Triangular extension of hinge flaps: A novel technique to resolve stomal stenosis and prevent restenosis in staged buccal mucosal urethroplasty.

OBJECTIVES: To verify the utility of triangular extension of a hinge flap in buccal mucosal staged urethroplasty to resolve stomal stenosis after the first stage and ultimately prevent restenosis. METHODS: A total of 23 patients (triangular extension group) were studied in 2013-2019. In the first stage, buccal mucosa was transplanted, and an extended triangle portion of the mucosa was placed beside the proximal and/or distal stoma that was created when the stricture segment of the urethra was resected. In the second stage, during tubularization of the urethral plate, an incision was made at the stoma to increase the caliber to which the triangular extension was inserted. The procedure was considered successful when a 17-Fr flexible cystoscope passed through the reconstructed urethra at 6 months after the second-stage urethroplasty and no additional surgery or bougie dilation required. The clinical course of the triangular extension group was compared with 24 patients who underwent conventional staged urethroplasty (control group). RESULTS: In total, 20 patients from each group underwent second-stage surgery. No patients in the triangular extension group required additional revision surgery because of stomal stenosis after first-stage surgery, whereas five (20%) control patients did. Urethroplasty was successful in 19 patients (95%) in the triangular extension group and in 19 patients (95%) in the control group. Uroflowmetry after the second-stage surgery indicated that the mean maximum urinary flow rate was 21.5 and 15.8 mL/s after triangular extension and the control procedure, respectively (P = 0.027). CONCLUSIONS: The triangular extension technique reduces the need for revision surgery and prevents postoperative restenosis.

Expressions of P-Glycoprotein, Multidrug Resistance Protein 1 and Annexin A2 as Predictive Factors for Intravesical Recurrence of Bladder Cancer after the Initial Transurethral Resection and Immediate Single Intravesical Instillation of Adriamycin.

OBJECTIVE: Immediate single instillation of chemotherapy following transurethral resection of bladder tumor (TURBT) is suggested for non-muscle invasive bladder cancer (NMIBC) patients. However, no study has evaluated molecular marker that was involved in intravesical recurrence (IVR) after single instillation of chemotherapy. Therefore, this study aimed to evaluate whether P-glycoprotein, multidrug resistance protein 1 (MRP1), Annexin A2 (ANXA2) or nucleophosmin (NPM) expression predicts IVR after initial TURBT and immediate single intravesical adriamycin instillation. METHODS: We retrospectively reviewed consecutive 443 patients who underwent TURBT. Of these, 54 patients who underwent initial TURBT and single instillation of adriamycin for NMIBC were included. The expressions of P-glycoprotein, MRP1, ANXA2 and NPM were evaluated immunohistochemically and were divided into 2 groups (low or high) according to the staining intensity and/or proportion of positive cells. IVR was assessed by Kaplan-Meier method. Cox`s multivaritate analyses were performed to identify independent predictors for IVR. RESULTS: Nineteen patients (35.1%) had IVR. High P-glycoprotein expression was significantly correlated with multiplicity, pT stage and high grade. High ANXA2 expression was significantly correlated with high grade. MRP1 and NPM were not correlated with any clinicopathological variables. MRP1 expression and ANXA2 expression were significantly correlated with P-glycoprotein expression. Patients with high P-glycoprotein expression had significantly worse IVR-free survival (IVRFS) than those with low P-glycoprotein expression (P =0.015). The difference in IVRFS rates between patients with high ANXA2 expression and those with low ANXA2 expression was nearly significant (P =0.057). Univariate analyses indicated multiplicity, high grade and high P-glycoprotein expression were significant predictors for IVR. Multivariate analysis indicated high grade was an independent predictor for IVR. CONCLUSIONS: High P-glycoprotein expression was associated with IVR. Further study was needed to determine significance of P-glycoprotein expression in IVR after single intravesical adriamycin instillation.

Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes.

PURPOSE: To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture. METHODS: Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively). CONCLUSIONS: EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed.

