(Purpose) We report five cases of adrenal myelolipoma with surgical treatment, and analyze the patients' background and clinical courses.
(Patients and methods) From 2004 to 2017, five patients diagnosed adrenal myelolipoma were underwent surgical treatment at our hospital. We investigate the patients' background and clinical courses retrospectively.
(Results) Median age was 53 years old. Four of them were male and one was female. The tumor was located on the right side in four cases and the left side in one case. All cases were incidentally found by abdominal ultrasound or computer tomography (CT) during a medical check or image examination for other disease. Whereas all cases were asymptomatic, they have past history either hypertension, diabetes or obesity. The tumor size at the time of diagnosis was from 28 mm to 80 mm (median 58 mm). All tumors were nonfunctioning, and diagnosed by CT scan preoperatively. The median tumor size at the time of operation was 66 mm.
(Conclusion) We report five cases of adrenal myelolipoma treated surgically. The opportunity of encountering this disease has been increasing as the recent improvement of diagnostic imaging such as CT, MRI, and etc. However, there is no widely-accepted treatment algorithm. We should manage them carefully, because spontaneous rupture of adrenal myelolipoma has been reported in some cases.
(Purpose) To describe our initial experience in salvage cryoablation targeting recurrent lesions after definitive irradiation for prostate cancer.
(Methods) Eligible patients for this treatment were those who developed biochemical failure after definitive radiotherapy for localized prostate cancer, but without distant metastasis, and with solid lesions identifiable on multiparametric magnetic resonance imaging (mpMRI). Histological proof of recurrence with mapping biopsy covering corresponding sites was obtained. Two to four cryoprobes were inserted transperineally into the prostate under general anesthesia with extensive lithotomy position. The rapid expansion of argon gas cryogen through a small opening within the cryoprobe cools itself to make an ice ball and the quick exchange to helium gas induces an active thawing phase. Entire procedure is monitored and guided with the use of transrectal ultrasonography. Postoperative follow-up included patient interview, digital rectal examination, prostate specific antigen (PSA) testing and quality of life (QOL) monitoring using IPSS and IIEF-5 at 1, 3, 6 and 12 months postoperatively. Changes of mpMRI findings with time, particularly at one month, were used to judge immediate treatment impact.
(Results) Five patients underwent salvage cryoablation between October 2015 and September 2016. No grade 3/4 complications such as rectal fistula or urethral stenosis were experienced. Mean and maximal percent decline of PSA from baseline levels at 1, 3, 6 and 12 months following cryoablation were 72.2 and 94.7%, 79.4% and 93.9%, 78.2% and 92.1%, 79.6% and 90.9%, respectively. Posttreatment IPSS showed temporary worsening with average changes in score of 1.8, 1.5, 1.6, and 1.0 times over baseline levels, respectively. IPSS score returned to the baseline in one at six months and two at 12 months. Two of 5 patients were sexually active prior to therapy and thus evaluable. Both showed significant decline in IIEF score by 95% at 12 months. No patients showed any signs of recurrence. mpMRI at one month following cryoablation confirmed complete disappearance of visible lesions in all cases.
(Conclusions) Salvage cryoablation for recurrent lesions of prostate cancer after definitive radiotherapy is feasible with minimal morbidity. Both oncological outcome and adverse events should be monitored carefully with longer follow up.
(Objective) To evaluate the efficacy and invasiveness of focal therapy with transrectal high-intensity focused ultrasound (HIFU) for localized prostate cancer based on spatial location of significant cancer with magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion image-guided biopsy.
(Methods) Patients with low- and intermediate-risk significant prostate cancer who were followed-up at least 1 year, were prospectively recruited. The spatial localization of the significant cancer was determined by MRI-TRUS fusion image-guided transperineal prostate biopsy. Focal therapy targeting the regions of significant cancer was performed by transrectal HIFU using a Sonablate® 500 (SonaCare Medical, Indianapolis, IN, USA). Serum prostate-specific antigen (PSA) kinetics, multi-parametric MRI, and MRI-TRUS fusion image-guided prostate biopsy were analyzed to determine the treatment efficacy. Questionnaires and uroflowmetry were performed to evaluate the invasiveness.
