[A Case of m0CRPC after Hormone Therapy for Pelvic Lymph Node Metastasis in which Salvage RARP was Effective].

The patient was a 63-year-old man with biopsy Gleason score of 4＋5 prostate cancer with an initial prostate specific antigen level of (PSA) 51.2ng/ml. On imaging examination, extracapsular invasion, rectal invasion, and pararectal lymph node metastasis were found (cT4N1M0). After 4 years of androgen deprivation therapy, PSA decreased to 0.631ng/ml, and then increased gradually to1.2ng/ml. Computed tomographic scan showed that the primary tumor had shrunk and lymph node metastasis had disappeared; so salvage robot-assisted resection of the prostate (RARP) was performed for non-metastatic castration-resistant prostate cancer (m0CRPC). Since PSA decreased to an undetactable level, hormone therapy was terminated at 1 year. The patient remained recurrence-free for 3 years after surgery. RARP may be effective for m0CRPC, enabling discontinuation of androgen deprivation therapy.

Anti-synthetase Syndrome That Relapsed with Pulmonary Arterial Hypertension and Malignancy.

A 69-year-old man with a history of anti-synthetase antibody-positive polymyositis and interstitial lung disease (ILD) stable for more than 20 years suddenly developed pulmonary artery hypertension (PAH) with a mean PA pressure of 46 mmHg. At this stage, ILD was mild, but it became acutely exacerbated later, and high-dose corticosteroid and intravenous cyclophosphamide ameliorated both PAH and ILD. The tricuspid regurgitation pressure gradient decreased from 80 to 49 mmHg and ILD recovered almost completely. During a systemic examination, bone metastatic cancer of unknown origin was found. We herein report the relationship between anti-synthetase syndrome (ASS) and PAH as well as ASS and malignancy.

Effect of continued perioperative antithrombotic therapy on bleeding outcomes following laparoscopic nephrectomy and nephroureterectomy.

INTRODUCTION: In this study, we aimed to assess the impact of perioperative continuation of antithrombotic therapy on bleeding and complications in patients undergoing laparoscopic radical nephrectomy (LRN) and nephroureterectomy (LNU). METHODS: This was a retrospective observational study. Patients who underwent LRN and LNU between January 2017 and July 2019 at our institution were recruited. All patients taking antithrombotic agents continued taking them during the perioperative phase (AA group). Surgical outcomes of patients in the AA group were compared with those of patients who were not taking antithrombotic agents (NA group). The primary outcome was the rate of bleeding complications. Secondary outcomes included intraoperative estimated blood loss, transfusion rate, and complications for up to 90 days. RESULTS: A total of 100 patients were included in the analysis, with 36 and 64 patients assigned to the AA and NA groups, respectively. Patients in the AA group were found to have more severe comorbidities than those in the NA group, with a Charlson Comorbidity Index ≥5, totaling 14 (39%) and 12 (19%), respectively (P = .03). According to surgical outcomes, none of the patients in the AA group required secondary procedures for bleeding complications. Moreover, there were no significant differences between the groups in intraoperative blood loss, hemoglobin deficit, rate of perioperative transfusion, readmission rate, or high-grade complications. DISCUSSION: These results indicate that perioperative use of antithrombotic agents does not increase the risk of bleeding and can be considered safe during LRN and LNU.

A case of bladder perivascular epithelioid cell tumors.

Perivascular epithelioid cell tumor (PEComa) was introduced in the WHO classification of bone and soft tissue tumors in 2002, and Bladder PEComa is very rare. A 60-year-old man underwent TURBT after CT and cystoscopy revealed a 2.5 cm tumor with a concave center on the posterior wall of the bladder. Pathological examination revealed a perivascular epithelioid cell tumor, which was diagnosed as primary bladder PEComa after systemic examination. We report a case of partial bladder resection for bladder PEComa, a type of mesenchymal tumor that does not originate from the bladder mucosa.

