Video-urodynamic effects of vibegron, a new selective ß3-adrenoceptor agonist, on antimuscarinic-resistant neurogenic bladder dysfunction in patients with spina bifida.

OBJECTIVES: To evaluate the efficacy, safety and tolerability of vibegron for the treatment of antimuscarinic-resistant neurogenic bladder dysfunction in patients with spina bifida. METHODS: In this retrospective study, 15 patients with antimuscarinic-resistant neurogenic bladder dysfunction due to spina bifida underwent a video-urodynamic study before and during the administration of vibegron 50 mg once daily instead of antimuscarinic agents from February 2019 through April 2021. The video-urodynamic study was carried out to evaluate bladder compliance, maximum cystometric bladder capacity, detrusor overactivity, detrusor leak point pressure and vesicoureteral reflux before and >3 months after the beginning of vibegron administration. RESULTS: Treatment with vibegron significantly improved bladder compliance and maximum cystometric bladder capacity compared with antimuscarinic agents, respectively (7.4 ± 4.2 vs 30.4 ± 48.2 mL/cmH2 O, P = 0.0001; 231.4 ± 81.2 vs 325.2 ± 106.5 mL, P = 0.0005). Detrusor overactivity did not change after the administration of vibegron. Bladder deformity, which was confirmed in 12 patients, improved in half of the patients after taking vibegron. Vesicoureteral reflux, which was confirmed in two patients, was extinguished after taking vibegron. Newly occurring adverse events were not observed, and all patients continued to take vibegron during the treatment period. CONCLUSIONS: Favorable efficacy of vibegron for antimuscarinic-resistant neurogenic bladder dysfunction due to spina bifida was shown video-urodynamically without apparent adverse events. Vibegron is a favorable option for the treatment of antimuscarinic-resistant neurogenic bladder dysfunction in patients with spina bifida.

[A Practical Technique for Challenging Ureterocystoneostomy : Application of Casale Vesicostomy with Rink-Modification].

In order to treat the iatrogenic ureteral stricture of more than 8 cm length after transurethral ureterolithotripsy, we planned to perform ureterocystoneostomy with psoas hitch and Boari flap. Because of the longer defect of the affected ureter than presurgically expected and the rigid and thickened ureteral stump resulting from chronic inflammation, anti-reflux technique by forming submucosal tunnel could not be achieved as in the standard Boari flap and we reluctantly anastomosed the ureteral stump to the end of the tubularized bladder wall flap in end-to-end fashion. In order to secure the anti-reflux mechanism we created a submucosal tunnel in the posterior bladder wall according to the technique reported by Casale and Rink where it originally worked as anti-incontinence mechanism of catheterizable vesicostomy. The follow-up examinations showed no recurrence of ureteral stricture nor occurrence of vesicoureteral reflux.

Optimal timing of ureteroscopic lithotripsy after the initial drainage treatment and risk factors for postoperative febrile urinary tract infection in patients with obstructive pyelonephritis: a retrospective study.

BACKGROUND: A history of preoperative obstructive pyelonephritis has been reported as a risk factor for febrile urinary tract infection (fUTI) after ureteroscopic lithotripsy (URSL). But there is no clear evidence of risk factors for developing fUTI including the optimal timing of URSL after obstructive pyelonephritis treatment. METHODS: Of the 1361 patients, who underwent URSL at our hospital from January 2011 to December 2017, 239 patients had a history of pre-URSL obstructive pyelonephritis. The risk factors were analyzed by comparing the patients' backgrounds with the presence or absence of fUTI after URSL. The factors examined were age, gender, body mass index, comorbidity, presence or absence of preoperative ureteral stent, stone position, stone laterality, stone size, Hounsfield unit (HU) value on computed tomography scan, history of sepsis during obstructive pyelonephritis, period from antipyresis to URSL, ureteral stenting period, operation time, and presence or absence of access sheath at URSL. In addition, the stone components and renal pelvic urinary culture bacterial species during pre-URSL pyelonephritis were also examined. RESULTS: Post-URSL fUTI developed in 32 of 239 patients (13.4%), and 11 of these 32 cases led to sepsis (34.4%). Univariate analysis showed that stone position, stone maximum HU value, presence of sepsis during obstructive pyelonephritis, period from antipyresis to URSL, pre-URSL ureteral stent placement, operation time were risk factors of fUTI. Stone components and urinary cultures during pyelonephritis were not associated with risk of fUTI. Multivariate analysis showed that renal stone position, pre-URSL ureteral stent placement > 21 days, and operation time > 75 min were independent risk factors of fUTI following the URSL. CONCLUSIONS: F-UTI following the URSL could be avoided by ureteral stent placement period 21 days or less and operation time 75 min or less in patients with obstructive pyelonephritis.

