[A Case of Castration-Resistant Prostate Cancer after Prostatectomy Treated with Resection of A Solitary Metastatic Site].

A 72-year-old man underwent a bilateral nerve-sparing radical retropubic prostatectomy (RRP) with pelvic lymph node dissection 11 years earlier. His prostate specific antigen (PSA) value at diagnosis was 61.024 ng/ml. Bone scans and computed tomographic (CT) scans showed no metastasis. Pathological findings and stage were adenocarcinoma, Gleason score 4+3, positive surgical margin, pT3b, and no lymph node metastasis. The postoperative PSA nadir was 0.218 ng/ml, and salvage radiotherapy (SRT, total 66 Gy) was performed six months after RRP. However, the PSA value continued to rise after SRT. Therefore, androgen deprivation therapy (ADT) was started 11 months after SRT. Nine years postoperatively, the PSA value showed a continuous rise despite ADT, and prostate cancer was considered to be castration-resistant. Although he was taking enzalutamide, his PSA value rose to 18. 271 ng/ml. Repeated bone scans and CT scans were negative. Eleven years after RRP, the fluoro-2-deoxy-D-glucosepositronemissiontomography (FDG-PET) revealed a nodule lesiondorsal to the left pubic bone. The patient underwent a resection of the lesion. Three months after the resection, his PSA level declined to 0.038 ng/ml, thus ADT was discontinued. Thirteen months after the resection, PSA re-elevation was absent, and follow-up without ADT is ongoing.

[A Case of Nivolumab-Induced Isolated Adrenocorticotropic Hormone Deficiency Presenting Dyspnea].

A 66-year-old man had undergone multiple treatments for metastatic renal cell carcinoma, including 11 cycles of nivolumab, which was discontinued because of disease progression. About three weeks after discontinuing nivolumab, he reported suffering from worsening of dyspnea. Pulse oximetry showed no desaturation. His cardiovascular and pulmonary functions were normal. His dyspnea slowly worsened with no underlying diagnosis. Two months after symptoms developed, he was diagnosed with isolated adrenocorticotropic hormone deficiency. His dyspnea disappeared soon after receiving hydrocortisone. Nivolumab-induced isolated adrenocorticotropic hormone deficiency may not present with typical symptoms, and can occur even after discontinuing nivolumab. Cortisol levels should be routinely monitored in patients who receive nivolumab.

[Efficacy of prophylactic intravesical mitomycin C in patients with non-muscle-invasive bladder cancer].

Intravesical chemotherapy is beneficial for patients with non-muscle-invasive bladder cancer (NMIBC), but optimal drug and regimen selection can be controversial. Mitomycin C (MMC) is commonly used as adjuvant treatment for NMIBC. We retrospectively evaluated the outcomes of 73 patients with NMIBC who were treated with weekly doses of low-dose MMC (20 mg ; n=28 ; 38.4%) or high-dose MMC (40 mg ; n=45 ; 61.6%) for 6 weeks each, at our hospital between 2001 and 2010. Treatment outcomes were examined by Kaplan‒Meier analysis with log-rank tests. Patients in the high-dose group showed greater recurrent-free survival (61.3%) at 2 years than did patients in the low-dose group (32.6%) (P<0.05). We also found that a single early dose of pirarubicin following transurethral resection of bladder tumor improved MMC efficacy in the high-dose group. The high-dose group had a somewhat higher incidence of dysuria, urinary frequency and drug eruption, but the difference was not significant.

[Gastric metastasis from renal cell carcinoma: two case reports].

Gastric metastasis from renal cell carcinoma (RCC) is a very rare event and treatment for such patients has not been established. We report two cases of gastric metastasis from RCC. The first case was in a 67- year-old man with a past history of right radical nephrectomy for RCC (ypT3aN0M0) six years ago. The whole-body computed tomography (CT) revealed multiple lung nodules. We performed gastrointestinal endoscopy to find the primary lesion, and detected multiple submucosal tumors in the gastric body. Needle biopsy of these tumors revealed gastric metastasis from RCC. Oral sorafenib tosylate therapy was started. Twenty months later, gastrointestinal endoscopy showed only gastric erosion without malignant evidence. The second case was in a 70-year-old man complaining of epigastralgia. He had undergone right partial nephrectomy for RCC (pT1aN0M0) six years ago, and thoracoscopic wedge resection of a solitary lung nodule one year ago. Gastrointestinal endoscopy detected a solitary hyperplastic polyp in the anterior wall of the gastric body. Needle biopsy of this polyp revealed gastric metastasis from RCC. We performed laparoscopic partial gastrectomy. Gastrointestinal endoscopy and CT showed no evidence of metastasis or recurrence for 14 months after gastrectomy.