Surgical and functional outcomes of robot-assisted versus laparoscopic partial nephrectomy with cortical renorrhaphy omission.

To evaluate the surgical and functional outcomes between robot-assisted (CRO-RAPN) vs. laparoscopic (CRO-LPN) methods of cortical-renorrhaphy-omitting partial nephrectomy. Between July 2012 and June 2020, patients with localized clinical T1-2 renal masses who underwent CRO-RAPN or CRO-LPN were reviewed. The outcomes of the two groups were compared using propensity-score matching. Trifecta was defined as negative surgical margin, warm ischemic time < 25 min, and absence of complications of Clavien-Dindo grade III or more until three months postoperatively. The preservation rate of the estimated glomerular filtration rate (eGFR) was evaluated at six months postoperatively. Among 291 patients (CRO-RAPN, n = 210; CRO-LPN, n = 81) included in the study, 150 matched pairs of patients were analyzed. Compared to the CRO-LPN group, the CRO-RAPN group was associated with shorter warm ischemic time (13 min vs. 20 min, P < 0.001), shorter total operation time (162 min vs. 212 min, P < 0.001), less estimated blood loss (40 mL vs. 119 mL, P = 0.002), lower incidence of overall complications (3% vs. 16%, P = 0.001), higher preservation rate of eGFR at six months postoperatively (93% vs. 89%, P = 0.003), and higher trifecta achievement rate (84% vs. 64%, P = 0.004). CRO-RAPN contributed to shorter warm ischemic time, less blood loss, fewer complications, and higher preservation of renal function, all of which allowed this technique to achieve a higher rate of trifecta compared to CRO-LPN.

Comparison between 5-aminolevulinic acid photodynamic diagnosis and narrow-band imaging for bladder cancer detection.

BACKGROUND: To compare 5-aminolevulinic acid (5-ALA)-mediated photodynamic diagnosis (PDD) with narrow-band imaging (NBI) for cancer detection during transurethral resection of bladder tumour (TURBT). METHODS: Between June 2018 and October 2020, 114 patients and 282 lesions were included in the analysis. Patients were orally administered 5-ALA (20 mg/kg) 2 h before TURBT. The bladder was inspected with white light (WL), PDD, and NBI for each patient, and all areas positive by at least one method were resected or biopsied. The imaging data were then compared to the pathology results. RESULTS: The sensitivities of WL, PDD, and NBI for detecting urothelial carcinoma were 88.1%, 89.6%, and 76.2%, respectively. The specificity, positive predictive value, and negative predictive value for detecting urothelial carcinoma were 47.5%, 80.9%, and 61.3%, respectively, for WL; 22.5%, 74.5%, and 46.2%, respectively, for PDD; and 46.3%, 78.2%, and 43.5%, respectively, for NBI. PDD was significantly more sensitive than NBI for all lesions (p < 0.001) and carcinoma in situ (CIS) lesions (94.6% vs. 54.1%, p < 0.001). CONCLUSIONS: PDD can increase the detection rate of bladder cancer, compared to NBI, by greater than 10%. Therefore, 100% of CIS lesions can be detected by adding PDD to WL.

Two cases of immunoglobulin G4-related disease diagnosed by transvaginal urethral needle biopsy.

INTRODUCTION: Immunoglobulin G4-related disease is a systemic disease characterized by multifocal systemic involvement. We report two cases of women diagnosed with immunoglobulin G4-related disease in the urethra. CASE PRESENTATION: Case 1: A 67-year-old woman presented with discomfort around her perineum. Magnetic resonance imaging revealed a well-defined mass around the urethra. She underwent an ultrasound-guided core needle biopsy of the mass. The pathologic specimen showed immunoglobulin G4 positive cells. Steroid therapy was initiated, causing improvement of symptoms, decreased serum immunoglobulin G4 levels, and shrinking of the mass. Case 2: An 89-year-old woman was accidentally diagnosed with renal pelvic wall thickening on computed tomography. The pathologic specimen captured by ultrasound-guided needle biopsy showed immunoglobulin G4 positive cells. She had no symptoms and received no medical treatment. CONCLUSION: The frequency of urethral mass formation in female patients with immunoglobulin G4-related disease may also be high, and an echo-guided transvaginal urethral biopsy may be performed as a definitive diagnostic tool for immunoglobulin G4-related disease.