Development and Validation of the Japanese Version of Quality of Life Assessment of Spina Bifida in Children (QUALAS-C-J).

BACKGROUND: We previously developed the Japanese version of The Quality of Life Assessment of Spina Bifida in Teenagers, a health-related quality-of-life instrument specific to children aged 13-17 years with spina bifida (SB). The Quality of Life Assessment of Spina Bifida in Children is a version of this questionnaire for children aged 8-12 years. The purpose of this study was to develop a Japanese version of the Quality of Life Assessment of Spina Bifida in Children (QUALAS-C-J) and verify its reliability and validity. METHODS: Three urologists specializing in SB, 2 nurses, and 1 statistician developed the QUALAS-C-J and conducted a pilot and main survey. Participants included children with SB and non-disabled (ND) children. Participants completed the QUALAS-C-J and the Japanese version of KIDSCREEN-27 (J-KIDSCREEN) without parental help. RESULTS: Five children with SB participated in the pilot study and provided face and content validity. Sixty-three children with SB and 40 age- and sex-matched ND children participated in the main survey. The intraclass correlation coefficient in the retest was 0.80, and Cronbach's alpha in each domain was 0.73. The validity was verified by factor analysis, convergent / divergent validity, and known-groups validity. Factor analysis converged to the same two-factor structure as the original version. The correlation between QUALAS-C-J and J-KIDSCREEN-27 was weak (r=-0.06-0.30). The scores of both groups for the two domains of the QUALAS-C-J were significantly lower in SB than ND children. CONCLUSIONS: QUALAS-C-J is easy to answer, suitable for Japanese children with SB, reliable, and valid. It can be a communication tool for children with SB, medical staff, families, communities, and school teachers.

[A Case of Bladder Squamous Cell Carcinoma with Neurogenic Bladder Caused by Myelomeningocele].

A 38-year-old woman with neurogenic bladder caused by myelomeningocele,who had been on clean intermittent self-catheterization for years,complained of gross hematuria. Computerized tomography, urinary cytology and cystoscopy failed to reveal causative lesions and the hematuria ceased spontaneously. Because gross hematuria recurred 2 years later,we examined the patient again and detected calcification of the urinary bladder. Mucosal lesions suspicious of bladder tumor were detected during the transurethral surgery for the calcified lesion,and we promptly performed biopsy. As a result,she was diagnosed with invasive bladder squamous cell carcinoma. Radical cystectomy and urinary diversion were performed and the histopathological diagnosis was pT3aN0. Adjuvant therapies were not performed. No recurrence has been observed for 36 months after the surgery.

The diagnostic utility of retroperitoneoscopic tissue biopsy for unresectable retroperitoneal lesions excluding urogenital cancers.

