(Objectives) Nephron sparing surgery (NSS) is strongly recommended for patients with T1a renal cell carcinoma (RCC) whenever surgically feasible. However, partial nephrectomy, particularly laparoscopic approach, remains underutilized in Japan compared to laparoscopic radical nephrectomy (LRN). In this study, we examined the safety and efficacy of laparoscopic partial nephrectomy (LPN) for T1a RCC compared to LRN. We also assessed the factors that affect the decision to perform LPN or LRN.
(Patients and methods) From March 2001 to September 2014, 112 patients with T1a renal tumors received renal surgery at our institution. Of these, 100 patients (LPN: 36 patients, LRN: 64 patients) underwent laparoscopic surgery. Treatment outcomes including surgical and oncological outcomes among each approach were compared. In addition, multivariate analysis was performed to reveal the factors that affect the decision on surgical approach.
(Results) The ratio of patients more than 75 years old and the RENAL nephrometry score were higher in LRN group than those in LPN group. Operating time was longer but renal function was well preserved in LPN group. Importantly, blood loss, intraoperative and postoperative complication rate, and oncological outcome (recurrence-free survival and overall survival) were similar in both groups. Multivariate analysis revealed that age (≥75 years old), high RENAL nephrometry score, operation period (before 2011), and the absence of Endoscopic Surgical Skill Qualification (ESSQ) in surgeon were independent predictive factors that select LRN.
(Conclusions) Our data suggests that LPN for T1a renal tumor could be performed safely and the decision whether LPN or LRN were performed were associated with technical factors such as the presence of ESSQ or operation period, as well as patient's factor such as age and tumor factor such as tumor complexity.
(Objectives) We retrospectively investigated the prognostic factors and the role of adjuvant chemotherapy against upper tract urothelial carcinoma (UTUC) after surgery.
(Materials and methods) 343 patients of UTUC who underwent radical nephroureterectomy at Jikei University Hospital and affiliated institutions between January 2004 and February 2012 were retrospectively analyzed. A chi-squared test was used for categorical variables. Survival probabilities after surgery were estimated using the Kaplan-Meier method. Multivariate Cox regression models addressed overall survival and cancer-specific survival after surgery.
(Results) The 5-year overall and cancer-specific survival rates were 64.6% and 74.6%, respectively. On multivariate analysis, higher age, male, higher pT-stage and lymphovascular invasion (LVI) were associated with worse overall survival and higher pT-stage and LVI were associated with worse cancer-specific survival. 44 patients (G3 and ≥pT3) who received cisplatin-based adjuvant chemotherapy had improved overall survival (P=0.044).
(Conclusions) Higher pT-stage, LVI were important prognostic variables associated with oncologic outcomes. Cisplatin-based adjuvant chemotherapy offered a significant benefit to overall survival in high risk UTUC (G3 and ≥pT3), but more investigations are needed to confirm its utility.
(Objective) The Clinical Practice Guidelines for Prostate Cancer (2012 Edition) recommend a 10- to 12-core biopsy comprising six standard cores from the apex, midgland, and base as well as cores from six peripheral zones (PZ) outside these sites. In this study, we compared localization results (mapping) based on 12-core prostate biopsy specimens from the six standard sites and six PZ outside these sites with results based on radical prostatectomy specimens.
(Subjects and methods) Of the 208 patients with prostate cancer who underwent radical prostatectomy at our hospital between January 2011 and July 2014, the 139 who had a 12-core biopsy before surgery were included in this study. Prostate needle biopsies were performed transrectally and the same pathologist evaluated preoperative biopsy specimens and resected pathology specimens. Patient age ranged from 52 to 77 years (median: 68 years). Prostate-specific antigen levels at the time of biopsy ranged from 3.1 to 84.7 ng/ml (median: 7.3 ng/ml) and the weight of excised tissue ranged from 17 to 90 g (median: 37 g). The surgical method was laparotomy in 63 cases, laparoscopy in 12 cases, and robot-assisted in 64 cases. The preoperative T classification was cT1c in 84 cases, cT2a in 29 cases, cT2b in 15 cases, and cT2c in 11 cases. The preoperative Gleason score was 3+3=6 in 36 cases, 3+4=7 in 48 cases, 4+3=7 in 33 cases, 4+4=8 in 9 cases, 4+5=9 in 11 cases, and 5+4=9 in 2 cases. The postoperative T classification was pT2a in 38 cases, pT2b in 12 cases, pT2c in 17 cases, pT2+in 20 cases, pT3a in 47 cases, and pT3b in 5 cases. The postoperative Gleason score was 3+3=6 in 19 cases, 3+4=7 in 60 cases, 4+3=7 in 39 cases, 4+4=8 in 1 case, 4+5=9 in 14 cases, 5+4=9 in 5 cases, and 5+5=10 in 1 case.
