Report of case series: Correlation between pathological and radiological evaluation and clinical course of three cases of metastatic renal cell carcinoma with cytoreductive nephrectomy after combined immuno-oncology therapy.

Introduction: The pathologic evaluation and clinical course of cytoreductive nephrectomy after combined immuno-oncology therapy were reviewed to understand the benefits of cytoreductive nephrectomy. Case presentation: Three patients with clear cell carcinoma underwent tumor biopsy before combined immuno-oncology therapy. Case 1 was found to have a sarcomatoid component upon nephrectomy and continued with combined immuno-oncology therapy. Case 2 discontinued combined immuno-oncology therapy due to adverse events but maintained tumor shrinkage. The patient was found to have viable cells in most nephrectomy specimens but has had no recurrence after combined immuno-oncology therapy was discontinued. In case 3, the residual tumor was deemed resectable with combined immuno-oncology therapy, and nephrectomy and metastasectomy were performed. No viable cells were observed in either specimen, and the patient has had no recurrence. Conclusion: Cytoreductive nephrectomy after combined immuno-oncology therapy may be useful to allow pathologic evaluation of treatment and provide an indicator for subsequent treatment.

Impact of lymph node dissection on surgical and oncological outcomes in patients undergoing robot-assisted radical cystectomy for bladder cancer: a multicenter retrospective study.

This study was performed to clarify the therapeutic and diagnostic roles of lymph node dissection (LND) by examining the impact of LND and lymph node yield (LNY) on oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC). Between 2014 and 2021, 216 patients underwent LND during RARC at Tokushima University Hospital and affiliated hospitals. Among the 216 patients, we compared 115 patients with an LNY of ≥ 20 and 101 with an LNY of < 20 to investigate the impact of LNY on surgical and oncological outcomes. Furthermore, we investigated the impact of LNY and the extent of LND on oncological outcomes by dividing the extent of LND into two groups (standard and extended). The 3-year rates of overall survival (OS) (p = 0.256), cancer-specific survival (CSS) (p = 0.791), and recurrence-free survival (RFS) (p = 0.953) did not differ between the two groups divided by the LNY. A higher LNY was associated with a significantly higher lymph node positivity rate (p = 0.020). The incidence of LND-related major complications was not significantly different between the two groups (p = 0.910). The 3-year survival rates did not differ between the two groups divided by the extent of LND: OS (p = 0.366), CSS (p = 0.814), and RFS (p = 0.689). The LNY and extent of LND were not associated with oncological outcomes in patients undergoing LND during RARC, whereas a higher LNY was associated with lymph node positivity. In the era of adjuvant therapy with immune checkpoint inhibitors, LND during RARC has an important diagnostic role in the detection of pathological node positivity.

A case of an advanced renal collecting duct carcinoma in which initial therapeutic effect was achieved with pembrolizumab plus axitinib.

Introduction: Renal collecting duct carcinoma is often found in advanced cancers and has a poor prognosis. Here, we present the case of symptomatic metastatic collecting duct carcinoma in which we observed an initial therapeutic effect of immune checkpoint inhibitors plus tyrosine kinase inhibitors. Case presentation: The patient was a 69-year-old male who was referred to our hospital for examination of a right chest tumor and related pain. Contrast-enhanced computed tomography and tumor biopsy were performed, leading to a diagnosis of collecting duct carcinoma. A combination of pembrolizumab plus axitinib was initiated as first-line therapy; right chest pain decreased, and tumor shrinkage was observed. Seven months after treatment initiation, tumor progression was noted. Cabozantinib was initiated as second-line therapy; however, was discontinued due to patient fatigue. The patient died 15 months after the initiation of treatment. Conclusion: For symptomatic metastatic collecting duct carcinoma, pembrolizumab plus axitinib may have initial therapeutic effects.

An obscure case of chronic unilateral hematuria bleeding point.

Chronic unilateral hematuria due to hemangioma of the renal papilla is endoscopically treatable. Hemangiomas of the renal papilla are usually located at the tip of the renal papilla. However in this case, the hemangioma was not located at the tip of the renal papilla, forcing the patient to exercise until just before surgery and to keep the renal pelvic pressure low to identify the hemangioma.

[NONRISING BLADDER PARAGANGLIOMA SUCCESSFULLY TREATED BY THE OPEN BLADDER SURGERY: A CASE REPORT].

