A Case of Candidemia after Long-term Presence of Urethral Foreign Bodies.

A 52-year-old man presented to our hospital complaining of general malaise, cough, and fever. Total body computed tomography revealed scattered pneumonia and urethral foreign bodies that had been inserted during adolescence. Candida glabrata was detected in blood and urine cultures. Based on these findings, the patient was diagnosed with candidemia that developed due to Candida urinary tract infection, complicated by septic pulmonary embolism and severe diabetes mellitus. Candidemia likely persisted despite the initiation of intravenous antifungal therapy and control of blood sugar level. Therefore, surgical removal of the urethral foreign bodies was performed, which resulted in resolution of the patient's symptoms. Herein, we report a rare case of candidemia complicated by Candida urinary tract infection that developed due to the long-term presence of urethral foreign bodies. A multidisciplinary therapeutic approach, including surgical removal of the infected foreign bodies, is effective in such cases. This case indicates that long-term presence of foreign bodies and acquired immune dysfunction can be risk factors for candidemia. Therefore, detailed history should be obtained and systemic examination should be performed to identify the complicating risk factors on diagnosis of candidemia.

Repeated spontaneous migration of ureteral stent in hemiplegia patient during ureteral stone treatment.

A 48-year-old man with a history of cerebral infarction presented with gross hematuria. The patient's limping accompanies twisting trunk on his walking. The diagnosis was right upper ureteral stone. Prior to Extracorporeal shockwave lithotripsy (ESWL) ureteral stent was inserted. After the second ESWL ureteral stent was displaced upwardly without patient's unknown. Retrograde intrarenal surgery (RIRS) was performed for both removal of ureteral stent and fragmentation of residual stone. Spontaneously, post RIRS ureteral stent was migrated upwardly to the same position. Ureteral stent migration is uncommon. Twisting walk may cause the position of ureteral stent upwardly.

[A Case of Consciousness Disturbance Due to Hyperammonemia Associated with Urinary Tract Infections].

We describe the case of a patient with hyperammonemia owing to urinary tract infections. The patient, a 66-year-old-woman, was previously diagnosed with bilateral hydronephrosis. She was admitted to the emergency room with macrohematuria and bilateral lumbar pain, which persisted for 2 days. She was hospitalized with the diagnosis of pyelonephritis. Despite antibiotic treatment, she developed sudden disturbance in consciousness on the 2nd day of illness. To improve the hyperammonemia and metabolic acidosis, we initiated continuous hemodiafiltration (CHDF) and urinary drainage by bilateral nephrostomy, after which her consciousness improved, and she was discharged on day 19. For patients with urinary tract infections and who are unaware of disturbance in consciousness, it is important to consider that obstructive urinary tract infections can cause hyperammonemia.

Development and external validation of a nomogram to predict high-grade papillary bladder cancer before first-time transurethral resection of the bladder tumor.

BACKGROUND: The aim of this study was to identify the clinical predictors related to the risk of high-grade papillary bladder cancer before first-time transurethral resection of a bladder tumor (TUR-Bt), and to develop and validate a nomogram predicting the risk of high-grade papillary bladder cancer. METHODS: A retrospective clinical study of consecutive patients who underwent first-time TUR-Bt for papillary bladder cancer was performed. Medical records were reviewed uniformly, and the following data were collected: age, sex, episodes of urinary symptoms, tumor size, number of tumors, location of the largest tumor (lateral walls, base, posterior wall, dome, and anterior wall), tumor appearance (papillary or non-papillary, pedunculated or sessile), and urinary cytology. Data from 254 patients (Group A) were used for the development of a nomogram, while data from 170 patients (Group B) were used for its external validation. RESULTS: High-grade papillary bladder cancer was pathologically diagnosed in 51.6 and 74.6% of Group A and Group B patients, respectively. Based on univariable analyses in Group A, macrohematuria, tumor size, multiple tumors, appearance, and positive urinary cytology were selected as variables to incorporate into a nomogram. The AUC value was 0.81 for the internal validation (Group A), and 0.78 for the external validation (Group B). This novel nomogram can predict high-grade papillary bladder cancer accurately. CONCLUSIONS: The present nomogram can help clinicians calculate the probability in patients with bladder cancer before TUR-Bt and decide on earlier intervention and priorities for the treatment of patients diagnosed with bladder cancer.

Clinical outcomes of second transurethral resection in non-muscle invasive high-grade bladder cancer: a retrospective, multi-institutional, collaborative study.