(Results) The concordance rate for detection of cancer (localization) in the 12 sites of the preoperative biopsy and the same sites of resected specimens was 59.2% (median: 7.11/12). Furthermore, the Gleason score of the resected specimen was higher than the preoperative score for 79 patients (56.8%) and 63 of the 88 patients (71.6%) whose cancer was classified as unilateral on the basis of the preoperative biopsy were found to have cancer on the other side as well when the resected specimen was examined.
(Conclusion) The results suggest that localization is not always consistent between positive biopsy sites and sites in resected specimens. This indicates that when attempting to localize prostate cancer preoperatively, it is necessary to use other tests such as MRI as well.
(Purpose) It has recently been suggested that a slow delivery rate of shockwaves by extracorporeal shock wave lithotripsy (SWL) improved treatment outcomes for urinary stones. We retrospectively analyzed the treatment outcomes of different shockwave delivery rates at 120 and 60 shockwaves per minute.
(Patients and method) A total of 88 patients were treated at a fast delivery rate of 120 shockwaves per minute between July 2010 and April 2012, and 139 patients were treated at a slow delivery rate of 60 shockwaves per minute between May 2012 and May 2014 (n=227) using a Sonolith® Praktis lithotripter. The treatment outcome of stone-free rate (SFR) after one SWL session was assessed at four weeks.
(Result) SWL at 60 shockwaves per minute resulted in a significantly higher SFR compared with SWL at 120 shockwaves per minute (39.8% and 59.0%, respectively, p=0.0047), particularly for upper ureter (U1) stones (53.1% and 72.0%, respectively, p=0.028). Multivariate analysis showed that younger age, stone sizes of 10 mm or less, U1 stones, and slow delivery rate were significant predictors of a stone-free outcome. There were fewer adverse events after the delivery rate of 60 shockwaves per minute (p=0.058).
(Conclusion) Our study suggests that SWL at 60 shockwaves per minute should be recommended to successfully treat urinary stones using the Sonolith® Praktis lithotripter.
(Objective) We examined the morphology and function of lower urinary tract in order to know characteristics of stress urinary incontinence after pelvic organ prolapse (POP) surgery.
(Methods) One hundred twenty-five female patients (mean age 64.9 years, mean parity 2.2, mean body mass index (BMI) 24.4) were performed anti-incontinence surgery for stress urinary incontinence. Sixty-one of 125 patients underwent POP surgery before anti-incontinence surgery. They were divided into groups as follows: post-POP surgery group and non-POP surgery group. All patients underwent one-hour pad test, chain cystourethrography (chain CG), Urodynamic studies (UDS) as preoperative assessment. Midurethral sling procedure was performed as an anti-incontinence surgery. Preoperative assessment criteria and postoperative treatment results were compared between two groups.
(Results) Post-POP surgery group showed a significantly greater amount of urinary leakage per 1-hour pad test than non-POP surgery group (65.2±74.3 g vs 14.3±25.2 g, p<0.05). The diagnosis of type III urinary stress incontinence (Blaivas' classification) was more frequently diagnosed in post-POP surgery group than non-POP surgery group (50.0% vs 25.0%, p<0.05). Maximum urethral closure pressure (MUCP) and functional profile length (FPL) of post-POP surgery group were lower than those of non-POP surgery group (27.4±9.2 vs 35.7±14.7, p<0.05, 27.3±4.7 vs 29.9±5.0, p<0.05). Postoperative treatment results of post-POP surgery group were worse than those of non-POP surgery group (78.7% vs 92.2%, p<0.05).
