Predictive factors for disease progression after salvage radiation therapy in biochemical recurrent patients treated by radical prostatectomy.

Objective: Salvage radiation therapy (SRT) is standard treatment for patients after radical prostatectomy (RP). However, the optimal timing of SRT remains to be elucidated. Material and methods: We retrospectively reviewed 133 prostate cancer (PCa) patients who underwent SRT for biochemical recurrence after RP. Disease progression was defined as repeated prostate-specific antigen (PSA) level more than 0.2 ng/mL, greater than the post-SRT nadir or radiographic progression. A receiver operating characteristic curve analysis was used to identify the optimal pre-SRT PSA level for predicting progression after SRT. Cox regression analyses were performed to elucidate the association between clinicopathologic characteristics and disease progression. Results: Fifty-one PCa patients (38.4%) experienced disease progression after SRT. The optimal cutoff value of the pre-SRT PSA for predicting disease progression was 0.44 ng/mL. In multivariable analysis, pre-SRT PSA >0.44 ng/mL was a significant independent predictor of post-SRT disease progression [hazard ratio (HR): 2.02, P = 0.02]. Although the pre-SRT PSA >0.44 ng/mL did not maintain its independent association with disease progression in the multivariable analysis of patients with adverse pathology (HR: 1.63, P = 0.22), PSA within 4 weeks after RP as a continuous variable was significantly associated with disease progression (HR: 1.19, P = 0.04). Conclusions: Our results highlight that in PCa patients who undergo RP, SRT should be performed before their PSA reaches 0.44 ng/mL. In patients with adverse pathology disease, a high PSA level within the 4 weeks after RP might identify those who are likely to have disease progression, and these patients might require systemic therapy.

Impact of ABO Compatibility/Incompatibility on the Perioperative Anti-SARS-CoV-2 Immunoglobulin G Levels in 2 Preoperatively Vaccinated Patients Undergoing Kidney Transplant: A Case Report.

Herein, we monitored the perioperative anti-SARS-CoV-2 spike immunoglobulin G titers in patients who were preoperatively vaccinated with 2 doses of a COVID-19 messenger RNA vaccine. Additionally, we compared the clinical settings between ABO-incompatible and ABO-compatible pre-emptive kidney transplant (KTx). Case 1 was of a 45-year-old man who was an ABO-incompatible KTx recipient. Before transplant, his serum antibody titers decreased from 278 U/mL at baseline to 41.9 U/mL after desensitization therapy (84.9% lower) and 54.7 U/mL (80.3% lower) at day 8; it is now maintained at 4.1 U/mL at 6 months posttransplant (98.5% lower). Case 2 was of a 50-year-old man who was an ABO-compatible KTx recipient. His serum antibody titer level decreased from 786 U/mL at baseline to 386 U/mL on day 8 (50.8% lower) and is now maintained at 156 U/mL at 6 months posttransplant (80.1% lower). We suggest that anti-SARS-CoV-2 spike immunoglobulin G titers should be monitored during the perioperative period to determine the optimal timing of COVID-19 vaccine booster doses for the maintenance of protective immunity, particularly in ABO-incompatible KTx recipients who require desensitization therapy.

Evaluation of the Correlation Between Responders and Non-Responders to the Second Coronavirus Disease Vaccination In Kidney Transplant Recipients: A Retrospective Single-Center Cohort Study.

