Ureteroureterostomy With Near-Infrared Ray Catheter in a Kidney Transplant.

Transplant ureteral stenosis (US) is a complication of kidney transplantation (KT) that sometimes adversely affects kidney function. Endoscopic treatment may be selected as the initial treatment; however, the recurrence rate is high. Ureteral reconstruction is necessary as a secondary treatment, but it is often difficult to identify the transplanted ureter due to reoperation; therefore, transplanted ureter and renal arteriovenous injury are intraoperative complications that should be noted. The Near-Infrared Ray Catheter (NIRC™) fluorescent ureteral catheter (NIRFUC) fluoresces by illuminating near-infrared rays, facilitating the identification of intraoperative ureteral locations. Herein, we report the case of a 34-year-old woman who developed US following KT. She underwent balloon dilation for transplant US, but the stenosis recurred; therefore, she underwent transplant ureteral auto-ureteral anastomosis. Although it was difficult to identify and detach the transplanted ureter owing to adhesions, the use of NIRFUC facilitated the identification of the ureter in the surgical field and enabled safe end-side anastomosis between the transplanted ureter and the autologous ureter. In conclusion, although there is no consensus on the best method for complex transplantation-related US cases, NIRFUC may be used to safely identify and perform surgeries on the ureter.

Standalone effects of focus mode and social comparison functions on problematic smartphone use among adolescents.

Problematic smartphone use (PSU) has been reported, particularly among adolescents. Digital interventions may be offered for preventing and reducing PSU. This study evaluated the effects of two smartphone-based interventions among adolescents. Grounded in nudge theory, the focus function allowed users to hide smartphone applications (apps) for a selected length of time, while the feedback function provided a social comparison of the smartphone use of the user and other users. In total, 305 adolescents with Android smartphones were randomly allocated to the focus-function group, feedback-function group or control group. Participants used their smartphones as usual during the two-week baseline period, followed by the one-week period of intervention app instillation and four-week period of intervention use. The primary outcome was self-reported PSU after the intervention period. The secondary outcomes were self-reported smartphone use time during weekdays and app-recorded smartphone use time and frequency. The Group × Time interaction effects showed reduced self-reported PSU in the focus-function and feedback-function groups, Cohen's d = -0.32, 95% CI [-0.63, -0.008], Cohen's d = -0.36, 95% CI [-0.66, -0.06], respectively. The app-recorded smartphone use frequency was also reduced in the focus-function and feedback-function groups, Cohen's d = -0.16, 95% CI [-0.07, -0.25], Cohen's d = -0.32, 95% CI [-0.23, -0.41], respectively. The findings suggest that both utilizing time-outs from nonessential apps and engaging in social comparison lower PSU and smartphone use frequency with small effect sizes. These functions may be noncoercive interventions for preventing and reducing PSU.

Metastatic prostate cancer with low PSA levels diagnosed after holmium laser enucleation of the prostate.

Holmium laser enucleation of the prostate is a widely accepted surgical treatment method for benign prostate hyperplasia, but its effect on prostate cancer remains unclear. In this study, we report the cases of two patients with metastatic prostate cancer diagnosed during follow-up after holmium laser enucleation of the prostate. Case 1 was a 74 year-old man who underwent holmium laser enucleation of the prostate. Prostate-specific antigen levels declined from 4.3 to 1.5 ng/mL at 1 month after surgery, but after 19 months, they increased to 6.6 ng/mL. Based on pathological and radiological findings, he was diagnosed as having prostate cancer, with Gleason score 5 + 4 with neuroendocrine differentiation, cT3bN1M1a. Case 2 was a 70 year-old man who also underwent holmium laser enucleation of the prostate. Prostate-specific antigen levels declined from 7.2 to 2.9 ng/mL at 6 months after surgery, but after 12 months, they increased to 12 ng/mL. Based on pathological and radiological findings, he was diagnosed as having prostate cancer, with Gleason score 4 + 5 with intraductal carcinoma of the prostate, cT3bN1M1a. This report suggests that advanced prostate cancer may be newly diagnosed after holmium laser enucleation of the prostate. Even if prostate cancer had not been demonstrated in the enucleated specimen, and postoperative PSA levels were below the standard values, physicians should regularly monitor prostate-specific antigen levels after holmium laser enucleation of the prostate, and further examination should be considered keeping in mind prostate cancer progression.