Is pre-referral management of anterior urethral strictures prior to urethroplasty appropriate?

OBJECTIVES: To evaluate whether the management of anterior urethral strictures prior to definitive urethroplasty is appropriate. METHODS: Of a total of 419 men diagnosed with anterior urethral strictures at hospitals across Japan and thereafter referred to our institution for definitive urethroplasty between 2004 and 2019, the medical records of 371, for whom data on stricture characteristics at the initial diagnosis and pre-referral management were available, were retrospectively reviewed. A pre-referral single transurethral procedure, such as direct vision internal urethrotomy or urethral dilation, was considered appropriate only for favorable stricture, defined as a single nontraumatic untreated bulbar urethral stricture ≤2 cm in size, and repeat transurethral procedures were considered inappropriate in any circumstances. The association between the appropriateness of the pre-referral management strategy and patient and clinical characteristics was analyzed. RESULTS: A total of 242 patients (65.2%) had a pre-referral history of at least one transurethral procedure, and performing the procedure was considered inappropriate for 221 patients (59.6%). On multivariate logistic regression analysis, location of the patient's residence far from our institution (outside of the Kanto area; odds ratio 3.35, 95% confidence interval 1.86-6.04; P < 0.0001), voiding with intermittent dilation (odds ratio 2.38, 95% confidence interval 1.38-4.12; P = 0.002), iatrogenic stricture (odds ratio 11.18, 95% confidence interval 5.30-23.61; P < 0.0001), and stricture longer than 20 mm (odds ratio 3.05, 95% confidence interval 1.47-6.38; P = 0.003) were the independent predictors of inappropriate use of transurethral procedures. CONCLUSIONS: Transurethral procedures are often inappropriately used. There is a clear need to promote appropriate management strategies for urethral strictures among general urologists.

Difficulty in differential diagnosis for renal cancer with microscopic papillary architecture: overlapped pathological features among papillary renal cell carcinoma (RCC), mutinous tubular and spindle cell carcinoma, and unclassified RCC. Lessons from a Japanese multicenter study.

OBJECTIVES: In our multicenter study evaluating metastatic papillary renal cell carcinoma (PRCC), 29% of tumors diagnosed as PRCC in collaborative institutes were finally diagnosed as other RCCs under central review. In those tumors, mucinous tubular and spindle cell carcinoma (MTSCC) was the leading histology, followed by unclassified RCC (ucRCC). We focused on those patients with MTSCC or ucRCC. METHODS: We reviewed the processes for the pathological diagnoses of nine tumors and reviewed their clinical features. RESULTS: All of the MTSCCs and ucRCCs were positive for AMACR, which is frequently positive in PRCC. Mucin was demonstrated in 80% of the MTSCCs, and its presence is important for their diagnoses. One MTSCC was diagnosed as a mucin-poor variant. The presence of spindle cells with low-grade nuclei was suggestive of MTSCC, but the diagnosis of high-grade MTSCC was difficult. Four tumors were diagnosed as ucRCC by histological and immunohistochemical findings. Three of the four tumors were suspicious of ucRCC in the initial review due to atypical findings as PRCC. Sunitinib and interferon-α were effective for one MTSCC patient who survived for >5 years. Two MTSCC patients who were Memorial Sloan-Kettering Cancer Center poor risk had unfavorable prognoses. One patient with mucin-poor MTSCC had an indolent clinical course. Two of four ucRCC patients showed durable stable disease with targeted agents (TAs) and survived >3 years. CONCLUSION: Some MTSCC metastases progressed very slowly and poor-risk tumors progressed rapidly. Systemic therapies including TAs showed some efficacies. Some patients who have metastatic ucRCC with microscopic papillary architecture can benefit from TAs.

Usefulness of a high-speed surgical air drill in pubectomy during delayed anastomotic urethroplasty for pelvic fracture urethral injury.

