[Percutaneous removal of a large calculus in Indiana pouch using a laparoscopic entrapment bag].

A 67-year-old man was referred to our hospital for evaluation of large urinary-diversion calculus. He had undergone urinary diversion for invasive bladder cancer with an Indiana pouch, when he was 52 years old. We performed the surgery using a laparoscopic trocar and an entrapment bag, for reducing the risk of bladder damage by the lithoclast and small residual fragments of the calculus. There has been no recurrence of stone formation 18 months after the surgery. This technique of percutaneous cystolithotomy of a large urinary calculus utilizing laparoscopic and endourologic instrumentation, is quick and safe, and can be used for complete stone removal, thereby decreasing the risk of recurrent stone formation.

Primary large cell neuroendocrine carcinoma of the urinary bladder.

Large cell neuroendocrine carcinoma (LCNEC) of the urinary bladder is rare. It is a type of neuroendocrine carcinoma morphologically distinct from small cell carcinoma. We report here a case of primary LCNEC of the urinary bladder. We observed a very large invasive tumor, which was not able to be detected three months previously by cystoscopy or computed tomography. The tumor cells morphologically and immunohistochemically resembled that of pulmonary LCNEC. With prompt cystoprostatectomy and chemotherapy, the patient is free of disease 16 months after diagnosis. Although LCNEC is usually very aggressive, it may be controlled by early diagnosis and treatment.

Severe gastrointestinal hemorrhage due to metastatic renal cell carcinoma to the pancreas successfully controlled by transarterial embolization and adjuvant administration of Sunitinib Malate.

Metastatic renal cell carcinoma to the pancreas rarely causes massive gastrointestinal hemorrhage. Management of patients who cannot undergo pancreaticoduodenectomy is difficult. Here, we report a case of severe gastrointestinal hemorrhage that was successfully controlled by combination therapy of transarterial embolization and Sunitinib Malate administration. Transarterial embolization was effective in controlling the acute phase of hemorrhage, and Sunitinib Malate effectively achieved long term control. We propose that such combination therapy is useful for hemorrhagic events due to renal cell carcinoma.

[Multi-institute survey on actual conditions of urologic management for severe bladder dysfunction after hysterectomy].

We conducted a multi-institute survey on the conditions related to urologic management of severe voiding dysfunction after hysterectomy for uterine cancer with or without postoperative irradiation. Our first study population was a group of adult female patients currently managed by urologists, using clean intermittent catheterization (CIC). Of the 287 patients in this group, 99 (34%) had suffered from uterine cancer. Of these patients, 94 underwent hysterectomy for this disease; 44 and 30 were treated with or without postoperative radiation, respectively, while postoperative irradiation status was unknown for 20. Median follow-up after surgery was 21 (0.2-52) years and median interval from operation to the introduction of CIC was 4.0 (0-49) years. CIC tended to be introduced later for patients with postoperative radiation than those without it. Seventy-four patients, who required invasive urologic interventions other than CIC for voiding dysfunction after hysterectomy, are the second study population. Most of these (82%) had received postoperative irradiation. Continuous Foley catheter placement was the most frequent procedure. Long-term follow-up and urologic management for voiding dysfunction is required for patients undergoing hysterectomy.

Clinical outcome of conservative therapy with transurethral resection for patients with invasive bladder cancer who cannot tolerate cystectomy.

Among patients with invasive bladder cancer, there are patients who cannot tolerate cystectomy due to high age or comorbidities. We retrospectively reviewed 27 patients who were treated conservatively with transurethral resection (TUR). All patients had undergone TUR and 5 patients had received subsequent pelvic radiation therapy. The survival and control of local symptoms were analyzed statistically. Sixteen patients died of bladder cancer and 4 died of other causes with a median survival of 10 months. Seven patients were alive at a median follow up of 36 months. Tumor stage, grade and hydronephrosis at diagnosis were related with survival. Hematuria, bladder tamponade, and lower urinary tract obstruction could be controlled with TUR. However, those patients who complained of bladder irritative symptoms at diagnosis were likely to develop uncontrollable bladder irritability. Conservative treatment with TUR alone was an acceptable option in terms of survival for stage II patients with a short life expectancy. Even at more advanced stages, most of the local symptoms could be controlled with TUR. However, in patients with bladder irritability at diagnosis, the merit of cystectomy may outweigh its risk even among high age patients or those with severe comorbidities.

