C-reactive Protein-albumin-lymphocyte Index as a Novel Biomarker for Progression in Patients Undergoing Surgery for Renal Cancer.

Background/Aim: Some patients with renal cell carcinoma (RCC) develop early or late recurrence after surgery. However, there is no clear consensus on which patients with postoperative RCC should be treated. This study aimed to establish a biomarker for selecting patients who are at a higher risk of relapse following renal cancer surgery. Patients and Methods: A total of 378 patients who underwent nephrectomy or partial nephrectomy for a diagnosis of RCC at our hospital were included, with a focus on pT3 cases at high risk of recurrence. Factors associated with postoperative progression, including pathological and hematological parameters, were examined. Results: Sarcomatoid features, Fuhrman grade 4, and C-reactive protein-albumin-lymphocyte (CALLY) index were statistically significant predictive factors for progression-free survival after surgery (p<0.0011, p=0.0047, and p<0.0001, respectively). In the multivariate Cox proportional regression analysis, the CALLY index was the most statistically significant predictor of the risk of postoperative recurrence (p=0.0002). Conclusion: In addition to the existing risk factors for RCC recurrence, such as sarcomatoid features and Fuhrman grade, we propose that the CALLY index is a predictor of postoperative recurrence and that patients with a low CALLY index are good candidates for postoperative treatment. Our study may help select patients with pT3 disease with a high risk of recurrence who require postoperative treatment.

HSF1/HSP25 system protects mitochondria function from heat stress and assists steroidogenesis in MA-10 Leydig cells.

Heat shock response is characterized by the induction of heat shock proteins (HSPs) or molecular chaperones that maintain protein homeostasis. Heat shock transcription factor 1 (HSF1) plays a central role in heat shock response in mammalian cells. To investigate the impact of the heat shock response mechanism on steroidogenesis, we generated MA-10 mouse Leydig tumor cells deficient in HSF1 using CRISPR-Cas9 genome editing. Under heat stress conditions, the levels of StAR protein, but not its mRNA, decreased more in HSF1-knockout cells than in wild-type cells, confirming that HSF1 stabilizes StAR protein. Simultaneously, HSP110, HSP70, and HSP25 were markedly upregulated in a manner dependent on HSF1. Mitochondrial membrane potential (MMP) and ATP synthesis were decreased in HSF1-knockout cells under heat stress conditions, and mitochondrial fragmentation was enhanced. Furthermore, treatment with carbonyl cyanide 3-chlorophenylhydrazone (CCCP), a disruptor of MMP, reduced the levels of StAR protein to a greater extent in HSF1-knockout cells than in wild-type cells, which was associated with decreased MMP and ATP synthesis. Unexpectedly, HSP25 expression was markedly increased in wild-type cells following CCCP treatment. HSP25 knockdown reduces MMP under heat stress conditions and decreases StAR protein levels and progesterone synthesis. HSP25 overexpression in HSF1KO cells restored StAR protein levels. These results show that the HSF1/HSP25 pathway protects mitochondrial function and maintains StAR synthesis.

Accuracy Evaluation of an Estimation System for Dental Treatment Sites by Using Image Recognition.

In dentistry, misidentification of the treatment site may occur an adverse event with irreversible consequences. Among these, the left-right tooth error is the second most common site misidentification. In this study, we developed a treatment site estimation system using image recognition, and the accuracy rate of the left and right teeth was more than 85%. The results suggest that this system can be used to prevent the misidentification of the left and right teeth.

Prominin-1 deletion results in spermatogenic impairment, sperm morphological defects, and infertility in mice.

