Robot-assisted laparoscopic partial nephrectomy (RAPN) is covered by insurance for renal cancer in Japan, and a dramatic increase in cases is expected. With regard to surgical indication, it is estimated that there are many facilities where the experience is limited initially to T1a or relatively easy cases, however the indication is gradually expanded and T1b or more or surgery difficulties may be expected. On the other hand, for RANP cases for single renal cases and cases with already impaired renal function, so-called imperative cases, consideration must be given to surgical indication and preoperative evaluation, surgical procedure, and perioperative patient care. In this paper, based on the experience of our institute, we give an outline for imperative case.
We clinically evaluated changes in the renal function of patients with long-term indwelling of a ureteral stent due to by upper urinary tract obstruction. The subjects were 28 patients (11 bilateral cases) whose ureteral stent had been indwelled for 3 years or longer due to upper urinary tract obstruction and replaced regularly. Changes in the renal function were investigated after ureteral stent indwelling. The average age was 62 years, there were 5 males and 23 females, and 7 cases involved the right side, 10 involved the left side, and 11 both sides. The median observation period of ureteral stenting was 69 months. The mean eGFR immediately after ureteral stent indwelling decreased significantly compared with that before indwelling, immediately after compared with after 3 years, immediately after compared with 5 years. In the case of long-term indwelling of a ureteral stent, it may be necessary to pay attention to changes in the renal function because the function may decrease.
Purpose : The aim of this study was to evaluate the clinical outcomes associated with full-length metallic stents for decompression of malignant ureteral obstruction.
Material and Methods : We reviewed the clinical outcomes of 16 ureteral units in 11 patients who were diagnosed with malignant ureteral obstruction between December 2014 and April 2017.
Results : The mean observation period was 4.0 months (0.6 to 9 months). Mean Serum creatinine levels improved from 1.77 (0.65 to 5.4) mg/dL to 1.11 (0.71 to 2.14) mg/dL after metallic ureteral stents placed. According to Core Lower Urinary Tract Symptom Score (CLSS) for the assessment of lower urinary tract symptoms (LUTS) associated with full-length metallic stents, not only in 5 out of 6 cases improved in the QOL index but also the progression of LUTS was not observed.
Conclusions : Full-length metallic ureteral stents are effective in preserving renal functional and improving QOL associated with LUTS for patients with malignant ureteral obstruction.
Purpose : We evaluated the safety and efficacy of transurethral lithotripsy (TUL) for elderly patients with upper urinary tract stones.
Material and Methods : Between 2007 and 2017, 955 TULs were performed at Gifu Prefectural General Medical Hospital. Elderly patients were defined as those aged 75 years or older.
Results : In the elderly group, 145 TULs were performed ; the median age and stone size were 79 years and 8 mm, respectively. In the younger group, 810 TULs were performed ; the median age and stone size were 58 years and 10 mm, respectively. The stone-free rate was 92.8％ in the elderly group and 96.2％ in the younger group (P＝0.239). Sixty-six cases (6.9％) developed urinary tract infections (UTIs) with fevers ; however, there was no significant difference between the elderly and younger groups for incidence of UTIs.
Conclusion : TUL was as safe and effective for elderly patients as it was for younger patients.
In the present study, we retrospectively identified 307 patients who underwent the removal of pure calcium oxalate/calcium phosphate/uric acid/magnesium ammonium phosphate stones, we measured the 3D-MSD (3D-mean stone density) and 3D-VCSD (3D-variation coefficient of stone density) using a high functional viewer, and investigated the usefulness of these parameters for discriminating calcium and uric acid compositions. The median 3D-MSD and 3D-VCSD of uric acid stones were lower than those of all other types. Receiver operating characteristic curves of uric acid stones for 3D-MSD and 3D-VCSD demonstrated that AUC of 3D-VCSD (0.87) was larger than that of 3D-MSD (0.75). These results suggest that VCSD could be useful for discriminating calcium oxalate/calcium phosphate and uric acid compositions as well as MSD.
The distance between tip of laser and stone is one of great important factors for impact of stone disintegration. In present study, we evaluated the optimal laser setting to minimize the stone retropulsion using variable pulse laser setting according to stone size in vitro setting. The stone retropulsion distance during laser pulse irradiation in 5 seconds was recorded for each laser settings. The laser setting of stone retropulsion distance in less than 5 mm was defined as optimal setting. Mean retropulsion distance in using short laser pulse was farther away than using long laser pulse in all stone sizes (p＜0.0001) and all laser settings (p＜0.001). Stone retropulsion distance using long laser pulse was significantly shorter compared to using short laser pulse with the holmium laser. The laser settings to minimize the stone retropulsion and to improve the contacting efficiency to stone according to various stone sizes provide effective stone comminution.
