[A Case of Renocolic Fistula Caused by Infected Renal Cyst].

A 76-year-old male was previously found to have a renal cyst at the center of the right kidney, on a computed tomography (CT)scan for examination of another disease. The patient was admitted to the hospital because of fever. The CT scan showed an enlarged mass at the center of the right kidney and an increase in the density of peripheral fat tissue, suggesting an infection of the right renal cyst. In spite of conservative treatment with antibiotics, CT scan on the sixth day of admission revealed an increase in the size of the mass, and penetration in the ascending colon was suspected. An ultrasound-guided abscess puncture was performed, and a pigtail catheter (PC)was placed. Injection of contrast agent through the PC showed communication with the colon. The fistula site was identified using colon fiberscopy, and it was clipped. PC was removed after the closure of the fistula was confirmed by imaging. This is a rare case of renocolic fistula caused by an infected renal cyst, which was diagnosed by colon fiberscopy, and was treated by clipping the fistula.

Does screening for prostate cancer improve cancer-specific mortality in Asian men? Real-world data in Yokosuka City 15 years after introducing PSA-based population screening.

BACKGROUND: Studies of prostate-specific antigen (PSA)-based population screening have been conducted in western countries, but there is little data in Asian populations. The objective of this study was to determine the efficacy of PSA screening in Asian men using real-world data over a period of 15 years after introducing population screening in Yokosuka City, Japan. METHODS: We investigated patients with pathologically diagnosed prostate cancer at four hospitals and two clinics across the Yokosuka area (Miura peninsula) between April 2001 and March 2015. Patients were divided into two groups; the S group consisted of those diagnosed by PSA-based population screening in Yokosuka City and the NS group consisted of those diagnosed by methods other than screening. Cancer-specific survival (CSS) and overall survival (OS) rates were calculated using the Kaplan-Meier method with the log-rank test to compare survival between the two groups. Clinical and pathological factors for cancer-specific mortality were assessed with Cox regression analyses to calculate the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: A total of 3094 patients had been diagnosed with prostate cancer over the 15-year period. The median follow-up period was 77 months. The S group and the NS group consisted of 977 and 2117 patients, respectively. Patients in the S group were younger (age: 71 years vs 73 years, P < .001) and had a lower Charlson comorbidity index (CCI) with favorable oncological factors, such as lower initial PSA, Gleason score (GS), and risk category. Kaplan-Meier curves for OS and CSS revealed significant differences between the two groups (OS: P < .001, CSS: P < .001). Analysis with Cox proportional hazards model indicated the NS group (HR: 1.584, 95% CI, 1.065-2.356, P = .023), a CCI > 4 (HR: 1.552, 95% CI, 1.136-2.120, P = .006), a GS ≥ 8 (HR: 4.869, 95% CI, 2.631-9.001, P < .001), and nonlocalized cancer (locally advanced; HR: 2.632, 95% CI, 1.676-4.133, P < .001, advanced; HR: 9.468, 95% CI, 6.279-14.278, P < .001) as independent risk factors for cancer-specific mortality. CONCLUSIONS: PSA-based population screening of prostate cancer might be useful in the Japanese population.

[A Case of Purulent Penile Cavernitis with Emphysema].

An 82-year-old man visited our department with a chief complaint of penile pain and swelling. He was receiving maintenance dialysis for chronic renal failure and was catheterized because of urinary retention associated with prostatic hypertrophy. The penis was reddened with swelling extending to the root and marked tenderness. Blood tests indicated inflammation and imaging revealed an abscess with emphysematous changes in the cavernous region of the penis. The diagnosis was purulent penile cavernitis. His symptoms improved after decompression with incision and drainage. There has been no recurrence of the abscess in the 4 months since treatment.

Hapln4/Bral2 is a selective regulator for formation and transmission of GABAergic synapses between Purkinje and deep cerebellar nuclei neurons.

