(Purpose) We report the detailed technique and results of transvaginal extraction of the kidney following laparoscopic nephrectomy.
(Patients and methods) From August 2013 onward, we planned to perform transvaginal extraction of the kidney following laparoscopic nephrectomy in a total of 6 female patients. Of the 6 patients, 5 underwent the procedure. After completion of the primary laparoscopic nephrectomy and entrapping the removed kidney, the patients were placed in the supine lithotomy position. A transverse posterior colpotomy was created transvaginally at the apex of the posterior fornix. An opening was made in the peritoneum bluntly with the fingers under laparoscopic view. After the drawstring of the entrapped specimen was delivered into the vagina, the specimen was extracted intact via the vagina. When the vaginal wall was too tight for a large specimen, the incision was extended on the affected side. After removal of the specimen, the peritoneum was sutured laparoscopically, and the posterior colpotomy incision was repaired transvaginally.
(Results) Transvaginal extraction was successful in 5 patients. The mean operative time for the vaginal extraction procedure was 59 minutes. Blood loss was minimal. The mean specimen weight was 447 g (range 271 to 655 g). No intraoperative complications occurred. Postoperatively, one case needed intermittent catheterization for a few days because of temporal dysfunction of the bladder.
(Conclusions) Transvaginal extraction is an efficacious and minimally morbid technique for removing the intact kidney after laparoscopic nephrectomy.
(Objective) Dutasteride is a 5-alpha reductase inhibitor used to treat benign prostatic hyperplasia. Dutasteride lowers prostate-specific antigen (PSA) levels, which may lead to delays in the diagnosis and treatment of prostate cancer (PCa). This study investigated patients who underwent prostate biopsy (PBx) while receiving dutasteride to investigate whether this agent affects the diagnosis and treatment of PCa.
(Patients and methods) PBx was performed on six patients receiving dutasteride for >3 months at our medical institutions between January 2010 and June 2013. No patients underwent PBx before dutasteride administration. We performed PBx both for patients with high initial PSA levels and for those with elevated PSA levels with or without initial PSA decline after dutasteride administration. We also investigated clinicopathological findings.
(Results) Mean age at the start of administration was 69.5±5.9 years (range, 59-77 years), mean duration of administration was 14.1±7.4 months (range, 4.0-23.5 months), mean prostate volume at the start of administration was 70.4±30.7 ml (range, 18.8-104.6 ml), and mean PSA level at the start of administration was 7.7±3.3 ng/ml (range, 4.9-14.2 ng/ml). PSA density was 0.098±0.045 ng/ml/cm3 (range, 0.042-0.181 ng/ml/cm3), and PSA level at PBx was 5.4±2.7 ng/ml (range, 2.5-10.7 ng/ml). We detected three PCa patients, and clinical stage in each case was cT1cN0M0. Radical retropubic prostatectomy was performed in two cases, and androgen-deprivation therapy was performed in one case.
(Conclusion) All PCa were detected in the early clinical stage. No delays in detection or treatment of PCa were seen in any cases. Careful observation of PSA levels is simple and useful for detecting PCa in patients under dutasteride administration.
(Objectives) Because obstructive pyelonephritis secondary to ureteral stones can easily cause sepsis and concomitant disseminated intravascular coagulation (DIC), it is a potentially lethal disease. However, the optimal treatment for such severe patients has yet to be established. In this study, we aimed at clarifying the effectiveness of emergent drainage and DIC treatments for patients with septic DIC due to obstructive pyelonephritis. In additon, we also evaluated the impact of recombinant human thrombomodullin (rTM) for severe patients with DIC.
(Materials and methods) From September 2006 to May 2013, 31 patients with obstructive pyelonephritis secondary to ureteral stones who met the acute DIC criteria from the Japanese Association of Acute Medicine were treated at our institution. All patients received emergent drainage of urinary tract and anti-DIC treatment, as well as administration of antibiotics and adequate volume infusion. To evaluate the impact of rTM, patients received rTM were compared with those managed by other DIC therapeutic agents.
(Results) The mean patients' age was 73 years old, and 27 patients (87.1%) were in a state of septic shock. All patients, except for one patient (3.2%) who died 6 days after drainage, could recover from sepsis and comcomitant DIC. Interestingly, thrombocyte count, creatinine, and SOFA Score in rTM group were recovered faster than those in no rTM group (p=0.017, 0.0038, and 0.0006, respectively).
(Conclusions) These results indicate that most patients with DIC caused by obstractive pyelonephritis can be successfully managed by emergency drainage and anti-DIC treatment. In addition, rTM may be effective for the treatment of such severe patients by improving organ failure associated with disordered coagulation.