OBJECTIVES: Pubectomy is an ancillary technique used to increase exposure of the disrupted urethra and reduce anastomotic tension, which can be difficult for inexperienced surgeons. The objective of the present study was to illustrate the use of an air drill enabling delicate and precise bone resection in pubectomy for delayed anastomotic urethroplasty for pelvic fracture urethral injury. METHODS: Between 2009 and 2019, 88 male patients underwent delayed anastomotic urethroplasty with pubectomy for pelvic fracture urethral injury. A total of 73 procedures used a high-speed surgical air drill (HiLAN HS; Aesculap, Tuttlingen, Germany) equipped with a short-hand piece. Operative time and blood loss in the air drill patient group (group 1) were compared with that of patients who underwent pubectomy using a rongeur and/or gouge (group 2, n = 15). RESULTS: In 65 group 1 patients, urethroplasty was carried out using the perineal approach, with partial inferior pubectomy. Eight group 1 patients, whose proximal urethral end was displaced upward superior to the upper edge of pubis, underwent urethroplasty using the perineal and abdominal approach, with a superior partial pubectomy and supracrural urethral rerouting. No difficulty was encountered using the air drill in any of the cases. There was no significant difference in median operative time between the groups (group 1 256 min vs group 2 228 min; P = 0.31). The median blood loss in group 1 was significantly lower than group 2 (149 mL vs 453 mL; P < 0.0001). CONCLUSIONS: Surgical air drills might facilitate pubectomy in patients undergoing delayed anastomotic urethroplasty for pelvic fracture urethral injury. This tool offers the advantage of a delicate bone resection with reduced blood loss.

[A CASE OF NEO-MEATAL STENOSIS AFTER PENECTOMY FOR PENILE CANCER, REPAIRED BY BLANDY PERINEAL URETHROSTOMY].

Surgical resection is the standard treatment for the management of localized penile cancer and a neo-urethral meatus is generally created on the penile stump or perineum. Neo-urethral meatus is often stenosed and requires repeated transurethral manipulations such as dilation and urethrotomy. These procedures are generally futile and are associated with poor quality of life. Here, we report a case of penile cancer that developed a neo-meatal stenosis after total penectomy, which was subsequently salvaged by perineal urethrostomy using Blandy technique. A 72-year-old male who was diagnosed with localized penile cancer, underwent total penectomy and creation of neo-meatus on the perineum. Neo-meatus stenosis had developed in the patient and he received repeated urethral dilations without any success. Finally, when the patient was unable to void, he was referred to us for the amelioration of meatal stenosis through the placement of a suprapubic catheter. Because the condition of the residual bulbar urethra was adequate and its length was enough, we planned to create a non-transecting perineal urethrostomy by Blandy technique. An inverted U-shaped perineal incision was made, and a skin flap was created. The scarred neo-meatus and spongiofibrosis at the distal bulbar urethra were completely excised. The residual bulbar urethra was exposed, and a longitudinal ventral incision of 4 cm was made. The edge of the bare urethral mucosa and tunica albuginea of the corpus spongiosum were sutured by 4-0 PDS for hemostasis. The apex of the U-shaped skin flap was brought to the proximal margin of the urethrotomy and a tension-free anastomosis was created between the skin flap and the urethral plate. Thereafter, the skin of the perineum was sutured to the open longitudinal urethrotomy. The patient started to void on the 5th day post-surgery. The subject could void without the help of any intervention and did not require any instrument, sixteen weeks after the surgery.

Surgical and patient-reported outcomes of urethroplasty for bulbar stricture due to a straddle injury.

