Clinical Factors to Predict Difficult Ureter during Ureteroscopic Lithotripsy.

Objective: To identify risk factors for difficult ureters during ureteroscopic lithotripsy and to determine the appropriate indications for preoperative stenting. Methods: We retrospectively analyzed 156 ureteroscopic procedures for upper urinary tract stones after excluding those with preoperative stenting or percutaneous nephrostomy. Traceability of the ureter was assessed by two urologists. Traceability was defined as positive if either or both urologists discerned the ureter in all slices on preoperative plain computed tomography. Patients' backgrounds were compared between the nondifficult ureter and difficult ureter groups. A multivariate logistic regression model was used to evaluate the relationships between difficult ureters and other clinical factors. Results: Of 156 patients, 31 (19.9%) were classified into the difficult ureter group. The positive traceability was higher in the nondifficult ureter group (48.3% vs. 83.2%, P < 0.001). The major axis was smaller in the difficult ureter group than in the nondifficult ureter group (8.8 ± 3.9 mm vs. 10.9 ± 4.5 mm, P < 0.018). A major axis <8 mm (odds ratio: 4.495, 95% confidence interval: 1.791-11.278, and P=0.001), negative traceability (odds ratio: 7.565, 95% confidence interval: 2.693-21.248, and P < 0.001), smoking status (odds ratio: 3.196, 95% confidence interval: 1.164-8.773, and P=0.024), and absence of diabetes mellitus (odds ratio: 5.813, 95% confidence interval: 1.121-30.142, and P=0.036) were identified as independent predictors of difficult ureters on multivariate logistic regression analysis. Conclusion: Patients with smaller stones, negative traceability, ongoing tobacco consumption, and absence of diabetes mellitus were at higher risk of difficult ureters. In these patients, preoperative stenting may be considered.

[A CASE OF RENAL CELL CARCINOMA WITH SMALL INTESTINE METASTASIS DURING NIVOLUMAB PLUS IPILIMUMAB].

A 71-year-old man with a history of hoarseness and right upper extremity numbness was referred to our department for evaluation of an intrathoracic mass that was detected on chest radiography and a right kidney tumor observed on computed tomography (CT). Histopathological examination of percutaneous kidney biopsy and bronchoscopic lung biopsy specimens revealed renal clear cell carcinoma with multiple lung metastases. The patient showed a poor risk based on the International Metastatic renal cell carcinoma Database Consortium score, and nivolumab plus ipilimumab were initiated as first-line therapy. His symptoms gradually improved, following four courses of nivolumab plus ipilimumab treatment, and CT revealed shrinkage of all lesions. However, he developed diarrhea, rash, anemia, and elevated serum C-reactive protein levels (CRP) following this therapy. Diarrhea and rash were considered immune-related adverse events, and he was treated with oral prednisolone and topical corticosteroid. Nivolumab administration was discontinued because anemia worsened together with elevated serum CRP levels despite improvement in diarrhea. He subsequently developed constipation and abdominal bloating, following further treatment for 4 months. CT revealed intestinal tumor-induced intussusception, necessitating partial resection of the small intestinal tumor, which was histopathologically diagnosed as metastases. Both anemia and elevated CRP improved postoperatively. Currently, all metastatic lesions other than the resected intestine have continued to respond to treatment over 12 months after initiation of nivolumab plus ipilimumab therapy.

Complete response of hereditary leiomyomatosis and renal cell cancer (HLRCC)-associated renal cell carcinoma to nivolumab and ipilimumab combination immunotherapy by: a case report.

Hereditary leiomyomatosis and renal cell cancer (HLRCC) is a rare autosomal dominant disorder that results from a germline mutation in the fumarate hydratase gene (FH). Individuals with FH mutations are at risk of developing renal cell carcinoma (RCC). Patients with HLRCC-associated RCC (HLRCC-RCC) have aggressive clinical courses, but there is as yet no standardized therapy for advanced HLRCC-RCC. We report an aggressive RCC case in a 49-year-old man. Nine weeks after undergoing a total nephroureterectomy of the right kidney, he had a metastasectomy at port site. Within 14 weeks of the initial surgery, multiple recurrent tumors developed in the right retroperitoneal space. The pathological diagnosis was FH-deficient RCC. Genetic testing identified a heterozygous germline mutation of FH (c.641_642delTA), which confirmed the diagnosis of HLRCC-RCC. He received combination therapy with the immune checkpoint inhibitors (ICIs) nivolumab and ipilimumab as the first-line therapy. After 31 weeks of ICI treatment, a complete response was achieved. The disease-free condition has been prolonged for 24 months since the initial surgical treatment. This is the first case report of successful treatment of HLRCC-RCC with nivolumab plus ipilimumab. This combination immunotherapy is expected to be an effective approach to treat patients with advanced-stage HLRCC-RCC.