BACKGROUND: A retrospective, multi-institutional collaborative study was conducted to evaluate the impact of second transurethral resection (TUR) on the clinical outcome of non-muscle invasive high-grade bladder cancer and to identify predictors of invasion to the lamina propria (pT1) or deeper and residual tumor at the second TUR. METHODS: The clinical and pathological features of 198 patients with non-muscle invasive high-grade bladder cancer treated in five medical institutions from April 1990 to March 2013 were reviewed retrospectively. All patients underwent a second TUR within a mean of 1.5 months after the first resection. Clinicopathological findings of the first and second TURs were compared. Cancer-specific survival and recurrence-free survival were evaluated. Univariate and multivariate analyses for predictors of residual cancer at the second TUR were performed using a logistic regression model. RESULTS: At the second TUR, no tumor was found in 111 (56 %) patients, and 87 (44 %) had residual cancer. At the first TUR, five pT1 patients (3 %) were upstaged to pT2, one pTa patient (1 %) was upstaged to pT1, and 12 G2 patients (6 %) had their tumor upgraded to G3. Patients the group with less than stage pT1 cancer at the second TUR had significantly better survival than those in the group with stage pT1 or deeper cancer. Tumor multiplicity at the first resection was an independent risk factor for pT1 or deeper tumor at the second TUR. CONCLUSION: A second TUR is a valuable diagnostic procedure for accurate staging of non-muscle invasive high-grade bladder cancer. Tumor multiplicity at the first TUR was a significant independent predictor of pT1 or deeper tumor at the second TUR.

Apparent diffusion coefficient value for estimating clinicohistological factors in bladder cancer including infiltration style and lymphatic invasion.

OBJECTIVE: To evaluate a role of apparent diffusion coefficient (ADC) values measured from diffusion-weighted imaging we investigated its association with clinicopathological tumor characteristics of bladder cancer. MATERIALS AND METHODS: Diffusion-weighted MRI at 1.5 Tesla using b-values of 0, 1000 s/mm(2) was taken before transurethral resection by 114 bladder urothelial tumor patients. ADC value was measured and its relationship with pathological factors including T stage, tumor grade, infiltration style (INF) and lymphatic invasion (ly) was analyzed. RESULTS: Median ADC value was significantly lower in Grade 3 than in Grade 1 (P < 0.001) or in Grade 2 (P = 0.002), in INFb than in INFa (P = 0.004), in INFc than in INFa (P < 0.001), in ly1 than in ly0 (P < 0.001) and lower in T2≦ than in T1≧ (P < 0.001), respectively. Receiver operating curve demonstrated the accuracy of detecting muscle invasive bladder cancer or ly+ by using area under curve (AUC), showing 0.758 and 0.748. CONCLUSION: ADC value is likely to serve as a useful biomarker showing clinicopathological characterictics of bladder cancer.

[Comparison of the Conventional Centrifuged and Filtrated Preparations in Urine Cytology].

The urine cytology test is one of the most important tools for the diagnosis of malignant urinary tract tumors. This test is also of great value for predicting malignancy. However, the sensitivity of this test is not high enough to screen for malignant cells. In our laboratory, we were able to attain a high sensitivity of urine cytology tests after changing the preparation method of urine samples. The differences in the cytodiagnosis between the two methods are discussed here. From January 2012 to June 2013, 2,031 urine samples were prepared using the conventional centrifuge method (C method) ; and from September 2013 to March 2015, 2,453 urine samples were prepared using the filtration method (F method) for the cytology test. When the samples included in category 4 or 5, were defined as cytological positive, the sensitivities of this test with samples prepared using the F method were significantly high compared with samples prepared using the C method (72% vs 28%, p＜0.001). The number of cells on the glass slides prepared by the F method was significantly higher than that of the samples prepared by the C method (p＜0.001). After introduction of the F method, the number of f alse negative cases was decreased in the urine cytology test because a larger number of cells was seen and easily detected as atypical or malignant epithelial cells. Therefore, this method has a higher sensitivity than the conventional C method as the sensitivity of urine cytology tests relies partially on the number of cells visualized in the prepared samples.

External validation and comparison of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology in two patient populations: a retrospective cohort study.

The aim of this study is to validate and compare the predictive accuracy of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology among representative patients with prostate cancer. We previously developed a nomogram, as did Chun et al. In this validation study, patients originated from two centers: Toho University Sakura Medical Center (n = 214) and Chibaken Saiseikai Narashino Hospital (n = 216). We assessed predictive accuracy using area under the curve values and constructed calibration plots to grasp the tendency for each institution. Both nomograms showed a high predictive accuracy in each institution, although the constructed calibration plots of the two nomograms underestimated the actual probability in Toho University Sakura Medical Center. Clinicians need to use calibration plots for each institution to correctly understand the tendency of each nomogram for their patients, even if each nomogram has a good predictive accuracy.