[Re-Administration of Pembrolizumab for Urothelial Carcinoma after immune-Related Myasthenia Gravis : A Case Report].

Immune checkpoint inhibitors (ICIs) provide excellent benefits to the treatment of various cancer types, including urothelial carcinoma. Conversely, they can cause immune-related adverse events (irAEs), and some of them are severe or fatal. Furthermore, evidence on the safety and effectiveness of the readministration of ICIs after the occurrence of irAEs is limited. In this case report, a 78-year-old man who suffered from metastatic right renal pelvic cancer was treated with pembrolizumab. He had a partial response to pembrolizumab, but he developed grade 3 myasthenia gravis. The myasthenia gravis symptoms were immediately relieved by corticosteroids and intravenous immunoglobulin therapy. When the disease rapidly progressed, he was treated again with pembrolizumab. After 5 days, a chest radiograph showed shrinkage of pulmonary metastases. Unfortunately, he died of multiple brain infarctions 7 days after the readministration. We report this case with a literature review on the efficacy and safety of the readministration of ICIs after the occurrence irAEs including myasthenia gravis.

Prednisolone Treatment Is Effective for an Idiopathic Penile Abscess: A Case Report and Review.

BACKGROUND Penile abscesses were traditionally regarded as an infectious disease; however, idiopathic cases in which prednisolone was effective have been reported. CASE REPORT A 64-year-old man was admitted to the hospital with symptoms of penile induration and dysuria. He was diagnosed with a penile abscess, which was punctured and then relapsed. An incision and drainage were performed on the abscess, and the pus and tissue samples were cultured and examined histologically. There was no evidence of malignancy or bacterial infection, and he was diagnosed with an idiopathic penile abscess. As pus continuously drained from the incision, prednisolone 40 mg was initiated, which resulted in a decreased amount of pus and eventual wound closure. Over 15 months, prednisolone was gradually tapered to 5 mg, and the abscess continued to decrease in size. CONCLUSIONS Idiopathic penile abscesses are rare but often lead to penectomy. Prednisolone is a new treatment method for such patients. This is the third case of an idiopathic penile abscess that was successfully treated with prednisolone. The causative agent of the idiopathic penile abscess was suggested to be pyoderma gangrenosum; however, this case did not exhibit the typical characteristics of pyoderma gangrenosum. Therefore, further investigation was needed. A differential diagnosis of an infectious abscess is required before initiating steroid treatment. Open drainage is useful, but the size of the incision should be minimized for the purpose of preserving penile function. The prednisolone dose should be started at 20 to 40 mg and reduced gradually to avoid relapse.

Clinical utility of head computed tomography scan during systemic therapy for metastatic renal cell carcinoma.

OBJECTIVES: The utility of brain metastasis screening in asymptomatic metastatic renal cell carcinoma is controversial. Our study evaluated the utility of routine head computed tomography during systemic therapy. METHODS: We retrospectively investigated 152 metastatic renal cell carcinoma patients who did not initially have brain metastasis at Yamagata University Hospital from January 2008 to July 2019. Patients who routinely received head computed tomography scan together with routine contrast-enhanced chest/abdominal/pelvic computed tomography scan every 2-4 months during systemic therapy ("Routine head computed tomography" group, n = 95) and patients without routine head computed tomography ("No routine head computed tomography" group, n = 57) were compared. RESULTS: Brain metastasis occurred in 16 patients in the "Routine head computed tomography" group and six patients in the "No routine head computed tomography" group. There was no statistical difference in overall survival after metastatic renal cell carcinoma diagnosis between groups (53.4 vs 37.3 months, respectively, P = 0.357) and neurological symptom-free survival after metastatic renal cell carcinoma diagnosis (53.4 vs 36.6 months, P = 0.336). Although there was no statistical difference on incidence of unrecovered neurological symptom (25.0% vs 50.0%, P = 0.334), fewer patients in the "Routine head computed tomography" group required craniotomy (0% vs 66.7%, P = 0.002). In the "No routine head computed tomography" group, the neurological symptom resolved for all patients without craniotomy. CONCLUSIONS: Routine head computed tomography during systemic therapy for metastatic renal cell carcinoma is not significantly associated with improved brain metastasis prognosis. However, routine head computed tomography enables brain metastasis diagnosis in the asymptomatic phase, which can avoid craniotomy.