PURPOSE: To report our experience with urethroplasty for bulbar stricture due to a straddle injury based on surgical and patient-reported outcomes. METHODS: Patients who underwent urethroplasty for bulbar stricture due to a straddle injury between 2010 and 2018 were retrospectively analyzed (N = 132). Successful urethroplasty was defined as the absence of the need for additional treatment. The patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 1 year after urethroplasty. RESULTS: The median (interquartile range) age was 50 (36-62) years; urethral stricture length estimated from urethrograms, 8.6 (5.1-12.5) mm; and postoperative follow-up, 41 (22-56) months. Urethroplasty was performed through excision with primary anastomosis in 95.5% (n = 126) and onlay augmentation with a buccal mucosa graft in 4.5% (n = 6). Urethroplasty was successful in 98.5% (n = 130). The 2 failures due to periurethral abscess were successfully salvaged with another urethroplasty. Eighty-four patients (63.6%) completed the questionnaires at 1 year postoperatively. The mean lower urinary tract (LUT)-specific quality of life, SHIM, and EuroQol-visual analog scale scores all improved significantly from 2.6, 8.5, and 57.5 at baseline to 0.3, 11.6, and 84.6 postoperatively (p < 0.0001, p = 0.004, p < 0.0001, respectively). All patients were either "satisfied" (19/84, 22.6%) or "very satisfied" (65/84, 77.3%). Lower postoperative LUT symptom score was an independent predictor of a "very satisfied" patient (odds ratio 0.81, 95% confidence interval 0.67-0.98, p = 0.002). CONCLUSIONS: Urethroplasty for bulbar stricture due to a straddle injury has a high success rate and is beneficial for both subjective and objective symptoms.

Analysis of Diffusion-weighted MR Images Based on a Gamma Distribution Model to Differentiate Prostate Cancers with Different Gleason Score.

PURPOSE: Prostate cancer management includes identification of clinically significant cancers that may require curative treatment. Statistical models based on gamma distribution can describe diffusion signal decay curves of prostate cancer. The purpose of this study was to evaluate the ability of parameters obtained with the gamma model in differentiating prostate cancers with different Gleason score values. METHODS: This study included 155 patients with prostate cancer who underwent multiparametric magnetic resonance imaging prior to prostate biopsy (127 patients) or radical prostatectomy (28 patients) between January 2015 and June 2017; 159 foci of prostate cancer were included in our study. We compared cases scored as Gleason score (GS) 3 + 3 and GS ≥ 3 + 4, and analyzed cases scored as GS ≤ 3+ 4 and GS ≥ 4 + 3 based on the gamma model (Frac < 1.0, Frac < 0.8, Frac < 0.5, Frac < 0.3, and Frac > 3.0), and apparent diffusion coefficient (ADC). RESULTS: Among 159 cancerous lesions in 155 patients, 13 (8.2%) were GS 3 + 3 prostate cancers, 51 (32.0%) were GS 3 + 4 prostate cancers, 30 (18.2%) were GS 4 + 3 cancers, and 65 (40.9%) were GS ≥ 4 + 4 cancers. Frac < 0.3, Frac < 0.5, Frac < 0.8, and Frac < 1.0 were significantly higher and ADC values were significantly lower in GS ≥ 4 + 3 cancers than in GS ≤ 3 + 4 cancers (P < 0.01, P < 0.01, P < 0.01, P = 0.01, and P < 0.01, respectively). With receiver operating characteristic (ROC) analysis, Frac < 0.3 and Frac < 0.5 had significantly greater area under the ROC curve for discriminating GS ≥ 4 + 3 cancers from GS ≤ 3 + 4 cancers than ADC (P = 0.03, P < 0.01, respectively). CONCLUSION: Frac < 0.3 and Frac < 0.5 showed higher diagnostic performance than ADC for differentiating GS ≥ 4 + 3 from GS ≤ 3 + 4 cancers. The gamma model may add additional value in discrimination of tumor grades.

Magnetic Resonance Imaging Findings of Traumatic Bulbar Urethral Stricture Help Estimate Repair Complexity.