(Purpose) We investigated the impact of lower urinary tract symptoms (LUTS) on generic health-related quality of life (HRQOL) in male patients without co-morbidity.
(Patients and method) From 2003 to 2011, a total 567 men who presented out urological department completed the questionnaires including International Prostate Symptom Score (IPSS), incontinence-frequency score (IFS) from the UCLA prostate cancer index, MOS 36-Item Short-Form Health Survey (SF-36). Among 230 patients with no co-existing morbidity, the relations between each LUTS score of IPSS indices and IFS and 8 domain scores of SF-36 were analyzed by Pearson's product-moment correlation and stepwise multiple regression analysis.
(Result) Univariate analysis showed that the IFS had a significant correlation with all of 8 domain scores of SF-36, and also the IPSS item scores of urgency, nocturia and straining correlated significantly with multiple domain scores of SF-36. In multiple regression analysis, the proportionate contributions of LUTS to each SF-36 domain scores were low (R2 was 10% or less). Incontinence was considered as the most influential factor that had a negative impact on HRQOL in 7 SF-36 domains of physical functioning, role-physical, bodily pain, general health perception, vitality, social functioning and mental health. Additionally, nocturia, straining and urgency were significantly associated with deficit of HRQOL in 4 SF-36 domains (role-physical, general health perception, role-emotional, mental health), 2 domains (bodily pain, social functioning) and 1 domain (role-emotional) of SF-36, respectively.
(Conclusion) Among LUTS, incontinence, nocturia and straining were the most important symptoms in association with the negative impact on generic HRQOL measured by SF-36.
Neurofibromatosis type 1 (NF1) is a distinct genetic disorder due to the NF1 gene mutation which induces the aberrant activation of the RAS-signaling. Because RAS-related proteins function as oncogenic factors, NF1 patients frequently develop malignant tumors, especially of neural crest origin, such as peripheral nerve sheath. In addition, malignant tumors of the pancreas, colorectum, and lung have been reported to frequently arise in NF1 patients. However, the association between germ cell tumor and NF1 has not been clarified yet. A 29-year-old male with dyspnea was referred to our hospital because of the large mass in the anterior mediastinum and cervical lymph node swelling. The diagnosis was extragonadal germ cell tumor with cervical lymph node metastasis, and complete remission was obtained by multidisciplinary treatment consisted of combination chemotherapy and surgical resection. To our acknowledgement, this is the first case of extragonadal germ cell tumor in NF1 patients. We discuss the relevance between activation of the RAS-signaling and the development of germ cell tumor.
Solitary adrenal metastasis of rectal cancer is comparatively rare condition and it is difficult to be diagnosed because it doesn' t have any characteristic symptoms. We report a case of this type of adrenal tumor that could be figured out by tumor markers and the analysis of CT scan image. A 67-year-old man visited our department with the right adrenal tumor. He has a past medical history of rectal cancer and a low anterior resection was performed in 2011. After the surgery, he received adjuvant chemotherapy for 6 months. There has been no finding of recurrence or metastasis after chemotherapy. However, his follow-up abdominal CT in 2013 showed the right adrenal tumor which was 23 mm in diameter. Serum CEA level has also increased to 4.1 ng/ml, but there was no abnormal finding with hormonal study. The tumor size and CEA level gradually increased up to 46 mm in size and 10.4 ng/ml during 6 months. Enhanced CT also showed 39% at rate of absolute percentage wash out, which was not the finding of typical functional adrenal tumor. Based on these findings, we diagnosed that the origin of this adrenal tumor should be solitary metastasis of the rectal cancer. For the treatment of surgical procedure, we performed laparoscopic right adrenalectomy. The pathological finding showed adenocarcinoma, the origin of which was the previous rectal cancer. Six months have passed since the surgery, but CEA level still has remained normal range and neither finding of recurrence nor metastasis has been found.
A 68-year-old woman presented with asymptomatic gross hematuria. Computed tomography (CT) scan revealed noninvasive tumor in the right ureteropelvic junction. After diagnosis with right pelvis carcinoma by ureteroscopy, she underwent laparoscopic nephroureterectomy in Aug. 2008. Six months later, hepatic metastasis was detected. Three courses of combination chemotherapy consisting of gemcitabine and cisplatin (GC) were conducted, and then partial response (PR) was achieved. In Aug. 2009, radical metastasectomy for liver metastasis was performed. More than four years and five months after hepatectomy, the patient has achieved a high quality of life.
