(Objective) The aim of this study is to investigate the treatment outcome of laparoscopic radical prostatectomy (LRP).
(Patients and methods) The study cohort consisted of 926 hormone-naïve patients with localized prostate cancer who underwent LRP at the Hiroshima Endourological Association from January 2007 to December 2016.
(Results) The mean age was 69.4 years, the mean initial PSA was 9.1 ng/ml, and the mean follow-up period was 40.3 months. The D'Amico Risk Classification was Low: 232 cases, Intermediate: 344 cases, and High: 350 cases. Nerve preservation was performed bilaterally for 138 patients and unilaterally for 181 patients. The mean operative time was 181.0 minutes and the mean estimated blood loss was 360.7 ml. As the number of experienced cases increased, the operative time was significantly shorter and the estimated blood loss was significantly decreased. According to Clavien-Dindo classification, the ratio of perioperative complication degree IIIa or above was 4.0% (37 cases). The pathological results were Gleason score (GS) ≤6: 174 cases, GS7: 514 cases, GS ≥8: 232 cases, pT2≥: 704 cases, pT3a: 172 cases, pT3b: 47 cases, pT4: 3 cases, pN0: 917 cases, and pN1: 9 cases. Positive surgical margins were found in 278 cases (30.0%). The biochemical recurrence-free survival rate at 5 years was 78.1%. In multivariate analysis, age (≥70 yrs), initial PSA (≥10 ng/ml), biopsy GS (GS ≥8), cancer positive core ratio at biopsy (≥30%), pT (pT≥3), pathological GS (GS≥8), positive surgical margin and total number of patients in the facility were predictive factors of postoperative biochemical PSA recurrence. Younger age and nerve preservation were found to be predictive factors for the early recovery of urinary continence after surgery, with 88% regaining urinary continence at 12 months after surgery.
(Conclusion) This study revealed the clinical outcome and appropriate candidates for LRP in Japanese patients.
A 77-year-old man with a complaint of impaired consciousness was brought to our emergency department. The patient was referred to our department because of a huge retroperitoneal tumor and multiple pulmonary nodules detected on computed tomography. Owning to an abnormally high level of dehydroepiandrosterone sulfate, right adrenal cancer was suspected. Pathological examination of the retroperitoneal tumor by echo-guided pericutaneous biopsy revealed an adrenocortical carcinoma. Under the diagnosis of stage IV adrenocortical carcinoma, mitotane therapy was started in May 2013. We adjusted the mitotane dose on the basis of the clinical evidence and the adrenocorticotropic hormone and cortisol levels.
The tumors had increased in size after 2 months of the mitotane therapy. However, 2 months later, the tumor had significantly decreased in size. The treatment was continued for 53 months until he could no longer take medications orally, because of his advanced age, worse condition, and disuse syndrome.
(Case) A 56-year-old woman who complained of urinary frequency and macrohematuria. Abdominal US, enhanced CT and MRI revealed a left renal tumor. A left radical nephrectomy was performed in May 1997, and the pathological diagnosis was renal fibrosarcoma. Follow-up computed CT was performed routinely. A metastatic lesion in the right lung revealed 19 months after the nephrectomy.
She underwent partial pneumonectomy in January 1999, and the pathological diagnosis was also fibrosarcoma. She was followed up until 2009 without recurrence.
In 2015, she was admitted in the Department of Orthopedics due to femoral neck fracture in 2015, thus we could find out she was alive, tumor-free 18 years after the nephrectomy. We added the immunohistochemistical study to her specimen of kidney and lung, and the diagnosis was changed to undifferentiated/unclassified sarcoma.
(Conclusion) Metastatic renal sarcoma has a poor prognosis in general. We experienced a long-term survival case of undifferentiated/unclassified renal sarcoma with lung metastasis, and report it with some literature review.
Three cases are reported of TURBT on the anterior wall, with bladder rupture occurring after discharge. Patient 1 was a 68-year-old man. He had macroscopic hematuria and he strained to void a bloody clot on the 10th day after TURBT. Subsequently, right lower abdominal pain occurred. Computed tomography (CT) revealed the extravasation of contrast medium into the prevesical space. He was diagnosed with extraperitoneal bladder rupture, and a urethral catheter was indwelled. Cancer invasion of muscle was diagnosed by pathological examination and total cystectomy was scheduled one and a half months later, but the prostate could not be resected due to hard tissue around the bladder neck. Patient 2 was an 82-year-old man and had a history of radiation therapy for a muscle invasive bladder tumor. He complained of pollakisuria two weeks after TURBT, and renal failure was detected on a blood test. CT revealed ascites, and a urethral catheter was indwelled. Ascites disappeared, but the urethral catheter deviated into the abdominal cavity based on repeated CT the next day, and he was diagnosed with intraperitoneal bladder rupture. Emergent surgery was performed, and the ruptured part was sutured with omentum covering and a cystostomy was created. Patient 3 was an 83-year-old man undergoing treatment for benign prostatic hypertrophy (BPH). He had received bladder instillation therapy of Bacillus Calmette-Guerin (BCG) ten months previously. When urinating 6 days after TURBT, lower abdominal pain developed. CT demonstrated retroperitoneal bladder rupture, and a urethral catheter was indwelled. The urethral catheter was removed 6 days later, but lower abdominal pain occurred again the next day. Thus, the urethral catheter was re-indwelled for a further two weeks.