OBJECTIVE: To evaluate the magnetic resonance imaging (MRI) findings of traumatic bulbar stricture and to evaluate their ability to estimate repair complexity. METHODS: Eighty-nine men with traumatic bulbar stricture who underwent urethrography and MRI at least 3 months postinjury and subsequent excision and primary anastomosis were retrospectively analyzed. The associations of MRI findings, including continuity of the tunica albuginea of the corpus spongiosum, periurethral fistula, spongiofibrosis length (SFL), and distal and proximal bulbar urethral length from the stricture, with urethrography and operative parameters were evaluated. RESULTS: Mean SFL was significantly longer than mean stricture length on urethrography (14.9 vs 7.9 mm, P <.0001). Periurethral fistula was found in 18 (20.2%) patients on MRI but not in 10 (55.6%) of them on urethrography. The corpus spongiosum was disrupted in 40 patients (55.1%) on MRI. On multivariate linear regression, SFL (standard coefficient, 0.25; t value, 2.31; P = .02) predicted operation time, while SFL (standard coefficient, 0.22; t value, 2.04; P = .04) and proximal bulbar urethral length (standard coefficient, -0.25; t value, -2.11; P = .04) independently predicted blood loss. Corporal splitting to reduce anastomotic tension and/or increase visualization during repair was needed in 33 patients (37.1%). Stricture length on urethrography (odds ratio [OR], 1.22; 95% confidence interval, 1.04-1.42; P = .006) and corpus spongiosum disruption (odds ratio, 5.51; 95% confidence interval, 1.57-19.34, P = .005) were independent predictors for the need of corporal splitting. CONCLUSION: In contrast to urethrography findings, MRI findings help predict traumatic bulbar stricture repair complexity.

Is Primary Realignment Appropriate for the Initial Management of Straddle Injuries to the Bulbar Urethra?

OBJECTIVE: To compare the clinical courses of patients with straddle injuries to the bulbar urethra based on the initial management strategy for urinary drainage, mainly suprapubic tube placement (SPT) and primary realignment (PR), and to examine whether PR has a beneficial effect on subsequent urethroplasty with regards to surgical and patient-reported outcomes. METHODS: We reviewed the clinical courses of 126 patients with bulbar urethral stricture following straddle injuries who underwent delayed urethroplasty between August 2010 and April 2019. Patients were categorized as being initially treated with SPT (82 patients) or PR (44 patients). Stricture was considered complicated if preoperative urethrography or cystoscopy revealed iatrogenic scarring or a stricture away from the injury site. RESULTS: The percentage of patients who experienced delayed transurethral treatment at least once before referral was significantly higher in patients treated with PR than in those treated with SPT (25/44, 56.8% vs 16/82, 19.8%, P < .0001). Although there was no difference in stricture length in both cohorts, the fraction of patients with complicated stricture was significantly higher in patients treated with PR than in those treated with SPT (15/44, 34.1% vs 14/82, 17.1%, P = .003). There was no significant difference in the selected type of urethroplasty, operative time, blood loss, success rate, postoperative maximum urinary flow rate, voiding symptoms, or erectile function between the 2 groups. CONCLUSION: PR does not facilitate delayed urethroplasty and had no beneficial effect on urethroplasty outcome. PR might lead to delayed transurethral procedures, resulting in increased risk of complicated strictures.

Sub-classification of patients with intermediate-risk metastatic renal cell carcinoma treated with targeted therapy.

BACKGROUND: International Metastatic Renal Cell Carcinoma Database Consortium model predicts the outcomes of metastatic renal cell carcinoma stratified into favorable, intermediate, and poor risk groups (FG, IG, and PG, respectively), with approximately 50% of patients being classified as IG. We aimed to generate better risk model based on the sub-classification of IG. METHODS: We analyzed records of 213 consecutive patients receiving molecular targeted therapy. Age, gender, histology, type of initial molecular targeted therapy, serum laboratory data, previous nephrectomy and immunotherapy, and metastatic sites were used for IG sub-stratification. Modified and original models were compared using a concordance correlation coefficient analysis. RESULTS: Median follow-up was 17.8 months. Serum albumin, serum C-reactive protein, and bone metastases were independent predictors of overall survival (OS) in IG. IG was sub-classified into low-, middle-, and high-risk IG according to the number of predictors. The following modified model was developed: modified FG (FG & low-risk IG), modified IG (middle-risk IG), and modified PG (PG & high-risk IG). Concordance indices for original and modified models were 0.68 and 0.73, respectively (P < 0.001). OS was significantly longer in modified PG treated with mammalian target of rapamycin inhibitors as second-line therapy than with tyrosine kinase inhibitors, whereas this was not observed in the original model. CONCLUSIONS: We successfully developed modified IMDC model using a two-step process: the original IMDC plus an IG sub-stratification, and demonstrated that it predicts outcomes more accurately than original model.