BACKGROUND: The immune response to COVID-19 vaccination in kidney transplant (KTx) recipients is significantly lower than that in healthy controls. We evaluated immune responses after the COVID-19 vaccine and their possible relationship with other cofactors in KTx recipients. METHODS: This retrospective single-center cohort study included 29 KTx recipients 2-8 weeks after receiving 2 doses of the Pfizer-BioNTech SARS-CoV-2 messenger RNA vaccine. Anti-SARS-CoV-2 spike (S) immunoglobulin (Ig)-G levels were evaluated to define cofactors influencing the immune response between the responder (anti-SARS-CoV-2 IgG level ≥0.8 U/mL) (n = 16) and nonresponder groups (anti-SARS-CoV-2 IgG level <0.8 U/mL) (n = 13). The kinetics of antibodies between 2 and 6 months after the second vaccination was also compared between the groups. RESULTS: KTx recipients with IgG levels ≥0.8 U/mL were younger (54 [interquartile range {IQR}, 46.5-61] years vs 65 [IQR, 55-71.5] years; P = .01), had been transplanted for a longer median time (1588 [IQR, 1382-4751] days vs 1034 [IQR, 548.5-1833] days; P = .02), and were more often treated with a lower mycophenolate mofetil dosage (765.6 ± 119.6 vs 1077 ± 76.9 mg; P = .04) than KTx recipients with IgG levels <0.8 U/mL. There was no significant difference in antibody titers between time periods after the second dose in the responder group. At the 6-month follow-up, a serologic response against the SARS-CoV-2 S was observed in 44.4% of KTx recipients in the nonresponder group. CONCLUSIONS: More than 50% of KTx recipients developed a higher antibody response after the second dose of COVID-19 vaccination.

Novel insight into the correlation between hernia orifice of cystocele and lower urinary tract function: a pilot study.

BACKGROUND: It has been hypothesized that women with significant pelvic organ prolapse (POP), particularly of the anterior vaginal wall, may have voiding dysfunction (VD). Although the VD mechanism due to cystocele is not fully understood, different vaginal compartments have rarely been closely examined. This study attempted to further elucidate the correlation between POP and VD through a new subgroup classification using cystoscopy. METHODS: This study reviewed clinical records of 49 women who underwent cystocele repair. All patients were scheduled for laparoscopic sacrocolpopexy, preoperatively underwent uroflowmetry and postvoid residual urine volume (PVR) measurement, and completed pelvic floor function questionnaires. Bladder examination by cystoscopy was additionally performed using the lithotomy position with the Valsalva maneuver. RESULTS: Subjects were divided into four groups according to hernia orifice presence determined by cystoscopy, which included the trigone type, posterior wall type, trigone and urethra type, and trigone and posterior wall type. The posterior wall type had statistically higher PVR values versus the trigone and posterior wall type (P = 0.013). The posterior wall type had statistically lower values for average urine flow rate versus the urethra and trigone type (P = 0.020). There were no significant differences noted in the pelvic floor function questionnaires among the four groups. CONCLUSIONS: A new bladder defect classification based upon hernia orifice location was associated with lower urinary tract function. Posterior wall hernia presence caused significant voiding function deterioration. This new subgroup classification, which can more clearly identify and indicate bladder function, is also comparable among patients.

Bladder cancer invasion along a tension-free vaginal mesh.

INTRODUCTION: The effect of synthetic mesh after pelvic organ prolapse surgery on the progression of bladder cancer remains unclear. CASE PRESENTATION: A 79-year-old woman who underwent a tension-free vaginal mesh procedure 8 years prior was diagnosed with carcinoma in situ of the bladder. Although intravesical Bacillus Calmette-Guérin therapy was started, the tumor rapidly became muscle invasive. Laparoscopic radical cystectomy was performed following radiochemotherapy; however, the tumor extended to the left internal obturator muscle along the mesh arm. Pathological findings showed desmoplastic high-grade urothelial carcinoma infiltrating around the mesh. Finally, cancer recurred rapidly in the left internal obturator muscle. CONCLUSION: Synthetic mesh can become an abnormal anatomical pathway for tumor infiltration. Therefore, in high-risk bladder cancer patients who underwent a tension-free vaginal mesh procedure, radical cystectomy should be performed without delay before the tumor invades the perivesical tissue.

Zoning inside the renal fascia: The anatomical relationship between the urinary system and perirenal fat.