Successful pembrolizumab treatment in a patient with metastatic urothelial carcinoma and underlying overlap syndrome involving systemic sclerosis and systemic lupus erythematosus.

INTRODUCTION: The safety and efficacy of pembrolizumab administration in patients with urothelial carcinoma and underlying autoimmune disease (including overlap syndrome) is unknown. CASE PRESENTATION: We present the case of a 67-year-old woman with cT3N2M0 metastatic renal pelvic cancer who had been treated with prednisolone for overlap syndrome involving systemic sclerosis and systemic lupus erythematosus for 20 years. She had a remarkable response to pembrolizumab as a third-line systemic therapy, wherein the tumor reduced in size and all regional lymph node and pulmonary metastases disappeared. She did not develop any immune-related adverse events or autoimmune disease flare-ups during the treatment. CONCLUSION: This case report suggests that pembrolizumab could be beneficial to patients with urothelial carcinoma and underlying well-controlled overlap syndrome.

New prognostic model for synchronous metastatic renal cell carcinoma.

OBJECTIVES: To create a new model for the prediction of overall survival in synchronous metastatic renal cell carcinoma. METHODS: Medical records of 158 patients with metastatic renal cell carcinoma diagnosed at the Yamagata University Hospital from August 2007 to February 2018 were reviewed. Among them, 77 with synchronous metastatic renal cell carcinoma were retrospectively analyzed using the univariate and multivariate analyses. A new prognostic model was constructed, followed by a bootstrap validation to estimate the model fitting. In addition, these prognostic factors were estimated in 67 metachronous metastatic renal cell carcinoma patients. RESULTS: Five independent prognostic factors were identified in synchronous metastatic renal cell carcinoma: cT3/4, cN1, high corrected calcium, >3.6 neutrophil-to-lymphocyte ratio and central nerve system metastasis. The number (%) and overall survival (95% confidence interval) in the favorable- (0 or 1 risk factor), intermediate- (2 risk factors) and poor-risk (≥3 risk factors) groups were 29 (45.3%) and 67.4 (31.8-NA), 21 (32.8%) and 16.8 (10.0-27.6), and 14 (21.9%) and 9.1 (7.3-13.7) months, respectively. The C-index was 0.72. Patients in the favorable-risk group had better overall survival with nephrectomy than without nephrectomy (hazard ratio 0.29, 95% confidence interval 0.09-0.91 with nephrectomy). In metachronous metastatic renal cell carcinoma, these prognostic factors showed no statistical differences in the overall survival. CONCLUSIONS: Prognostic factors are completely different between synchronous and metachronous metastatic renal cell carcinoma. The new model for synchronous metastatic renal cell carcinoma can predict a good candidate for cytoreductive nephrectomy.

Effect of third- and fourth-line systemic therapies for metastatic renal cell carcinoma.

Data on the outcomes of third- or fourth-line therapy for metastatic renal cell carcinoma (mRCC) are limited. The aim of our study was to evaluate the efficacy of therapy beyond the second line. We retrospectively analysed data of mRCC patients who underwent systemic therapy at Yamagata University Hospital. The best objective response (BOR), response rate (RR), and progression-free survival (PFS) were assessed for each line of treatment. To investigate the correlation between overall survival (OS) and the number of treatment lines during a patient's lifetime, the median OS was assessed using univariate and multivariate analyses. In the first-, second-, and third-line therapies, approximately 20% of patients had long PFS of >15 months. In targeted treatments beyond the third line, only one treatment suppressed disease progression for >10 months. Among patients who died during the follow-up period, those treated with triple and quadruple lines had similar OS (42.5 months vs. 48.4 months, respectively). Multivariate analysis showed that patients with triple or more lines of therapy had better OS; however, quadruple or more lines of therapy was not an independent prognostic factor. We concluded that third-line systemic therapy could improve OS; however, fourth-line therapy could not.

Reinforcement of the Triple D score with simple addition of the intrarenal location for the prediction of the stone-free rate after shockwave lithotripsy for renal stones 10-20 mm in diameter.