(Results) Ten men with median age of 67 years (range, 48-79), median PSA level of 7.07 ng/ml (range, 4.67-15.99), median prostate volume of 25 ml (range, 19-36) were treated. Median operative time was 29.5 minutes (range, 14-85). Catheterization was performed within 24 hours after the treatment in all patients. The median PSA concentration significantly decreased to 1.35 ng/ml (p<0.0001) at 3 months after the treatment. Contrast-enhanced T1-weighted MRI showed the disappearance of blood flow in all targeted regions of the prostate. MRI-TRUS fusion image-guided prostate biopsy detected the significant cancer out of the treated region in 1 patient. In urinary function, residual urine was significantly increased at 3 months after the treatment (p=0.007), but improved to the preoperative level (p=0.411). There was no significant deterioration in IPSS, IPSS QOL, OABSS, and the urinary function domain of EPIC between before and 3, 6, 9, and 12 months after the treatment. In sexual function, there was no significant difference in IIEF-5 and the sexual domain of EPIC between before and 3, 6, 9, and 12 months after the treatment. In quality of life, there was no significant difference in EPIC and SF-36 between before and 3, 6, 9, and 12 months after the treatment. The proportion of men with erections sufficient for penetration and ejaculation remained unchanged at 100% (5 of 5 patients). No serious adverse events were recorded.
(Conclusions) The focal therapy with HIFU has the potential to provide accurate treatment with low morbidity in patients with localized prostate cancer. Further large studies are required to investigate the effects of the focal therapy with HIFU for analysis of oncological and functional outcomes in patients with localized prostate cancer.
(Background) Penile fracture as a result of sexual activity is exceedingly rare. Therefore, few studies have investigated it specifically in Japan.
(Methods) We evaluated the clinical features and complications of all patients with penile fractures treated at Jikei University Hospital between 2005 and 2017. A total of 16 patients were identified and their etiologies, symptoms, treatment strategy, operative approach, and complications were reviewed.
(Results) The median patient age was 41 years (range: 22-67). We were able to identify the etiology in 15 patients: 5 patients (31%) had suffered the fracture during sexual intercourse and 4 (25%) during masturbation. All patients were not suspected of having urethral injury. Eight patients underwent magnetic resonance imaging (MRI) prior to surgical repair. Disruption of tunica albuginea could be identified in all 7 patients with decent descriptions of the findings recorded for review. All patients underwent surgery, and the ruptured tunica albuginea was repaired. None of the patients developed erectile dysfunction (ED) but 1 patient (6%) had postoperative penile curvature.
(Conclusions) Penile fracture most frequently occurred during sexual intercourse and masturbation. Our series had no ED, but longer follow-up is needed to draw definitive conclusions.
(Objectives) For the staging of cervical cancer, we investigated the relationship between computed tomography/magnetic resonance imaging (CT/MRI) and cystoscopy and evaluated the need for cystoscopy to diagnose bladder invasion resulting from cervical cancer.
(Patients and Methods) We retrospectively reviewed the patients who underwent cystoscopy because of a diagnosis of bladder invasion of cervical cancer from April 2012 to March 2017 in our hospital. A total of 217 women (median age 53 years old) underwent cystoscopy. We also reviewed whether or not there were findings showing bladder wall infiltration on CT/MRI and cystoscopy.
(Results) CT was performed in all cases, and MRI was performed in 216 cases. Seventy cases were judged to have possible bladder infiltration by CT, and 35 were judged to have possible bladder infiltration by MRI. In cystoscopy, 24 cases were reported to have "suspicion of bladder invasion" by urologists, but only 12 cases had bladder mucosal findings with "ridges and furrows" (defined as bladder infiltration without a bladder biopsy in this study). The sensitivity and negative predictive values of CT/MRI were both 100%. Only one case underwent a bladder biopsy, and the histological diagnosis was cystitis.
(Conclusions) The findings of our investigation suggested that cystoscopy is not required when there were no obvious findings of bladder invasion by CT/MRI at the clinical staging of cervical cancer.
To investigate the efficacy and safety of first-line Pazopanib advanced or metastatic renal cell carcinoma (RCC): a single-institution study.
(Patients and methods) We gathered 23 RCC patients treated between April 2014 and February 2018 in our institution and examined the treatments outcome and adverse events (AEs).
(Results) Their risk criteria were categorized as follows: Favorable (n=2), Intermediate (n=12) and Poor (n=9) by International mRCC Database Consortion (IMDC). Median progression free survival (PFS) was 8.6 months and median overall survival (OS) was unreached. Best response (BR) of Pazopanib was partial response (PR): n=10, 50.0%, stable disease (SD): n=8, 40.0% and progression disease (PD): n=2, 10.0% (Three patients had no evaluable data,). AEs of Grade3 had liver dysfunction (n=3), thrombocytopenia (n=2), hand-foot syndrome (n=1), vomiting (n=1) and bowel bleeding (n=1).
(Conclusion) The fist-line pazopanib demonstrated good clinical benefit with well-tolerance.