Purkinje cells (PCs) convey the sole output of the cerebellar cortex to the deep cerebellar nuclei (DCN). DCN neurons are enwrapped in densely organized extracellular matrix structures, known as perineuronal nets (PNNs). PNNs are typically found around fast-spiking GABAergic interneurons expressing parvalbumin but interestingly also exist surrounding other neurons, such as the neurons in the DCN and medial nucleus of the trapezoid body, which are the post-synaptic neurons of large axo-somatic synapses adapted for fast signaling. This characteristic localization prompted the hypothesis that PNNs might play a role in the maintenance and formation of large fast-signaling synapses. To elucidate the role of the PNN at these synapses, we investigated the electrophysiological and morphological properties of DCN synapses in hyaluronan and proteoglycan binding link protein 4 (Hapln4/Bral2) knockout (KO) mice around postnatal day (P)14. Hapln4/Bral2 is important for PNN structure, as it stabilizes the interaction between hyaluronan and proteoglycan. Here, using immunohistochemistry we show that Hapln4/Bral2 localized closely with GABAergic terminals. In DCN neurons of Hapln4/Bral2 KO mice, inhibitory synaptic strengths were reduced as compared to those in wild-type mice, whereas the properties of excitatory synapses were unaffected. The reduced IPSC amplitudes were mainly because of reduced numbers of releasable vesicles. Moreover, Hapln4/Bral2 deficiency reduced the number of PC GABAergic terminals in the DCN. These results demonstrate that Hapln4/Bral2 is a PNN component that selectively contributes to formation and transmission of PC-DCN synapses in the cerebellum. OPEN SCIENCE BADGES: This article has received a badge for *Open Materials* because it provided all relevant information to reproduce the study in the manuscript. The complete Open Science Disclosure form for this article can be found at the end of the article. More information about the Open Practices badges can be found at https://cos.io/our-services/open-science-badges/.

Cortical Venous Redness Represents Tissue Circulation Status in Patients With Moyamoya Disease.

BACKGROUND AND PURPOSE: Venous oxygen saturation (SO2) is measured in medical fields to assess tissue circulation insufficiency. This study aimed to elucidate the use of a cortical venous redness measurement to evaluate hemodynamic changes during revascularization surgery for patients with moyamoya disease. METHODS: In this retrospective case-series analysis, we first quantitatively measured and correlated SO2 and R intensity of 24-bit color digital red-green-blue pictures of blood samples from 3 volunteers. Subsequently, based on intraoperative digital pictures of 29 patients with moyamoya disease, we measured the R intensities of a cortical vein near the anastomosis site before and after anastomosis. Cerebral blood flow (CBF) at the site was measured using a single-photon emission computed tomography before and 1 to 3 days after surgery. Venous R intensity and CBF were measured twice by 4 raters, and their correlations were examined using generalized linear mixed effect model and linear regression analysis. RESULTS: A strong linear correlation was found between blood R intensity and its SO2 (coefficients, 0.522; 95% confidence interval, 0.364-0.680, using generalized linear mixed effect model). Venous R intensity before the anastomosis was not correlated with preoperative CBF (coefficients, 0.000352; 95% confidence interval, -0.000369 to 0.00107, by generalized linear mixed effect); however, the increases in venous R intensity after anastomosis were correlated with postoperative increases in CBF (R2, 0.367; 95% confidence interval, 0.116-0.618 to 0.548; 95% confidence interval, 0.331-0.764, by linear regression analysis). CONCLUSIONS: Cortical venous redness represented impaired CBF and could be a useful parameter for assessing hemodynamic changes during revascularization surgery.

Retrograde intrarenal surgery for urinary stone disease in patients with solitary kidney: A retrospective analysis of the efficacy and safety.

OBJECTIVES: To compare outcomes of retrograde intrarenal surgery for urolithiasis between patients with solitary kidneys and patients who have single-side urolithiasis with bilateral kidneys. METHODS: We retrospectively analyzed outcomes of retrograde intrarenal surgery in solitary kidney patients (group A) carried out during 2007-2014, and in patients with bilateral kidneys with comparable stone burdens (group B). Stone-free status was defined as no residual fragment on computed tomography 1 month later. RESULTS: There were 19 patients in group A (mean age 62.5 ± 18.4 years, range 14-76 years). The mean stone diameter and burden were 6.0 mm (range 3-24 mm) and 10.42 ± 6.92 mm, respectively. The stone-free rate was 94.7%, and no repeat procedure was required. The glomerular filtration rate tended to rise post-surgery (postoperative day 1: 48.67 ± 15.92 mL/min, 100.2%, P = 0.940; postoperative month 1: 51.32 ± 16.90 mL/min, 105.7%, P = 0.101) compared with preoperative rates. The stone-free rate and surgery time were not significantly different between the two groups, although post-surgical hospitalization time was longer for group A (4.05 vs 3.08 days, P = 0.037). The change in glomerular filtration rate was not significantly different between groups A and B (postoperative day 1: +0.101 vs +0.547 mL/min, respectively, P = 0.857; postoperative month 1: +2.749 vs 3.161 mL/min, respectively, P = 0.882). No significant difference was found in terms of complication rate. CONCLUSIONS: Retrograde intrarenal surgery in solitary kidney patients is as safe and effective as in bilateral kidney patients.

