Totally retroperitoneal approach for robot-assisted nephroureterectomy with bladder cuff without repositioning.

INTRODUCTION: Robot-assisted nephroureterectomy (RANU) for upper urinary tract urothelial carcinoma is typically performed via the transperitoneal approach because of limited surgical space. However, a retroperitoneal approach may be preferable in patients with a history of abdominal surgery or in those in whom pelvic lymph node dissection is unnecessary. MATERIALS AND SURGICAL TECHNIQUES: RANU via the retroperitoneal approach was selected for two patients diagnosed with high-grade upper urothelial carcinoma with a history of abdominal surgery. Nephrectomy was performed in the 90° flank position, and the bed was tilted at 20°. The retroperitoneal space was extended, and the robot trocar was subsequently repositioned in the left lower quadrant. After redocking the robot, the distal ureter was dissected, and the bladder cuff was resected en bloc along with the kidney and the ureter. Neither patient had any complications within 3 months postoperatively. DISCUSSION: By devising a new technique for trocar placement, total retroperitoneal RANU without repositioning was possible, even in a small patient.

Prostate Biopsy May Not Be Indicated Early after Bacillus Calmette Guérin Treatment.

Bacillus Calmette-Guérin (BCG) treatment for non-muscle-invasive bladder cancer frequently causes an intraprostatic BCG granuloma. We investigated the optimal timing for a prostate biopsy after BCG treatment by retrospectively analyzing the cases of 22 patients with non-muscle-invasive bladder cancer who underwent a prostate biopsy after BCG treatment at our institute (2013-2017). Biopsies were indicated for a rising prostate-specific antigen (PSA) level, positive digital rectal examination findings, or the appearance of de novo low apparent diffusion coefficient lesions on MRI. The control group was comprised of 28 age- and PSA-matched patients. The relationships among the cancer detection rate and the patients' PSA levels and MRI findings were analyzed. Prostate cancer was detected by biopsy in only 13.9% (3/22) of the patients in the BCG group but in 78.5% (22/28) of the control patients (p=0.0001). The three patients in the BCG group in whom prostate cancer was detected had all undergone the biopsy > 1 year after their BCG treatment. The remaining biopsies were performed within 1 year after BCG treatment and resulted in no diagnoses of prostate cancer. We suggest that performing a prostate biopsy early after BCG treatment is not informative or useful.

Castration-resistant prostate cancer with metastasis to external auditory canal - Case report.

We report a case of castration-resistant prostate cancer metastasis to an external auditory canal. A 68-year-old man was diagnosed with prostate cancer (cT3aN1M1b GS5+5). Although abiraterone, docetaxel, and cabazitaxel were administered, and PSA decreased, liver metastasis appeared. Hearing loss in the left ear was also noted and the patient was referred to an otolaryngologist for an examination, which showed a neoplastic lesion in the external auditory canal. Biopsy findings resulted in a diagnosis of adenocarcinoma. Presented here are details of a rare case of prostate cancer with metastasis to an external auditory canal.

Pancreatic FDG uptake on follow-up PET/CT in patients with cancer.

To evaluate the breakdown of unexpected pancreatic 18F-fluorodeoxyglucose (FDG) uptake and the proportion of secondary primary pancreatic cancer on follow-up, patients with cancer underwent positron emission tomography/computed tomography (PET/CT). The participants consisted of 4,473 consecutive patients with cancer who underwent follow-up PET/CT between January 2015 and March 2019 at Kochi Medical School. Among the participants, 225 with a history of pancreatic cancer were excluded from the present study. Retrospective and blinded PET/CT evaluations of 4,248 patients were performed. In patients with pancreatic FDG uptake, the distribution of FDG uptake in the pancreas was evaluated. The final diagnosis was determined pathologically. A total of 14 (0.3%) of the 4,248 patients exhibited FDG uptake in the pancreatic area. Pancreatic abnormalities were detected in 14 patients, and included five cases of pancreatic metastases (36%), four cases of secondary primary pancreatic cancer (29%), two cases of lymph node metastases (14%), one case of malignant lymphoma (7%), one case of autoimmune pancreatitis (7%) and one case of pseudolesion (7%). One patient with early-stage secondary primary pancreatic cancer had a maximum standardized uptake value (SUVmax) <3.0. The remaining 13 patients had a SUVmax >3.0 in the pancreas. Of the 14 patients, two had multiple foci of FDG uptake in the pancreas. Patients with multiple foci of FDG uptake exhibited pancreatic metastasis from renal cell carcinoma and malignant lymphoma. In conclusion, the majority of patients with unexpected pancreatic FDG uptake on follow-up PET/CT exhibited malignancies; furthermore, ~30% of the malignancies detected in patients with pancreatic FDG uptake were secondary primary pancreatic cancers. In patients with unexpected pancreatic FDG uptake on follow-up PET/CT, primary cancer should be considered as well as metastatic tumors.

