Ureteroscopy for urolithiasis in bedridden patients: it is feasible and acceptable.

PURPOSE: To investigate the safety of transurethral ureteroscopy (URS) for urolithiasis in bedridden patients and to identify bedridden patient-specific risk factors for postoperative complications. METHODS: The patients who underwent URS for urolithiasis were divided into bedridden patients and good performance status (PS) patients, and the groups were compared regarding their clinical characteristics and postoperative complications. A multivariable logistic regression analysis was performed to evaluate independent predictors of postoperative febrile urinary tract infection (fUTI). RESULTS: A total of 1626 patients were included, 276 in the bedridden patient group, and 1350 in the good PS patient group. The bedridden patient group had a significantly higher age and higher proportion of females and had multiple comorbidities. In 77 patients (27.9%), 88 postoperative complications developed for the bedridden patient group. Clavien-Dindo grade III or IV complications were observed in only 8 patients. No grade V complications were observed. The most common complication was fUTI. The frequency of fUTI with grade III or IV for the bedridden patient group (2.2%) was higher compared with the good PS patient group (0.5%), but the difference was not statistically significant (p = 0.13). Bedridden patient-specific risk factors for fUTI included female sex, diabetes mellitus, cerebrovascular comorbidities, lower extremity contracture, and prolonged operative time. CONCLUSION: URS for urolithiasis is a feasible and acceptable procedure in bedridden patients, despite the moderate rate of postoperative complications. The identified risk factors provide a framework for risk stratification and individualized care in this unique patient population.

Hydronephrosis severity as a predictor of postoperative renal function decline following laparoscopic radical nephroureterectomy.

BACKGROUND: This study aimed to investigate factors, including the degree of hydronephrosis, that may be associated with decreased renal function after radical nephroureterectomy (RNU). METHODS: This study included 252 patients who underwent laparoscopic RNU with an estimated glomerular filtration rate (eGFR) ≥ 30 ml/min/1.73 m2 in three institutions. We assessed the association between hydronephrosis grade and perioperative renal function and performed a stepwise multivariate linear regression analysis to identify factors associated with postoperative eGFR. Patients with preoperative eGFR ≥ 50 ml/min/1.73 m2 were divided into a training set and an independent external validation set to develop a predictive model for postoperative renal function. RESULTS: The median preoperative and postoperative eGFR were 61.1 and 46.4 ml/min/1.73 m2, respectively. The eGFR preservation rates were 66.9%, 66.6%, 88.1%, and 100.0% in groups without, with mild, moderate, and severe hydronephrosis, respectively, and this difference was statistically significant (p < 0.001). Multivariate analysis revealed that factors predictive of postoperative eGFR included sex, preoperative eGFR, clinical T stage (cT3-4), and the presence of moderate or severe hydronephrosis. Our predictive model, based on these factors, positively correlated with actual postoperative renal function, and the similarity in categories with or without renal function insufficiency between predicted and actual postoperative renal functions was 78% in both training and validation sets. CONCLUSION: Moderate or severe hydronephrosis is associated with a modest postoperative decline in renal function, while mild hydronephrosis is not. Our predictive model may be useful in predicting postoperative renal function insufficiency and guiding decision-making for perioperative medical treatment.

Minimally invasive total pelvic exenteration for symptomatic locally advanced prostate cancer with rectal invasion: Indications and technical considerations.

In cases of rectal invasion by locally invasive prostate cancer (LAPC) leading to severe pain or bleeding, total pelvic exenteration (TPE) is necessary. Here, we present two cases of successful minimally invasive TPE: one performed laparoscopically for local recurrence with rectal bleeding after laparoscopic radical prostatectomy, and another done robotically for LAPC (clinical T4N1M0) accompanied by rectal bleeding. Medical treatments were ineffective in the latter case, and the tumor occupied a significant portion of the pelvis. We adopted a simultaneous transperineal approach and performed intracorporeal ileal conduit formation. Our cases highlight the challenging nature of minimally invasive TPE for symptomatic LAPC. Despite its complexity, these techniques prove viable and valuable in managing LAPC-related symptoms, emphasizing their practical utility in clinical settings.

Preoperative risk classification for intravesical recurrence after laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma in a multi-institutional cohort.