OBJECTIVES: To examine the anatomical relationship between the urinary system and perirenal fat, and to clarify the zoning inside the renal fascia. METHODS: Using computed tomography images from 50 men, we examined perinephric veins to reveal vessel communication in perirenal fat. Nine cadavers were dissected to investigate connective tissue continuity and vessel communication inside the renal fascia. Eight retroperitoneal specimens were macroscopically observed: four from the anterior and four from the posterior aspects. One specimen was used to obtain retroperitoneal transverse sections to study macroscopic anatomy and histology. RESULTS: Perinephric veins were classified into four types (superior, middle, inferior and lateral) using computed tomography. Most of the inferior perinephric veins were connected to the ipsilateral gonadal vein. In the cadaveric study, the superior and middle perinephric veins communicated with veins deriving from the ipsilateral adrenal gland. A fibrous connective tissue gap between perirenal fat and renal hilar fat was observed in posterior aspect dissection. From the gap, we could dissect the urinary system from perirenal fat en bloc along with a thin fibrous connective tissue layer. Communicating vessels between perirenal fat and the urinary system were rare. CONCLUSIONS: Our results suggest that perirenal fat belongs to the connective tissue of the gonad and the adrenal gland. The urinary system is separate from perirenal fat, and is located on the dorsal side inside the renal fascia. This concept of zoning inside the renal fascia is valuable particularly in retroperitoneoscopic donor nephrectomy.

Red cell distribution width predicts time to recurrence in patients with primary non-muscle-invasive bladder cancer and improves the accuracy of the EORTC scoring system.

PURPOSE: To investigate the clinical prognostic value of red cell distribution width (RDW) in patients with non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively evaluated 582 consecutive patients with primary NMIBC. The efficacy of preoperative RDW at predicting treatment outcome was assessed. A cut-off point for predicting recurrence was also identified. Uni- and multivariable analyses of time to recurrence (TTR) and progression were conducted. Harrell's concordance index (c-index) was used to evaluate the additive value of RDW to the European Organization of Research and Treatment of Cancer (EORTC) risk scoring model for recurrence. RESULTS: According to the receiver operating characteristic curve of RDW for recurrence, a RDW ≥ 14.5% was classified as high. In the multivariable analysis, a high RDW could independently predict shorter TTR (subdistribution hazard ratio [SHR]: 2.65, 95% confidence interval [CI]: 1.83-3.84, P < 0.001), irrespective of tumor characteristics. No significant relationship was observed between RDW and time to progression (SHR: 1.75, 95% CI: 0.76-4.08, P = 0.19). Adding binary-coded RDW to the EORTC risk scoring model significantly improved its discriminatory performance in assessing recurrence risk (c-index: 0.62, improvement: 0.052, P < 0.001). High RDW was associated with shorter TTR in patients treated with bacillus Calmette-Guerin in the multivariable analysis (SHR: 2.0, 95% CI: 1.01-3.98, P = 0.047). CONCLUSIONS: RDW was an independent, significant prognostic factor of TTR in patients with primary NMIBC. Adding RDW to the EORTC risk model significantly improved the model's predictability for tumor recurrence.

Laparoscopy-Assisted Cutaneous Vesicostomy in Combination with Radical Nephrectomy in an Adult Patient with Neurogenic Bladder and Difficulty with Permanent Urinary Catheterization.