Purpose: Spermatogenesis is a complex process orchestrated by several essential genes. Prominin-1 (Prom1/PROM1) is a gene that is expressed in the testis but with a poorly understood role in spermatogenesis. Methods: We used Prom1 knockout (Prom1 KO) mice to assess the role of Prom1 in spermatogenesis. To this end, we performed immunohistochemistry, immunofluorescence, western blotting, ß-galactosidase staining, and apoptosis assay. Additionally, we analyzed the morphology of sperm and assessed litter sizes. Results: We observed that PROM1 is localized to the dividing spermatocytes in seminiferous epithelial cells, sperm, and columnar epithelium in the epididymis. In the Prom1 KO testis, an aberrant increase in apoptotic cells and a decrease in proliferating seminiferous epithelial cells were observed. Cellular FLICE-like inhibitory protein (c-FLIP) and extracellular signal-regulated kinase 1/2 (ERK1/2) expression were also significantly decreased in Prom1 KO testis. In addition, a significantly increased number of epididymal spermatozoa with abnormal morphology and less motility was found in Prom1 KO mice. Conclusions: PROM1 maintains spermatogenic cell proliferation and survival via c-FLIP expression in the testis. It is also involved in sperm motility and fertilization potential. The mechanism underlying the effect of Prom1 on sperm morphology and motility remains to be identified.

An efficient annotation method for image recognition of dental instruments.

To prevent needlestick injury and leftover instruments, and to perform efficient dental treatment, it is important to know the instruments required during dental treatment. Therefore, we will obtain a dataset for image recognition of dental treatment instruments, develop a system for detecting dental treatment instruments during treatment by image recognition, and evaluate the performance of the system to establish a method for detecting instruments during treatment. We created an image recognition dataset using 23 types of instruments commonly used in the Department of Restorative Dentistry and Endodontology at Osaka University Dental Hospital and a surgeon's hands as detection targets. Two types of datasets were created: one annotated with only the characteristic parts of the instruments, and the other annotated with the entire parts of instruments. YOLOv4 and YOLOv7 were used as the image recognition system. The performance of the system was evaluated in terms of two metrics: detection accuracy (DA), which indicates the probability of correctly detecting the number of target instruments in an image, and the average precision (AP). When using YOLOv4, the mean DA and AP were 89.3% and 70.9%, respectively, when the characteristic parts of the instruments were annotated and 85.3% and 59.9%, respectively, when the entire parts of the instruments were annotated. When using YOLOv7, the mean DA and AP were 89.7% and 80.8%, respectively, when the characteristic parts of the instruments were annotated and 84.4% and 63.5%, respectively, when the entire parts of the instruments were annotated. The detection of dental instruments can be performed efficiently by targeting the parts characterizing them.

Risks and benefits of transurethral resection of the bladder tumor using photodynamic diagnosis with oral 5-aminolevulinic acid hydrochloride according to age and history of recurrence in patients with non-muscle invasive bladder cancer.

BACKGROUND: Patient selection for transurethral resection of the bladder tumor using photodynamic diagnosis (PDD-TURBT) with oral 5-aminolevulinic acid (5-ALA) hydrochloride for non-muscle-invasive bladder cancer (NMIBC) is still unclear as to the best balance of risks (adverse events including hypotension) and benefits (reduction of intravesical recurrence). METHODS: This single-center retrospective study between April 2013 and March 2022, compared the intravesical recurrence-free survival between patients who underwent PDD-TURBT and WL-TURBT using propensity score matching. RESULTS: A total of 222 patients who underwent PDD-TURBT and 177 patients who underwent WL-TURBT for NMIBC were included. Propensity score matching was used to compare intravesical recurrence-free survival in 119 NMIBC patients in the both treatment groups. The intravesical recurrence-free survival within 500 days was significantly higher in the PDD-TURBT group than in the WL-TURBT group (P = 0.039; hazard ratio [HR] 0.48 [0.23-0.98]). Subgroup analysis showed that PDD-TURBT contributed to the reduction of short-term intravesical recurrence in patients aged < 75 years (P = 0.02; HR 0.22 [0.06-0.79]) and primary disease (P = 0.038; HR 0.35 [0.13-0.94]). Hypotension with a systolic blood pressure of < 80 mmHg was observed in 79 patients (35.6%) during PDD-TURBT surgery. In particular, age ≥75 years and general anesthesia were independent prognostic factors for predicting intraoperative hypotension. CONCLUSIONS: PDD-TURBT reduced short-term intravesical recurrence in NMIBC, whereas a higher frequency of hypotension was found in patients aged ≥ 75 years. These results suggest that the risks and benefits of PDD-TURBT are well balanced in younger patients (< 75 years) and those with primary disease.