Bilateral Ureteral Obstruction and Acute Renal Failure in Spite of Prior Ureteral Catheterization in Radical Hysterectomy.

We present an extremely rare case of acute renal failure following radical hysterectomy although we inserted ureteral catheter bilaterally. A 76-year old female received bilateral ureteral catheterization prior to operation. Just after operation oliguria was admitted and serum creatinine level increased to 3.6 mg/dL. An abdominal computed tomography (CT) revealed bilateral hydronephrosis. From soon after exchange to double J catheter large amount of urine was collected and the level of creatinine normalized 2 days later. The shape of J catheter may be more effective than open-end catheter because it has multiple side hole and can ensure urinary drainage.

[An infected renal cyst communicating with the urinary tract: a case report].

A 36-year-old man presented with fever and right backache. Abdominal computed tomographic scan revealed a right renal cyst, with a maximum diameter of 12 cm, and surrounded by a hyperdense area of perirenal fat tissue. The cyst appeared to be infected. Accordingly, we performed a percutaneous puncture of this cyst, and drained the fluid. The brown and cloudy fluid gradually became clear, the fluid volume increased a few days after the drainage. A communication between the infected cyst and urinary tract was suspected ; retrograde pyelography confirmed the presence of fistulas. The urine was drained, ＞ 600 ml per day, for four weeks. Surgical resection of the cyst wall and closure of the fistulas were performed as an additional treatment. A year after the open surgical procedure, the renal cyst did not recur, and his renal function has been normal.

[Clinical impact of peripheral lymphocyte counts for metastatic urothelial carcinoma patients treated with chemotherapy].

Pre-chemotherapeutic factors to assess the prognosis of patients with advanced urothelial carcinoma have not yet been completely established. The immune response of the host to the tumor is lymphocyte dependent. However, the effect of lymphocytes on chemotherapy prognosis is unknown. In this study, we investigated the correlation between pre-chemotherapeutic lymphocyte counts and the clinical characteristics of urothelial carcinoma and determined the effectiveness of lymphocytes as a prognostic predictor for metastatic urothelial carcinoma treated with chemotherapy. Between April 2003 and March 2011, data from 34 patients with unresectable or metastatic urothelial carcinoma were retrospectively subjected to multivariate regression analysis to determine the patient characteristics with independent prognostic significance for survival. The median patient age was 71 ; 21 patients were male and 13 female. The number of primary tumors in the pelvis, ureter, and bladder were four, six, and 24, respectively. Seventeen patients underwent prior curative resections, and visceral metastases at chemotherapy were detected in 14 patients. The median lymphocyte count at chemotherapy was 1,292/ml. Cancer-specific survival was significantly lower in patients with lymphocyte counts ＜1,000/ml than in patients with lymphocyte counts ≥1,000/µl (p＝0. 001). During multivariate analysis, visceral metastasis and lymphocyte counts were independent factors for predicting poor prognosis. In addition, lymphocyte counts of ＜1, 000/ml or positive visceral metastases also affected survival. This information may be useful for identifying patients who are likely to benefit from chemotherapy.

Early effect of dutasteride added to alpha-1 blocker therapy for patients with lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVE: To investigate the hypothesis that 5-alpha-reductase inhibitors exert early ameliorative effects on voiding and storage symptoms in men with lower urinary tract symptom-associated benign prostatic hyperplasia. METHODS: This was a prospective study involving the participation of eight outpatient clinics in Chiba Prefecture, Japan. The patients received dutasteride (0.5 mg) once daily orally for 24 weeks as an add-on to their ongoing therapy with an alpha-1 blocker. The study patients recorded their urinary symptoms every day for 14 days after starting dutasteride. The International Prostate Symptom Score, prostate volume, uroflowmetry results, and residual urine volume were checked at 3 and 6 months after starting dutasteride. RESULTS: A total of eighty-eight patients participated in the present study; 74 were eligible for analysis of the early effects of dutasteride. The median age was 69.6 years (range 54-89), the median prostate volume was 50.3 mL (range 24.7-103.3) and the median International Prostate Symptom Score was 17.6 (range 8-35). The proportion of patients with International Prostate Symptom Score improvements (≥3 points, or ≥25%) or 3 points or more decreased International Prostate Symptom Score were defined effective, 37 (50.0%) and 47 (63.5%) experienced improvement at 1 month after administration, respectively. CONCLUSION: This is the first prospective clinical study to show the early beneficial effects of 5-alpha-reductase inhibitors for lower urinary tract symptom-associated benign prostatic hyperplasia. Patients with severe symptoms were found to be responsive to dutasteride. The influence of the placebo effect was not denied. Further study is necessary.