[Effect of change to flutamide for prostate cancer patient who developed breast pain during bicalutamide treatment (BIP-F study)].

In Japan, prostate cancer is treated with non-steroidal anti-androgen (flutamide and bicalutamide). Development of breast pain during bicalutamide treatment, in prostate cancer patients reduces their quality of life (QOL) and treatment compliance. We studied the safety and effectiveness of switching from bicalutamide to flutamide in 13 prostate cancer patients who developed breast pain during bicalutamide treatment. We estimated the change in breast pain using a face scale and the Expanded Prostate Cancer Index Composite (EPIC) and EPIC-hormone domain (HD) score. The switch to flutamide relieved breast pain in nine patients, had no effect in one patient, and increased breast pain in two patients. One patient dropped out. Furthermore, summary score and hormone function were improved with a significant difference in the EPIC-HD score. Switching to flutamide in prostate cancer patients who develop breast pain during bicalutamide is safe and effective.

Antimicrobial prophylaxis to prevent perioperative infection in urological surgery: a multicenter study.

We prospectively investigated the rates of incidence of surgical site infection (SSI), urinary tract infection (UTI), and remote infection (RI) in 4,677 patients who underwent urological surgery from January to December 2010, including 2,507 endourological cases, 1,276 clean cases, 807 clean-contaminated cases, and 87 contaminated cases involving bowel segments. A single dose of antimicrobial prophylaxis (AMP) was administered in the endourological, clean, and clean-contaminated surgery cases, except for patients who underwent transurethral resection of the prostate (TURP) or percutaneous nephrolithotripsy (PNL). AMP was administered within 72 h in TURP and PNL, and AMP was administered within 48 h in contaminated surgery cases. In cases of endourological surgery, UTI was observed in 4% and RI in 0%, and SSI, UTI, and RI were seen in 1%, 1%, and 1%, respectively, of clean surgery cases, in 3%, 3%, and 2%, respectively, of clean-contaminated surgery cases, and in 17%, 30%, and 10%, respectively, of contaminated surgery cases. In multivariate analysis of the risk factors for infection, operative time was a significant risk factor for UTI in endourological surgery, and American Society of Anesthesiologists score and operative time were significant risk factors for RI in clean surgery. No significant risk factor was found in analyses of clean-contaminated and contaminated surgery cases. A single-dose AMP regimen was shown to be effective and feasible for prevention of perioperative infection in urological surgery.

[The role of dynamic contrast-enhanced magnetic resonance imaging in diagnosis of torsion of the testicular appendix : a case report].

A 7-year-old male presented to our hospital with pain and swelling in the right scrotum for 9 days. On physical examination a swollen right scrotum was noted and right side cremasteric reflex disappeared. Ultrasound examination showed enlarged right testis and epididymis. Subsequent dynamic contrast enhanced magnetic resonance imaging (MRI) showed a 7 mm area of high signal intensity anterior to the right testis on coronal imaging of T2-weighted. Subtraction MRI revealed testicular perfusion and a nonenhanced mass was also identified anterior to the right testis. These findings indicated a diagnosis of torsion of the testicular appendix. We performed excision of the torsed appendage.

Effectiveness and Safety of a Mixture of Nobiletin and Tangeretin in Nocturia Patients: A Randomized, Placebo-Controlled, Double-Blind, Crossover Study.