Heat stress upregulates aromatases expression through nuclear DAX-1 deficiency in R2C Leydig tumor cells.

An appropriate balance between testicular testosterone and estradiol is required for spermatogenesis. Excess estradiol is often identified in the semen and serum of infertile men; however, the mechanisms behind this observation remain unclear. This study indicates the relationship between heat stress and aromatase synthesis in Leydig cells. We used R2C rat Leydig tumor cells, which can synthesize both testosterone and estradiol. Aromatase transcription was regulated by the PⅡ promoter with or without heat stress. Heat stress at 40 °C increased aromatase expression and decreased testosterone to estradiol ratio and nuclear DAX-1 (dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1), which is a suppressor of steroidogenic factor 1 (SF-1). Leptomycin B and KPT-185, a nuclear export inhibitor, prevented nuclear DAX-1 deficiency induced by heat stress and inhibited aromatase transcription. These results indicate that heat stress interferes with DAX-1-SF-1 interaction and induces SF-1-dependent aromatase transcription.

Testicular Testosterone and Estradiol Concentrations and Aromatase Expression in Men with Nonobstructive Azoospermia.

CONTEXT: Spermatogenesis is strictly regulated by the intratesticular hormonal milieu, in which testosterone (T) and estradiol (E2) play pivotal roles. However, the optimal expression of aromatase and intratesticular T (ITT) and E2 (ITE2) levels are unknown. OBJECTIVE: To investigate ITT/ITE2 and aromatase expression in men with nonobstructive azoospermia (NOA) and to elucidate the roles of aromatase in spermatogenesis, as determined based on sperm retrieval by microdissection testicular sperm extraction (micro-TESE). DESIGN AND SETTING: A retrospective study at a reproductive center using serum, testicular specimens, and intratesticular fluid. PATIENTS: Seventy-six men with NOA, including 4 men who received 3 months of anastrozole administration prior to micro-TESE, and 18 men with obstructive azoospermia. INTERVENTIONS: Testicular aromatase expression was evaluated using immunohistochemistry and quantitative reverse transcription-polymerase chain reaction (RT-PCR). Intratesticular T and ITE2 levels were determined using liquid chromatography-tandem mass spectrometry. RESULTS: Aromatase was mainly located in Leydig cells, and the levels of its transcript and protein expression levels were increased in men with NOA. No correlation was observed between serum T/E2 and ITT/ITE2 levels, whereas significant associations were observed between decreased ITT and increased ITE2, aromatase expression, and sperm retrieval. Treatment with anastrozole increased the ITT/ITE2 ratio and decreased aromatase expression. CONCLUSIONS: A close association between the expression of aromatase in Leydig cells and ITT/ITE2 was shown. Leydig cell aromatase is a factor that is independently correlated with spermatogenesis, and aromatase inhibitors may open a therapeutic window by increasing ITT/ITE2 in selected patients.

Significance of Membranous Urethral Length for Recovery From Postoperative Urinary Incontinence Following Holmium Laser Enucleation of the Prostate.

PURPOSE: The aim of this study was to determine the significance of the membranous urethral length (MUL), including the thickness of the urethral sphincter, for recovery from postoperative stress urinary incontinence (SUI) following holmium laser enucleation of the prostate (HoLEP). METHODS: We analyzed 78 patients who underwent HoLEP between June 2013 and September 2018, all of whom preoperatively received magnetic resonance imaging. MUL was measured using sagittal T2-weighted fast spin-echo images. The clinical and anatomical factors associated with MUL were evaluated. The recovery time of urinary incontinence was compared between patients with a long MUL (≥14 mm) and a short MUL (<14 mm). SUI included both stress and mixed urinary incontinence. Continence was defined as complete dryness. RESULTS: The median MUL in patients without incontinence at 1 month postoperatively was significantly longer than the MUL in patients with incontinence (15.3 mm vs. 12.7 mm, P<0.001). The continence rates at 1 month after HoLEP in patients with longer MULs and shorter MULs were 80.4% and 30.0%, respectively. The recovery time of urinary incontinence in patients with longer MULs (≥14 mm) was significantly shorter than that in patients with shorter MULs (<14 mm) (log-rank test, P=0.001). After 6 months, the continence rates in patients with longer MULs and shorter MULs were similar (97%). MUL was significantly correlated with the recovery period of urinary incontinence (r=-0.459, P<0.001). CONCLUSION: MUL was useful for predicting early recovery from urinary incontinence following HoLEP. This study provides evidence that postoperative urinary incontinence following a transurethral procedure for benign prostatic hyperplasia was associated with anatomical factors. A long MUL was associated with better tolerance to urinary sphincter damage by the transurethral procedure.