Perineal urethrostomy with combined buccal mucosal graft and skin flap after complete loss of anterior urethra.

INTRODUCTION: We report a novel perineal urethrostomy procedure for complete loss of anterior urethral tissue. CASE PRESENTATION: A 74-year-old man had complete necrosis of the corpus spongiosum and corpora cavernosa after repeated transurethral surgical procedures. He had been managed with a suprapubic cystostomy tube for 10 years. A perineal urethrostomy was performed, and a posterior wall with an inverted U-shaped perineal skin flap and an anterior wall with a buccal mucosal graft were created. Five months later, an internal urethrotomy was required for mild anastomotic stenosis. Thereafter, an indwelling Foley catheter was used for urine drainage at night to prevent restenosis of the neourethra and avoid excessive nocturia due to low capacity of the long-time disused bladder, and the patient became catheter-free during the daytime. CONCLUSION: The method presented here is a reasonable option for patients lacking whole anterior urethral tissue.

[SERTOLI CELL TUMOR OF TESTIS: CASE REPORT].

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.

Optimized Acquisition Time for Dopamine Transporter Imaging.

Excess acquisition counts were often obtained by the current image acquisition of 30 minutes after 123I-ioflupane administration in a dopamine transporter study. The purpose of this study was to calculate the minimum acquisition time while retaining sufficient image quality, which could be adjusted for individual characteristics. Fifty patients who underwent dopamine transporter imaging were included in this retrospective study. The brain count density, determined by a striatum phantom, was compared to the participant's characteristics. The individual characteristics were divided into five categories of gender, age, height, weight, and body mass index. The values of 40 counts / voxel (brain count density) were set as the image quality criteria by the striatum phantom study. Weight was the characteristic that most correlated with brain count density in the 50 patients (correlation coefficient: -0.728). The acquisition time for the 50 patients was calculated as 23.4±2.6 minutes using the following formula: 0.332×W+5.42 minutes (W kg (individual weight)). A shorter acquisition time with sufficient image quality can be achieved by adjusting for individual patient weight.

Usefulness of Technetium-99 m-2-methoxy-isobutyl-isonitrile liver scintigraphy for evaluating disease activity of non-alcoholic fatty liver disease.

AIM: Non-alcoholic steatohepatitis (NASH) is a progressive form of non-alcoholic fatty liver disease (NAFLD). Therefore, it is important to evaluate disease activity and distinguish NASH from simple steatosis in NAFLD. Technetium-99 m-2-methoxy-isobutyl-isonitrile ((99m) Tc-MIBI) is a lipophilic cation designed for myocardial perfusion scintigraphy in the diagnosis of ischemic heart diseases, and its retention reflects mitochondrial function. It was reported that hepatic mitochondrial abnormalities would be an important predictive factor for NASH disease progression. The aim of this study was to examine the clinical usefulness of (99m) Tc-MIBI liver scintigraphy for evaluating disease activity of NAFLD and distinguishing NASH from simple steatosis in patients with NAFLD. METHODS: Twenty-six patients with biopsy-proven NAFLD were enrolled. Clinicolaboratory tests and (99m) Tc-MIBI liver scintigraphy were performed. To evaluate hepatic uptake, regions of interest were set at the liver and heart, and the uptake ratio of the liver to heart (liver/heart ratio) was calculated. RESULTS: All patients with NAFLD were classified into three groups according to the NAFLD activity score: non-NASH (simple steatosis) (n = 4), borderline NASH (n = 11), and NASH (n = 11). Liver/heart ratios were significantly lower in NASH than in simple steatosis (P < 0.05). Moreover, liver/heart ratios were significantly correlated with NAFLD activity scores among the patients (r = -0.413, P < 0.05). CONCLUSIONS: The present study indicates that (99m) Tc-MIBI liver scintigraphy would be a useful non-invasive functional imaging method with which to evaluate disease activity of NAFLD and distinguish NASH from simple steatosis.

Cross-sectional and longitudinal studies of three-dimensional stereotactic surface projection SPECT analysis in Parkinson's disease.

Although dementia is increasingly recognized as a common feature in Parkinson's disease (PD), its pathological substrate remains unknown. We conducted cross-sectional and longitudinal brain perfusion SPECT analyses to explore changes during the course of developing dementia in PD. Fifty-five patients originally diagnosed with PD were imaged in the cross-sectional study. Twenty-one of these, nine without dementia and 12 with dementia (PDD), were included in the longitudinal study to observe perfusion changes during the course of their disease. Data were analyzed using three-dimensional stereotactic surface projection SPECT analysis. The UK Parkinson's Disease Society Brain Bank criteria were used to diagnose PD and the revised criteria for the clinical diagnosis of dementia with Lewy bodies for PDD. The cross-sectional study showed that patients with PDD had significantly reduced perfusion in the right posterior cingulate, the right precuneus and the left posterior cingulate area. In the longitudinal study, significantly reduced perfusion was observed in the left anterior frontal gyrus in PD without dementia, and in the right inferior parietal lobule in those that developed PDD. We suggest that a relationship exists between developing dementia in PDD and reduced perfusion in the posterior parietal area.