Insulin-like growth factor 1 sustained-release collagen on urethral catheter prevents stricture after urethral injury in a rabbit model.

OBJECTIVES: To evaluate the preventive effect of an insulin-like growth factor 1 sustained-release collagen urethral catheter on urethral stricture after urethral injury in a rabbit model. METHODS: We made urethral catheters coated either with insulin-like growth factor 1 impregnated collagen or with only collagen, and we divided 19 male Japanese white rabbits into three groups according to the kind of catheter inserted immediately after the rabbit's urethra was injured by electrocoagulation. Group 1 (n = 7) had a catheter coated with insulin-like growth factor 1 impregnated collagen inserted; group 2 (n = 7) had a catheter coated with only collagen inserted; and group 3 (n = 5) had an uncoated catheter inserted. A total of 14 days later, the injured urethras were evaluated by urethrography and urethroscopy, and were also histologically examined. RESULTS: Urethrography showed that the ratio of the urethral lumen diameter in injured urethra to that in normal urethra was the largest in group 1 (P < 0.0001). In addition, five of the seven rabbits in group 1 (71.4%) had a urethral lumen large enough for passage of a urethroscope, a fraction larger than the corresponding fractions in groups 2 (57.1%) and 3 (20%). On histological analysis, the injured area not covered with regenerated urethral epithelium tended to be smaller in group 1 than the other two groups, but the mean difference was not significant (P = 0.19). CONCLUSIONS: An insulin-like growth factor 1 sustained-release collagen urethral catheter significantly improves wound healing and prevents urethral stricture after urethral injury.

Single-surgeon series of delayed anastomotic urethroplasty for pelvic fracture urethral injury: an analysis of surgical and patient-reported outcomes of a 10-year experience in a Japanese referral center.

PURPOSE: To report our experience with delayed anastomotic urethroplasty for pelvic fracture urethral injury (PFUI) during the last 10 years and evaluate both surgical and patient-reported outcomes. METHODS: Retrospective analysis of 115 patients undergoing delayed anastomotic urethroplasty for PFUI between 2008 and 2017 by a single surgeon (AH) was performed. Success was defined as a urethral lumen large enough for passage of a 17-Fr flexible cystoscope. We asked patients to complete questionnaires before (baseline) and 1 year after urethroplasty and compared by paired t and Wilcoxon signed-rank tests the answers to a question about LUTS-specific QOL and the health-related QOL indicated by EQ-5D index and visual analogue scores (EQVAS). Overall patient satisfaction 1 year after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 108 patients (93.9%), and failed urethroplasty was significantly associated with greater intraoperative blood loss (p = 0.009) and smaller surgical experience (p = 0.018). Sixty-six patients (57.4%) completed questionnaires 1 year after urethroplasty, and 65 of those 66 (98.5%) were "satisfied" (36.4%) or "very satisfied" (62.1%) with the outcome of their urethroplasty. The LUTS-specific QOL scores (p < 0.0001), EQ-5D index scores (p < 0.0001), and EQVAS scores (p < 0.0001) all improved significantly after urethroplasty. CONCLUSIONS: Delayed anastomotic urethroplasty has a high success rate and significant beneficial effects on both LUTS-specific and health-related QOL, resulting in high patient satisfaction. Careful manipulation in a bloodless operative field by experienced surgeons could be the key to successful urethroplasty.

Penile-preserving surgery for male distal urethral carcinoma followed by buccal mucosa urethroplasty.