BACKGROUND: Retroperitoneal tumors are an uncommon disease known to consist of a diverse group of benign and malignant neoplasms. Treatment of unresectable retroperitoneal lesions requires pathological diagnosis. Here, we report the utility and safety of retroperitoneoscopic biopsy for unresectable retroperitoneal lesions excluding urogenital cancers. METHODS: We analyzed 47 patients consisting of 23 (49%) and 24 (51%) cases that underwent retroperitoneoscopic tissue biopsy and open biopsy, respectively. The clinicopathological features, including postoperative complications, were compared between the two groups. RESULTS: Tumor pathology was diagnosed successfully with a single operation in all patients. Malignant pathology (68%) was more common than benign pathology (32%). The most common pathology was malignant lymphoma, which accounted for about 50% of all cases. There was no significant difference with respect to the age, sex, tumor size, presence of tumor-related symptom, histopathology, operative time, and complications. Three (13%) of 23 patients in the retroperitoneoscopic biopsy group received percutaneous needle biopsy before laparoscopic excisional biopsy because the evaluation of needle cores failed to confirm subclasses of diagnosed pathologies. One patient was converted to open surgery just after the initiation of operation due to severe adhesion of adjacent structures. We had two cases with iatrogenic urinoma due to ureteral injury after retroperitoneoscopic biopsy. CONCLUSIONS: We conclude that retroperitoneoscopic biopsy is a safe and useful tool for benign and malignant retroperitoneal lesions, in comparison to open biopsy. It is critical to carefully examine the preoperative imaging for the location of tumors, especially those close to the renal pelvis and ureter.

Development and validation of the Japanese version of the Quality of Life Assessment of Spina Bifida in Teenagers (QUALAS-T-J).

BACKGROUND: Spina bifida (SB) is the second-most common birth defect in Japan. In recent years, health-related quality of life measurements have been used to assess the psychosocial status of children with SB. The Quality of Life Assessment of Spina Bifida in Teenagers (QUALAS-T) is a self-reported questionnaire for subjects aged 13-17 years with SB. It focuses particularly on factors related to independence, bladder and bowel. The purpose of this study was to develop and validate a Japanese version of QUALAS-T (QUALAS-T-J). METHODS: Three urologists specialized in SB, two nurses, one statistician, and the author of the original version developed the QUALAS-T-J. Subjects with SB completed the QUALAS-T-J and the Japanese version of KIDSCREEN-27 (J-KIDSCREEN-27) independently from their parents. RESULTS: A pilot study involving seven adolescents with SB and confirmed face and content validity. Sixty-nine adolescents with SB participated in the main survey. The intraclass correlation coefficient in the retest was 0.77, and Cronbach's alpha in each domain was 0.83 and 0.79. Validity was verified on factor analysis and convergent/divergent validity. Five items converged in the one domain, Bladder and Bowel. The remaining five items converged in the concept of Family and Independence. The correlation between each domain of the QUALAS-T-J and J-KIDSCREEN-27 was low-moderate. CONCLUSION: The reliability and validity of the QUALAS-T-J were verified in Japanese adolescents with SB. The QUALAS-T-J would be a useful tool for communication between adolescents with SB and medical staff.

Clinical benefit of early treatment with bone-modifying agents for preventing skeletal-related events in patients with genitourinary cancer with bone metastasis: A multi-institutional retrospective study.

OBJECTIVES: To evaluate the clinical benefit of bone-modifying agents and identify the risk factors of skeletal-related events in patients with genitourinary cancer with newly diagnosed bone metastasis. METHODS: This was a multicenter retrospective study including a total of 650 patients with bone metastasis of the following cancer types: hormone-sensitive prostate cancer (n = 443), castration-resistant prostate cancer (n = 50), renal cell carcinoma (n = 80) and urothelial carcinoma (n = 77). Clinical factors at the time of diagnosis of bone metastasis were analyzed. Early treatment with bone-modifying agents was defined as follows: administration of bone-modifying agents before the development of skeletal-related events and within 6 months from the diagnosis of bone metastasis. RESULTS: During the follow-up period (median 19.0 months, interquartile range 6.0-43.8 months), skeletal-related events were reported in 88 (20%) patients with hormone-sensitive prostate cancer, 17 (34%) patients with castration-resistant prostate cancer, 58 (73%) patients with renal cell carcinoma and 34 (44%) patients with urothelial carcinoma. Early treatment with bone-modifying agents significantly prolonged the time to the first skeletal-related event in castration-resistant prostate cancer, renal cell carcinoma and urothelial carcinoma, but not in hormone-sensitive prostate cancer. Bone pain and elevated alkaline phosphatase levels were independent predictive risk factors of the first skeletal-related event. The subgroup analysis showed that early treatment with bone-modifying agents was associated with prolonged time to the first skeletal-related events in patients with bone pain or elevated alkaline phosphatase levels. CONCLUSIONS: Early treatment with bone-modifying agents should be considered, especially for patients with bone pain and elevated alkaline phosphatase levels, to prevent skeletal-related events in patients with genitourinary cancer with bone metastasis.