The patient is a 47-year-old female. MRI revealed a well-defined submuscular mass in the bladder muscle layer. Bladder paraganglioma was suspected based on MRI findings. Endocrinologic Testing showed no significant elevation. 123I-MIBG scintigraphy of the mass showed a significant uptake, and we made diagnosis of bladder paraganglioma. The mass was nonrising and showed no color differentiation making its location undetectable. Using MRI with a ureteral stent and urethral catheter in place, we were able to determine its location. The possibility of damage to the ureteral or internal urethral opening was feared. We chose open bladder surgery, emphasizing ease of operation and visualization. Although a transient increase in blood pressure was observed during the operation, the mass was resected as a single mass from all layers of the bladder without damaging the ureteral or internal urethral opening. Histopathological examination revealed a paraganglioma.MRI (ureteral stent and urethral catheter placement) and open bladder surgery were useful for identifying the location and resecting this case of this otherwise undetectable bladder paraganglioma.

[LAPAROSCOPIC LIVE DONOR NEPHRECTOMY WITH HORSESHOE KIDNEY: A CASE REPORT].

We performed laparoscopic live donor nephrectomy (LDN) on approximately 200 patients in Ehime Prefectural Center Hospital between 2003 and 2016. In 2016, a fifty-something woman who was a donor candidate for her husband was revealed to have a horseshoe kidney through contrast-enhanced computed tomography; other LDN procedures used a retroperitoneal approach, but this one used a transperitoneal approach since the latter approach allowed for a more favorable visual field. The left kidney was selected since renal scintigraphy showed equal bilateral renal function and renal arteries are simpler on the left side. The kidney was removed after the isthmus was successfully transected without ischemia. The opened calyx in the left kidney was sutured via bench surgery, and the kidney was transplanted to the recipient. Postoperative courses of both donor and recipient were good.

A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy.

BACKGROUND: Robot-assisted radical cystectomy (RARC) and intracorporeal urinary diversion are less invasive than conventional procedures. However, for older patients, cutaneous ureterostomy (CUS) may be preferred because urinary diversion using the intestine has a high incidence of perioperative complications and is highly invasive. The purpose of this study was to demonstrate the safety and efficacy of intracorporeal ileal conduit (ICIC) compared with CUS in patients aged 75 years or older who underwent RARC. METHODS: From October 2014 to December 2021, 82 patients aged 75 years or older who underwent RARC at Tokushima University Hospital, Tokushima Prefectural Central Hospital, or Ehime Prefectural Central Hospital were retrospectively reviewed. Of these, 52 and 25 patients who underwent ICIC and CUS, respectively, were included. After adjusting the patients' characteristics using propensity score-matching, surgical results and prognoses were retrospectively compared. The propensity score was based on age, Eastern Cooperative Oncology Group Performance Status Scale (ECOG-PS), American Society of Anesthesiologists physical status classification (ASA-PS), clinical tumor stage, and neoadjuvant chemotherapy. RESULTS: The median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30-90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group. CONCLUSION: In older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

Validation of the diagnostic utility of D-dimer measurement in patients with acute aortic syndrome.

OBJECTIVE: The objective of this study was to evaluate the validity of D-dimer measurements for the diagnosis of acute aortic syndrome in patients admitted to hospital with acute chest pain. METHODS: A retrospective observational study design was used. Consecutive patients ( n=887) admitted to a tertiary hospital with acute chest pain (acute aortic syndrome, 123; acute pulmonary embolism, 29; and other disease, 735) from the emergency department between January 2011 and April 2014 were assessed to validate the diagnostic value of D-dimer measurements. RESULTS: The D-dimer level was significantly increased in patients with acute aortic syndrome (median (interquartile range) 4.9 (2.0-17.4) µg/ml) compared with control patients (median (interquartile range) 0.6 (0.3-1.4) µg/ml; p<0.001). At a cut-off point of 0.5 µg/ml, the sensitivity for acute aortic syndrome was 0.97 (95% confidence interval 0.92-0.99) and was similar to that for acute pulmonary embolism (0.97 (0.82-0.99)). The age-adjusted D-dimer cut-off point, defined as age × 0.01 µg/ml in patients ⩾50 years, successfully reduced the number of false-positive diagnoses by 13%, while still retaining a high sensitivity (0.96 (0.91-0.99)). The five false-negative diagnoses of acute aortic syndrome included three patients with intramural haematoma, one patient with a penetrating aortic ulcer and one patient with an impending aortic rupture. A combination of probability assessment and the D-dimer approach reduced the number of false-negatives from five patients to two patients. CONCLUSIONS: This study demonstrated that the D-dimer test can distinguish acute aortic syndrome from other diseases presenting with acute chest pain with high sensitivity and modest specificity. Using the D-dimer approach presents limitations with some subtypes of acute aortic syndrome, such as intramural haematoma.