Role of Heat Shock Factor 1 in Conserving Cholesterol Transportation in Leydig Cell Steroidogenesis via Steroidogenic Acute Regulatory Protein.

Testicular testosterone synthesis begins with cholesterol transport into mitochondria via steroidogenic acute regulatory (StAR) protein in Leydig cells. Acute heat stress is known to obstruct testicular steroidogenesis by transcriptional repression of StAR. In contrast, chronic heat stress such as cryptorchidism or varicocele generally does not affect testicular steroidogenesis, suggesting that Leydig cells adapt to heat stress and retain their steroid synthesis ability. However, the mechanisms of the stress response in steroid-producing cells are unclear. We examined the relationship between the heat stress response and heat shock factor 1 (HSF1), which protects cells from proteotoxic stress by inducing heat shock protein as a molecular chaperone. The influences of HSF1 deficiency on cholesterol transport by StAR and the expression of steroidogenic enzymes under chronic heat stress were studied in testes of HSF1-knockout (HSF1KO) mice with experimental cryptorchidism. StAR protein in wild-type-cryptorchid mice was transiently decreased after induction of cryptorchidism and then gradually returned to basal levels. In contrast, StAR protein in HSF1KO mice continued to decrease and failed to recover, resulting in impaired serum testosterone. StAR messenger RNA was not decreased with cryptorchidism, indicating that posttranslational modification of StAR, not its transcription, was obstructed in cryptorchidism. Other steroidogenic enzymes, including CYP11A1, 3ß-HSD, and CYP17A1, were not decreased. Lipid droplets were increased in the cytosol of HSF1KO-cryptorchid mice, suggesting dysfunctional cholesterol transportation. These findings provide insight into the role of HSF1 in Leydig cell steroidogenesis, suggesting that it maintains cholesterol transport by recovering StAR under chronic heat stress.

Predictive Factors for Sperm Recovery after Varicocelectomy in Men with Nonobstructive Azoospermia.

PURPOSE: The ability of testicular histopathology to predict the success of microsurgical varicocelectomy in patients with nonobstructive azoospermia was investigated. We used a next generation sequencer to compare the transcriptomes of varicocelectomy responsive and nonresponsive testes to identify the factors that predict sperm in the ejaculate. MATERIALS AND METHODS: A total of 83 men with nonobstructive azoospermia and left varicocele underwent microsurgical varicocelectomy with simultaneous testicular biopsy. Transcriptome results using the Illumina® platform were expressed as the number of fragments per kb. Immunohistochemistry for proliferating cell nuclear antigen was performed on tissue samples from men with maturation arrest. Sperm recovery was evaluated with respect to patient age, testicular volume, varicocele grade, follicle-stimulating hormone level and testicular histology. RESULTS: Mean age was 34 years and the mean follicle-stimulating hormone level was 12.3 IU/l. Sperm recovery was confirmed in 20 patients (24%) within 12 months after varicocelectomy, including 1 of 43 (2%) with Sertoli cell only, 10 of 27 (37%) with maturation arrest and 9 of 13 (69%) with hypospermatogenesis. Comparisons of 23,003 genes between the groups with and without sperm in the ejaculate of men with maturation arrest revealed a number of cell cycle related genes that were up-regulated and several antioxidant genes that were down-regulated in men with sperm recovery. Proliferating cell nuclear antigen expression was significantly higher in the 10 varicocelectomy responsive men than in the 17 nonresponsive men. CONCLUSIONS: Transcriptome analysis of patients with maturation arrest revealed a distinct difference in the transcription of cell cycle regulation genes between varicocelectomy responsive and nonresponsive patients. Cell cycle assessment can predict sperm recovery and could improve our understanding of varicocele pathophysiology.