PURPOSE: We investigated the clinical efficacy of the Triple D score (TrD-S) on stone-free rate (SFR) prediction following shockwave lithotripsy (SWL) for renal stones 10-20 mm in diameter and modified the scoring system to improve outcome prediction. METHODS: We retrospectively examined clinical data from the medical records of 226 consecutive patients who underwent SWL for 10-20 mm kidney stones. The TrD-S was calculated according to the cutoffs of < 150 mm3 for stone volume, < 600 Hounsfield unit for stone density, and < 12 cm for skin-to-stone distance on computed tomography. The Quadruple D score was defined as the sum of the TrD-S and stone location (0/1 point for intrarenal stone distribution at lower/non-lower poles, respectively). Complete clearance 3 months after the final SWL was considered the stone-free status. RESULTS: The residual group (n = 102) had significantly older age, larger stones, higher stone density, higher lower-pole stone incidence, and lower TrD-S than the stone-free group (n = 124). In the multivariate analysis, age, TrD-S, and non-lower-pole stones independently predicted the SFR. The TrD-Ss of 0, 1, 2, and 3 points showed SFRs of 40.0%, 51.9%, 73.0%, and 100.0%, respectively. The Quadruple D scores of 0, 1, 2, 3, and 4 points showed SFRs of 0.0%, 37.9%, 54.5%, 84.4%, and 100.0%, respectively, with better prediction accuracy than the TrD-S (p = 0.01). CONCLUSIONS: The TrD-S is successfully validated for use in Japanese patients with 10-20-mm renal stones. Simple addition of the stone location to the TrD-S could reinforce SFR prediction after SWL.

[AN EXPERIENCE OF PARTIAL NEPHRECTOMY IN A PATIENT WITH VON WILLEBRAND DISEASE].

A 28-year-old male visited a nearby hospital with chief complaint of bilateral back pain and fever. He was diagnosed with a right complex renal cyst (Bosniak classification, IIF) with a kidney stone and was referred to our hospital. We first suspected an incarcerated kidney stone and performed flexible transurethral lithotomy; however, his symptoms did not improve. Blood examination revealed prolonged APTT; subsequently, he was diagnosed with von Willebrand disease (VWD). Because he experienced pain due to the hemorrhagic renal cyst, we performed partial nephrectomy. Preoperatively, we supplemented the von Willebrand factor (VWF) based on the VWF activity in the patient. Although intraoperative bleeding was well controlled, he developed bleeding from pseudoaneurysms on the postoperative day (POD) 6. We immediately performed transarterial embolization along with VWF replenishment. VWF supplementation was discontinued on POD 14, and the patient was discharged on POD 23. Since then, he has not experienced a bleeding recurrence or pain. In patients with VWD, the perioperative administration of desmopressin or VWF is recommended. Although several reports showed that surgeries involving these treatments are safe, only three cases with VWD, including the present case where the patient underwent partial nephrectomy, have been reported. In the present case, postoperative bleeding occurred despite exhibiting adequate perioperative VWF activity. Thus, bleeding complications in patients with VWD undergoing partial nephrectomy must be considered and should be carefully followed up.

Levels of 4EBP1/eIF4E Activation in Renal Cell Carcinoma Could Differentially Predict Its Early and Late Recurrence.

BACKGROUND: The objective was to explore the predictive markers of late recurrence (LR) > 5 years after curative nephrectomy for renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively examined the data from 303 patients with localized clear cell RCC treated surgically at our institution from 1993 to 2011. Activation of the eukaryotic initiation factor (eIF)4E-binding protein 1 (4EBP1)/eIF4E axis at the mammalian target of rapamycin complex 1 (mTORC1) was evaluated in the tumor specimens. Weak, intermediate, and strong immunohistochemistry staining grades were defined for 4EBP1, phosphorylated 4EBP1, and eIF4E. The effects of clinicopathologic factors and activation level grades on tumor recurrence were analyzed using multivariate Cox regression models. To validate the present findings, we investigated clinical data from The Cancer Genome Atlas and protein/phosphoprotein data from corresponding patients from The Cancer Proteome Atlas. RESULTS: Of the 303 patients, 31 and 16 patients developed early recurrence (ER, ≤ 5 years) and LR, respectively. The activation levels were comparable among the subcategories of pathologic TN stage, Fuhrman grade, and microvascular and capsular invasion. Pathologic stage ≥ T1b, Fuhrman grade 3/4, and an intermediate or strong activation level correlated significantly with overall recurrence and ER. Strong activation of the axis and pathologic stage ≥ T1b were identified as independent predictors of LR. Only 2 patients with weak activation experienced recurrence (1 each with ER and LR). Similar results were confirmed by the analyses of The Cancer Genome Atlas and The Cancer Proteome Atlas data. CONCLUSION: The activation level of the axis in RCC tissues could independently predict for recurrence and differentially affect the timing of recurrence.