Introduction : Upper tract urothelial carcinoma is difficult to diagnose and stage accurately before surgical treatment. Although ureteroscopy and ureteroscopic tumor biopsy are useful tools for the definitive diagnosis of upper urinary tract carcinoma, there is concern about the risks of tumor dissemination and intravesical recurrence. In this study, we examined the usefulness of preoperative ureteroscopy.
Patients and Methods : Data of 177 patients diagnosed with upper tract urothelial carcinoma who underwent nephroureterectomy at our hospital between January 2004 and January 2018 were retrospectively reviewed. We compared the preoperative ureteroscopy group and without ureteroscopy group, analyzed the influence on oncological outcomes, and examined the correspondence between the biopsy grade and pathological stage.
Results : A total of 125 (70.6％) patients underwent preoperative ureteroscopy, and 52 (29.7％) did not undergo ureteroscopy. The preoperative non-ureteroscopy group was significantly correlated with a high complication rate of gross-hematuria and an advanced clinical T stage (P＝0.033 and P＝0.007, respectively). The waiting period for surgery in the ureteroscopy group was significantly longer than in the non-ureteroscopy group (66 days vs. 51.5 days, respectively, P＜0.001). However, there was no significant difference between the two groups in terms of the overall, recurrence-free and intravesical recurrence-free survival rates (P＝0.426, P＝0.766, and P＝0.809, respectively). According to the 91 patients undergoing ureteral tumor biopsy, the patients with biopsy grade 3 were significantly more likely to have invasive cancer (pT3 or more) compared with patients with biopsy grade 1 or 2 (P＝0.004).
Discussion : Preoperative ureteroscopy significantly prolongs the waiting period for surgical treatment, but does not increase the rate of a poor prognosis or intravesical recurrence. Therefore, in cases where neoadjuvant chemotherapy and kidney-sparing surgery are considered, preoperative ureteroscopy may be a useful supplementary test when it is difficult to decide on the diagnosis and treatment based on imaging alone.
〈Introduction〉 As laser prostatic vaporization techniques for prostatic hyperplasia, we compared contact laser vaporization of the prostate (CVP) and photoselective laser vaporization of the prostate (PVP) in terms of the patient background and perioperative data.
〈Subjects and Methods〉 The subjects consisted of 97 patients who underwent CVP (CVP group) and 502 who underwent PVP (PVP group). The patient background, perioperative data, and early adverse events within 1 month after the operation were compared between the two groups.
〈Result〉 The CVP group included significantly more patients with preoperative urinary retention and those continuously receiving antithrombotic therapy. Concerning perioperative data, the operative time was significantly shorter and changes in the hemoglobin level were significantly smaller in the CVP group. The balloon indwelling duration was significantly shorter in the PVP group. As early adverse events, the frequencies of continuous bladder irrigation and postoperative transient urinary retention were significantly higher in the CVP group.
〈Conclusion〉 The CVP group included more patients receiving antithrombotic therapy as high-risk patients than the PVP group. However, CVP was associated with a shorter operative time, a smaller bleeding volume, and better safety than PVP.
Purpose : To examine the photoselective vaporization of the prostate (PVP) postoperative urination states in patients with urinary retention.
Patient and Methods : From July 2011 to May 2018, among 939 patients who underwent PVP, we selected 132 cases (39 self-catheterization ; 93 urethral catheterization) who showed urinary retention just before a surgery. We examined the presence of self-urination during postoperative 1 month and 3 months just after a surgery.
Result : In patients with urinary retention (average age, 74 ［54-101］ years), preoperative estimated prostatic volume was 77 (11-276) mL, mean operative time of PVP was 106 (14-225) minutes, mean laser time was 64 (7-156) minutes. Self-urination was observed in 100％ patients at three months after surgery.
Conclusion : Our data suggest that the enforcement of PVP is effective for ADL and QOL improvement in patients with urinary retention.
In this study, we clarified patients suitable for single-port laparoscopic adrenalectomy by focusing on the optimal cut-off values of the body mass index (BMI).
A retrospective study was conducted on 126 consecutive patients who underwent single-port adrenalectomy. We re-evaluated all medical records and surgical videos. The pneumoperitoneum time (PT) was employed as an objective index for the assessment of surgical difficulty.
The total mean PT was 84 minutes. In 27 patients with a BMI less than 20 kg/m2, the mean PT was 71 minutes, whereas the mean PT was 104 minutes in 9 patients with a BMI exceeding 28 kg/m2.