Extracellular miR-224 as a prognostic marker for clear cell renal cell carcinoma.

Exosome-miRNAs (exo-miR) have recently been identified as modulators of cancer progression and distant metastasis. We previously found that intracellular miR-224 is up-regulated and significantly related to cancer invasion and metastasis in clear cell renal cell carcinoma (ccRCC). We therefore investigated the role of exosome miR-224 in ccRCC and explored the interaction between intra- and extracellular miR-224 in renal cell carcinoma. To validate the method for isolating exosomes from blood samples or cell culture media, we examined exosome morphology using transmission electron microscope (TEM). We investigated the relationship between exo-miR-224 expression and patient prognosis in 108 ccRCC patients. We isolated exosomes from a metastatic renal cancer cell line and tested their effects on a primary renal cancer cell line with several functional analyses. We found that the high expression level exo-miR-224 group has significantly shorter progression-free survival, cancer-specific survival, and overall survival compared with the low expression group. In multivariate analysis, a high level of exo-miR-224 was a significant risk factor related to all prognoses investigated. After adding exosomes from a metastatic RCC cell line to a primary RCC cell line, cell proliferation and invasion were increased while the percentage of apoptotic cells was significantly decreased. Intracellular levels of miR-224 were significantly up-regulated in the primary renal cancer cell line. Extracellular miR-224 in exosomes impacts on patient prognosis and is a potential prognostic biomarker for ccRCC patients.

Surgical comparison of subinguinal and high inguinal microsurgical varicocelectomy for adolescent varicocele.

OBJECTIVE: To compare the surgical outcomes of subinguinal and high inguinal approaches for microsurgical varicocelectomy. METHODS: A total of 81 patients with left varicocele were randomly assigned to undergo microsurgical left varicocelectomy by the subinguinal (n = 41) or high inguinal (n = 40) approach. These two techniques were compared with regard to the operative parameters, complications and testicular growth. Anatomical parameters, including the numbers and diameters of internal spermatic arteries, veins and lymphatic vessels, were recorded. RESULTS: The microsurgical step was significantly shorter for the high inguinal approach compared with the subinguinal approach (25.5 vs 33.3 min, respectively, P < 0.01). The numbers of preserved arteries and ligated veins were significantly greater and the artery size was significantly smaller for the subinguinal (1.6 arteries, 11.5 veins and 1.1 mm, respectively) compared with the high inguinal approach (1.2 arteries, 7.3 veins and 1.3 mm; P < 0.001, <0.0001 and <0.01, respectively). There was one patient with postoperative hydrocele, and three with persistent scrotal pain after treatment with the subinguinal approach. The postoperative catch-up growth rates at 24 months were 70% and 78% for the subinguinal and high inguinal approaches, respectively. CONCLUSIONS: The microsurgical subinguinal and high inguinal approaches seem to yield similar success rates in terms of testicular growth. However, the high inguinal approach is easier to carry out, as it requires fewer divisions of veins and is associated with a larger diameter of the spermatic artery.

Microsurgical Anatomy of the Spermatic Cord and Spermatic Fascia: Distribution of Lymphatics, and Sensory and Autonomic Nerves.