Apalutamide-induced severe interstitial lung disease: A report of two cases from Japan.

Apalutamide, a competitive inhibitor of the androgen receptor, is being increasingly used for the treatment of prostate cancer. There have been few reports of interstitial lung disease in clinical trials of apalutamide. However, two cases of apalutamide-induced interstitial lung disease with respiratory failure in Japanese males, who were successfully treated with high-dose corticosteroids, are presented here. These cases suggest that clinicians should be alert to the potentially life-threatening risk of pulmonary toxicity associated with apalutamide treatment.

[Risk Factors for Recurrence in Patients with Pathological Lymph Node-Positive Prostate Cancer after Extended Lymph Node Dissection in Laparoscopic and Robotic-Assisted Radical Prostatectomy].

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Effect of Continued Perioperative Anticoagulant Therapy on Bleeding Outcomes Following Robot-assisted Radical Prostatectomy.

OBJECTIVE: To assess the impact of continued perioperative anticoagulant drug administration on bleeding and complications in patients undergoing robot-assisted radical prostatectomy. METHODS: Between January 2014 and January 2020, 620 patients with prostate cancer underwent robot-assisted radical prostatectomies and were retrospectively reviewed. Fourteen patients who discontinued antithrombotic therapy were excluded. Among the 606 included patients, 31 continued anticoagulant therapy during the perioperative phase (anticoagulant group). The anticoagulant group outcomes were compared with those of patients who continued clopidogrel and prasugrel (thienopyridine group = 13), aspirin monotherapy (aspirin group = 61), and no chronic antithrombotic agent (control group = 501). The primary outcome was the incidence of bleeding complications requiring transfusion, additional intervention, or readmission. Secondary outcomes were the incidence of thrombotic complications, estimated blood loss, and overall complication rates. RESULTS: Among the 31 patients in the anticoagulant group, 20 (65%) used directed oral anticoagulants, 11 (35%) used warfarin, and 5 used combined aspirin. Only 1 (3%) patient in the anticoagulant group required postoperative transfusion, and none required additional interventions or readmission. No significant differences were detected between the anticoagulant and other groups (anticoagulant vs thienopyridine, aspirin, and control groups) regarding bleeding complications (3% vs 8%, P = .51; 0%, P = .34; 0.4%, P = .17, respectively), thrombotic complications (3% vs 0%, P = .70; 2%, P = .56; 0.2%, P = .11, respectively), estimated blood loss (200 vs 100 mL, P = .63; 175 mL, P = .64; 165 mL, P = .74, respectively), or other high-grade complications (6% vs 0%, P = .49; 2%, P = .26; 3%, P = .24, respectively). CONCLUSION: Perioperative continuation of anticoagulant use is feasible for patients undergoing robot-assisted radical prostatectomy.

[Simple Methods to Prevent Postoperative Inguinal Hernia after Extraperitoneal and Transperitoneal Robot-Assisted Radical Prostatectomy].