[A Case of Small Cell Carcinoma of the Renal Pelvis].

A 84-year-old female visited our hospital with the chief complaint of asymptomatic gross hematuria. The computed tomography and magnetic resonance imaging revealed a large invasive tumor in the right renal pelvis. Metastatic workup was negative. On imaging studies and voided urine cytology, diagnosis of right renal pelvic cancer (cT3N0M0) was made. Laparoscopic right nephroureterectomy was performed. Histopathological examinations revealed a small cell carcinoma of the renal pelvis. The patient declined adjuvant chemotherapy and died 5 months after surgery. Primary small cell carcinoma of the renal pelvis is a rare disease. To our knowledge, this is the 29th case of primary small cell carcinoma of the renal pelvis in the world literature.

[Spontaneous Tumor Lysis Syndrome in a Patient with Testicular Malignant Lymphoma : A Case Report].

A 75-year-old man, highly suspected as having malignant lymphoma originating from his left testis, underwent exploratory orchiectomy for a definitive diagnosis. Laboratory examinations before the surgery showed high lactate dehydrogenase (652 IU/l), elevated serum creatinine level (1.85 mg/dl) and sIL-2R level (8,930 U/ml). As the postoperative course passed uneventfully, the patient was discharged from the hospital on the eighth day after the surgery. Ten days after the surgery the patient was transferred to the emergency room of the hospital complaining of severe abdominal pain and malaise. Laboratory examinations revealed highly elevated lactate dehydrogenase (2,807 IL/l), uric acid (24.9 mg/dl) and serum creatinine (5.31 mg/dl). Computed tomography demonstrated rapid growth of the retroperitoneal mass and occurrence of bilateral hydronephroses. Under the diagnosis of spontaneous tumor lysis syndrome, the patient was urgently treated with hemodialysis, steroidal pulse and rituximab following percutaneous nephrostomy for the right kidney. After improvement of the laboratory data, the patient was transferred to another hospital for the treatment of malignant lymphoma.

[A Case of Neurofibromatosis Type 1 Presenting Voiding Symptoms Caused by Giant Bladder Diverticulum].

A 40-year-old man complaining of voiding symptoms was referred to our hospital for further examinations and treatment of giant bladder diverticulum and possibly underlying neurogenic bladder dysfunction. Because computed tomography and magnetic resonance imaging revealed the presence of a tumorous lesion covering the bladder diverticulum, transurethral biopsy was performed to elucidate its pathological characteristics. Through the histopathological examination of the biopsy specimens the tumorous lesion was diagnosed as ganglioneuroma which was benign. The whole diverticulum with the concomitant tumor lesion was surgically excised. Full examination of the surgical specimen concluded the final histopathological diagnosis of the tumor to be plexiform neurofibroma. As multiple café-au-lait spots were found on the patient's skin, he was clinically diagnosed with neurofibromatosis type 1.

[Misdirection of a Catheter for Clean Intermittent Catheterization into the Upper Ureter in a Female Patient with Neurogenic Bladder Due to Myelomeningocele : A Case Report].

We report a case of misdirection of a catheter for clean intermittent catheterization (CIC) into the ureter. A four-year-old girl with neurogenic bladder due to myelomeningocele had been managed with CIC by her parents for several years. From about a month before her visit, macroscopic hematuria appeared intermittently followed by abdominal pain and fever-up for a short time which ceased spontaneously. As cystography demonstrated bilateral vesicoureteral reflux, we performed endoscopic intraureteral injection of Deflux[TM] and during the operation we confirmed influx of bloody urine from the right ureteral orifice but not from the left one. As computed tomography revealed a tubular foreign body located in the upper portion of the right ureter, another endoscopic operation was performed and it was removed successfully. The removed foreign body was identified as a disposable catheter that was used for CIC.

[Predictive Factors of Biochemical Recurrence in Positive Surgical Margin Patients by Radical Prostatectomy].