[A CASE OF TUMOR-TO-TUMOR METASTASIS OF BREAST CANCER WITHIN RENAL CELL CARCINOMA].

A 76-year-old woman presented with a left chest ulcer. Computed tomography (CT) showed a 9-cm-sized invasive mass with ulceration in the left breast, along with regional lymph node and distant metastases, and a 4-cm-sized tumor at the upper pole of the left kidney. Needle biopsy of the left breast tumor was performed, and she was diagnosed with breast cancer, cT4cN3M1, Stage IV. She underwent endocrine therapy and chemotherapy. After undergoing treatment for 2 years, CT showed no progression in the primary and metastatic lesions except for increasing renal mass. Primary kidney cancer was suspected, and she underwent laparoscopic nephrectomy. In the surgical specimen, a solid, brown-colored nodule was observed in the upper pole of the left kidney. The pathological diagnosis was clear cell renal cell carcinoma, including a metastatic lesion of breast cancer. She was diagnosed with tumor-to-tumor metastasis of breast cancer within renal cell carcinoma. Two years after the surgery, no recurrence of renal cell carcinoma has been observed, and she is undergoing secondary endocrine therapy against breast cancer.

Expression of androgen receptor in non-muscle-invasive bladder cancer predicts the preventive effect of androgen deprivation therapy on tumor recurrence.

Our recent retrospective study revealed a significantly reduced risk of bladder cancer (BC) recurrence in men who received androgen deprivation therapy (ADT) for their prostate cancer. However, whether androgen receptor (AR) signals contributed to the preventive effect of ADT remained unclear because ADT could reduce serum estrogens as well. The purpose of this study is to investigate the associations between the expression of AR/estrogen receptors (ERs) and BC recurrence in patients treated with ADT. We immunohistochemically stained 72 BCs and 42 corresponding normal urothelial tissues. AR/ERα/ERß were positive in 44(61%)/22(31%)/39(54%) tumors and 35(83%)/24(57%)/34(81%) corresponding normal urothelial tissues, respectively. There were no statistically significant correlations between AR/ERα/ERß expression and clinicopathological features of BC. With a median follow-up of 31.3 months, 12 (43%) of 28 patients with AR-negative tumor versus 11 (23%) of 44 patients with AR-positive tumor experienced BC recurrence. Thus, patients with AR-positive tumor had a significantly lower risk of BC recurrence (P=0.031), compared with those with AR-negative tumor. Meanwhile, the expression of ERα/ERß in tumors and that of AR/ERα/ERß in normal urothelial tissues were not significantly correlated with BC recurrence. A multivariate analysis revealed AR positivity in tumors as an independent prognosticator (hazard ratio: 0.27; 95% confidence interval: 0.11-0.67) for BC recurrence. These results indicate that ADT prevents BC recurrence via the AR pathway, but not via the ERα/ERß pathways.

[PATHOLOGICAL COMPLETE RESPONSE WITH EVEROLIMUS FOR MULTIPLE LUNG METASTASES OF RENAL CELL CARCINOMA RESISTANT TO SUNITINIB].

A 55-year-old man was referred to our hospital because of a tumor in his right kidney. A Fluorodeoxyglucose-positron emission tomography (PET)/computed tomography (CT) scan revealed strong abnormal uptake by the tumor in the right kidney and a nodule in the right lung. The patient was diagnosed with stage IV renal cell cancer, for which he underwent transperitoneal nephrectomy. Pathological diagnosis revealed the tumor to be a renal cell carcinoma (clear cell carcinoma, G2, pT3a, v (+), INF-ß). Sunitinib was administered because of the occurrence of multiple lung metastases; however, the therapeutic effect was insufficient, and progressive disease was observed on a CT scan. Therefore, everolimus was immediately administered as a second-line therapeutic agent. After treatment, the lung metastases reduced in size, as observed on a CT scan, and partial response continued for 1 year after therapy. One metastatic lesion persisted in the right lung; therefore, he underwent right upper lobe resection after discontinuing everolimus administration. No viable tumor cells were observed on pathological diagnosis, and the patient achieved pathological complete response. 3 month after discontinuing everolimus administration, no metastatic lesions have been observed.