[Spontaneous Remission of Everolimus-Induced Interstitial Lung Disease in Metastatic Renal Cell Carcinoma : An Autopsy Case Report].

Interstitial lung disease (ILD) is a common side effect of the mechanistic target of rapamycin inhibitor everolimus. Most cases of everolimus-induced ILD are mild and reversible. As per guidelines, even if Common Terminology Criteria for Adverse Events grade 1 or 2 everolimus-induced ILD occurs, either continuation of everolimus without dose reduction or readministration at a low dose is possible. However, the pathophysiology of everolimus-induced ILD is unknown. We present a case of everolimus-induced ILD with spontaneous remission during treatment in a patient with metastatic renal cell carcinoma. At autopsy, there was no evidence of remodeling or chronic inflammation in the lungs. Cryptogenic interstitual pneumonia and broncholitis obliterans with organizing pneumonia can be suspected as a pattern of mild everolimus-induced ILD. This case report provides evidence that everolimus-induced ILD is reversible fromthe pathological perspective.

Rise in ambient temperature predisposes aging, male Japanese patients to renal colic episodes due to upper urolithiasis.

OBJECTIVE: Urolithiasis is a common urological problem, and its incidence has been increasing worldwide, including in Japan. Relationships between stone etiology and rise in ambient temperature have been reported, but it remains unclear how age and gender affect these relationships. MATERIALS AND METHODS: A retrospective examination was conducted of the medical archives of 1005 patients (aged ≥15 years) with acute renal colic diagnosed with urolithiasis upon image examination who consecutively visited emergency departments in three hospitals. The patients were categorized into six groups according to age: younger than 30, 30-39, 40-49, 50-59, 60-69, and 70 years and older. The net difference and fold increase in the number of patients in summer (July to September) versus in winter (December to February) were calculated. RESULTS: Overall, the actual number of the patients varied according to the temperature rise throughout the year and among the age groups. Net increases in the number of patients were observed in all age groups for both genders, apart from 30-39-year-old women. The age group of 50-59 years considerably outnumbered all other groups. A significant statistical correlation was detected between the fold increase and male aging using Spearman's rank correlation analysis (ρ = 0.94, p = 0.017), but not in females (ρ = -0.03, p = 1). CONCLUSIONS: These results support a positive association between ambient temperature rise and increase in the incidence of renal colic due to urolithiasis in Japan, and indicate that aging and gender affect the association differently.

[CEREBRAL VENOUS SINUS THROMBOSIS IN PATIENTS WITH METASTATIC TESTICULAR CANCER DURING CHEMOTHERAPY: REPORTS OF TWO CASES].

Cerebral venous sinus thrombosis (CVT) is rare but sometimes develops in association with malignant neoplasm. We report two cases of CVT that occurred during cisplatin-based chemotherapy for testicular cancer. A 46-year-old man with stage IIA non-seminomatous germ cell tumour was treated with conventional doses of etoposide and cisplatin (EP). On day 11 of the third treatment course, he developed a systemic seizure. Brain computed tomography (CT) and magnetic resonance (MR) imaging could not detect the cause. Enhanced chest-pelvic CT revealed pelvic thrombosis. Administration of phenytoin for epilepsy of unknown cause and heparin for thrombosis was started. He had completed 4 courses of EP therapy without seizure recurrence. After re-evaluating the brain CT images retrospectively, we found high density of superior sagittal sinus (SSS) and strongly suspected CVT. Another patient was a 47-year-old man with stage IIIB seminomatous germ cell tumour treated with bleomycin, etoposide, and cisplatin (BEP) therapy. On day 11 of the second treatment course, he developed a systemic seizure. Brain CT revealed subarachnoid haemorrhage localised in the right parietal lobe. CT venography revealed a filling defect in the superior sagittal sinus (SSS). MR venography revealed a SSS stenosis. We diagnosed the cause of the seizure as CVT and started administration of anticoagulant therapy. After the thrombus had diminished, chemotherapy was restarted and another 2 courses of BEP therapy was completed.