The predictive factors for biochemical recurrence (BCR) were investigated in patients with positive surgical margin of the extirpated prostate by radical retropubic prostatectomy (RRP). The records of 365 patients who underwent RRP in our hospital between January 2002 and December 2014 were retrospectively analyzed. Patients who had received additional therapy before or after RRP, who had not been followed up for more than a year after surgery, and who had pN1 lesions were excluded from the study. Positive surgical margin was observed in 112 cases. Prostate specific antigen (PSA) before surgery ≥20 ng/ml, biopsy positive core ratio ≥40%, Gleason score of the surgical specimen ≥8, and postoperative PSA nadir ≥0.01 ng/ml were identified as significant predictors of BCR.

[Predictive Factors of Positive Surgical Margin in Radical Prostatectomy].

To identify the predictive factors for positive surgical margin after radical prostatectomy, we retrospectively analyzed the records of 381 patients who underwent radical prostatectomy in our hospital between January 2002 and December 2014. Patients who had received hormonal therapy before surgery were excluded from the study. Positive surgical marginwas observed in121 cases (31.8%), and prostate specific antigen (PSA) before surgery ≧10 ng/ml (HR1.89 : 95%CI 1.17-3. 07) and BMI≧25 kg/m2 (HR2.73 : 95%CI 1.60-4. 68) were identified as significant predictors of positive surgical margin. The existence of PSM significantly correlated to the operation time of 240 minutes or longer (HR2.27 : 95%CI 1. 35-3.79), pT2c or higher local stage (HR2.08 : 95%CI 1.17-3.72) and 7 or higher Gleason score of the resected specimen(HR1.63 : 95%CI 1.03-2.59).

[Causative Bacterial Strains and Sensitivityto Antimicrobial Agents in Female Acute Uncomplicated Cystitis].

Recently, wide spreading of fluoloquinolone resistant Escherichia coli is a serious problem inthe treatment of urinary tract infection. To investigate the causative bacterial strains of female acute uncomplicated cystitis (AUC) in the community and their sensitivity to antimicrobial agents, we retrospectively reviewed the medical records of 215 female AUC patients treated at our clinics from April 2014 to June 2015. Two hundred and nineteen strains were isolated as the causative bacteria from the patients'urine samples, including E. coli of 179 strains (82%) followed by Klebsiella pneumoniae (5.5%). One hundred and forty five strains (81%) of the isolated E. coli were sensitive to levofloxacin, whereas 32 strains (17.9%) were levofloxacin-resistant. To fosfomycin, the isolated E. coli showed the highest sensitivity (93.9%) among all antimicrobial agents tested. In univariate analysis, factors associated with levofloxacinresistant E. coli included two or more episodes of cystitis within the past year and levofloxacin use at the latest episode of cystitis. Inmultivariate analysis, two or more episodes of cystitis withinthe past year were found to be associated with levofloxacinresistan ce (p＝0.004). To prevent the increasing prevalence of infections caused by antibiotic-resistant bacteria, it is important to confirm the sensitivity of the causative agents for optimal antimicrobial therapy. The community-based surveillance data should be collected and considered when selecting empirical antimicrobial agents.

[Multiple Recurrences in Perirenal Fatty Tissue 10 Years after Enucleation for Treatment of T1a Renal Cell Carcinoma : A Case Report].

A 71-year-old man underwent simple enucleation for T1a renal cell carcinoma of the left kidney 10 years ago, and, the capsule of the tumor was injured during that surgery. The histopathological diagnosis of the tumor was papillary renal cell carcinoma type1 pT1a, G2 and the surgical margin was negative. Eight years after the surgery, computed tomography (CT) scan imaging showed a mass 13 mm in diameter which was adjacent to the left kidney. In the following year, the mass had grown to 22 mm in diameter. Thus it was suspected as local recurrence of renal cell carcinoma. Magnetic resonance imaging revealed multiple tumors in the left perirenal fatty space and positron emission tomography CT showed abnormal uptake in the same lesions with a maximal standardized uptake value of 3.2. We diagnosed multiple local recurrences of renal cell carcinoma and planned open radical nephrectomy and extirpation of perirenal fat including tumors entirely. The histopathological diagnosis of the tumor was papillary renal cell carcinomas type 1, Fuhrman grade 2＞3. The patient had no recurrence or metastases 10 months after the surgery. It is possible that the tumor cells were disseminated during the first surgery due to an injury to the capsule of the tumor and resulted in multiple local recurrences.