Herein we present simple methods to prevent postoperative inguinal hernia (IH) after extraperitoneal and transperitoneal robot-assisted radical prostatectomy (RARP). Among 275 patients who underwent RARP between January 2014 and December 2016 at our institution, we evaluated 143 and 115 patients who underwent extraperitoneal-RARP (e-RARP) and transperitoneal-RARP (t-RARP), respectively, after excluding those with intraoperative detection of IH (17 patients). In the e-RARP group, all 143 patients (286 groins) underwent an IH prevention procedure. In the t-RARP group, the first 22 patients (44 groins) did not undergo an IH prevention procedure, whereas 29 patients (37 groins) with patent processus vaginalis (PPV) among the last 93 patients underwent the procedure. The IH prevention procedure during e-RARP included release of the vas deferens from the peritoneum and spermatic cord, and peritoneal dissection of the spermatic cord at the internal inguinal ring. The IH prevention procedure during t-RARP included release of the vas deferens from the peritoneum and spermatic cord, complete circumferential dissection of the peritoneum around the PPV at the level of the internal inguinal ring, and ligation of the PPV with a Hem-o- Loc○R clip. In the e-RARP group, postoperative IH occurred in 3 of the 143 patients (1.9%) during the follow-up period of 22.0±9.2 months. In the first subgroup of t-RARP, postoperative IH developed in 4 of the 22 patients (18%) during the follow-up period of 33.1±12.1 months, whereas in the last t-RARP group, postoperative IH developed in 3 of the 93 patients (3.3%) during the follow-up period of 20.1±8.6 months. Different IH prevention procedures performed in patients undergoing e-RARP and t-RARP were simple and effective in preventing postoperative IH.

[Necessity of Pelvic Drain Placement after Robot-Assisted Radical Prostatectomy].

Sixty eight patients had robot-assisted radical prostatectomy (RARP) from January 2016 to April 2017 with estimated blood loss of less than 500 ml. We compared the postoperative complication rates and the length of hospital stay between 34 of these patients who had pelvic drain placement (PD group), and the remaining 34 patients who had no drain placement (ND group). The approach was intraperitoneal in 25 patients in each group. The PD and ND groups were comparable for age (69.5 vs 70 yrs, P=0.459), clinical Gleason Score (6/7/≧8) 2/17/15 vs 3/8/23 (P=0.077), clinical stage (1c/2/3) 3/25/6 vs 1/25/8 (p=0. 539), operative time (311 vs 309 min, P=0.868), and estimated blood loss (p=0.166). The PD group had significantly higher median PSA level than the ND group (8.01 vs 6.25 ng/ml, P=0.023). Incidence of 30- day overall complications in the PD group (35 events) was lower than that in the ND group (38 events). All complications were classified as Clavien Dindo grade I. The postoperative hospital stay was 8 days in the PD group and 7 days in the ND group, showing no prolongation in the ND group. Pelvic drainage may be omitted after RARP without increasing postoperative complications or prolonging the hospital stay.

Atypical oncologic failure after laparoscopic and robot-assisted radical cystectomy at a single institution.

BACKGROUND: The incidence of atypical oncologic failure in patients with bladder cancer, including peritoneal carcinomatosis, and recurrences at the port site and soft tissue after laparoscopic and robot-assisted radical cystectomy are not well characterized. METHODS: We retrospectively reviewed the records of 52, 51, and 12 patients who underwent open, laparoscopic, and robot-assisted radical cystectomy, respectively, for bladder cancer from 2007 to 2018 at our institution. We identified techniques associated with atypical oncologic failure. RESULTS: The median follow-up period was 29 months. Among the 115 patients, 29 (25%) experienced oncological recurrences, and 7 (6%), 12 (10%), and 23 (20%) had atypical, local, and distant recurrences, respectively. The laparoscopic and robot-assisted radical cystectomy groups had significantly higher incidences of total atypical oncologic failure than the open radical cystectomy group (p = 0.013), including six, one, and two patients with peritoneal carcinomatosis, port site carcinomatosis, and soft tissue involvement, respectively. All 7 patients with atypical oncologic failure died of cancer; the median time from surgery to death was 9.3 months. All these patients were cT â‰§ 3 and had grade 3 disease. In three patients (43%), the pathological tissue contained variants other than urothelial carcinoma. Five (71%) were among the initial twenty patients. Four patients (57%) had histories of intraoperative urine spillage or bladder perforation during transurethral resection. CONCLUSIONS: Patients with cT â‰§ 3 stage, with pathological variants other than urothelial carcinoma, and those undergoing procedures that lead to extravesical dissemination should avoid laparoscopic radical cystectomy when the procedures are first introduced.