Nobiletin and tangeretin (NoT) are flavonoids derived from the peel of Citrus depressa, and they have been found to modulate circadian rhythms. Because nocturia can be considered a circadian rhythm disorder, we investigated the efficacy of NoT for treating nocturia. A randomized, placebo-controlled, double-blind, crossover study was conducted. The trial was registered with the Japan Registry of Clinical Trials (jRCTs051180071). Nocturia patients aged ≥50 years who presented nocturia more than 2 times on a frequency-volume chart were recruited. Participants received NoT or a placebo (50 mg once daily for 6 weeks), followed by a washout period of ≥2 weeks. The placebo and NoT conditions were then switched. Changes in nocturnal bladder capacity (NBC) were the primary endpoint, and changes in nighttime frequency and nocturnal polyuria index (NPi) were secondary endpoints. Forty patients (13 women) with an average age of 73.5 years were recruited for the study. Thirty-six completed the study, while four withdrew. No adverse events directly related to NoT were observed. NoT had little effect on NBC compared with the placebo. In contrast, NoT significantly changed nighttime frequency by -0.5 voids compared with the placebo (p = 0.040). The change in NPi from baseline to the end of NoT was significant (-2.8%, p = 0.048). In conclusion, NoT showed little change in NBC but resulted in decreased nighttime frequency with a tendency toward reduced NPi.

[A case report of Cowper's syringocele in an adult treated with transurethral unroofing].

We present an adult case of Cowper's syringocele. A 19-year-old male presented with the chief complaint of persistent post-voiding dribbling 5 months after onset. Urethroscopy demonstrated a thin membrane with a small orifice on the ventral aspect distal to the external sphincter. Magnetic resonance imaging showed a restiform shadow on the left side of the corpus spongiosum. Retrograde urethrogram showed filling of diverticulum-like structure in the region of urethral bulb terminating in the urogenital diaphragm. Considering the results mentioned above, we diagnosed the patient with Cowper's syringocele. Transurethral unroofing of the Cowper's syringocele was performed with a cold knife, and the excessive tissue on the edge of syringocele was electroresected to avoid recurrence. His post-voiding dribbling resolved completely after the procedure and has not recurred in 13 months postoperatively. Cowper's syringocele is typically diagnosed presenting with hematuria, urinary tract infection, and disuria in male infants and children. Adult cases of Cowper's syringocele are rare, and only 32 cases including the present case have been reported. Proper awareness of this entity and careful evaluation are important if patients present with persistent adult-onset voiding dysfunction.

[Two cases of congenital pelvic arteriovenous malformation in male].

Congenital pelvic arteriovenous malformation(AVM) is extremely rare, especially in males. Herein we report two males with pelvic AVM. Computed tomography (CT) or magnetic resonance imaging (MRI) demonstrated markedly dilated, and tortuous vessels in the pelvis in both patients. The first patient, a 77- year-old male, presented with difficulty in voiding and weak urinary stream. He was scheduled to have a prostate biopsy for suspicion of prostate cancer with pelvic lymph node swelling. However, the mass was diagnosed as pelvic AVM with MRI, and the prostate biopsy was cancelled. He has been followed conservatively since then. The second patient, a 55-year-old male, presented with gross hematuria which caused severe hemorrhagic hypovolemic shock. He had pelvic AVM, and he was treated with transcatheter arterial embolization two times. When patients with this disease present with general urological symptoms, urological procedures, without attention to this disease, might cause severe complications such as serious hemorrhage. We discuss the clinical course and the treatment for AVM, and review the literature.

Predictive factors and radiological findings of adrenohepatic adhesion during laparoscopic adrenalectomy.

Purpose: This retrospective study aimed to identify predictive factors and imaging features of adrenohepatic adhesion found during laparoscopic right adrenalectomy. Materials and Methods: Altogether, 77 patients underwent laparoscopic right adrenalectomy between January 2005 and December 2018. Adrenohepatic adhesion was defined as strict adhesion that required either partial adrenalectomy with coagulation of residual tissue or partial hepatectomy to accomplish complete resection. We assessed their surgical video records to determine if adrenohepatic adhesion was present. Age, sex, body mass index, tumor size, tumor diagnosis and radiological findings (attachment between the liver and the adrenal gland, diameters of the right and left adrenal veins and its ratio) were evaluated as preoperative variables. Results: Adrenohepatic adhesion was present in 11 of the 77 patients (14.3%). Age, sex, and body mass index were not statistically significant factors. Tumor size was significantly small in adhesion group (14.2 mm vs. 25.9 mm, p=0.02). Attachment to the liver and adrenal gland was frequently seen regardless of the adhesion. The mean right/left adrenal veins diameters ratio was significantly lower in the adhesion group (0.8 vs. 1.1, p=0.01). Multivariate logistic regression analysis demonstrated the right/left adrenal veins diameters ratio was the only significant predictor of adhesion. The sensitivity, specificity, negative predictive value and positive predictive value were 0.82, 0.76, 0.43, and 0.95 respectively when the optimal cutoff value for the ratio was 0.9 (area under the curve, 0.75; 95% confidence interval, 0.60-0.90). Conclusions: The right/left adrenal veins diameters ratio was possible predictor of adrenohepatic adhesion.