[Successful combination chemotherapy of gemcitabine plus nedaplatin for invasive ureteral squamous cell carcinoma].

A 77-year-old female was indicated pelvic mass and hydronephrosis when her examination of advanced gastric cancer. Computed tomography revealed left ureteral dilatation and mass around the left ureter. Laparotomy biopsy was abandoned because of her low cardiac function. Thereafter, hemorrhagic stool was observed and colonoscopy revealed hemorrhagic mucosal protrusion at sigmoid colon. This lesion was diagnosed as squamous cell carcinoma by pathology of biopsy specimen. Colonic invasion of other organ carcinoma was suspected by colonoscopic findings. Retrograde pyelogram revealed a defect of left lower ureter. Positron emission tomography revealed the mass excluding sigmoid colon and high value (SUV max was 10.3) at the mass. Therefore, it was diagnosed invasive ureteral squamous cell carcinoma and she was treated with 2 cycles of combination chemotherapy consisting of gemcitabine (800 mg/m2: day 1 and 8) and nedaplatin (60 mg/m2: day 1). During the chemotherapy, only cytopenia (grade 4: CTCAE guidelines) was observed. About 4 months after 2 courses of chemotherapy, the tumor size was reduced by almost 100% (CR; RECIST guidelines). Thereafter, recurrence of pelvic mass was not observed.

[Recipient of living kidney transplantation during which heparin-induced thrombocytopenia (HIT) was suspected: a case report].

A 67-year-old woman with a diabetic renal failure was scheduled for a living kidney transplantation. Heparin was first used during hemodialysis 5 days before operation. Thrombocytopenia was found immediately after induction of general anesthesia, and the diagnosis of HIT was wade based on clinical symptom and 4 T's scoring. The surgery was continued because of the progress of donor surgery. Argatoroban was administered based on APTT measurement as an anticoagulation therapy during and after the operation. Although deep vein thrombosis was found 13 days after the operation, the transplanted kidney was established successfully. It is necessary to take a great caution in HIT development after heparin use.

[Retrospective analysis of predicting biochemical recurrence after initial radical prostatectomy].

We evaluated clinical outcomes of radical prostatectomy in 244 patients who had undergone radical prostatectomy as initial treatment from January 2000 to December 2011, and were followed up for more than 6 months. Biochemical recurrence after prostatectomy was defined as prostate-specific antigen (PSA) level of at least 0. 2 ng/ml. We evaluated potential risk factors for significant associations with biochemical recurrence. Median follow-up period after prostatectomy was 49 months (range, 6-144). Of the total, 192, 31, and 20 patients were at pathological stage pT2, pT3a, and pT3b, respectively. In 83 patients with the positive surgical margin, apexes were mostly in the positive area. Of the 68 patients with PSA recurrence, PSA non-relapse rate was 66.6% for 5 years. Multivariate analysis was performed for seminal vesicle invasion, PSA nadir, surgical margins, and Gleason score. Thirty-two patients with PSA recurrence underwent salvage radiotherapy, and the biochemical recurrence rate at 5 years was 73.8%. The group in which the PSA level before salvage radiotherapy was ＜0.5 ng/ml had a low rate of biochemical recurrence. We must consider the recurrence of poorly differentiated or non-confined cancer after radical prostatectomy. These results suggest that early use of salvage radiotherapy is effective for patients with biochemical recurrence after radical prostatectomy.

[A case of pneumomediastinum during BEP (bleomycin, etoposide, cisplatin) chemotherapy for testicular cancer].

We report a case of drug-induced pneumomediastinum by bleomycin in testicular cancer, which is extremely rare ; to our knowledge, only 3 cases have been reported. A 28-year-old man presented with a left testicular mass. He underwent radical left inguinal orchiectomy that demonstrated a seminoma, pT3N0M0. Ten months after surgery, para-aortic lymph node metastasis appeared, and he received three cycles of bleomycin, etoposide and cisplatin (BEP) chemotherapy. On day 13 of the fourth course of BEP, he complained of snowball crepitation of the neck and computed tomography revealed subcutaneous emphysema, extensive mediastinal air, and intraspinal air accumulation without pneumothorax. The pneumomediastinum and subcutaneous emphysema tended to deteriorate until 15 days after the onset of pneumomediastinum, but fortunately he had no signs or symptoms of infection. These findings resolved spontaneously after 1 month.