In TURBT on the anterior wall or dome, for the patients who had previously received radiation therapy to the pelvis, or intravesical instillation therapy of the BCG or accompanied by urinary disturbance, such as BPH, it is necessary to consider bladder rupture after discharge.
Trousseau's syndrome is known as a thromboembolic disorder due to hypercoagulation accompanied with advanced cancer. A 67-year-old man presented with disequilibrium and back pain, and magnetic resonance imaging of his brain indicated multiple cerebral infarctions at the acute stage. A computed tomography scan showed enlargement of multiple paraaortic lymph nodes. From these findings, we suspected that this patient had Trousseau's syndrome. The patient started anticoagulant treatment involving constant infusion with heparin Na. We also examined the origin of enlarged multiple paraaortic lymph nodes by investigating the tumor markers, which showed that the prostate specific antigen value (PSA) was extremely high. We conducted a prostatic biopsy and the pathological findings showed prostate cancer. The Combined Androgen Blockade (CAB) therapy was effective in reducing PSA value and shrinkage of the paraaortic lymph nodes. After the blood coagulation ability was improved to a normal state, we changed the anticoagulant treatment to subcutaneous injection of heparin Ca. There was no recurrence of cerebral infarction and no regrowth of prostate cancer 6 months after CAB therapy. Trousseau's syndrome is known as a poor prognosis syndrome because there is no effective therapy for the advanced stage of the accompanying cancer. However, CAB therapy is effective for advanced prostate cancer and long-term prognosis is expected. Starting anticoagulant treatment at the acute stage and maintaining anticoagulant treatment at the chronic stage are important in the treatment of Trousseau's syndrome accompanied with prostate cancer.
A 70-year-old woman, with an 8 cm tumor in the left kidney and multiple lung tumor and was diagnosed with Renal Cell Carcinoma (cT3aN0M1). The kidney tumor were unresectable and we started treatment with Tyrosine Kinase Inhibitors (sunitinib, pazopanib, axitinib, temsirolimus), but they failed because of disease progression or adverse events. We used nivolumab for 5th line treatment; then, interstitial pneumonia was observed. The renal tumor shrunk and pulmonary metastatic foci revealed prominent disappearance. The renal tumor became resectable and we tried nephrectomy. Pathological findings were clear cell carcinoma with marked necrosis, hyperplasia and internal bleeding.
We report a case of drug-induced interstitial lung disease as a result of combined androgen blockade. A 75 year-old male was receiving bicalutamide and reuprorelin acetate treatment for advanced prostate cancer. Two weeks after starting therapy, the patient developed dyspnea due to interstitial lung disease. Based on the clinical diagnosis of drug-induced interstitial lung disease, bicalutamide was withdrawn and steroid therapy was initiated. The patient succumbed 6 days later due to respiratory failure. Drug-induced interstitial lung disease following combined androgen blockade is a rare, but potentially serious adverse effect that requires close attention.
A 59-year-old female experienced gross hematuria and right back pain, and she visited our hospital in March 2015. Abdominal computed tomography (CT) showed bilateral renal pelvic calculi; the right stone was 15 mm and the left stone was 18 mm in diameter. She had ulcerative colitis and had been taking salazosulfapyridine (SASP) for about 30 years. Urinalysis showed aciduria and deposition of urate crystals. An abdominal X-ray picture did not show a calculus shadow. We suspected uric acid calculus and started treatment with urinary alkalizer and uric acid production inhibitor.
Three months later, abdominal CT showed enlargement of the bilateral renal pelvic calculi; the right stone was 25 mm and the left stone was 24 mm in diameter. She also complained of worse right back pain and underwent transurethral ureterolithotripsy for the right renal pelvic stone. The stone was orange, comparatively soft, and chipped down until it was approximately half of its original size. The stone analysis suggested suspected drug-induced urolithiasis, but not uric acid calculus. Thus, we investigated the stone and SASP using infrared spectroscopy, and the infrared absorption pattern was similar in both. The stone analysis demonstrated drug-induced urolithiasis induced by SASP.
The patient's ulcerative colitis therapy was switched to mesalazine, and the amount of urinary alkalizer was increased. Abdominal CT 3 months thereafter showed dissipation of bilateral renal pelvic calculi. The patient did not take any preventative medication, and there was no recurrence of urolithiasis.