[Hormone refractory prostate carcinoma metastasizes to the penis: a case report].

A 76-year-old man presented with urinary retention and penile discomfort. At 67-years-old, he was diagnosed with stage D2 prostate cancer and then, was treated with hormone therapy. Several nodules were observed on the glans, and histological examination of the penile tumor biopsy showed metastatic adenocarcinoma of the prostate. For the purpose of maintaining quality of life, transurethral resection of the prostate and partial penectomy were done. Twelve months have passed after the surgery, he is free from discomfort and progressive disease has not been observed.

[Hormone refractory prostate carcinoma metastasizes to the penis: a case report.]

A 76-year-oldman presentedwith urinary retention andpenile discomfort. At 67 years old, he was diagnosedwith stage D2 prostate cancer andthen, was treatedwith hormone therapy. Several nodules were observedon the glans, andhistological examination of the penile tumor biopsy showedmetastatic adenocarcinoma of the prostate. For the purpose of maintaining quality of life, transurethral resection of the prostate andpartial penectomy were done. Twelve months have passedafter the surgery, he is free from discomfort and progressive disease has not been observed.

Acute renal failure after exercise in a Japanese sumo wrestler with renal hypouricemia.

Familial renal hypouricemia is a hereditary disease characterized by extraordinary high renal uric acid clearance and is associated with acute renal failure (ARF). An 18-year-old sumo wrestler developed ARF after anaerobic exercise. Several hours after the exercise, he had a pain in the loins with oliguria, headache, and nausea. On admission, his serum uric acid was decreased despite the elevation of serum creatinine (9.5 mg/dL). The level of creatine kinase was normal and there was no myoglobinuria or urolithiasis. Magnetic resonance imaging showed no significant abnormality. Renal function improved completely within 2 weeks of hydration treatment. After remission, hypouricemia became obvious (1.0 mg/dL) from the initial level of uric acid (6.1 mg/dL) and fractional excretion of uric acid was 49%. Polymerase chain reaction of a urate anion exchanger known to regulate blood urate level (SLC22A12 gene: URAT1) demonstrated that homozygous mutations in exon 4 (W258X). Both parents showed heterozygous mutation of the URAT1 gene, but both siblings showed no mutation. Thus, we describe a Japanese sumo wrestler of familial renal hypouricemia complicated with anaerobic exercise-induced ARF, with definite demonstration of genetic abnormality in the responsible gene, URAT1.

Peritoneal Tuberculosis After Robot-Assisted Laparoscopic Prostatectomy with Extended Lymph Node Dissection.

Background: Peritoneal tuberculosis (TB) is a relatively uncommon presentation of extrapulmonary TB. Early diagnosis of peritoneal TB is difficult because of its nonspecific clinical manifestation such as abdominal pain, fever, or ascites. Especially early after surgery of abdomen or pelvis, these symptoms can be misdiagnosed as septic peritonitis. There are few reports of peritoneal TB as a postoperative complication of laparoscopic surgery. Here, we describe a first case of peritoneal TB after robot-assisted laparoscopic prostatectomy (RALP) with extended lymph node dissection. Case Presentation: A 78-year-old man presented 25 days after this surgery with fever and abdominal distension. Ultrasonography and computed tomography (CT) revealed massive abdominal ascites. Ascites sample was cloudy, with increased white blood cells and normal creatinine level. No anastomotic leak was found. Bacterial infection of a lymphocele was considered, and cefmetazole 2 g/day for 3 days was prescribed. Despite antibacterial therapy, fever persisted. Polymerase chain reaction testing of ascitic fluid was positive for Mycobacterium tuberculosis. The patient was effectively treated with anti-TB therapy. Conclusion: This is the first report of peritoneal TB as a postoperative complication of RALP with extended lymph node dissection. His preoperative chest CT showed granular shadows in left upper lung, indicating his old asymptomatic TB infection. Flare-up of TB can happen even after robot-assisted laparoscopic surgery, which is minimally invasive. Peritoneal TB must be considered especially when there is unexplained ascites unresponsive to antibiotics.