[A case of retroperitoneal angiosarcoma effectively treated with recombinant interleukin-2].

Angiosarcoma is rare and highly malignant vascular neoplasm, and primary retroperitoneal angiosarcoma is extremely rare. Preoperative diagnosis is very difficult because there are no specific imaging features, and definitively effective treatment has not yet been established. We recently treated a patient with primary retroperitoneal angiosarcoma in which a prompt and exact diagnosis was difficult to obtain. One month after surgery, local recurrence appeared, but salvage immunotherapy using recombinant interleukin-2 (rIL-2) showed good efficacy, and the patient obtained complete response. Here we report this rare case of angiosarcoma. A 60-year-old woman with abdominal pain was diagnosed with a left retroperitoneal mass on CT scan. The tumor was about 9 cm in diameter and positioned above the left kidney. Further study using MRI, 131I-MIBG scintigraphy, and enhanced CT suggested chronic expanding hematoma and the patient underwent surgical resection. Histopathological diagnosis was primary retroperitoneal angiosarcoma based on positive staining for VIII factor, CD31, CD34, and p53. One month after surgery, FDG-PET revealed local recurrence adjacent to the psoas major. We initiated salvage immunotherapy using rIL-2. The patient was treated effectively and achieved complete response. She is alive and well 19 months after surgery and rIL-2 treatment.

[Clinical study of penis-conserving treatment for carcinoma of penis].

We retrospectively reviewed 9 patients with squamous cell carcinoma of the penis who were treated with penis preservation between April 1988 and January 2008. Six patients had recurrence and 4 patients died of cancer. Patients treated with penis preservation had a significantly higher. Future studies are needed on a larger number of cases.

[Two cases of pellagra associated with chemotherapy of docetaxel, estramustine, dexamethasone].

An 81-year-old male with hormone refractory prostate cancer, received chemotherapy of Docetaxel, Estramustine and dexamethasone as an outpatient. After 4 courses of chemotherapy, he was admitted to our hospital in December 2007 because of general fatigue, appetite loss and erythema of the back of hands and face. He was diagnosed with pellagra. Nicotinic acid was administered and the symptoms disappeared. An 80-year-old male with hormone refractory prostate cancer, received chemotherapy of Docetaxel, Estramustine and dexamethasone without admission. After 8 courses of the chemotherapy, appetite loss appeared. In January 2008, medical examinations revealed nails peeling off, facial erythema and erosion of the back of his hands. He was diagnosed with pellagra. Nicotinic acid was administered and the symptoms disappeared. Pellagra, a nicotinic acid deficiency disease, is rarely observed clinically nowadays. However, it may occur in the patients, undergoing chemotherapy without admission.

Ultrasound-guided peripheral nerve blocks for anterior cruciate ligament reconstruction: effect of obturator nerve block during and after surgery.

PURPOSE: Three studies were conducted to determine whether and how the obturator nerve bears relevance to intra- and postoperative pain in patients undergoing anterior cruciate ligament (ACL) reconstruction using a hamstring autograft. METHODS: Patients undergoing arthroscopic ACL reconstruction using a hamstring autograft were enrolled in three studies. In the first study, we studied the analgesic effect of combined posterior lumbar plexus (PLP) and sciatic nerve blocks as well as combined femoral, lateral femoral cutaneous, and sciatic nerve blocks during and for 24 h after surgery. The second study was conducted to compare the analgesic effect of the combination of femoral, lateral femoral cutaneous, and sciatic nerve blocks with and without an obturator nerve block. Finally, we compared a postoperative continuous femoral nerve block and PLP block both during and for 48 h after surgery. RESULTS: In the first study, patients receiving the PLP block required significantly less fentanyl intraoperatively than those given the femoral nerve block. In the second, significantly less fentanyl was required during surgery for patients with the obturator nerve block than for those without. Finally, the continuous postoperative PLP block showed higher visual analog pain scores than those with the continuous femoral nerve block during movement at 48 h. CONCLUSION: The present results suggest the involvement of the obturator nerve in ACL reconstruction using a hamstring autograft. However, although obturator nerve blockade is crucial for intraoperative analgesia, a continuous obturator nerve block is not necessary beyond 24 h postoperatively.