[Asynchronous Bilateral Testicular Infarction with Suspected Polyarteritis Nodosa : A Case Report].

This report documents a case of asynchronous bilateral testicular infarction. The patient was a 42- year-old man who presented with left testicular pain and swelling. He had a past history of right idiopathic testicular infarction and underwent a right orchiectomy 6 years ago. He also had received treatment for 5 years for suspected polyarteritis nodosa (PAN). The left scrotal pain persisted for a week and left orchiectomy was performed. Pathological evaluations demonstrated a benign testis with testicular hemorrhage and chronic vasculopathy. There was no fibrinoid necrosis of medium-size vessel walls which characterizes PAN. In this report, we review the pathogenesis, risk of contralateral testicular infarction, and management of testicular infarction.

Estimate of organ radiation absorbed doses in clinical CT using the radiation treatment planning system.

Organ absorbed doses in computed tomography (CT) scans can be measured with anatomical phantoms but not inside the human body. In this study, a straightforward method was investigated to estimate organ doses in clinical CT using the radiation treatment planning system (RTPS) and compared them with experimental results of photoluminescence dosemeters (PLD). In a heterogeneous phantom, the average difference between PLD and RTPS values were -5.0% for the body and 7.1% for the lung. Using CT data, organ doses in 30 clinical cases were then calculated. There was a significant inverse correlation between the calculated values of organ doses and body mass index (BMI, correlation coefficients (r) = -0.69 (whole body), -0.80 (right lung), -0.81 (left lung), -0.76 (spinal cord), -0.74 (vertebra bone), -0.74 (heart), and -0.79 (oesophagus), all p < 0.01). An RTPS can be a simple and useful tool for estimating equivalent doses inside the human body, during whole-body CT scans.

Examination of beam profile measurement using an imaging plate by the light exposure fading method for quality assurance of external radiation therapy.

High-resolution film dosimetry has been used for several decades to check and to measure two-dimensional dose distributions. However, in recent years, the automatic processor has been replaced by the spread of computed radiography, or has been little used hospitals. In this study, we measured the off-center ratio (OCR) of the open field, after an irradiating radiation beam was delivered to the imaging plate (IP) under conditions in which the IP was exposed to a fixed amount of light with fading, and compared these data with the OCR measured by an ionization-chamber dosimeter, which is the standard method used for measuring radiation dose. Profile measurement using IP could be achieved by performing light fading, even at a range of more than 100 MU. Further, by using a metallic filter, we succeeded in demonstrating that the profile measurement of IP in an open irradiation field could approximate the values of those obtained by an ionization chamber dosimeter. This method can serve as a simple, easy-to-use method for evaluating the QA of dose distribution in radiation therapy.

Efficient route to (S)-azetidine-2-carboxylic acid.

A new and efficient route to (S)-azetidine-2-carboxylic acid (>99.9% ee) in five steps and total yield of 48% via malonic ester intermediates was established. As the key step, efficient four-membered ring formation (99%) was achieved from dimethyl (S)-(1'-methyl)benzylaminomalonate by treating with 1,2-dibromoethane (1.5 eq) and cesium carbonate (2 eq) in DMF. Krapcho dealkoxycarbonylation of dimethyl (1'S)-1-(1'-methyl)benzylazetidine-2,2-dicarboxylate, the product of this cyclization procedure, proceeded with preferential formation (2.7:1, 78% total yield) of the desired (2S,1'S)-monoester, with the help of a chiral auxiliary which was introduced on the nitrogen atom. The undesired (2R,1'S)-isomer could be converted to that with proper stereochemistry, by a deprotonation and subsequent re-protonation step. Finally, lipase-catalyzed preferential hydrolysis of the (2S,1'S)-monoester and subsequent deprotection provided enantiomerically pure (S)-azetidine-2-carboxylic acid in a 91% yield from the mixture of (2S,1'S)- and (2R,1'S)-isomers.