Risk factors of systemic inflammation response syndrome after endoscopic combined intrarenal surgery in the modified Valdivia position.

OBJECTIVE: To identify risk factors of developing systemic inflammation response syndrome after endoscopic combined intrarenal surgery in the modified Valdivia position for renal stone treatment. METHODS: We retrospectively analyzed 370 consecutive patients who underwent endoscopic combined intrarenal surgery procedures in the modified Valdivia position to treat renal stones. Antibiotic therapy based on preoperative urine cultures was administered to all patients from induction of anesthesia until at least postoperative day 3. Postoperative systemic inflammation response syndrome was diagnosed if the patient met two or more systemic inflammation response syndrome criteria. A multivariate logistic regression model with backward selection was used to evaluate the relationships between the incidence of systemic inflammation response syndrome after endoscopic combined intrarenal surgery and other clinical factors. RESULTS: Of the 370 patients, 61 patients (16.5%) were diagnosed with systemic inflammation response syndrome after endoscopic combined intrarenal surgery. Significant differences were found between the non-systemic inflammation response syndrome and systemic inflammation response syndrome groups with regard to female sex (29.8% vs 44.3%, P = 0.027), history of febrile urinary tract infection (16.5% vs 32.8%, P = 0.015) and number of involved calyces (2.68 vs 4.1, P < 0.001). Multivariate analysis found three independent predictors of postoperative systemic inflammation response syndrome: the number of involved calyces (P = 0.017), stone surface area (P = 0.021) and history of febrile urinary tract infection (P = 0.005). CONCLUSIONS: The number of involved calyces larger than four, stone surface area >500 mm(2) and a history of febrile urinary tract infection independently predicted the development of systemic inflammation response syndrome after endoscopic combined intrarenal surgery. This is the first study to identify the independent predictors of systemic inflammation response syndrome after endoscopic combined intrarenal surgery in the modified Valdivia position.

[A Case of Endoscopic Combined Intrarenal Surgery for Multiple Encrusted Stones on a Forgotten Ureteral Stent Left for 4 Years].

A 43-year-old man underwent extracorporeal shock wave lithotripsy (ESWL) for a left ureteral stone and implantation of a loop stent for the treatment of stone pain in February 2011. However, he was lost to follow-up before the complete removal of the stones and stent. He presented to our hospital with left back pain in March 2015. An abdominal radiograph and a noncontrast computed tomography showed extensive stone formation throughout the stent. A single cystolithotripsy and a double endoscopic combined intrarenal surgery (ECIRS)were performed. All the stones and the encrusted ureteral stent were successfully removed.

[A Case of Abdominal Wall Desmoid Tumor after Radical Nephrectomy for Renal Cancer].

A 71-year-old man with a right renal tumor underwent nephrectomy. The procedure was converted from laparoscopy to open surgery due to profound bleeding from the renal vein. Pathological diagnosis was clear cell carcinoma G2pT3b v1 ly1 INFα. Three years after surgery, a 5 cm tumor in the abdominal wall was found on computed tomography (CT). A mild uptake was shown on positron emission tomography/CT and as the tumor was located near the surgical wound, recurrence of the renal cell carcinoma was suspected. However, desmoid tumor was suggested by the pathological examination of the tumor biopsy. En-bloc resection of the mass was carried out and the pathological examination showed an array of proliferating and tangling atypical spindle-shaped tumor cells. Immunohistochemical staining of the tumor cells was positive for vimentin, but negative for CD34, c-kit, and s100. Pathological diagnosis was desmoid tumor. There has been no recurrence so far. Desmoid tumor, despite its extremely low incidence, should be considered in a postoperative neoplasm.

[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.

[A case of pneumatosis cystoides intestinalis secondary to sunitinib treatment for renal cell carcinoma].