INTRODUCTION: This study aimed to identify preoperative risk factors and create a risk classification for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy in a multi-institutional cohort. METHODS: We retrospectively analyzed 283 patients who had undergone laparoscopic radical nephroureterectomy for nonmetastatic upper tract urothelial cancer between March 2002 and March 2020. The cumulative incidence of intravesical recurrence for 224 patients without previous or concomitant bladder cancer was examined using multivariate Fine-Gray competing risks proportional hazards models. A risk stratification model was created to predict subsequent patient outcomes based on the results. RESULTS: The median follow-up duration was 33.3 months, and 71 (31.7%) patients experienced intravesical recurrence. The estimated cumulative incidence of intravesical recurrence at one and 5 years was 23.5% and 36.4%, respectively. In multivariate analysis, the presence of ureter tumors and multiple tumors were shown to be independently significant predictive factors for intravesical recurrence. Based on the results, we classified patients into three risk groups. The cumulative incidence rates of intravesical recurrence within 5 years after surgery were 24.4%, 42.5%, and 66.7% in the low-, intermediate-, and high-risk groups, respectively. CONCLUSIONS: We identified risk factors and created a risk classification model for intravesical recurrence of upper urinary tract urothelial carcinoma only after laparoscopic radical nephroureterectomy. Based on this model, an individualized surveillance protocol or adjuvant therapy could be provided.

The useful technique of laparoscopic segmental ureterectomy with ureteral reimplantation for distal upper tract urothelial carcinoma.

INTRODUCTION: Segmental ureterectomy (SU) has been proven effective in cases of distal upper tract urothelial carcinoma (UTUC). Nonetheless, SU has been performed infrequently in the real world, and there is no consensus on the preferred surgical technique in laparoscopic surgery. We describe our first experience of laparoscopic segmental ureterectomy (LSU) with psoas hitch ureteral reimplantation. MATERIALS AND SURGICAL TECHNIQUE: LSU starts using a fan-shaped, five-port, transperitoneal approach. First, the cancerous ureter segment is clipped to avoid tumor seeding, and then the diseased segment is dissected. Second, the psoas hitch is performed by fixing the external part of the ipsilateral dome of the bladder to the psoas muscle and its tendon. Third, at the top of the bladder, an incision is made in the muscle layer and mucosa. The ureter is then spatulated. A guide wire is used to place a retrograde ureteral double J stent. Finally, the anastomosis of the bladder and ureter mucosa is performed by interrupted suturing of both ends, followed by continuous suturing, and the muscular layer of the bladder is closed in a double layer. We performed LSU for distal UTUC in 10 patients. There was no decrease in renal function before or after surgery. During follow-up, three patients experienced a recurrence of urothelial carcinoma in the bladder and one patient had a local recurrence. DISCUSSION: LSU is a safe and feasible procedure in our experience, and it can be recommended for selected cases of distal UTUC with optimal perioperative, renal functional, and oncologic outcomes.

Atypical Oncologic Failure After Laparoscopic Radical Nephroureterectomy in a Japanese Multicenter Study.

Objectives: To investigate the recurrence patterns and the atypical oncologic failure (AOF) defined as the presence of atypical recurrences, such as retroperitoneal carcinomatosis or port-site recurrence, after laparoscopic radical nephroureterectomy (LRNU). Methods: LRNU performed at three institutions were included in this retrospective study. The primary endpoints were the first recurrence site and recurrence-free survival. The recurrence sites were classified as atypical recurrences, such as retroperitoneal carcinomatosis or port-site recurrence, as well as distant, local, and intravesical. The Kaplan-Meier curves were obtained to elucidate the time until recurrence and survival. Results: A total of 283 patients were included in the final analysis. Postoperative pathology was T3 or higher in 112 (40%) patients. The median follow-up period was 31 months, and the 3-year recurrence-free, cancer-specific, and overall survival rates were 69.6%, 78.1%, and 72.0%, respectively. The first recurrence sites involved distant, local, atypical, and intravesical recurrences in 51 (18%), 36 (13%), 14 (5%), and 94 (33%) patients, respectively. Of the 14 patients with AOF, 12 had pathologically locally advanced tumors, but seven patients had a preoperative diagnosis of clinical stage T2 or less. Conclusion: A small number of AOF cases were found after LRNU for patients with upper tract urothelial carcinoma. Careful patient selection is critical for AOF prevention.

The efficacy of ultrasonography for the detection of upper tract urothelial carcinoma.

PURPOSE: Ultrasonography and computed tomography urography are two commonly used modalities to image the upper tracts for the evaluation of hematuria. This study evaluated the efficacy of ultrasonography for the detection of upper tract urothelial carcinoma compared to computed tomography urography as a standard reference. METHODS: This retrospective study included patients with urothelial carcinoma of the renal pelvis and/or ureter who were diagnosed using computed tomography urography and underwent surgical treatment. We calculated the sensitivity of ultrasonography in upper tract urothelial carcinoma diagnosis, further classified the degree of hydronephrosis on ultrasonography, and analyzed the relationship between the sensitivity and the degree of hydronephrosis and tumor location. Additionally, the usefulness of the combination of the screening ultrasonography findings, the presence of gross hematuria, and/or urine cytology was analyzed. RESULTS: This study included 136 patients with upper urothelial carcinoma. Ultrasonography in the diagnosis had 45.6% sensitivity, and ultrasonography findings, including the detection of hydronephrosis, were present in 72.8%. The presence of hydronephrosis and tumor location were associated with detection by ultrasonography. The tumor was identified in a total of 134 (98.5%) patients by combining tumor detection and hydronephrosis using ultrasonography with gross hematuria and positive urine cytology as screening. CONCLUSION: Ultrasonography showed acceptable sensitivity for upper tract urothelial carcinoma diagnosis. Considering the hydronephrosis findings, ultrasonography is a useful screening tool for upper tract urothelial carcinoma. Additionally, excessive computed tomography examinations can be reduced by adding gross hematuria and positive urine cytology.