Three-dimensional stereotactic surface projection SPECT analysis in Parkinson's disease with and without dementia.

We investigated regional cerebral blood flow (rCBF) using three-dimensional stereotactic surface projection (3D-SSP) analysis in 30 patients initially diagnosed as Parkinson's disease (PD), and compared differences in rCBF between patients with and without PD-related manifestations. 3D-SSP analysis of cerebral perfusion was performed by use of a control database. Compared to age-matched controls, there were multiple hypoperfusion areas in cases where the original diagnosis was PD. Temporal bases showed the lowest perfusion; frontal bases and medial parietal lobes the second; visual cortices the third; and parietal association areas exhibited the fourth lowest. During the clinical course, 10 of the patients suffered dementia, 9 had fluctuating cognition, and 19 experienced repeated visual hallucinations. Significant negative correlations were observed between dementia and the bilateral posterior cingulate area, and among fluctuating cognition and bilateral medial parietal lobes, parietal association areas, and dorsal occipital lobes. Repeated visual hallucinations did not show any correlation with any region of interest. We concluded that multiple hypoperfusion areas were observed in the 3D-SSP SPECT analysis. Although the presence of dementia showed a significant relationship with the bilateral posterior cingulate areas, perfusion in the frontal bases, temporal bases, or parietal lobes was markedly more reduced than that seen in the bilateral posterior cingulate areas.

Quantitative study of the difference in pulmonary perfusion in different respiratory phases in healthy volunteers.

OBJECTIVE: The purpose of this study is to investigate the physiological pulmonary perfusion pattern in different respiratory phases by calculating the normalized volume center of perfusion intensity. METHODS: Four nonsmoking volunteers underwent single photon emission computed tomography (SPECT) of maximum inspiration and expiration after the injection of Tc-99m-MAA in each respiratory phase at a week's interval. Quantitative analysis by calculating the normalized volume center of perfusion intensity was performed. RESULTS: Quantitative measurement of the normalized volume center of perfusion intensity showed that the percentage averages of ventrodorsal (Y) shift in maximum respiration were 16% (left) and 15% (right) in the upper part, 15% (left) and 14% (right) in the middle part, 17% (left) and 18% (right) in the lower part, 18% (left) and 16% (right) in each total lung. These readings indicated that the normalized center of pulmonary perfusion activity at maximum expiration moved in the ventral direction in contrast to that at maximum inspiration. In horizontal (X) and craniocaudal (Z) directions, the shift in the normalized center of pulmonary perfusion activity at maximum expiration indicated no agreement in movement direction. CONCLUSION: The normalized center of the pulmonary perfusion activity in maximum expiration moved in the ventral direction compared to that in maximum inspiration. This phenomenon might be caused by the increase in physiological intrathoracic pressure and by a definite reserve of pulmonary perfusion.

Scintigraphic prediction of response to chemotherapy in patients with breast cancer: Technetium 99m-tetrofosmin and thallium-201 dual single photon emission computed tomography.

We have investigated the usefulness of dual-isotope single photon emission computed tomography (SPECT) for predicting the response to chemotherapy in patients with breast cancer. Twenty-five patients with breast cancer were analyzed by SPECT using both 99m-technetium-tetrofosmin (99mTc-TF) and 201-thallium-chloride (201Tl). The relationship between response to chemotherapy and retention of each tracer was analyzed. 99mTc-TF retention was significantly higher in responders (42.0+/-37.9) than in non-responders (-11.3+/-34.6) (p=0.003). Ten of 13 patients (76.9%) with high 99mTc-TF retention (>15%) showed good response to chemotherapy, whereas 11 of 12 patients (91.7%) with low 99mTc-TF retention (<15%) did not respond to the therapy. The overall predictability to the response to chemotherapy was 84.0%. 201Tl retention (responders, 47.5+/-60.2% vs. non-responders, 55.8+/-45.0%; p=0.443) was not useful in therapeutic prediction, but was required to identify the lesion on the SPECT image. This is the first report to find that dual-isotope SPECT using 99mTc-TF and 201Tl is useful in predicting the response to chemotherapy in patients with breast cancer. Low 99mTc-TF retention is a strong predictor of therapeutic resistance, and high 99mTc-TF retention suggests a favorable response to chemotherapy.