(Conclusions) Post-POP surgery group showed more severe urinary incontinence, lower urinary function and lower cure rate. Therefore we should keep in mind when approaching urinary stress incontinence.
The patient is a 43-year-old male, presented with numbness of the left lower extremities. Imaging studies showed a pelvic tumor 20 cm in diameter, involving the left ureter, left common iliac vessels, left internal and external iliac vessels, and inferior mesenteric artery, which was deemed unresectable. Tumor biopsy confirmed liposarcoma. As chemotherapy was not effective, he was referred to us. Following femoral-femoral artery bypass in advance, the tumor was resected with the sigmoid colon, left kidney, ureter, left iliac vessels, and interior mesenteric artery. Removal of the tumor caused massive venous hemorrhage from the pre-sacral plexus, which was scarcely managed by gauze packing. Open abdominal management was selected to avoid abdominal compartment syndrome by severe intestinal edema. The packed gauze was retrieved on the fourth post-operative day, with laparotomy closed. The postoperative course was uneventful.
The Hem-o-lok clips (HOLC) is frequently used for hemostasis of the lateral pedicles in robot-assisted prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP). We report a rare post-operative complication, the migration of a HOLC into the bladder leading to calculus formation after RARP. A 54 year-old man underwent RARP with nerve- sparing procedure with HOLCs in the left neurovascular bundle. Three months later, he was referred to our hospital for pollakisuria and spontaneous hematuria. Abdominal ultrasonographic examination and computed tomography (CT) demonstrated a bladder stone that was 7 mm in diameter. On cystourethroscopy, he was noted to have a yellow-colored stone at 9 o'clock position of vesicourethral anastomosis. A cystolithotripsy for a bladder stone was performed until the surface of it was broken. A HOLC with a calculus was revealed and retrieved by stone forceps through the urethra. Since then, Intravesical migration of a HOLC has not been observed.
A 25-year-old man with a left testicular tumor underwent a high inguinal orchiectomy. Histopathological examination of the resected specimen revealed tumors of more than one histological type, mixed forms (seminoma, immature teratoma). Further evaluation revealed no metastasis (pT1N0M0S1 Stage IS).
Four months after orchiectomy, alpha-fetoprotein (AFP) was elevated.CT scan revealed retroperitoneal masses of recurrent tumor. Although the AFP returned to normal level after four courses of BEP (bleomycin, etoposide and cisplatin), the retroperitoneal lymph nodes continued to grow. He underwent excision of the retroperitoneal lymph node dissection. Histopathological examination of the resected specimen revealed mature teratoma.
Few reports examined about the development mechanism of growing teratoma syndrome (GTS). We considered that the development mechanism of GTS in this case is induction of differentiation. In this case report, we discuss the development mechanism of GTS based on bibliographical consideration.
A 64-year-old man had complained of a left scrotal mass and gynecomastia since June 2012. A left testicular tumor was suspected and the patient was referred to our department in December 2013. He presented with bilateral gynecomastia and a painless left scrotal mass that was firm, smooth surfaced, and the size of large hen's egg. Levels of markers of testicular germ cell tumors were all within normal range. Endocrinological examination revealed a marked elevation in serum estradiol (E2) level. The patient underwent high inguinal orchiectomy in December 2013.
The pathological diagnosis was a Sertoli cell tumor of the left testis. Immunohistochemistry revealed the expression of aromatase synthesis; we speculated that this E2 production by the tumor caused the gynecomastia.
Serum E2 level normalized after the orchiectomy. Owing to the diagnosis of malignancy, retroperitoneal lymph node dissection was performed in January 2014. No lymph node metastasis was found in the specimen. The gynecomastia improved gradually, and the patient has been free of disease since the surgery.
We herein report and discuss our first experience about a sex reassignment surgery (SRS) with laparoscopic sigmoid colon vaginoplasty for a 40s male to female gender identity disorder. SRS for this subject included bilateral orchiectomy, penectomy, clitoroplasty, vaginoplasty, and vulvoplasty. About 20 cm of the sigmoid colon was harvested laparoscopicaly for the neovagina. Total operating time was about 9 hours, and the estimated blood loss was 900 ml without transfusion. There was no trouble during the postoperative course, and a sufficient length of vagina has been maintained.