Our results suggested that patients with a BMI less than 20 kg/m2 are suitable for novice surgeons. Conversely, even experienced surgeons should carefully consider performing single-port surgery on patients whose BMI exceeds 28 kg/m2.
The original training program to obtain the license in endoscopic surgical skill qualification system (ESSQS) of the JSE started at 2006 at the Department of Urology of Okayama University Hospital. We reviewed the outcomes of laparoscopic adrenalectomy surgeries that were performed by the trainees enrolled in the program. We retrospectively evaluated the case of 76 patients who underwent laparoscopic adrenalectomy by trainees in comparison with 43 cases performed by ESSQS certified urologists from March 2009 to November 2017. The median number of cases performed by 18 trainees (6-11 years after graduation) was 4 (range : 1-9), and by 9 certified urologists was 2 (range : 1-26). There were no significant differences in the patient background between two groups. The operative time was significantly shorter in the certified group (p ＝ 0.0122). There was no case that required blood transfusion nor conversion to open surgical approach. The operative time and blood loss were presented without following the expected learning curve when they were compared to similar training programs. The systematic education achieved favorable outcome in the trainee group.
We retrospectively analyzed 103 consecutive patients who underwent robot-assisted radical prostatectomy (RARP) with bilateral or unilateral endopelvic fascia preservation (pEPF) and intrafascial or interfascial nerve-sparing (INS). Based on the content of the operative video and pathological assessment of the specimen of the prostatic base immunohistochemically stained using S-100 antibody, the patients were divided into three groups : bilateral pEPF and INS HG group, n＝49), bilateral pEPF and unilateral INS (MG group, n＝37), and unilateral pEPF and INS (LG group, n＝17). At 1 month after surgery the pad-free urinary continence rates of the HG (46.9％) and MG (29.7％) groups were significantly higher than that of the LG (0％) group (p＜0.001 : HG vs. LG group, p＝0.012 : MG vs. LG group). At 3 months the HG (62.5％) group showed a significantly higher rate of pad-free urinary continence than the LG (29.4％) group (p＝0.035). Based on multivariate analysis, LG was the only significant prognostic indicator of delayed continence recovery at 1 month after surgery. The surgical procedures intended for bilateral pEPF and the performing of bilateral INS during RARP were considered to be effective for early continence recovery.
We assessed sarcopenia-associated factors and anatomical factors to predict postoperative urinary incontinence in robot-assisted radical prostatectomy (RARP). We included 65 cases who underwent RARP from June 2015 to May 2017. Before surgery, we evaluate QOL, amount of urinary incontinence, grip strength and 3 meters timed up & go test (TUG). Membranous urethral length (MUL) was measured by preoperative MRI. In univariate analysis, the usage of the safety pad at 3 months after surgery significantly correlated with the MUL (p＝0.0264). In multivariate analysis, we picked up age, grip strength, TUG, nerve sparing, and MUL, MUL ≥ 13 mm was the only significant predictor of postoperative incontinence (p＝0.0313). Although sarcopenia evaluation might be considered for further investigation, MUL evaluation before RARP seems to be useful for treatment selection and procedure determination in predicting postoperative early phase urinary incontinence.
In this study, we examined the positive surgical margin rate and associated risk factors of localized prostate cancer (within pT2 cases) following robot-assisted radical prostatectomy (RARP) in our hospital. From March 2014 to March 2017, 162 consecutive patients who underwent RARP and the pathological results within pT2 were retrospectively reviewed. We defined the operators with experience of more than 50 LRPs as Experts and fewer than 50 as non-Experts. The positive surgical margin rate was 14.8％ (24/162 patients). The most common location was the apex. In multivariate analysis, cT2b was an independent risk factor for a positive surgical margin. The number of experiences of laparoscopic radical prostatectomy (more/fewer than 50) did not contribute to the positive surgical margin rates of RARP.
Purpose : We aimed to retrospectively investigate the surgical outcomes and postoperative kidney function in patients with clinical T1b renal tumors who underwent robot-assisted and open partial nephrectomies.
Methods : A propensity score analysis was used to adjust for patient- and tumor-related factors (robot-assisted partial nephrectomy group : 38 patients, open partial nephrectomy group : 38 patients).
Results : We observed that the estimated blood loss and length of postoperative hospitalization were significantly lower in the robot-assisted partial nephrectomy group (p＝0.0014 and p＝0.0281, respectively). Preservation of the kidney function 12 months after operation was better in the robot-assisted partial nephrectomy group, although the difference was not statistically significant (p＝0.1018).
Conclusions : As compared with open partial nephrectomy, robot-assisted partial nephrectomy had a more favorable perioperative result and may be associated with better long-term preservation of kidney function after partial nephrectomy.