We report two cases of pediatric deep renal injury at a local hospital. Case 1 was a 13-year-old girl. She fell from a bicycle and hit her back in a gutter. She complained of left back pain. Computed tomography (CT) revealed left deep renal injury accompanied by peripancreatic hematoma. Emergent surgery was performed and the transected kidney was resected, but pancreatic injury was not noted. Case 2 was a 10-year-old girl. She slipped during walking on her way home from school and hit her back on a concrete block. She complained of left back pain and gross hematuria. CT revealed left deep renal injury. Interventional radiology (IVR) was performed, but arterial bleeding was not noted, and so conservative therapy was performed.
Although pediatric deep renal injury might be treated conservatively in general, treatment of such cases should be performed ideally at a hospital with IVR available for general anesthesia, and radiologists on-call in the event of any sudden change in the patient's condition. However, pediatric patients with serious renal injury, including the above, who cannot be transported to an advanced treatment hospital, can be treated through cooperation between skilled interventional radiologists and surgeons even in local hospitals with limited facilities and manpower.
A 65-year-old man was admitted to our institution with vomiting and right flank pain. Computed tomography (CT) imaging showed a 21-cm retroperitoneal multilocular cystic tumor which had been identified four years previously. It had increased from 17 to 21 cm. The initial diagnosis was cystic lymphangioma because it was a clear cystic tumor without a boundary or a solid component in the first CT, but later CT revealed an unclear boundary with surrounding organs suggesting malignancy. We decided to resect the tumor because it was symptomatic and might be malignant. The tumor was then resected along with surrounding organs because invasion was suspected. Pathological findings indicated a diagnosis of cystic lymphangioma with chronic inflammation and confirmed complete resection of the tumor. The patient has remained free of recurrence at one year after surgery. This experience indicates that cystic lymphangioma should be completely resected to prevent recurrence.
Herein we report the confirmation of fungus balls (circular collections of C.tropicalis) during a transurethral ureterolithotomy, which is as far as we know the first reported instance. A-61-year old man was referred to the urology department with bilateral ureteral calculi. Initially a transurethral ureterolithotomy was attempted but residual stones existed. During the second operation, we found numerous white fluffy material in the renal pelvis. Because of them, we were unable to have a clear field of vision to complete operation. During the third operation, we found the fungus balls again and cultured them. Cultures yielded C.tropicalis.
A 75-year-old man with urinary retention was referred to our hospital. Pelvic magnetic resonance imaging showed that his prostate was remarkably enlarged, with an estimated prostate weight of 509 g. He underwent TUEB (transurethral enucleation with bipolar) combined with cystotomy. The surgical specimen weighed 349 g. He did well postoperatively, and his urinary function was improved at 3 months after the operation. Although transurethral methods are effective for resection of adenoma and control of bleeding, effective performance of the procedure with a resectoscope and resection of an adenoma in cases of giant prostatic hypertrophy need to be considered on a case-by-case basis.
We report non-specific granulomatous prostatitis in a 58-year-old man who visited a Urology clinic with fever and dysuria. Digital rectal examination revealed prostatic tenderness, and laboratory examination of the urinary sediment revealed pyuria. Thus, he was diagnosed with acute bacterial prostatitis and treated with antibiotics. He remained symptomatic despite treatment; therefore, he was referred to our hospital. A second digital rectal examination (performed at our hospital) revealed stony hard nodules in the prostate and an irregularity of its surface. Moreover, magnetic resonance imaging (MRI) suggested a prostate cancer. We performed a transperineal needle biopsy, which revealed only non-specific inflammatory cells without any evidence of neoplasm in the specimen. Therefore, a definitive diagnosis could not be established. Nevertheless, he continued to show a high index of suspicion for prostatic malignancy based on his clinical findings. Therefore, we performed a transurethral resection of the prostate and a transrectal biopsy to obtain more specimens. Microscopic findings revealed granulomatous prostatitis without any evidence of prostate carcinoma. Notably, an MRI demonstrated remarkable shrinkage of the prostate 3 months after the diagnosis. Non-specific granulomatous prostatitis is a rare inflammatory disease. Because it is difficult to differentiate this disease from prostatic neoplasms based on clinical findings or imaging modalities such as MRI, a few reports have described performing a radical prostatectomy in patients. This disease usually demonstrates a good prognosis as was noted in our patient. We conclude that establishing a preoperative histopathological diagnosis is important to avoid invasive procedures.
We describe a patient with thrombosis of the pampiniform plexus cured using heparin. A 40-year-old man was referred to our hospital with pain in the left scrotum. A physical examination revealed a painful, 20-mm long, beaded mass in the upper left paratesticular region. Magnetic resonance imaging and ultrasonography revealed 10-mm long thrombosis in the left pampiniform plexus, so intravenous heparin was started. The patient recovered well and was discharged on oral anticoagulation therapy after five days of hospitalization. The patient was completely asymptomatic, and ultrasonographic findings of the left testicle were normal at six months after starting treatment. We found 19 patients with thrombosis of the pampiniform plexus including the present patient, in the English and Japanese literature to date. Here, we review these 19 patients and discuss their clinical features.