Clinical outcomes following laparoscopic radical nephroureterectomy in octogenarians.

BACKGROUND: This study aimed to compare the incidence of postoperative complications occurring within 30 days of surgery between octogenarians and younger patients and identify preoperative risk factors for the incidence of postoperative complications. Moreover, we also compared the oncological outcomes between octogenarians and younger patients. METHODS: This retrospective study included 283 patients who underwent laparoscopic radical nephroureterectomy for upper tract urothelial carcinoma from 2002 to 2020. The patients were divided into octogenarians and younger patients (age: < 80 years), and their clinical characteristics, perioperative parameters, and postoperative complications were evaluated. The predictors of postoperative complications were evaluated using logistic regression models. Recurrence-free survival, cancer-specific survival, and overall survival were measured using the Kaplan-Meier method. RESULTS: Twelve (17.1%) octogenarians and 40 (18.7%) younger patients had postoperative complications. No significant difference in the incidence of postoperative complications was observed between octogenarians and younger patients (p = 0.14). A high body mass index was a significant risk factor for complications (p = 0.03). The 5-year recurrence-free survival, cancer-specific survival, and overall survival rates for octogenarians and younger patients were 72% and 64% (p = 0.31), 76% and 63% (p = 0.63), and 43% and 63% (p = 0.06), respectively. CONCLUSION: Laparoscopic radical nephroureterectomy can be performed in octogenarians with complication rates similar to those in younger patients. Similarly, the outcomes of laparoscopic radical nephroureterectomy for oncological control do not differ significantly between octogenarians and younger patients. This procedure is safe and effective for selected octogenarians.

Safety and efficacy of ureteroscopy for urolithiasis in octogenarians.

OBJECTIVE: To examine the safety and efficacy of ureteroscopy (URS) for urolithiasis in octogenarians, and identify preoperative risk factors for the incidence of postoperative complications. METHODS: The patients who underwent URS for urolithiasis were divided into octogenarians and younger patients (age: <80 years), and the groups were compared regarding their clinical characteristics, intraoperative and postoperative complications, and stone-free rate. The predictors of postoperative complications were evaluated using logistic regression models. RESULTS: A total of 1207 patients were included, 166 in the octogenarian patient group and 1041 in the younger patient group. The proportion of female patients (p < 0.001), American Society of Anesthesiologists (ASA) score (p < 0.001), rate of preoperative pyelonephritis (p < 0.001), and diabetes mellitus (p = 0.003) were higher in the octogenarian group. No statistically significant differences were found between the two groups regarding stone size, location, and intraoperative complications. Postoperative complications, which reached a significant difference, were observed in 34 (20.5%) octogenarians and 117 (11.2%) younger patients (p = 0.002). However, age itself was not significantly associated with postoperative fever, the most frequent postoperative complication, in multivariate analysis. Female sex, ASA score of ≥3, history of diabetes mellitus, and prolonged operative time (≥120 min) were the significant predictors of fever. The stone-free rate in the octogenarian group was superior to that in the younger patient group (80.1% vs. 70.6%, respectively; p = 0.035). CONCLUSION: Our results suggest that URS for urolithiasis can be safely and effectively applied to octogenarians in selected cases.

Extremely slow, half-number shockwave lithotripsy for ureteral stones.

To elucidate and compare the efficacy and safety of the reduced (30 shocks/min with 1200 shocks/session) and standard protocols (60 shocks/min with 2400 shocks/session) of extracorporeal shockwave lithotripsy (SWL) for ureteral stones treatment. This study was a retrospective review of 2410 SWL procedures with reduced or standard protocols (groups R and S) in 1106 patients for ureteral stones between March 2014 and March 2021. The primary outcome was treatment success, defined as the absence of residual fragments on ultrasonography and plain radiography within 30 and 90 days. A multivariate logistic regression and propensity score matching analysis evaluated the association between the reduced protocol and treatment success. This study included 311 and 544 patients in the reduced (R) and standard (S) protocol groups, respectively. The patient's characteristics were comparable, excluding the lithotripter machine. No significant difference was observed between groups R and S in treatment success rates within 30 (63.3 vs. 65.8%, p = 0.50) and 90 days (88.7 vs. 91.5%, p = 0.18). The multivariate analysis indicated no significant association between reduced protocol and treatment success within 30 and 90 days (p = 0.44 and p = 0.68, respectively). Propensity score matching showed no significant difference in the treatment success rates within 30 and 90 days. The Extremely slow, half number protocol outcomes are comparable to those of the standard protocol for treating ureteral stones.