PURPOSE: An understanding of the microsurgical anatomy of the spermatic cord and spermatic fascia is important for surgeons during microsurgical varicocelectomy and denervation. We examined the distribution of the lymphatics, and the sensory and autonomic nerves of the spermatic cord. MATERIALS AND METHODS: We collected spermatic cords from 11 men undergoing orchiectomy for localized testicular tumors and we biopsied a third of the spermatic fascia from 36 men undergoing microsurgical varicocelectomy. Immunohistochemical staining of the pan-neuronal marker PGP 9.5 (protein gene product 9.5), the sensory nociceptor marker CPRP (calcitonin gene-related peptide), the sympathetic marker TH (tyrosine hydroxylase), the parasympathetic marker VIP (vasoactive intestinal polypeptide) and the lymphatic marker D2-40 was performed. We counted the number of nerves and lymphatics. RESULTS: PGP 9.5 staining revealed dense nerve distributions in the spermatic cord and fascia. Sensory and autonomic nerve fibers were basically co-localized in the same nerve. Of the nerves 50% were identified near the vas deferens and 20% were identified in the spermatic fascia. Sensory and sympathetic nerve fibers represented most of the nerves but a few parasympathetic nerve fibers were observed. Of the lymphatics 36 per patient were identified in the spermatic cord but only a few were identified in the spermatic fascia. CONCLUSIONS: Sensory and sympathetic nerves accounted for the majority of the nerves. Although the functional aspects of the nerves remain undetermined, information on the distribution of nerves and lymphatics is useful when dealing with nerves and preserving lymphatics during microsurgical varicocelectomy or denervation.

Assessment of quality of life during gonadotrophin treatment for male hypogonadotrophic hypogonadism.

OBJECTIVE: The management of male hypogonadotrophic hypogonadism (MHH) with gonadotrophins is effective in promoting genital development and spermatogenesis. We investigated the changes in SF-36 subscales, including physical, social and psychological QOL, during gonadotrophin or testosterone treatment and analysed the factors that are involved in the outcomes of health-related quality of life (HRQOL) in MHH patients. PATIENTS AND DESIGN: Thirty-seven MHH patients (mean age: 26.1 years old) who underwent gonadotrophin (n = 31) or testosterone treatment (n = 6), excluding infertility cases, were asked to respond to a SF-36 questionnaire before and every 6 months during the 2-year treatment period. The changes in SF-36 domains and the associations between improvements and patient factors were examined. RESULTS: The scores in all of the SF-36 domains were lower than in the normal Japanese population. In all eight domains, except for bodily pain and social functioning, the mean scores for physical function (PF), role-physical (RP), general health (GH), vitality (VT), role-emotional (RE) and mental health (MH) significantly increased over the course of treatment in patients with gonadotrophin. These changes were particularly noticeable in the psychological domains; GH, VT, RE and MH exhibited large increases 18 months after treatment. Testosterone treatment increased only PF and RP domains. In patients with sperm in their ejaculate, the improvements in GH, VT, RE and MH were significantly greater than those who did not exhibit sperm. CONCLUSION: Gonadotrophin treatment for MHH was associated with significant improvements in SF-36 domains. Gonadotrophin treatment could prevent negative physical and psychological sequelae in the management of MHH.

Comparison of the results and complications of retroperitoneal, microsurgical subinguinal, and high inguinal approaches in the treatment of varicoceles.

The simplicity of the surgical procedure, as well as the high rate of success and low rate of complications, is of particular importance for varicocelectomies. We compared operative parameters, complication rates, and sperm parameters after retroperitoneal, microsurgical subinguinal and high inguinal varicocelectomy approaches in infertile men with varicoceles. This study included 307 infertile men with left varicoceles who underwent varicocelectomy by the retroperitoneal (n = 43), microsurgical subinguinal (n = 107), or high inguinal (n = 157) approach. The operative time was shorter for the retroperitoneal approach (29 minutes) compared with the microsurgical approaches and was significantly shorter for the high inguinal approach (52 minutes) compared with the subinguinal approach (66 minutes). Pain, as assessed by a visual analogue scale, and the use of nonsteroidal anti-inflammatory drugs were greatest following the retroperitoneal approach and significantly preferable following the high inguinal compared with the subinguinal approach. Recurrence/hydrocele was observed in 9.3%/9.3%, 0.9%/0.9%, and 1.3%/0.6% of patients after use of the retroperitoneal, subinguinal, and high inguinal approaches, respectively. Significant postoperative improvements in sperm concentration and motility were observed after all approaches, but such improvements were observed sooner and showed higher sperm concentration and motility after the use of the microsurgical approaches. Both microsurgical subinguinal and high inguinal approaches yielded comparable success rates, but the operative time and pain control were superior with the high inguinal approach. Because of its favorable safety profile, the microsurgical high inguinal approach should be of value to both experienced microsurgeons and trainees.