A 61-year-old female presented with the complaints of fever and left back pain. She had previously undergone bone marrow transplantation for acute myeloid leukemia and achieved remission. Abdominal computed tomography (CT) revealed left hydronephrosis and suspected tumor lesions in the right upper ureter and left lower ureter. Ureteroscopy was performed for a diagnosis. A yellowish tumor was detected in the left lower ureter, and tissue biopsy was performed. Two weeks after the examination, abdominal CT revealed ascites and retroperitoneal dissemination. The results of the ascites cytology showed infiltration by leukemia cells, and the patient was diagnosed as having recurrent leukemia. A week later, she died. The ureteral tumor was diagnosed as a granulocytic sarcoma.
Granulocytic sarcoma, a condition characterized by mass formation outside the bone marrow by granulocytic cells, is classified as a myeloid sarcoma, occurring in an estimated 2-8% of patients with myeloid leukemia. The possibility of granulocytic sarcoma should be considered when treating patients with a history of leukemia.
The sexual dysfunction and infertility after treatment of bilateral germ cell tumors (GCT) becomes the serious problem. Therefore andrological aspects as well as cancer curability should be considered in planning of bilateral GCT treatment. Here we report 3 cases of metachronous bilateral GCT treated with different regimens, and discuss from the viewpoint of preservation of sexual function.
Case presentations: (1) A 38-year-old man underwent right-sided orchitectomy for a right testicular tumor at the age of 26 years. Pathological diagnosis was seminoma and clinical stage was T1N0M0S2. 12 years later, contralateral testicular tumor developed. Left-sided orchitectomy was performed. Pathological diagnosis was seminoma and clinical stage was T1N0M0S2. He has been followed up for 4 years after the second operation without any evidence of tumor recurrence. Endocrinological examination show low testosterone level, and high LH and FSH levels. Erection and ejaculation are impossible but he does not request androgen replacement therapy.
(2) A 21-year-old man underwent right-sided orchitectomy for a right testicular seminoma at the age of 20 years (T1N0M0S0). 1 year later, contralateral seminoma (T1N0M0S0) developed and left-sided organ-preserving operation was performed. Histologic specimens showed seminoma and intratubular malignant germ cells (ITMGC) in surrounding seminiferous tubules. 2 cycles of BEP was added after the operation. He has been followed up for 5 years without any evidence of tumor recurrence. Endocrinological examination shows normal levels of testosterone and LH, but FSH is slightly high. Erection and ejaculation are possible.
(3) A 36-year-old man underwent right-sided orchitectomy for a right testicular embryonal carcinoma at the age of 30 years. Clinical T1N0M0S1 was confirmed. 6 years later, he noticed the induration at his left testis. The result of fine needle aspiration cytology was embryonal carcinoma. At first, organ-preserving operation after chemotherapy was planned. However, he refused the operation considering the possibility of erectile dysfunction and infertility. As a result, he received only chemotherapy (3 cycles of BEP), and has been free of the disease for 11 years after chemotherapy. The level of testosterone, LH, and FSH are all normal. Erection and ejaculation are possible.
A 42-year-old man was referred to our hospital for macrohematuria. Computer tomography and magnetic resonance imaging revealed right hydronephrosis and a retroperitoneal mass, located next to right side of the bladder. Cystoscopy showed a protruded lesion covered with normal mucosa at the right lateral wall. The patient underwent transurethral resection of the bladder tumor and biopsies of the bladder wall. Histological examination showed squamous cell carcinoma. Neoadjuvant chemotherapy using paclitaxel and carboplatin (TC) was performed. A total cystectomy, right nephroureterectomy and construction of the ileal conduit were performed after one course of systemic chemotherapy. Histological examination showed urothelial carcinoma with squamous cell differentiation. Unexpectedly, a small amount of CIS was detected only in the vicinity of the TUR scar. The patient received 2 cycles of TC chemotherapy as adjuvant chemotherapy. Unfortunately, 11 months later, local recurrence and liver metastasis were detected. He died 17 months after the surgery.
The patient was a 37-year-old woman who had suffered from repeated pyelonephritis. Computed tomography (CT) of the abdomen revealed a 1.9 cm retroperitoneal mass with compression of the right ureter and hydronephrosis. The patient visited our medical center and admitted. The patient underwent a simple total excision of the mass and end-to-end ureteral anastomosis. The tumor involved right ovarian vein and right ureter. Histopathological diagnosis was leiomyosarcoma of the ovarian vein.
At 12 months after operation, local recurrence of surroundings tissue of the right ureter and gallbladder, and inferior vena cava invasion is found. Thus, the patient underwent a right nephroureterectomy with partly resection of the inferior vena cava and en block excision of the gallbladder. While CT revealed no recurrence three months after the operation, adjuvant postoperative combination chemotherapy with gemcitabine and docetaxel was administered.
Nine cases of this leiomyosarcoma arising from ovarian vein have been reported in the literature. Leiomyosarcoma arising from ovarian vein with hydronephrosis is a second example.