Intravesical mitomycin C (MMC) and MMC + cytosine arabinoside for non-muscle-invasive bladder cancer: a randomised clinical trial.

OBJECTIVES: To compare the urinary pH, recurrence-free survival (RFS), and safety of adjuvant intravesical therapy in patients with non-muscle-invasive bladder cancer (NMIBC) receiving mitomycin C (MMC) therapy and MMC + cytosine arabinoside (Ara-C) therapy. PATIENTS AND METHODS: A total of 165 patients with NMIBC from six hospitals were randomly allocated to two groups: weekly instillation of MMC + Ara-C (30 mg/30 mL + 200 mg/10 mL) for 6 weeks and the same instillation schedule of MMC (30 mg/40 mL). The primary outcome was RFS, and secondary outcomes were urinary pH and toxicity in the two groups. RESULTS: A total of 81 and 87 patients were randomised into the MMC and MMC + Ara-C groups, respectively. Overall, the RFS in the MMC + Ara-C group was significantly longer (P = 0.018) than that in the MMC group. A similar significant difference was detected in patients with intermediate-risk NMIBC, but not in those with high-risk NMIBC. The mean (SD) urinary pH was significantly higher in the MMC + Ara-C group than in the MMC group, at 6.56 (0.61) vs 5.78 (0.64) (P < 0.001), and the frequency of a urinary pH of >7.0 in the MMC and MMC + Ara-C groups was 6.3% and 26.7%, respectively (P < 0.001). Multivariate analysis models including clinicopathological features and second transurethral resection demonstrated that increased urinary pH was associated with better outcomes (hazard ratio 0.18, 95% confidential interval 0.18-0.038; P < 0.001). In all, there were 14 and 10 adverse events in the MMC and MMC + Ara-C groups, respectively, without a significant difference (P = 0.113). CONCLUSIONS: Our randomised clinical trial suggested that intravesical therapy with MMC and Ara-C is useful and safe for patients with intermediate-risk NMIBC. Increase in urinary pH with Ara-C is speculated as a mechanism for increased anti-cancer effects.

Preliminary Study of a Single Instillation of Low-Concentration High-Volume Silver Nitrate Solution for Chyluria: Is >10 mL Instillation an Absolute Contraindication in the Real World?

Silver nitrate instillation (SNI) is one form of treatment for chyluria. However, there is the opinion that a high volume of SNI (>10 mL) should be avoided because life-threatening complications have been reported. However, we have noticed that most severe complications occur in high-concentration treatments (≥1%), even with a small volume. In addition, a small volume (≤10 mL) of low-concentration (<1%) SNI occasionally causes recurrence. Based on these facts, we aimed to evaluate a preliminary study of a novel single-injection regimen of low-concentration high-volume SNI. In this preliminary study, nine patients who underwent SNI were retrospectively examined. Patient characteristics, anesthesia, procedure, efficacy, complications, and duration of hospital stay were investigated. The volume of silver nitrate solution was decided based on symptoms, findings of pyelography, and vital signs, and it was given as a single instillation. This study was approved by the Institutional Review Board. The ranges of silver nitrate concentration and volume were 0.1%-0.5% and 15-30 mL, respectively. In all patients, proteinuria and cloudy urine disappeared immediately. However, two patients had recurrence after the initial SNI. These two patients were subsequently treated with increasing concentrations of silver nitrate (0.2% and 0.5%) from 0.1%, and they had complete symptomatic relief without recurrence for more than 6 years. None of the patients experienced severe complications. In conclusion, our preliminary study showed that a single instillation of low-concentration (0.1%-0.5%) and high-volume (15-30 mL) SNI is safe and useful. It is worth considering as a treatment option for chyluria.

[Indwelling of Full-Length Metallic Ureteral Stents as an Initial Treatment for Patients with Untreated Malignant Ureteral Obstruction].

To examine the efficacy and safety of a full-length metallic ureteral stent (MS), Resonance®, we retrospectively evaluated 16 cases (22 ureteral units) with indwelling MS as the initial treatment for patients with untreated malignant ureteral obstruction (MUO). All patients had undergone MS insertion by the retrograde approach without cystoscopy, with indirect stent placement under fluoroscopy, as a new method that can be performed even if the number of medical staff is one less than that required. Both serum creatinine and estimated glomerular filtration rate values in all cases improved significantly (p<0. 001). Moreover, MS failure occurred in only one patient and the stent patency rate was 93.8%. Stent-related complications were observed in four patients. Two patients experienced stent dislodgement, and one each had fever and acute pyelonephritis, although none of the complications were life-threatening. After the introduction of MS in our hospital, the rate of percutaneous nephrostomy in MUO patients excluding those not suited for indwelling MS, clearly decreased from 80% to 20%. This is the first report on the clinical evaluation of indwelling MS as the initial treatment of MUO in Japan, and this report indicates that MS is a very useful choice in terms of effectiveness, safety, medical cost, and reduction in the workload of medical staff. We believe that the indwelling MS will become a standard initial treatment for patients with untreated MUO in the future.

[Case of persistent false elevation of prostate-specific antigen after radical prostatectomy].

We report a rare case of persistent false elevation of prostate-specific antigen (PSA) after radical prostatectomy (RP). Preoperative total PSA was 25.4 ng/ml and final pathology was Gleason score 3+5=8, pT3aN0M0. His first postoperative total PSA was 3.85 ng/ml. He received adjuvant hormone therapy for 10 months. Since PSA gradually elevated despite adjuvant hormone therapy, he underwent imaging for metastasis, confirming no evidence of prostate cancer recurrence. Moreover, total PSA was unmeasurable level in three other PSA assays.

[A case of retroperitoneal schwannoma extracted by a nerve sparing procedure under microscopic surgery].

We report a case in which we extracted retroperitoneal schwannoma by a nerve sparing procedure under microscopic surgery. A 63-year-old male was diagnosed with left ureter stone and left hydronephrosis. A left retroperitoneal tumor was found by the abdominal ultrasound sonography. Abdominal computed tomography and magnetic resonance imaging revealed the mass 20 mm in diameter in the retroperitoneal cavity. We considered that the tumor arose from the left femoral nerve, and removed it under microscopic surgery. There was no malignancy. There was neither recurrence nor neuropathy after operation. Since it is rare to find the origin nerve of schwannoma before operation, we report our experience.