Surgical outcomes and learning curve of totally intracorporeal ileal conduit urinary diversion following laparoscopic radical cystectomy at a single institution.

INTRODUCTION: Constant evaluation of the outcomes of laparoscopic intracorporeal urinary diversion is not yet established. This study aimed to describe surgical outcomes and learning curve of intracorporeal ileal conduit (ICIC) following laparoscopic radical cystectomy (LRC) at a single institution. METHODS: From June 2012 to February 2018, 38 patients with bladder cancer underwent LRC with ileal conduit at our institution. Surgical outcomes were compared between ICIC (n = 30) and extracorporeal ileal conduit (ECIC) (n = 8). The learning curve during ICIC with regard to the operative time and complication rate was compared. RESULTS: No significant differences in patient characteristics between the ICIC and ECIC groups were found. Comparison of outcomes between the ICIC and ECIC groups were as follows: median total operative time, 688 vs 713 minutes; urinary diversion time, 213 vs 192 minutes; and estimated blood loss, 450 vs 420 mL, respectively. The median time to walking and oral intake were similar in both groups. Rates of high-grade complications associated with urinary diversion (Clavien-Dindo grade ≥ III) were 3% in ICIC and 25% in ECIC. Although 25% of ECIC patients developed wound dehiscence (Clavien-Dindo grade IIIb), no patient in the ICIC group had postoperative wound infection. For the learning curve of ICIC (n = 30), urinary diversion time decreased significantly (27 minutes decrease per 10 cases, P = .02). Clavien-Dindo grade ≥ II complication did not occur after 20 cases. CONCLUSIONS: LRC with ICIC could be performed safely with low incidence of severe wound infection compared with ECIC. The incidence and severity of complications also decreased with time.

Absence of asymptomatic unruptured renal artery pseudoaneurysm on contrast-enhanced computed tomography after robot-assisted partial nephrectomy without parenchymal renorrhaphy.

OBJECTIVE: To assess the incidence of asymptomatic unruptured renal artery pseudoaneurysm (RAP) on contrast-enhanced computed tomography (CE-CT) after robot-assisted partial nephrectomy (RAPN) without parenchymal renorrhaphy. METHODS: From May 2016 to December 2017, 78 patients underwent RAPN for renal tumors. Inner suture was performed in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft coagulation system was used, and absorbable hemostats were placed on the resection bed. CE-CT was carried out within 7 days after surgery. Data on these patients were prospectively collected. A single radiologist determined the diagnosis of RAP. RESULTS: Median (range) data were as follows: Patient age, 65 (19-82) years; radiographic tumor size, 30 (12-95) mm; operating time, 166 (102-294) min; warm ischemic time, 16 (7-67) min; and blood loss, 15 (0-4450) mL. One patient (1.6%) required a perioperative blood transfusion. No patient required conversion to open surgery or nephrectomy. CE-CT was carried out at median 6 (3-7) days after surgery. CE-CT showed no RAP development in all 61 patients. Urinary leakage was not observed. One patient had acute cholecystitis, a postoperative complication classified as Clavien-Dindo grade higher than 3, which was treated with cholecystectomy. Positive surgical margin was identified in four patients (6.6%). CONCLUSION: RAPN using soft coagulation and absorbable hemostats without renorrhaphy appears to be feasible and safe. Our technique could eliminate the risk of RAP.

[Traumatic Adrenal Injury : A Single-Institution Experience].

