[Experience with gemcitabine monotherapy in three patients with metastatic urothelial carcinoma].

Three patients who had metastatic urothelial carcinoma have been administered gemcitabine monotherapy (GEM). A 78-year-old male who underwent nephroureterectomy for right ureteral cancer presented with liver and retroperitoneal lymph node metastases postoperatively. GEM was administered because of severe renal insufficiency. Although 8 cycles of this therapy were done, we discontinued it because of progressive disease. A 68-year-old male who underwent nephroureterectomy for left ureteral cancer presented with retroperitoneal lymph node metastasis postoperatively. GEM for the purpose of maintenance therapy was administered after first-line chemotherapy. He maintained a stable disease after 9 cycles. A 70-year-old female who underwent transurethral resection of a bladder tumor presented with neck lymph node metastasis postoperatively. She was administered GEM for second-line chemotherapy as an outpatient because she did not want hospital treatment. However, it failed due to progressive disease after 3 cycles. There were few adverse events that forced the patient to be admitted into the hospital, although bone marrow suppression of grade 3 or 4 occurred in 2 patients. GEM for metastatic urothelial carcinoma may be adapted for patients who have severe renal insufficiency and need maintenance therapy.

Effect of delayed maximal androgen blockade therapy for patients with advanced prostate cancer who fail to respond to initial androgen deprivation monotherapy.

OBJECTIVES: We analyzed the efficacy of additional antiandrogens as second- and third-line treatments after the failure of initial androgen deprivation monotherapy. METHODS: This retrospective study included 53 patients with advanced prostate cancer initially treated with androgen deprivation monotherapy alone. An antiandrogen was added to androgen deprivation monotherapy as the second-line treatment after the failure of the initial androgen deprivation monotherapy. Another antiandrogen, estrogen or steroid was given as the third-line treatment after the second-line treatment failed. RESULTS: The initial androgen deprivation monotherapy was effective in all 53 patients for a median of 9.6 months. Thirty-three (62.3%) patients showed a prostate-specific antigen response to the second-line treatment for a median of 10.7 months. Of the 46 patients who received the third-line treatment, 16 (34.8%) showed a prostate-specific antigen response for a median of 6.0 months. Patients who responded to the second-line treatment had a significantly higher cancer-specific survival rate than those without a response. In multivariate analysis, a nadir prostate-specific antigen of 4.0 ng/ml or greater during androgen deprivation monotherapy and prostate-specific antigen doubling time of less than 10 months after androgen deprivation monotherapy failure were independent risk factors for prostate cancer death after androgen deprivation monotherapy failure, with hazards ratios of 5.59 and 8.00, respectively. The 5-year cancer-specific survival rates were 100%, 65.0% and 15.5% in patients with 0, 1 and 2 risk factors, respectively (P = 0.047). CONCLUSIONS: In this study, the second- and third-line treatments were effective for patients with advanced prostate cancer. Nadir prostate-specific antigen during androgen deprivation monotherapy and prostate-specific antigen doubling time just after the failure of androgen deprivation monotherapy are factors that can predict the prognosis.

Decrease in incidence of surgical site infections in contemporary series of patients with radical cystectomy.

We previously reported that the incidence of surgical site infection (SSI) after radical cystectomy was 33% between January 1996 and December 2003 at Sapporo Medical University Hospital. Base on that result, we modified perioperative management for surgical wounds after January 2004. The modifications included the method of suturing and standardization of the period for removal of closed drains and surgical dressings. This study compared the incidence of SSI between the former and latter periods, and assessed risk factors for SSI. The study consisted of 109 patients between January 1996 and December 2003 (Group A), and 104 patients between January 2004 and December 2007 (Group B), who underwent radical cystectomy and urinary diversion or reconstruction. The incidence of SSI was reduced from 32.1% in Group A to 18.2% in Group B (p = 0.027). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from SSI wounds in 40.0% of patients in Group A and 42.1% of those in Group B. Preoperative MRSA bacteriuria was the only risk factor for SSI in both groups. The incidences of SSI in patients who had such bacteriuria were 45.4% in Group A and 50.0% in Group B. Modification of perioperative management for the surgical wound was partly responsible for the reduction of the incidence of SSI. In conclusion, MRSA is still the main isolated pathogen of SSI after radical cystectomy and this clinical problem remains a challenge to urologists. Effective countermeasures are needed for MRSA bacteriuria involved in the development of SSI.

[Neurotoxicity of valacyclovir in a peritoneal dialysis patient].

The patient was a 67-year-old man with a 2-year history of peritoneal dialysis for end-stage renal disease due to hypertensive nephropathy. He presented to a dermatologist with a complaint of pain in the right femoral region. He was diagnosed as having herpes zoster and valacyclovir, 1,000 mg/day, was prescribed. After 5 days of taking valacyclovir orally, he felt fretful and hallucinations appeared. He was admitted to our hospital and was hospitalized in our urology ward. We diagnosed his condition as neurotoxicity caused by an overdose of valacyclovir. As his general condition was stable, he was treated only by continuation of peritoneal dialysis. After 7 days of hospitalization, the neurotoxicity completely disappeared and he left the hospital. His serum acyclovir concentration at admission was 20.20 µg/l, and was reduced to 0.7 µg/l when he left the hospital. This supported our diagnosis of valacyclovir-induced neurotoxicity. In this case, valacyclovir should have been reduced to 500 mg/day, considering his renal function. Although we could treat the patient only by continuation of peritoneal dialysis, hemodialysis seems to be an effective treatment method in the case of unstable general condition or severe adverse effects, because it can eliminate the serum acyclovir.

[Case of male accessory urethra with orifice in the scrotal skin].

A 67-year-old male had an innate fistular orifice at the scrotal skin. In spite of occasional pus discharge from the orifice, no treatment had been performed for the fistula because it improved spontaneously. Due to increasing pus discharge, the fistula was resected at a dermatology clinic, but a persistent fistula tract was confirmed postoperatively by MRI. The fistula adjoined the bulbar urethra and was considered an accessory urethra. We performed resection of the fistula to resolve the frequent pus discharge and pain due to infection of the fistula. The isolated fistula did not communicate with the urethra and the proximal edge ended blindly. Pathological examination showed that the proximal end consisted of transitional epithelium and the distal end consisted of stratified squamous epithelium which meant an accessory urethra. Accessory urethra is not a rare condition, but cases like this one with an orifice that opened at the scrotal skin are extremely rare. As the treatment for the fistula, complete resection should be indicated.