Clinical outcomes by relative docetaxel dose and dose intensity as chemotherapy for Japanese patients with castration-resistant prostate cancer: a retrospective multi-institutional collaborative study.

BACKGROUND: The aim of this study was to retrospectively investigate clinical outcomes by relative dose and dose intensity of docetaxel (DOC) as chemotherapy for Japanese patients with castration-resistant prostate cancer (CRPC). METHODS: A total of 145 CRPC patients who received more than 4 courses of DOC chemotherapy at 14 hospitals between 2005 and 2011 were enrolled. Patients were divided into two groups--those receiving a higher or lower dose (mg/m(2)) or dose intensity (mg/m(2)/week). Differences between the groups regarding treatment outcomes and adverse events (AEs) were determined. Additionally, prognostic factors predictive of cancer-specific survival (CSS) in these patients were identified by both univariate and multivariate analysis. RESULTS: The total patient group underwent a mean of 11.2 ± 7.4 DOC cycles, and the mean CSS after therapy was 15.6 ± 10.1 months. The higher-dose group had a better prostate-specific antigen (PSA) response than the lower-dose group. However, there was no significant difference between the groups in prognosis after DOC chemotherapy. Leukopenia and neutropenia were observed more frequently in the higher-dose group. Serum biomarkers (including PSA, lactate dehydrogenase and alkaline phosphatase), hemoglobin levels and presence of pain at initiation of chemotherapy, as well as the PSA nadir level on first-line hormone therapy, all were significant predictors of CSS. CONCLUSIONS: In the Japanese population, relatively low-dose DOC chemotherapy had no deleterious effect on the CSS of CRPC patients, and a lower incidence of AEs occurred, in spite of a diminished PSA response compared with those receiving a higher dose.

Clinical Impact of Solifenacin on Generic and Symptom-Specific Quality of Life for Females with Overactive Bladder: Using the Overactive Bladder Symptom Score and Rand Medical Outcomes Study 36-Item Health Survey.

OBJECTIVES: We evaluated the effectiveness of antimuscarinic treatment on disease-specific and generic quality of life (QoL) in females with clinically diagnosed overactive bladder (OAB) by prospectively analyzing improvements in the overactive bladder symptom score (OABSS) and the Rand Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). METHODS: We prospectively recruited newly diagnosed female patients with OAB. Pretreatment disease-specific symptoms were documented, and generic QoL questionnaires were administered. All subjects received solifenacin 5 mg/day for >8 weeks. Symptoms and general health-related QoL (HRQoL) were assessed using the OABSS and SF-36, respectively. Other objective variables, such as maximum urinary flow rate and postvoid residual urine volume, were also evaluated. RESULTS: Seventy-eight subjects met all inclusion criteria and no exclusion criteria. After 8 weeks, the mean OABSS decreased by approximately 50% compared with baseline (from 9.1 ± 2.8 to 4.5 ± 3.6). All individual scores in OABSS improved after administration of solifenacin. Before treatment, the scores of the study subjects in all SF-36 domains were significantly worse than the age- and gender-adjusted Japanese national norms (P < 0.01), except the vitality (VT) scale. Intra-group comparisons between age groups showed worse mental health (MH) scores in all age groups. In the OAB group, three mean SF-36 scales (physical function [PF], VT, and MH) significantly improved after treatment. CONCLUSION: Treatment of OAB with solifenacin is associated with significant improvement in generic HRQoL and disease-specific symptoms at 8 weeks after drug administration. Particularly for generic HRQoL as measured by the SF-36, solifenacin treatment effectively improves three SF-36 scores: PF, VT, and MH.

[Syphilitic orchitis: a case report].

Tertiary syphilis is recently a rare disease in Japan. In this paper, we report a rare case of syphilitic orchitis. The patient was in his early forties. The left scrotal contents were swelling and a low echoic nodule measuring about 30 mm in diameter was detected on ultrasonography. Serum alpha fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin were within the normal range, whereas Treponema pallidum hemagglutination assay and rapid plasma reagin were strongly positive. High orchiectomy was performed for suspicion of testicular tumor. Histological findings showed the non-specific inflammatory granuloma with lympho-plasmatic infiltration. It was diagnosed as granulomatous inflammation of left testis caused by syphilis.

[A case of carcinosarcoma of the urinary bladder].