[A Case of Penile Squamous Cell Carcinoma, Sarcomatoid Subtype].

A 70-year-old man was referred to our department for further examination and treatment of a painless penile mass of about 2cm. The patient first noticed the mass onlya few weeks before presentation. Diagnostic biopsy was interpreted as leiomyosarcoma. Through systemic examinations the clinical stage of his disease was diagnosed as cT2N0M0 and we performed total penectomy. Histopathological examination for the totallyresected tissue disclosed the concomitant presence of regions compatible to squamous cell carcinoma and the results of immunohistochemistrywere compatible with the diagnosis of squamous cell carcinoma, sarcomatoid subtype of the penis. One month after the surgery, multiple metastases to left inguinal lymph nodes and lungs developed, for which systemic chemotherapy by doxorubicin was ineffective and the patient died of respiratoryinsufficiencyfive months after presentation.

[Bladder Metastasis of Renal Cell Carcinoma 7 Years after Ex Vivo Partial Nephrectomy and Auto-Transplantation : A Case Report].

Metastasis of renal cell carcinoma (RCC) to urinary bladder is extremely rare. We report a case of metastasis arising from RCC to the urinary bladder 7 years after treatment of bilateral RCC. A 74-year-old man was diagnosed with bilateral multiple renal tumors (T1aN0M1, PUL, OSS) with two lesions in the right kidney and a solitary lesion of the left kidney in 2008. He underwent laparoscopic radical nephrectomy for the right side in September 2008. The next month, ex vivo partial nephrectomy and auto-transplantation was performed for the left kidney because the tumor was located very close to the collecting system. Metastatectomies for the lung and bone followed and the histopathological findings of all lesions were clear cell carcinoma. The following years went well without any recurrence. Seven years after the surgery, the patient complained of asymptomatic gross hematuria and cystoscopy revealed a solitary non-papillary tumor of the bladder. Transurethral resection of the tumor was performed in June 2015 and the histopathological diagnosis of the resected specimens was clear cell carcinoma. Because the additional immunohistochemical examinations were positive for CD10 and negative for CK7, we diagnosed the bladder tumor as metastasis arising from RCC. Direct dissemination of the tumor cells into the urinary tract during partial nephrectomy followed by implantation to the bladder mucosa is a probable mechanism of metastasis in this case.

[Case of xanthogranulomatous pyelonephritis complicated by simultaneous septic pulmonary embolism].

A 57-year-old man with fever-up and multiple nodules in the peripheral area of the lungs on the chest CT was referred to the department of respiratory medicine of our hospital for further examination. The whole body CT disclosed a space-occupying lesion in the left frontal lobe of his brain, an irregular mass in the left kidney, and swelling of paraaortic lymph nodes. A pathological diagnosis could not be made from the results of the bronchoscopic examination and percutaneous needle biopsy for the renal mass. Left nephrectomy and lymph node dissection were carried out because of possible renal malignancy with distant metastases. The renal lesion was diagnosed as xanthogranulomatous pyelonephritis histopathologically. After the nephrectomy, the multiple lung nodules disappeared spontaneously leaving scars in some lesions. Septic pulmonary embolism was highly suspected on the basis of the clinical course. The brain nodule also decreased in size significantly and is currently under careful surveillance.

[A case of testicular tumor presenting with acute scrotum].

A 37-year-old man visited our hospital with a chief complaint of sudden onset of right scrotal pain. Because spermatic cord torsion was suspected, an exploratory incision was made. There was no spermatic cord torsion, but an induration was palpated in a part of the right testis. Because a testicular tumor was strongly suspected, right high orchiectomy was performed. The histopathological diagnosis was a pT1 seminoma. Our experience with this case suggests that testicular tumor should be considered in the differential diagnoses of acute scrotum.