Traumatic adrenal injury is quite rare. From January 2008 to March 2018, out of 287 patients with genitourinary trauma, 23 patients (8%) were diagnosed with traumatic adrenal injury at Kobe City Medical Center General Hospital. We retrospectively reviewed the medical records and assessed the traumatic category, image findings and outcome. All 23 patients were bluntly injured. The causes of traumatic adrenal injury were motor vehicle accident (11 patients : 48%) and falls (9 patients : 39%). The majority of injuries occurred on the right side (18 patients : 78%). Associated injuries occurred in all 23 patients, most frequently in the liver (57%) and ribs (57%). Extravasation of contrast materials was identified on computed tomography (CT) in 4 patients (17%). Although 22 patients (96%) were conservatively managed, only 1 patient was treated by transcatherter arterial embolization because of hypotension. One patient died of intraabdominal bleeding. To our knowledge, the present study is the largest on traumatic adrenal injury in Japan.

Comparison of perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy: Comparative outcomes of cT1a versus cT1b renal tumors.

OBJECTIVES: To assess the perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy for cT1b renal tumors compared with cT1a. METHODS: From February 2015 to May 2018, 100 robot-assisted partial nephrectomy patients who underwent robot-assisted partial nephrectomy without renorrhaphy for renal tumors were included. We retrospectively reviewed the medical records, and compared the perioperative outcomes of 66 and 34 patients for cT1a and cT1b tumors, respectively. Inner suture was carried out in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft-coagulation system was used, and absorbable hemostats were placed on the resection bed. RESULTS: The median tumor size and RENAL nephrometry score were significantly different between the two groups (cT1a vs cT1b: 23.5 vs 45 mm, P < 0.001, 6 vs 8, P < 0.001). The median operating time and warm ischemic time were significantly longer in the cT1b group than in the cT1a group (154 vs 184 min, P < 0.001; 14 vs 21 min, P < 0.001). The median blood loss was not significantly different (2.5 vs 50 mL, P = 0.109). The positive surgical margin rate was 4.5% versus 11.7% (P = 0.22). Postoperative complications classified as Clavien-Dindo grade III or higher were port-site herniation (one patient), acute cholecystitis (one patient) and pseudoaneurysm (one patient) in the cT1b group. Urinary leakage was not observed in the two groups. CONCLUSIONS: Robot-assisted partial nephrectomy without renorrhaphy using the soft-coagulation system and absorbable hemostats appears to be feasible for renal or cT1b tumors. However, longer warm ischemic time and a high rate of complications can be expected compared with cT1a tumors.

[A Case of Systemic Polyarteritis Nodosa Presenting with Scrotal Pain].

A 76-year-old man with a history of hypertension was admitted with high fever and left scrotal pain. Laboratory findings revealed high serum C-reactive protein levels. The left epididymis appeared to be swollen on computed tomography. The patient was diagnosed with bacterial epididymitis and treatment with antibiotics was initiated. Despite treatment, his left scrotal pain and fever did not improve. Additionally, he developed right scrotal and posterior neck pain. For histopathological diagnosis, a left high orchiectomy was performed and the findings revealed thickened arteriolar walls with infiltration of inflammatory cells around the testis, leading to a final diagnosis of systemic polyarteritis nodosa. Treatment with steroids led to complete resolution of the patient's systemic pain and inflammation.

A case of Ewing sarcoma family tumor of the kidney treated with robotic-assisted partial nephrectomy.

Ewing sarcoma family tumors (ESFTs) of the kidney represents less than 1% of all renal tumors. A 45-year-old Japanese woman presented with right abdominal pain. Contrast-enhanced computed tomography showed a 12 × 8-cm right cystic renal mass. The mass was diagnosed as cystic renal cell carcinoma (RCC) and right partial nephrectomy was performed. Immunohistochemical studies showed that the tumor was positive for CD99 (membranous staining in tumoral cells), indicating ESFT. The patient is doing well without further therapy after 1 year of follow-up. To our knowledge, this is the first report of renal ESFT mimicking cystic RCC on diagnostic imaging.