Ultrasound-guided anterior approach to sciatic nerve block: a comparison with the posterior approach.

BACKGROUND: Although the anterior approach to the sciatic nerve block has rarely been performed due to lack of reliable surface anatomical landmarks and technical difficulty, ultrasound guidance may make performance of this approach easier. In this study, we evaluated the clinical use of the ultrasound-guided anterior approach to sciatic nerve block and compared this approach with the posterior approach in adults. METHODS: One hundred patients undergoing minor knee surgery were randomly divided into two groups to receive anterior and posterior (subgluteal) approaches to sciatic nerve block, using 1.5% mepivacaine 20 mL with epinephrine combined with femoral and lateral femoral cutaneous nerve blocks. Both approaches to sciatic nerve block were performed using a low-frequency, 5 to 2 MHz, curved array transducer. Measurements included block execution time, depth and size of the nerve, needle depth, onset time of sensory and motor blockade, and duration of the block. RESULTS: The sciatic nerve was located significantly deeper and the needle depth was significantly greater in patients undergoing the anterior approach compared with the subgluteal approach. Both approaches were similar for execution time of sciatic nerve block, but the former took less time than the latter to perform all combinations of blocks. Although sensory block in the posterior femoral cutaneous nerve was achieved less often with the anterior approach compared with subgluteal approach (14.9% and 68.1%, respectively; P < 0.001), there were no differences in success rate, onset time or duration of blockade of the peroneal and tibial nerves between the two groups. CONCLUSION: The anterior approach to sciatic nerve block is performed as easily and successfully as the posterior approach using ultrasound guidance.

[Ultrasound-guided sciatic nerve block].

Theoretically, sciatic nerve block can be used alone or in combination with lumbar plexus block or femoral nerve block for anesthesia and/or analgesia of lower limb surgery. However, clinical use of sciatic nerve block was limited by technical difficulties in performing the block since techniques used relies only on surface anatomical landmarks. Recent advances in ultrasound technology allow direct visualization of nerves and other surrounding structures and have increased the interest in performing many kinds of peripheral nerve blocks including sciatic nerve block. Preliminary data suggest that ultrasound-guided technique can help perform the sciatic nerve block more reliably and safely. In this article we describe the anatomy of the sciatic nerve, sonographic features, and technique of three major approaches including subgluteal, anterior, and popliteal approaches. The use of this technique for postoperative analgesia is also discussed.

[A case of ductal carcinoma of the prostate after transurethral resection of prostate].

A 66-year-old man visited our hospital complaining of a high prostate-specific antigen (PSA) (6.9 ng/ml) and dysuria. Prostatic needle biopsies revealed no malignancy in January 1998 and February 1999 (PSA 8.0 ng/ml). Transurethral resection of prostate (TURP) was performed in March 1999. Although none of the TURP specimen showed any malignancy, the PSA level remained high (3.7 ng/ml 1 year after the TURP), and gradually increased. About 3 years later, re-biopsy was done (PSA 13.2 ng/ml) and pathological finding was moderately differentiated adenocarcinoma (Gleason score 3 + 3 = 6). After 9-month MAB, radical prostatectomy (RP) was performed in January 2003 (PSA 4.2 ng/ml). Though the RP specimen showed moderately differentiated adenocarcinoma with negative capsule penetration and negative surgical margins, PSA decreased to 2.5 ng/ml and gradually increased. Computed tomography (CT), magnetic resonance imaging (MRI), and bone scintigraphy showed neither distant metastasis nor local recurrence. Review of the RP specimen revealed ductal carcinoma with positive capsular penetration and suspicion of positive surgical margins. Although the patient was treated with maximum androgen blockade, diethylstilbestrol diphosphate, and tegafururacil, PSA gradually increased and was kept at a high level (5-6 ng/ml). In December 2005, the patient complained of anal pain and MRI showed a 4.8 x 2.3 cm tumor in the prostatic bed. Needle biopsy of the tumor revealed ductal carcinoma (PSA 6.39 ng/ml). In January 2006 (PSA 11.9 ng/ml), we initiated a treatment with 66 Gy of intensity modulated radiation therapy. In November 2006, PSA decreased to 0.279 ng/ml, and the tumor reduced (3.8 x 1.0 cm) on MRI.