INTRODUCTION: We report a case of distal urethral carcinoma treated with segmental urethral excision and reconstruction by staged buccal mucosa urethroplasty. CASE PRESENTATION: A 60-year-old man presented with difficulty urinating and a palpable mass on the ventral side of his penis. He was diagnosed as having localized distal urethral carcinoma (cT2N0M0) and underwent penile-preserving surgery with staged urethroplasty using buccal mucosa as substitute tissue. The pathological diagnosis was squamous cell carcinoma of the urethra (T2) with negative surgical margin. At 2 years of follow-up, there was no recurrence or metastasis, he could void in a standing position with an acceptable urinary stream, and he found the appearance of his external genitalia acceptable. CONCLUSION: In cases of distal primary urethral carcinoma, urethroplasty using buccal mucosa graft could be alternative treatment option providing a better postoperative quality of life.

[A CASE OF EMPHYSEMATOUS PYELONEPHRITIS WHO PRESENTED THE PRESERVATION OF THE IPSILATERAL KIDNEY FOLLOWING OPEN DRAINAGE].

We report a case of a 53-year-old woman with emphysematous pyelonephritis who presented the preservation of the ipsilateral kidney following open drainage. She was transferred to our hospital with chief complaints of right back pain and high fever. On diagnosis, diabetes mellitus and a stone in the right ureter were confirmed, and she was followed up at a local clinic. Computed tomography revealed the presence of gas in the right renal pelvis, and the stone led to right hydronephrosis. Additionally, her hemoglobin A1c level was 11.3%. Hence, we diagnosed the patient with emphysematous pyelonephritis. Although right percutaneous nephrostomy was performed immediately after her admission, the gas in the right renal pelvis extended to the renal parenchyma one day later. Therefore, we performed open drainage of the right kidney to control severe inflammation. The gas disappeared after the procedure, and her systemic status gradually improved. We hypothesize that emphysematous pyelonephritis is treated with open drainage instead of nephrectomy while preserving the ipsilateral kidney.

Impact of inflammatory marker levels one month after the first-line targeted therapy initiation on progression-free survival prediction in patients with metastatic clear cell renal cell carcinoma.

OBJECTIVES: Progression-free survival of first-line targeted therapy greatly influences the survival of patients with metastatic renal cell carcinoma. We evaluated whether post-treatment inflammatory markers and lactate dehydrogenase levels had impacts on progression-free survival prediction in addition to those of conventional predictors. METHODS: Two hundred and fifteen patients whose tumors were clear cell type and in whom first-line targeted therapies could be continued for >1 month were evaluated. Pretreatment clinical factors, pathological factors and laboratory data 1 month after targeted therapy initiation-including inflammatory markers (neutrophil count, neutrophil-to-lymphocyte ratio and C-reactive protein) and lactate dehydrogenase-were reviewed. To identify progression-free survival predictors, multivariate analyses were done. RESULTS: The 1-year progression-free survival rate was 47%. Female gender, Karnofsky performance status <80%, time from diagnosis to systemic treatment <12 months, pretreatment C-reactive protein >3.0 mg/dl and post-treatment neutrophil-to-lymphocyte ratio >3.0 were independent predictors for progression-free survival. In contrast, neither C-reactive protein increase nor neutrophil-to-lymphocyte ratio increase after targeted therapy initiation were independent predictors. Pretreatment lactate dehydrogenase, post-treatment lactate dehydrogenase and lactate dehydrogenase decline were not independent predictors. When all patients were stratified by these independent factors into three groups (0 risk vs. 1 or 2 risks vs. 3 or more risks), there were significant differences in progression-free survival rates between the groups (P < 0.0001). Furthermore, there were also significant differences in overall survival rates between the groups (P < 0.0001). CONCLUSIONS: Integration of post-treatment neutrophil-to-lymphocyte ratio value with pretreatment factors may lead to the establishment of effective predictive model for disease progression in patients with metastatic clear cell renal cell carcinoma who received first-line targeted therapies.

Evaluation of the effect of urethroplasty for anterior urethral strictures by a validated disease-specific patient-reported outcome measure.