A 78-year-old man was diagnosed as having right renal cell carcinoma (RCC) with metastasis to the right lung. He received sunitinib and the treatment reduced the size of both RCC and lung metastasis. Then he received right radical nephrectomy. The pathological diagnosis was clear cell RCC. After the initial surgery, he was diagnosed with polymyalgia rheumatic and steroid therapy was started. During follow-up, local recurrence was discovered and sunitinib was then started at a dose of 25 mg/day. Two months after the treatment, abdominal computed tomography (CT) revealed colonic pneumatosis cystoides intestinalis. Administration of sunitinib was stopped and the patient was observed carefully without pursuing surgical intervention. A follow-up CT demonstrated resolution of the colonic pnumatosis.

[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.

Unexpected change in hydrogel spacer volume during external-beam radiation therapy.

PURPOSE: To reduce the rectal radiation dose during local radiation therapy of prostate cancer, a hydrogel spacer is typically implanted between the prostate and rectum. However, the spacer volume can change during external beam radiation therapy (EBRT). Therefore, we used magnetic resonance imaging (MRI) to determine changes in the spacer volume during EBRT and analyzed the data to identify patient factors influencing this change. MATERIALS AND METHODS: A hydrogel spacer was implanted in each enrolled patient diagnosed with prostate cancer (n = 22, age = 69-86 years) for EBRT with a total dose of 70 Gy over 35 fractions. T2-weighted MRI images were acquired before (median = 8 days) and during EBRT, when the radiation dose of 48 Gy (median) was given at 55 days (median) after implantation. MRI images were used to determine the spacer volume as well as the maximum and minimum distances between the prostate and anterior wall of the rectum at the middle height of the prostate. Scatterplots were created to determine whether correlations existed between changes in the spacer volume and these two distances, while uni- and multivariate analyses were conducted to determine if the spacer volume change was influenced by the following patient factors: age, body mass index, estimated glomerular filtration rate, and visceral fat areas at the umbilical and femoral head positions. RESULTS: The spacer volume increased in all 22 patients, with the smaller spacer volume before EBRT increasing by a larger amount during EBRT. This increase in the spacer volume was unaffected by other patient factors. However, it correlated with the change in the maximum distance between the prostate and anterior wall of the rectum. CONCLUSION: To avoid adverse changes in the rectal radiation dose during EBRT, hydrogel spacer volume should be monitored, especially if the pre-EBRT volume is small.

Total laparoscopic wedge resection for an intramural ectopic pregnancy using an intraoperative ultrasound system: A case report.

Intramural pregnancy is a rare form of ectopic pregnancy, and the optimal treatment remains uncertain. We describe a 33-year-old woman (gravida 2, para 0) who visited our hospital with suspected ectopic pregnancy. The patient was asymptomatic and hemodynamically stable. Transvaginal ultrasonography revealed pregnancy at 6 weeks of gestation and a gestational sac and fetal heartbeat in the anterior muscular layer of the uterus, away from the endometrium. The fetal sac measured 26 mm. The serum human chorionic gonadotropin (hCG) level had increased to 27 655 mIU/mL. Accordingly, the patient was diagnosed with an intramural ectopic pregnancy and underwent total laparoscopic wedge resection using intraoperative ultrasonography. The postoperative course was uneventful, and she was discharged after 4 days. Her serum hCG level normalized at 26 days postoperatively. This case indicates that intraoperative laparoscopic ultrasonography seems viable for treating intramural pregnancies.

[A case of retroperitoneal bronchogenic cyst treated by laparoscopic surgery].

A 51-year-old woman was referred to our hospital because of continuing back pain for 2 weeks. Computed tomography revealed a mass 30x40 mm in diameter adjacent to the left adrenal gland. We performed laparoscopic surgery in order to relieve the symptoms and make a diagnosis. Because there was adhesion between the mass and gastric wall, the mass was resected together with the gastric wall. Histopathological findings revealed the cyst with ciliated columunar epithelium and the final diagnosis was retroperitoneal bronchogenic cyst. There was no evidence of malignancy and the back pain disappeared.

[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 aggressively growing bladder cancer in patient with long-term cystostomy due to spinal cord injury].