Background: Cutaneous vesicostomy is a urinary diversion for chronic urinary retention caused by neurogenic bladder. In this procedure, urine is drained directly from the bladder into a pouch attached to the lower abdomen, where the use of a catheter is unnecessary. Although complications of this procedure have been described, such as stoma stenosis, bladder prolapse, bladder calculi, and peristomal dermatitis, it is useful for patients who have difficulty with permanent bladder catheterization. The laparoscopy-assisted technique for cutaneous vesicostomy has not been described in the existing literature. In this report, we describe the case of an adult patient with chronic urinary retention caused by a neurogenic bladder who underwent laparoscopy-assisted cutaneous vesicostomy. Case Presentation: A 61-year-old man with intellectual disability was referred to our department because of macroscopic hematuria and urinary retention. Abdominal ultrasonography and computed tomography images showed excessive bladder dilation and bilateral hydronephrosis. A left kidney tumor was found incidentally. We diagnosed left renal carcinoma and chronic urinary retention caused by a neurogenic bladder. We suspected that the hematuria resulted from the renal cancer or from mucosal or submucosal vessel injury caused by excessive dilation of the bladder. Because of the patient's intellectual disability, self-intermittent catheterization or management of a urethral catheter was not possible. Therefore, we performed left radical nephrectomy laparoscopically followed by laparoscopy-assisted cutaneous vesicostomy under general anesthesia. By using laparoscopy, we could construct the vesicostomy in the bladder dome with less tension, and no stomal complications had occurred at 7 months postoperatively. Conclusion: Laparoscopy-assisted cutaneous vesicostomy was a safe and feasible surgical technique in our adult patient with chronic urinary retention. This procedure may be considered effective for patients having difficulty with permanent urinary catheterization.

Effectiveness of Intravesical Doxorubicin Immediately Following Resection of Primary Non-muscle-invasive Bladder Cancer: A Propensity Score-matched Analysis.

BACKGROUND: The purpose of this study was to investigate whether adding single immediate postoperative intravesical instillation of doxorubicin (SID) to transurethral resection of bladder tumor (TURBT) significantly reduced the risk of recurrence in patients with non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively analyzed the records of 720 patients diagnosed with primary NMIBC between 2002 through 2018 at the Kameda Medical Center. The primary outcome measure was time to recurrence. Time to progression was also compared. The cohort of SID and the cohort of TURBT alone were matched one-to-one by propensity scores. Matching was done by patient age, gender, and factors of the European Organization of Research and Treatment of Cancer recurrence risk table. The associations of adding SID and clinical outcomes were assessed with uni- and multivariate competing-risk regression models. RESULTS: After matching, a total of 364 patients, including 182 receiving SID and 182 receiving TURBT alone, were analyzed. No statistically significant differences existed among the measured baseline characteristics in propensity score-matched cohorts. In the multivariate analysis, there was a significantly longer time to recurrence in patients receiving SID (subdistribution hazard ratio, 0.68; 95% confidence interval, 0.49-0.95; P = .024) in propensity score-matched cohorts. There was no significant difference in time to progression (subdistribution hazard ratio, 0.61; 95% confidence interval, 0.11-3.49; P = .58) in univariate analysis. CONCLUSIONS: Our results demonstrated that SID significantly reduced the recurrence risk of primary NMIBC. Doxorubicin could be an inexpensive alternative to other evidenced-based chemotherapeutic agents for single immediate intravesical chemotherapy.

Two-step technique of early adrenal artery ligation in open adrenalectomy of giant right adrenal pheochromocytomas: Three case reports.

INTRODUCTION: Surgical manipulation of a pheochromocytoma carries the risk of releasing catecholamines into bloodstream leading to severe intraoperative hypertension. CASE PRESENTATION: We present three patients with right adrenal pheochromocytoma over 10 cm diameter: a 40-year-old woman, 63-year-old man, and 66-year-old woman. They were diagnosed by 123I-MIBG scintigraphy and received preoperative antihypertensive treatment with 16 mg/day of doxazosin. Open adrenalectomy was performed with early right adrenal artery ligation between the inferior vena cava and ventral aorta (Step 1) as well as between the tumor and upper pole of the right kidney (Step 2). There was no severe intraoperative hypertension, and no recurrence was observed over 33 months, postoperatively. CONCLUSION: Early adrenal artery ligation may stop tumor blood supply and significantly reduce the catecholamine release. Our technique was thought to be safe and useful for preventing severe intraoperative hypertension in giant right adrenal pheochromocytoma.

