsy is contraindication.
(Objective) We investigated lower urinary tract symptoms (LUTS) and function in patients who had undergone renal transplantation (RTx).
(Methods) Fifty patients (34 males and 16 females; age 16-68 years) undergoing RTx at our hospital were included in this study. Average follow-up after RTx was 6.1 years (range 0.5-28). The pre-transplant dialysis period averaged 2.5 years (range preemptive-18.6 years). We conducted the evaluation of lower urinary tract symptoms (LUTS) and function using uroflowmetry (UFM), residual urine measurement, 24h bladder diary, International Prostate Symptom Score (IPSS), QOL score, Overactive Bladder Symptom Score (OABSS) and Core Lower Urinary Tract Symptom Score (CLSS).
(Results) Average first desire to void and maximum desire to void were 89.9 mL and 185 mL respectively in cystometry before RTx. Atrophy of the bladder before RTx showed a correlation with the dialysis period. UFM of post-RTx was maximum urinary flow rate of 21.8 mL/s and a voided volume of 287.6 mL. Severe cases of IPSS, QOL, OABSS and CLSS were not observed. Average 24h voided volume, urination times and nocturia were 2,329 mL, 8.2 times and 0.9 times respectively. Polyuria after RTx was observed in 21 patients (42%). Aging and vascular lesions such as diabetes and cardiovascular disease were the most important factor of LUTS.
(Conclusions) After RTx, LUTS were present in a number of cases after RTx. Patients undergoing RTx has been aging, it is considered necessary to perform the evaluation of LUTS before RTx.
(Purpose) Transurethral electrocoagulation (TUC) is a rare event but occurs in a constant manner with various causes or disorders and reduces patient quality of life. So far there have been no reports focusing on the details of TUC. We focused on the clinical background and related causes in cases of TUC in our institution.
(Patients and methods) We identified 76 cases (65 patients) who underwent TUC at Keio University Hospital between April 2001 and March 2011. We focused on patient background, especially with respect to the primary disease, treatment modality, use of antiplatelet or anticoagulant agent, timing of TUC, type of electrosurgical device, and the incidence of transfusion.
(Results) The primary disease for TUC included bladder tumor (BT) in 31 cases, benign prostate hyperplasia (BPH) in 13, prostate cancer (PCa) in 13, idiopathic bladder bleeding in 4, periarteritis nodosa in 3, uterine cervical cancer in 3, and others in 9. TUC after transurethral resection (TUR) was found in 38 cases, including transurethral resection of bladder tumor (TURBT) in 26 of 31 BT cases and transurethral resection of prostate (TURP) in 12 of 13 BPH cases. After TURBT, TUC was performed before removal of a urethral catheter in 7 cases, and after removal of a urethral catheter in 19 cases. With regard to TUC associated with TURP, the average estimated prostate volume in TUC cases before removal of the urethral catheter was 66.2 ml, which was significantly larger than that in TUC cases after removal of the urethral catheter (46.1 ml, p=0.045). TUC after the radiation therapy was observed in 21 cases, and the average time from the radiation therapy to TUC was 3.4 years (7 months-10 years).
(Conclusion) TUC was caused by multiple causes or disorders, and 75% of our TUC was associated with BT, BPH or PCa. TUC associated with TURBT frequently occurred within 1 week after TURBT but was still observed after 1 month following the operation. All TUC associated with TURP occurred within 3 weeks after operation. The average period from radiation therapy to TUC was 3.4 years (7 months-10 years) and TUC associated with radiation cystitis could occur beyond 5 years after radiation.
A 69-year-old woman visited our hospital with a chief complaint of fever. Five years ago, she was diagnosed as ascending colon cancer and received right hemi-colectomy. One year later, local recurrence with right hydronephrosis was detected, and she received chemotherapy -4 cycles of modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) plus bevacizumab, and 12 cycles of fluorouracil, leucovorin, and irinotecan (FOLFIRI) plus bevacizumab- for two years. Local recurrence and right hydronephrosis disappeared on positron emission tomography performed 4 years postoperatively.
This time, abdominal computed tomography for investigation of fever showed a relapse of right hydronephrosis and pyonephrosis. Cystoscopy revealed non-papillary tumor from the right ureteral orifice. Pelvic magnetic resonance imaging showed multiple tumors in the right ureter, and the distal lesion projecting into the bladder.
After the general condition became well by right nephrostomy for infection control, transurethral resection of bladder tumor was performed. Histological examination of the specimen revealed a metastatic tubular adenocarcinoma (colon origin). Although right nephrectomy was performed for pyonephrosis control, she died of local progression of ascending colon cancer 10 months after first visit.
Intraluminal ureteral progression of carcinoma originating from organs other than urinary tract is very rare. To our knowledge, this is the 9th report in the English or Japanese literature. In this case we could not rule out primary ureteral cancer preoperatively, and histological examination revealed intraluminal ureteral dissemination of ascending colon cancer.
A 81-old-woman underwent a transurethral resection of bladder tumor (TURBT) at a nearby hospital in April 2011. The diagnosis was invasive urothelial carcinoma, G3 with a component of bladder small cell carcinoma, T1 or more. She was recommended to visit our hospital for combined modality therapy of bladder cancer, but she refused the treatment for over one year. In May 2012, she came to our hospital with the chief complaint of pain at urination. Cystoscopy revealed non-papillary sessile tumor in the top of the bladder, and CT scan demonstrated the presence of the right obturator lymph nodes swollen up to 1.2 cm in size. The second TURBT was performed and the diagnosis was bladder small cell carcinoma (pT3N2M0) according to urothelial cancer guidelines of the Japanese Urological Association (JUA).