PURPOSE: To better understand our urethroplasty outcome, we translated the English version of a urethral stricture surgery patient-reported outcome measure (USS-PROM) into Japanese and used it to evaluate the effect of urethroplasty for anterior urethral strictures. METHODS: The PROM quantifies lower urinary tract symptoms (LUTS) and health-related quality of life (EQ-5D), and it evaluates overall satisfaction by asking patients to choose "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". 93 Japanese-speaking male patients with anterior urethral stricture who underwent urethroplasty completed it before (baseline) and 6 months after urethroplasty. The psychometric criteria evaluated in the present study were the PROM's internal consistency, test-retest reliability, criterion validity, and responsiveness. RESULTS: Qmax was negatively correlated with the LUTS-total scores (r = - 0.61). Cronbach's alpha was 0.80 and the test-retest intraclass correlation coefficient for the LUTS-total score was 0.82. 83 patients (89.2%) achieved stricture-free, which was defined as no re-stricture on cystoscopy and no need for additional treatment. The mean total LUTS-score improved from 12.4 at baseline to 3.7 postoperatively (p < 0.0001). The mean EQ-5D visual analogue scores and EQ-5D index improved from 61.2 and 0.76, respectively, at baseline to 77.9 and 0.89 postoperatively (p < 0.0001, p < 0.0001). 55 patients (59.1%) were "very satisfied" with the outcome of their urethroplasty and 33 (35.5%) were "satisfied". CONCLUSIONS: The Japanese version of the USS-PROM has adequate psychometric properties. Urethroplasty improved not only objective data but also voiding symptoms and health-related QOL, and it resulted in a high rate of patient satisfaction.

Metastatic Small Cell Carcinoma of the Urinary Bladder That Recurred in the Vagina 6 Years after Radical Cystectomy: A Case Report.

Small cell carcinoma (SCC) of the urinary bladder is highly aggressive and portends a poor outcome. Herein, we report a patient with recurrent SCC of the urinary bladder who experienced an unusually long-term disease-free duration after radical cystectomy. The patient was a 60-year-old woman who had undergone transurethral resection followed by radical cystectomy for muscle-invasive bladder cancer (high-grade urothelial carcinoma with adenocarcinomatous differentiation) 6 years prior; the surgical specimen had a negative surgical margin. She was referred to our hospital because of continuous bleeding from her vagina. Magnetic resonance imaging showed a mass located at the anterior wall of her residual vagina, a biopsy of which confirmed a pathological diagnosis of adenocarcinoma. The vaginal tumor and a section of the sigmoid colon were resected en bloc and were pathologically diagnosed as adenocarcinoma and SCC. We reevaluated the initial transurethral resection specimen and found SCC with foci of adenocarcinoma concomitant with high-grade urothelial carcinoma. Local recurrence and metastasis at the pelvic bone occurred 4 months later; although radiation therapy was performed, she died of the progressive disease.

Evaluation of Therapeutic Potential of Phenoxodiol, a Novel Isoflavone Analog, in Renal Cancer Cells.

BACKGROUND/AIM: In the present study, the antineoplastic activity and mechanism of action of phenoxodiol, a novel isoflavone analog, was investigated in renal cancer cells. MATERIALS AND METHODS: A panel of renal cancer cells (769-P, 786-O, Caki-2) was treated with phenoxodiol in vitro, and the efficacy of treatment was evaluated. RESULTS: MTS assay results showed that phenoxodiol decreased renal cancer viability in a dose-dependent manner. In addition, it inhibited colony formation significantly and perturbed the cell cycle. Treatment with phenoxodiol increased the number of annexin-V-positive cells as well as the expression of cleaved poly ADP ribose polymerase, demonstrating that phenoxodiol induced apoptosis in renal cancer cells. Phenoxodiol also inhibited Akt pathway via dephosphorylation of Akt. CONCLUSION: Phenoxodiol inhibited Akt pathway and induced apoptosis of renal cancer cells. The present study provides a theoretical basis for future development of a novel therapy effective against renal cancer.