A 66-year-old woman visited our hospital complaining of painful, irritative urinary symptoms and macroscopic hematuria. Cystoscopy revealed a non-papillary tumor covered with necrotic tissue on the right side of the posterior wall of the bladder. Transurethral resection was performed ; histologically, the tumor was found to be composed of carcinomatous and sarcomatous elements. The carcinomatous element consisted of urothelial and squamous cell carcinomas. The sarcomatous element was composed of osteosarcoma, chondrosarcoma and spindle cell sarcoma. Immunohistochemical examination showed that the carcinomatous component was positive for cytokeratin and the sarcomatous component was positive for S-100 protein. The patient underwent total cystectomy with ileal conduit under the diagnosis of carcinosarcoma. Pathological examination showed no residual tumor. She was followed up with no signs of recurrence or metastasis. Computed tomography (CT) at nine months following surgery showed no evidence of recurrence. However, thirteen months after the operation, she complained of lower abdominal pain, and CT demonstrated a bulky intrapelvic tumor and right hydronephrosis. Her condition worsened rapidly and she died one month later.

[A case of urachal carcinoma treated with S-1/CDDP combination chemotherapy].

No established treatment exists for urachal carcinoma,except curative resection,and its prognosis is poor. More than 80% of urachal carcinomas are adenocarcinomas. We report a case of advanced urachal carcinoma treated with S-1 and cisplatin combination (S-1/CDDP) chemotherapy. The patient,a 61-year-old woman,presented with macroscopic hematuria. A tumor was detected on the bladder dome and transurethral resection was performed. Histopathological findings indicated poorly differentiated adenocarcinoma. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were 3.5 ng/ml and 140 U/ml respectively. Magnetic resonance images indicated an extension of this tumor to the retroperioneal space. Metastasis to her right ischium was suspected from bone scintigraphy results. The tumor was diagnosed as stage IVB (Sheldon's category) urachal carcinoma. After one cycle of S-1/CDDP chemotherapy,the size of the tumor on the bladder dome decreased,after which total cystectomy was performed. The surgical margin of the cystectomy specimen was negative for malignant cells,although poorly differentiated adenocarcinoma was still observed in this specimen. The findings of this study indicate that this therapy might be beneficial for treating advanced urachal carcinomas. This is the second report of successful treatment of advanced urachal carcinoma with S-1/CDDP chemotherapy.

Clinical effect of naftopidil on the quality of life of patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a prospective study.

OBJECTIVES: To investigate the benefit of alpha1-adrenoceptor antagonist naftopidil on the quality of life (QOL) of patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (BPH/LUTS). METHODS: A total of 99 men with BPH/LUTS were prospectively recruited. The Short Form-8 (SF-8) was used for generic QOL assessment and each parameter was compared with the norm in these patients. Longitudinal changes were evaluated using the SF-8 and the International Prostatic Symptoms Score (I-PSS) at baseline, 4 and 8 weeks after naftopidil administration. The relationship between SF-8 and I-PSS was analyzed. RESULTS: Five of eight components in the SF-8 were significantly lower than the Japanese national norm at baseline. SF-8 score was improved by naftopidil at 4 and 8 weeks in general health (GH) and physical component summary (PCS) in the patients in their 70s. Mental health (MH) and mental component summary (MCS) were improved at 8 weeks in patients in their 60s. When analyzing the whole cohort, SF-8 GH, role emotional (RE) and MH had improved at 8 weeks, which was similar to the norm, and bodily pain (BP) results were better. Compared with the baseline, total I-PSS, storage/voiding symptoms and QOL index scores improved significantly under naftopidil. Each component of I-PSS (except for hesitancy) correlated with SF-8 sub-scales (except for BP) to some extent. CONCLUSIONS: BPH/LUTS impairs generic QOL, which is improved by naftopidil treatment. SF-8 can be a useful instrument to assess the efficacy of BPH/LUTS treatment because its simplicity to complete and analyze, and its meaningful relationship to I-PSS.

[Case of malignant lymphoma of the prostate complicated with prostate adenocarcinoma].

A 68-year-old man was referred to our hospital with complaints of palpation, hematemesis and melena. Esophagogastroduodenoscopy revealed a huge ulcer in the stomach, and based on biopsy findings, he was pathologically diagnosed as having diffuse large B-cell type malignant lymphoma. A computed tomographic scan demonstrated prostatic enlargement and swelling of the left external iliac lymph nodes. Since his serum PSA level was 13.0 ng/ml, prostatic needle biopsy was performed. Histological findings revealed diffuse large B-cell type malignant lymphoma and moderately differentiated adenocarcinoma of the prostate. The patient achieved complete response after eight cycles of combination chemotherapy with rituximab cyclophosphamide, adriamycin, vincristine and predonisolone. At the same time of chemotherapy, androgen deprivation therapy was initiated. The current his PSA level is 0.2 ng/ml or less.