(Objective) The number of elderly people is increasing in Japan, and there are many reports on the safety and effectiveness of treatment for the elderly. As the number of elderly men with benign prostatic hyperplasia is increasing, it is necessary to consider surgical treatment for the elderly. We analyzed the treatment outcome of transurethral enucleation with bipolar (TUEB), and investigated the effectiveness and safety of TUEB in the elderly (over 80 years old) at Saiseikai Izuo Hospital.

(Methods) In total, 47 patients who underwent TUEB were enrolled. The patients were divided into two groups by age (< 80 years old group and ≥ 80 years old group). We investigated the factors related to the occurrence of complications by multivariate analysis.

(Results) Mean duration of surgery was 107.8 min and 85.8 min (p=0.11) in the < 80 group and the ≥ 80 group, respectively. Mean resected prostate weight was 33.9 g and 31.0 g (p=0.61) and mean hemoglobin loss was 1.29 g/dL and 0.66 g/dL (p=0.01), respectively. Hemoglobin loss was significantly lower in the over 80 years old group. Complications were observed in six patients (24.0%) in the under 80 years old group and two patients (9.1%) in the over 80 years old group; however, there was no significant difference between the two groups (p=0.17). Fever was a complication in the over 80 years old group. In multivariate analysis, operative time was significant predictive factor for complications (odds ratio: 1.03, 95% confidence interval: 1.00-1.06, p=0.03) and, age was not significant predictive factor.

(Conclusion) This study shows that TUEB for patients over 80 years old is effective and safe.

(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence.

(Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes.

(Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m² or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery.

(Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.

(Objective) We compared the perioperative parameters of robot-assisted radical cystectomy (RARC) and laparoscopic radical cystectomy (LRC) to evaluate the utility of RARC.

(Patients and methods) At Hiroshima City Asa Hospital, 25 patients underwent RARC from July 2018 to May 2020 (R group) and 79 patients underwent LRC from July 2012 to June 2018 (L group). We retrospectively compared the patient characteristics, perioperative outcomes, and pathological outcomes between the R group and the L group.

(Results) Regarding the patient characteristics, the R group had significantly more neo-adjuvant chemotherapy than the L group (64.0% vs. 32.9%, P=0.009), but the other characteristics did not differ. Between the R group and the L group, there were no significant differences in the total operating time (R group = 400 minutes vs. L group = 421 minutes), estimated blood loss (R group = 228 ml vs. L group = 318 ml), or pathological outcomes. However, there were significantly less postoperative complications in the R group than in the L group (24.0% vs. 52.6%, P=0.020).

(Conclusion) This study showed that there might be benefits to introducing RARC into medical centers that perform LRC.

We present a case of pelvic organ prolapse and inguinal hernia worsened by a benign ovarian tumor with ascites. A 61-year-old woman was referred to us complaining of feeling of something protruding from her vagina. She was diagnosed with Stage III cystocele. Behavioral therapy was administered as she had only slight subjective symptoms. She visited us eight months later due to a rapid aggravation of cystocele and voiding difficulty. She subsequently developed acute abdominal pain caused by incarcerated inguinal hernia. Abdominal ultrasound, MRI and CT showed a 10.6×9.0 cm pelvic mass with ascites. As an ovarian cancer with peritoneal dissemination was suspected, she immediately underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and colposuspension. Pathological diagnosis was fibrothecoma, a benign ovarian tumor. Postoperative course was uneventful, and ascites quickly disappeared in a manner similar to Meigs syndrome. Although no procedure was done to manage inguinal hernia, it was unproblematic for 18 months, after that it worsened, necessitating hernial repair. She had no recurrence of prolapse or ascites.

Increased intra-abdominal pressure due to abdominal mass or ascites can worsen prolapse and hernial diseases such as inguinal, umbilical, and abdominal hernia. In this case, ovarian fibrothecoma with ascites seemed to be responsible for worsening of the prolapse and inguinal hernia. To conclude, it is important to consider background diseases when examining patients with prolapse and coexisting hernial diseases.

We experienced a case of fumarate hydratase (FH) -deficient renal cell carcinoma (RCC) suspected of hereditary leiomyomatosis renal cell carcinoma (HLRCC) and herein report our findings. A 42-year-old man with an unremarkable medical history was referred to our hospital with an initial impression of renal cancer, cT3aN2M0. He underwent a right radical nephrectomy with lymph node dissection and showed a pathological diagnosis of FH-deficient RCC, pT3aN2. Clinicopathologic features indicated the possibility of HLRCC; however,-associated RCC. genetic testing showed negative for pathogenic FH mutation.

HLRCC is an autosomal dominant condition caused by an FH gene mutation on chromosome 1q43. It is also a syndrome that develops in the smooth muscles of the skin and uterus, and has a renal cancer risk of 10-16%. HLRCC-associated RCC tends to metastasize early and shows poor prognosis. In FH-deficient RCC, the possibility of HLRCC-related RCC should be considered; thus, if patients fulfill the clinical diagnostic criteria, genetic counseling and screening of HLRCC are needed. Even if genetic testing does not confirm HLRCC, FH-deficient RCC still has a poor prognosis and careful follow-up is required.

A 36-year-old male with right scrotal induration visited a local physician and ultrasonography showed a mass in the right testicle. He was referred to our hospital, where an additional ultrasonography examination revealed a 1×1-cm mass with clear borders, a heterogeneous interior, slight hyperintensity, and abundant blood flow in the upper part of the right testis. Contrast-enhanced computed tomography results indicated a massive lesion with an uneven contrast effect in the right testis and no evidence of metastasis, while magnetic resonance imaging showed the tumor with bleeding and internal heterogeneity. All tumor markers were negative. Under a diagnosis of primary germ cell tumor of the testis without metastasis, a high orchiectomy was performed. The pathological diagnosis was sertoli cell tumor. Histopathologically, the tumor was benign and no additional treatment was performed. Three years after the operation, the patient was well and without complications.

A 74-year-old male with post-prostatectomy incontinence underwent artificial urinary sphincter replacement due to device malfunction. Three months after the replacement surgery, he presented for a consultation due to a bulging area in his lower abdomen. Computed tomography revealed a hernia of the pressure-regulating balloon (PRB), while the device was working well. In the reparative surgery, reopening the lower abdominal incision, the PRB was carefully restored to its previous position after creating a sufficient submuscular space. As the rectus abdominis fascia showed an adequate strength, the fascia was tightly sutured without using a prosthetic mesh. Thereafter, the patient has been free from incontinence for two and a half years without hernia recurrence. Given the mechanical nature of the device, replacement surgery is sometimes required over time. Tissue fragility due to repetitive surgeries and increasing ambient pressure due to space reduction derived from the PRB deflation could cause PRB hernia. Such cases can be treated under careful manipulation without damaging the device. Considering the future potential need for repeated surgery, it would be preferable not to use prosthetic mesh, as it can cause dense adhesion.

A 5-month-old boy was referred to our department to examine poor development of external genitalia. The patient was diagnosed with micropenis and bilateral impalpable testes, and testosterone replacement therapy was recommended. The testes remained impalpable at 14 months of age; therefore, laparoscopy was performed to explore intra-abdominal testes. The patient was incidentally diagnosed with congenital unilateral absence of the right vas deferens. A renal sonography performed after the operation revealed a high possibility of right renal agenesis. Congenital absence of the vas deferens is associated with a high probability of renal anomalies. It is, therefore, essential to pay careful attention to renal dysfunction.