Living-donor kidney transplantation in an end-stage renal disease patient with situs inversus totalis: Three case reports.

INTRODUCTION: Only few cases of renal dysfunction in patients with situs inversus totalis have been reported. Thus, studies on kidney transplantation in patients with this condition are still limited. CASE PRESENTATION: We present three cases of end-stage renal disease patients with situs inversus totalis: a 30-year-old man, 21-year-old woman, and 31-year-old man. Each left living-donor kidney was transplanted in the right iliac fossa in the usual way. Because of the anatomical reversal and right external iliac vein being deep, the internal iliac vein was cut for venous anastomosis in one patient. Another one patient developed temporary congestive kidney, which was speculated to be due to poor blood flow in the renal vein. All recipients could be weaned off dialysis, with stable allograft function. CONCLUSION: Kidney transplantation in patients with situs inversus totalis is the same as anatomical normal cases, except that attention is paid to venous anastomosis.

Laparoscopic pelvic organ prolapse repair by mesh interposition following radical cystectomy.

INTRODUCTION: The present study aims to introduce laparoscopic treatment by the interposition of polypropylene mesh for a pelvic organ prolapse in females following radical cystectomy for treating muscle-invasive bladder carcinoma. CASE PRESENTATION: The patients included two women aged 77 and 79 years with symptomatic enterocele following radical cystectomy and ileal conduit urinary diversion. We performed laparoscopic sacrospinous colpopexy using polypropylene and polypropylene/ePTFE composite meshes. CONCLUSION: No recurrent prolapse occurred during 26 and 14 months of follow-up after the operation. No severe perioperative complications were noted. This is a first report on cases of laparoscopic sacrospinous colpopexy for post-cystectomy pelvic organ prolapse. Our procedure could be safely performed in two patients with post-cystectomy pelvic organ prolapse.

Laparoscopic-assisted surgery for liposarcoma of the spermatic cord extending to the retroperitoneal cavity through the internal inguinal ring.

INTRODUCTION: Liposarcoma of the spermatic cord is a rare disease, reportedly treated with radical high orchiectomy. However, laparoscopic-assisted surgery for spermatic cord liposarcoma extending to the retroperitoneal cavity through the internal inguinal ring has not yet been reported. CASE PRESENTATION: A 78-year-old man had a spermatic cord tumor that extended to the retroperitoneal cavity through the internal inguinal ring and invaded the abdominal wall muscles. We performed laparoscopic-assisted surgery and successfully separated the tumor from the contiguous organs and vessels. The tumor was resected en bloc with abdominal wall muscles, and a muscular defect was repaired with a left tensor fascia lata muscle flap. Pathological analysis revealed a well-differentiated liposarcoma with negative surgical margins. There was no recurrence at 1 year post-surgery. CONCLUSION: Laparoscopic-assisted surgery is a feasible and minimally invasive procedure for treating liposarcoma of the spermatic cord extending to the retroperitoneal cavity through the internal inguinal ring.

Elderly living donor kidney transplantation allows worthwhile outcomes: The Japan Academic Consortium of Kidney Transplantation study.

OBJECTIVE: To compare transplant outcomes among elderly (aged ≥60 years) and non-elderly recipients, and to evaluate the acceptability of elderly living donor kidney transplantation in practice after consideration of living donor type. METHODS: We included 830 adult patients with living donor kidney transplantation between 2000 and 2011 in this retrospective cohort study. We compared death-censored graft survival, patient survival, biopsy-proven rejection, complications, and renal function in elderly (n = 119) and non-elderly recipients (n = 278). RESULTS: There was no significant difference in 10-year death-censored graft survival (P = 0.980). Corresponding patient survival rates in the elderly and non-elderly groups were 84.1% and 98.1%, respectively (hazard ratio 6.15, 95% confidence interval 2.12-17.82, P < 0.001). Elderly patients had more complications and chronic T-cell-mediated rejection. Factors associated with death in elderly recipients with functioning grafts were residual advanced recipient age (hazard ratio 1.39), decreased hemoglobin (hazard ratio 4.10), hepatitis B virus (hazard ratio 7.89), hepatitis C virus (hazard ratio 13.12) and elevated alanine aminotransferase (hazard ratio 1.13). CONCLUSIONS: Elderly living donor kidney transplantation seems to provide adequate acceptable outcomes. However, physicians should be cautious when evaluating elderly patients with hepatitis, and further studies are required to improve long-term outcomes.