A 75-year-old man was referred to our hospital with a complaint of difficulty swallowing and was diagnosed with left medullary infarction. Computed tomography and magnetic resonance imaging revealed a right adrenal tumor, 4 cm in size, and a left adrenal tumor, 1.6 cm in size. Abnormally high concentrations of serum catecholamine and urinary total metanephrine were also observed. In addition, 131I-MIBG scintigraphy revealed an abnormal accumulation of 131I in both tumors, which comprehensively led to the diagnosis of bilateral pheochromocytoma. Laparoscopic right adrenalectomy was planned first. After initiating pneumoperitoneum, the systolic blood pressure rose to 270 mmHg. Pneumoperitoneum was suspended briefly, and once resumed, the patient's blood pressure dropped gradually and was followed by cardiac arrest. A decision was made to interrupt surgery and start cardiopulmonary resuscitation. Once blood pressure stabilized above 160 mmHg, the patient was transferred to the intensive care unit with intubation. Subsequently, blood pressure was controlled to around 140 mmHg. He was discharged on the eleventh day after surgery without any major complications. Currently, he is being managed with more aggressive antihypertensive drug treatment.
An 82-year-old man presented with lower abdominal pain and general malaise. Noncontrast computed tomography revealed a remarkably enlarged prostate and a full bladder with a giant stone 80 mm in diameter causing bilateral hydroureteronephrosis. Laboratory data demonstrated systemic inflammation and renal dysfunction with hyperkalemia. Acute postrenal dysfunction caused by urinary retention was diagnosed. A urethral catheter was inserted and emergent dialysis was initiated. After renal function recovered, we performed lithotripsy for the urinary bladder calculi. To achieve stone free status with a single-stage procedure, we performed simultaneous percutaneous suprapubic and transurethral cystolithotripsy. The procedure was successfully performed without significant complications.
The patient was discharged 9 days after surgery, although clean intermittent catheterization was required.
Giant bladder calculi are often treated with cystolithotomy because transurethral cystolithotripsy requires time to remove all fragments. In this case, we achieved stone free status in acceptable operative time by performing simultaneous percutaneous suprapubic and transurethral cystolithotripsy. In conclusion, the endourological management is an effective treatment choice, even in a case with a giant bladder calculus.
Typical etiologies of vesicovaginal fistula (VVF) include obstructed labor, iatrogenic surgical injury, pelvic irradiation and cancer invasion. VVF caused by cystocele are very rare. To date, there are no documented cases in Japanese literature.
A 74-year-old woman presented with near total incontinence. On physical examination, she was found to have severe cystocele and pressure necrosis of anterior vaginal wall, which caused partial breakdown of vaginal mucosa and VVF. She underwent vesicovaginal fistula repair using transvaginal and transabdominal approaches. Catheter drainage was performed for 10 days and postoperative cystogram showed no sign of leakage. She is currently symptom-free at 55 months.
A 73-year-old man with progressive prostate cancer visited our hospital after prostate biopsy performed at another hospital. His serum PSA level was 29.02 ng/ml. CT revealed invasion of the bladder, bilateral ureters, and rectum. Otherwise, there was no evidence of metastasis. Pathological findings showed a poorly differentiated adenocarcinoma (Gleason score 4+5) and small cell carcinoma component. Two months after administering combined androgen blockade therapy, he was admitted due to severe hyponatremia caused by the inappropriate secretion of antidiuretic hormone. Furthermore, CT revealed right ureter metastasis, although the PSA levels remained low. Therefore, the patient was put on fluid restriction and sodium administration. After the patient recovered from hyponatremia, chemotherapy, including VP-16 and CDDP, was initiated. However, CT after two chemotherapy cycles revealed disease progression, with multiple bone metastases. Second-line chemotherapy, including CPT-11 and CDDP, was less effective, and the patient died 9 months after the diagnosis.
Posterior periurethral abscesses due to Neisseria gonorrhoeae are rare and thus difficult to diagnose and treat. We diagnosed this type of abscess using MRI and treated it conservatively.
A 27-year-old man presented with perineal discomfort that had persisted for 1 week. Physical and CT findings indicated a prostate abscess, but MRI after admission revealed a multilocular mass in the posterior periurethra and polymerase chain reaction was positive for Neisseria gonorrhoeae. The posterior periurethral abscess was treated with Ceftriaxone and drainage via a cystostomy. This strategy improved the inflammation and CT confirmed the disappearance of the abscess from start of therapy in 43 days.
A 19-year-old man was referred to our department because of repeated urinary retention. Urethroscopy and retrograde urethrography revealed a stricture 25 mm long at the mid to distal bulbar urethra. As he does not have any histories of trauma, urological procedure, sexually transmitted disease and lichen sclerosus, he was diagnosed as having an idiopathic bulbar urethral stricture. Therefore, we performed substitutional urethroplasty with buccal mucosa placed on the dorsolateral surface (one-sided dorsolateral onlay). The maximum flow rate by uroflowmetry and the International Prostate Symptom Score remarkably improved. His subjective symptom of ejaculatory function was also improved, while the erectile function was not affected. This is the first reported case of bulbar urethral stricture successfully treated with one-sided dorsolateral onlay urethroplasty using a buccal mucosa graft in our country.