Because she strongly refused hospitalization anymore, we started daily oral intake of low dose Tegafur-Uracil (100 mg) for the treatment. After one month, the serum Neuron-Specific Enolase (NSE; tumor maker of small cell cancer) level was elevated to 27.6 ng/ml and the right obturator lymph node was enlarged up to 1.9 cm. Therefore, the Trgafur-Uracil dose was increased to 200 mg daily. After then, the serum NSE level was decreased to 15.5 ng/ml following reduction in size of the obturator lymph nodes with partial response in December 2013. After two years of follow-up period, her regular urine test showed normal findings, and no apparent recurrence was detected on urinary bladder with MRI and Cystoscopy. This is a case of advanced bladder small cell carcinoma significantly improved by oral administration of Tegafur-Uracil 200 mg/day for over 2 years.
A 41-year-old man with a history of cloacal exstrophy presented to a local clinic with abdominal pain and bowel sounds. He was noted to have pain at the site of scarring due to cloacal exstrophy and a laceration at its center, which was stained with feces. He was referred to our department because of an enterocutaneous fistula. Skin biopsy of the neoplastic lesion at this site led to a diagnosis of squamous cell carcinoma. Computed tomography showed tumor invasion of the ileum and right inguinal lymph node enlargement. We performed tumor resection, partial enterectomy, intestinal anastomosis, abdominal wall reconstruction with a left pedicled anterolateral thigh flap, split-thickness skin grafting, and right inguinal lymph node biopsy. Histopathological examination revealed cancer growth, invasion, and pearl formation in the lymph nodes, leading to a diagnosis of abdominal squamous cell carcinoma with metastasis to the inguinal lymph nodes. The skin graft took well, and the patient was discharged. He is scheduled for right inguinal lymph node dissection at a later date.
Small cell carcinoma of the prostate (SCCP) is rare, and no standard treatment regimen has yet been established. The overall prognosis remains poor. We experienced a case who obtained relative long-term survival with two types of chemotherapy treatments. A 69-year-old man underwent combined androgen blockade (CAB) with a diagnosis of prostate adenocarcinoma (Gleason score=5+3) that was staged T3bN1M1b (initial PSA=352 ng/ml). Twenty-five months after hormonal therapy, the level of serum PSA had elapsed remain low, however, FDG-PET/CT revealed high value at the lymph node of para-aortic and pelvic lesion. The levels of serum NSE and Pro-GRP elevated, and a prostate re-biopsy revealed a small cell carcinoma. Therefore, he was treated with 12-cycles of combination chemotherapy consisting of etoposide and carboplatin. Then, disease has progressed, so he was changed to second line chemotherapy with amrubicin. He underwent 12-cycles chemotherapy with amrubicin, but he died of cancer 39 months after the initial treatment of SCCP.
Management strategy for upper urinary tract calculi in small children is still a matter controversial. We report successful management of ureteral stone with transurethral ureterolithotripsy (TUL) in 2 boys weighing around 10 kg. Case 1: A 2-year-old boy (78 cm in height, 9.6 kg in weight), who received hydrocortisone and fludrocortisone for the treatment of 21-hydroxylase deficiency, was referred to our hospital with a right 9-mm lower ureteral stone. For TUL, a 7.5 Fr rigid cystoscope was introduced into the ureter directly after dilation of the ureteral orifice. By using Holmium:YAG laser for lithotripsy, complete stone evacuation was achieved. Stone analysis showed the composition of calcium phosphate and calcium oxalate. Case 2: A 1-year-old boy (80 cm in height, 10.5 kg in weight) with neurofibromatosis type 1 was referred to our hospital with a left 7.5-mm ureteral stone at the ureteropelvic junction. TUL was performed using a 4.5 F rigid ureteroscope and Holmium:YAG laser. No residual stone was identified. Stone analysis showed the composition of calcium oxalate. TUL is a safe and feasible option for small children, even in boys weighing approximately 10 kg.
A 6-month-old boy was referred to our hospital with left scrotal swelling. Scrotal ultrasound examination revealed a 2 cm cystic mass without solid component in left testicular parenchyma. Serum AFP, hCG and LDH levels were within normal limits. Although we suspected a simple cyst of the testis or a benign testicular tumor, the left testicle was explored via an inguinal incision in case of malignancy. Since intraoperative frozen section revealed benign, we preserved the remaining testis. The wall of cystic mass had a small solid lesion. The definitive pathological examination of the cyst wall showed mature teratoma including squamous epithelium, glandular epithelium of enteric type and cartilage. At 4 years of follow up, he was free of recurrence without testicular atrophy.
Microsurgical subinguinal varicocelectomy is one of the best treatment modalities for varicoceles. However, the difficulty in identifying testicular arteries that should be spared is a limitation of this technique. We assessed the efficacy of intraoperative indocyanine green angiography (ICGA) during microsurgical subinguinal varicocelectomy in three pilot cases. We performed microsurgical subinguinal varicocelectomy using a surgical microscope for observing infrared fluorescence in patients with infertility or chronic pain associated with varicoceles. After the exposure of the spermatic cord blood vessels, ICG was injected intravenously to identify and isolate the testicular artery. Thereafter, the varicose veins were repeatedly ligated, while preserving a few lymphatic vessels and the spermatic duct. The testicular artery could be clearly identified by ICGA and were able to separate under ICGA. The preserved arteries were confirmed by ICGA at the end of microsurgical operation. Though, all the internal spermatic veins could be safely ligated, while sparing the testicular arteries and lymphatic vessels.
Microsurgical subinguinal varicocelectomy using intraoperative ICGA facilitated safe and quick surgery by enabling the visualization of the spermatic cord blood vessels. This is the first report to indicate the usefulness of vessel visualization by ICGA during microsurgical subinguinal varicocelectomy.