[ANEURYSMAL TYPE RENAL ARTERIOVENOUS FISTULA WITH GIANT VENOUS ANEURYSM, MIMICKING RENAL CELL CARCINOMA: A CASE REPORT].

A 39-year-old man was referred to our clinic for a 7 cm tumor in the right kidney, found by simple CT scan. It was suspected as renal cell carcinoma accompanying tumor emboli in the inferior vena cava by enhanced CT scan. For further evaluation of the tumor emboli, color Doppler ultrasound and enhanced MRI was performed. They showed a large cystic lesion with high velocity turbulent flow and flow voids in T2-weighted imaging, it seemed as giant venous aneurysm of the right renal vein. Subsequently, angiography revealed aneurysmal type renal arteriovenous fistula (AVF), transarterial embolization (TAE) of the arterial feeder with coils was performed on the same day. After 6 months from embolization, there was no recurrences or reinterventions. Color Doppler ultrasound and MRI are beneficial in distinguishing vascular disease from neoplastic disease which may sometimes mimick in other diagnostic imaging studies. In addition TAE seems to be an effective treatment for the AVF.

Soft coagulation in partial nephrectomy without renorrhaphy: feasibility of a new technique and early outcomes.

OBJECTIVES: To study the feasibility of a new partial nephrectomy technique using soft coagulation without renorrhaphy. METHODS: Open partial nephrectomy using soft coagulation without renorrhaphy was carried out on 39 consecutive patients with renal tumors. The renal artery was clamped in the initial 23 cases (59%), whereas 16 surgeries (41%) were carried out without clamping. The resected surface of the kidney was coagulated solely by soft coagulation without renorrhaphy. Suturing was used only when the urinary collecting system was opened. The surgical results and perioperative complications were retrospectively evaluated. RESULTS: The mean age of patients was 63.1 years. The mean tumor size was 28.2 mm (range 10-56 mm). The mean RENAL nephrometry score was 8.03 (range 4-10). The mean cold ischemic time (in clamped cases) was 25 min. The mean operative time was 193 min (range 113-310 min), and the mean estimated total blood loss was 172 mL (range 20-530 mL) in all cases. All operations were uneventful, and none required blood transfusion or conversion to nephrectomy. Postoperative complications, such as hemorrhage, urinary fistula formation and requirement of hemodialysis, were not observed. All patients had negative surgical margins, and were free of disease recurrence during the follow-up period (3-49 months). Overall, a remarkable decrease in renal function was not evident at the end of the follow-up period. CONCLUSIONS: This new technique using soft coagulation appears to be safe and feasible for partial nephrectomy.

[Group a streptococcal necrotizing fasciitis of the genital area (Fournier's gangrene): a case report].

A necrotizing fasciitis especially caused by group A streptococcal infection is a life-threatening disease. This infection cause death due to septic shock and multiple organ failure in a short time without the immediate and adequate treatment. Currently a rapid test kit for streptococcal pharyngitis (strep A) is useful for prediction of group A streptococcal infection. We here demonstrate a 61 years old man's case of life-saved necrotizing fasciitis in genital area (Fournier's gangrene) by group A streptococcus infection, and usefulness of this kit for rapid diagnosis, aggressive debridement, and selection of adequate antibiotics.