[Experience on the use of extra slim gastrointestinal endoscopes in ileal conduit endoscopy].

Using extra slim gastrointestinal endoscopes, we have examined ileal conduits in two patients. This endoscope has almost the same caliber as a flexible cystoscope and has multiple manipulation levers and channels as ordinal gastrointestinal endoscopes. It is often difficult to examine ileal conduits with flexible cystoscopes because ileal conduits lack continent mechanisms and cannot be dilated adequately with water irrigation. With air insufflations, extra slim gastrointestinal endoscopes could adequately distend ileal conduits, and with multiple levers, they provided much more freedom of manipulation than flexible cystoscopes. Visualization of ureterointestinal anastomosis sites and biopsy of tumors could be performed very easily. We strongly recommend the use of extra slim gastrointestinal endoscopes than flexible cystoscopes when retrograde examinations and procedures are necessary in patients with ileal conduits.

Immune thrombocytopenia during interferon-alfa therapy for renal cell carcinoma.

Immune thrombocytopenia is a rare complication of interferon-alfa (IFN-alpha). A patient with renal cell carcinoma developed severe thrombocytopenia during therapy with purified IFN-alpha. The patient's exposure to IFN, exclusion of other causes, and bone marrow biopsy were consistent with drug-induced immune thrombocytopenia. Cessation of IFN and corticosteroid administration resulted in the prompt recovery of platelets. The patient was re-challenged with recombinant IFN-alpha-2b under careful observation; there was no occurrence of severe thrombocytopenia. It was suggested that the difference of the subtypes composing IFN-alpha resulted in the lack of cross reactivity.

[Clinical review of conservative management of upper urinary tract transitional cell carcinoma].

We reviewed 18 patients with transitional cell carcinoma of the renal pelvis and ureter undergoing nephron-sparing surgery between April 1990 and Febrary 2003. The mean age of the patients, 17 males and one female, was 69 years (range 33-88 years). The tumor site was the renal pelvis in 2, ureter in 13 and ureteral orfice in 2. Six of them were imperative cases and 12 were elective. Eight patients underwent endourological treatment and 10 patients open surgery including partial ureterectomy performed on 8 patient. The follow up period was 3 to 104 months (mean 37 months). Among those defined as imperative, the histopathological stage was pT1 in one, pT2 in one, pT3 in 3 and one in pT4. Among the elective cases, the histopathological stage was pTa in 7, pT1 in 2, pT2 in one, pT3 in 2 patients. Of the three defired as elective with tumors cT2 or higher, two died of disease. The 5-year survival rate was 50% and 68% in the imperative and elective cases, respectively. In the patients with tumors pT2 or higher and/or grade 3, the prognosis was poor which suggests the need for intensive therapy including lymph node dissection and/or adjuvant chemotherapy. It is necessary to consider the possibility of selecting nephron-sparing surgery for locally advanced tumors.

Ectopic adrenocorticotropic hormone syndrome in a case of small cell carcinoma of the bladder manifesting as severe muscle weakness.

Ectopic adrenocorticotropic hormone syndrome is a paraneoplastic syndrome associated with small cell carcinoma. However, ectopic adrenocorticotropic hormone syndrome is rare in association with small cell carcinoma of the bladder. We report what we believe to be the first case of ectopic adrenocorticotropic hormone syndrome associated with small cell carcinoma of the bladder that manifested as severe muscle weakness due to hypokalemia. An early diagnosis and aggressive potassium replacement is essential for retaining muscle strength. The patient died of pneumonia less than 2 months after the diagnosis. Severe immunosuppression by excess cortisol production was suspected. Control of cortisol levels before chemotherapy might be beneficial in preventing infective complications.

Superior anti-tumor efficacy of bicalutamide 80 mg in combination with a luteinizing hormone-releasing hormone (LHRH) agonist versus LHRH agonist monotherapy as first-line treatment for advanced prostate cancer: interim results of a randomized study in Japanese patients.

OBJECTIVES: To evaluate bicalutamide (Casodex) 80 mg as a component of maximum androgen blockade (MAB) in Japanese patients with previously untreated advanced prostate cancer. METHODS: 205 patients with previously untreated stage C/D prostate cancer were randomized (1:1) to receive once-daily bicalutamide 80 mg or placebo, each combined with a luteinizing hormone-releasing hormone (LHRH) agonist. Primary study variables were the 12 week prostate-specific antigen (PSA) normalization (i.e. PSA level