The patient was a 38-year-old man. A cystostomy catheter had been inserted when he was 23 years of age for neuropathic bladder due to cervical spinal cord injury at 20 years of age. Purulent discharge from around the cystotomy had continued for approximately 4 months. Examination revealed the formation of a subcutaneous tumor around the cystostomy, with elevated carcinoembryonic antigen (CEA) levels (459.4 ng/ml) in the blood. Urothelial carcinoma was detected using open biopsy. It was considered that primary urothelial carcinoma of the bladder had progressed along the cystostomy, and clinical stage 4 cT4N2M0 was diagnosed, with intrapelvic lymph node metastasis evident on imaging. Four courses of gemcitabine-cisplatin chemotherapy were administered; a partial response was obtained, after which cystectomy and ileal conduit formation were performed with the main aim of improving difficulty in urination. However, retroperitoneal lymph node and liver metastases were observed 1 month postoperation with rapid enlargement; the patient died approximately 2 months after the surgery. The CEA level was observed to be 18,998 ng/ml before he died. Here, we have reported this case with a discussion of the literature concerning the association between long-term indwelling catheter in patients with spinal cord injury and the development of bladder cancer.

A case of perforation of the prostatic abscess into the rectum resulting in a rectoprostatic fistula.

Introduction: A rectoprostatic fistula complicating a prostatic abscess is extremely rare, and there are many uncertainties regarding its treatment and prognosis. Case presentation: We present the case of a 68-year-old male who presented with rectal bleeding. Computed tomography reveals a prostatic abscess in contact with the rectum. As conservative treatment with antibiotics resulted in the aggravation of symptoms, we placed a transperineal catheter placement in the prostate, followed by drainage of the abscess through the catheter. The abscess communicated with the rectum, forming a rectoprostatic fistula. Subsequently, a transverse colostomy was performed. The abscess resolved, and no recurrence was observed even after 6 months of drainage. However, the rectal ulceration that resulted in the formation of the fistula persisted, and stoma closure was not achieved. Conclusion: In cases of prostatic abscess complicated by rectoprostatic fistula, drainage of the abscess along with colostomy seems essential for a curative approach.

Combination therapy with predicted body weight-based dexamethasone, remdesivir, and baricitinib in patients with COVID-19 pneumonia: A single-center retrospective cohort study during 5th wave in Japan.

BACKGROUND: Dexamethasone, remdesivir, and baricitinib reduce mortality in patients with coronavirus disease 2019 (COVID-19). A single-arm study using combination therapy with all three drugs reported low mortality in patients with severe COVID-19. In this clinical setting, whether dexamethasone administered as a fixed dose of 6 mg has sufficient inflammatory modulation effects of reducing lung injury has been debated. METHODS: This single-center retrospective study was conducted to compare the treatment strategies/management in different time periods. A total of 152 patients admitted with COVID-19 pneumonia who required oxygen therapy were included in this study. A predicted body weight (PBW)-based dose of dexamethasone with remdesivir and baricitinib was administered between May and June 2021. After this period, patients were administered a fixed dose of dexamethasone at 6.6 mg/day between July and August 2021. The additional respiratory support frequency of high-flow nasal cannula, noninvasive ventilation, and mechanical ventilation was analyzed. Moreover, the Kaplan-Meier method was used to analyze the duration of oxygen therapy and the 30-day discharge alive rate, and they were compared using the log-rank test. RESULTS: Intervention and prognostic comparisons were performed in 64 patients with PBW-based and 88 with fixed-dose groups. The frequency of infection or additional respiratory support did not differ statistically. The cumulative incidence of being discharged alive or oxygen-free rate within 30 days did not differ between the groups. CONCLUSIONS: In patients with COVID-19 pneumonia who required oxygen therapy, combination therapy with PBW-based dexamethasone, remdesivir, and baricitinib might not shorten the hospital stay's length or oxygen therapy's duration.

[Three dysuria adults without continuous medical treatment after surgery for spina bifida in infancy].

We encountered three patients with dysuria who had undergone spinal surgery for spina bifida during infancy. The patients presented with mental disability and dysbasia. Difficulty in urination, urinary incontinence, and a residual sensation of urine were resolved through intermittent self-catheterization in all patients. It was speculated that treatment for dysuria in these patients was delayed because they were not aware of its association with their condition during infancy, dysuria was relatively mild, and they had no history of febrile urinary tract infection. It is important for attending physicians to explain to parents of such infants the possible association of spina bifida with the future risk of dysuria, and to consider long-term follow-up to monitor their outcome.