[Tumor Lysis Syndrome in a Patient with Germ Cell Tumor : A Case Report].

A 36-year-old man presented to our hospital with right scrotal swelling. A computed tomographic scan revealed a mass in the right scrotum, multiple masses in the lung and liver, and enlarged cervical, mediastinal, and retroperitoneal lymph nodes. After right high orchiectomy, he was diagnosed with nonseminomatous germ cell tumor (pT3N3M1b), with poor risk prediction according to the International Germ Cell Consensus classification. We started chemotherapy with bleomycin, etoposide, and cisplatin. Since serum alphafetoprotein (AFP) and human chorionic gonadotropin (HCG) levels did not decrease to normal levels, second-line chemotherapy with paclitaxel, ifosfamide, and cisplatin was administered. Six days after the start of treatment, the patient became unconscious, and his blood pressure decreased. Seven days later, blood tests revealed high uric acid levels, hyperphosphatemia, and increased creatinine. This was diagnosed as tumor lysis syndrome. Following diagnosis, continuous hemodiafiltration was started, and his condition gradually improved.

Oncological Outcomes of Retroperitoneal Lymph Node Dissection During Retroperitoneal Laparoscopic Radical Nephroureterectomy for Renal Pelvic or Upper Ureteral Tumors: Matched-Pair Analysis.

Objectives: The aim of this study was to investigate the oncological outcomes and recurrence patterns in clinically node-negative patients with renal pelvic and/or upper or middle ureteral tumors after template-based retroperitoneal lymph node dissection (RPLND) in conjunction with retroperitoneal laparoscopic radical nephroureterectomy (LRNU). Materials and Methods: A total of 283 patients who received LRNU with and without RPLND at three Japanese institutions were enrolled. The template for RPLND included the renal hilar and para-aortic lymph nodes (LNs) (left side) and renal hilar, paracaval, retrocaval, and intra-aortocaval LNs (right side). The LNs and kidneys were removed en bloc. The primary endpoint was set as recurrence-free survival. All RPLND cases were matched one-to-one with no-RPLND cases using a propensity score matching approach, and 47 matched pairs were included in analyses. Results: Compared with the control group, significant differences were not observed in the RPLND group in terms of operation time, blood loss, postoperative complication rate, and pathological findings. The estimated 5-year recurrence-free survival was significantly higher in the RPLND group (86.8%) compared with the group without RPLND (64.2%) (p = 0.014). The estimated 5-year cancer-specific survival showed a similar tendency; however, it did not reach a statistically significant difference (87.5% vs 71.3%, respectively; p = 0.168). As for the first recurrence site, the RPLND group showed a lower incidence of distant recurrence, while no significant difference was observed in the rate of regional LN recurrence. Conclusions: This study suggests that template-based RPLND in conjunction with retroperitoneal LRNU efficiently improves recurrence-free survival by reducing distant recurrences.

A case of infectious thoracic aortic aneurysm after intravesical Bacillus Calmette-Guérin instillation therapy for a superficial bladder cancer.

Intravesical Bacillus Calmette-Guérin instillation therapy after transurethral resection of bladder tumor is considered as the most effective treatment for prophylaxis against the recurrence of high-risk, non-muscle bladder cancer. However, intravesical Bacillus Calmette-Guérin instillation therapy has some characteristic complications. Here, we report a case of infectious thoracic aortic aneurysm related to prior intravesical Bacillus Calmette-Guérin instillation, which consequently allows the spread into the adjacent lung tissue and secretion in sputum of Mycobacterium bovis.

Solitary synchronous gastric metastasis of renal cell carcinoma.

INTRODUCTION: There have been some reports describing metastasis to the stomach from renal cell carcinomas. However, there are few reports describing solitary synchronous gastric metastasis of renal cell carcinomas. CASE PRESENTATION: The patient was a 70-year-old woman who underwent an upper gastrointestinal endoscopy to examine her progressive weight loss. There was a submucosal tumor in the stomach, which was biopsied. The gastric tumor was pathologically proven to be a metastatic clear cell renal cell carcinoma. Furthermore, contrast-enhanced computed tomography showed right renal cell carcinoma invading the renal vein (cT3aN0M0). The patient underwent right radical nephrectomy and endoscopic resection for the treatment of the primary renal cancer and the gastric metastatic lesion, respectively. The resected specimen of the stomach had a clear resection margin. CONCLUSION: Endoscopic resection for early stage gastric metastatic lesions of renal cell carcinomas is a reasonable approach because it is a minimally invasive surgical technique.