Robot-Assisted Radical Cystectomy for Invasive Bladder Cancer With Vesicovaginal Fistula: A Case Report.

An 89-year-old woman was diagnosed with vesicovaginal fistula (VVF) during transurethral surgery for repeated bladder cancer recurrences. She was referred to our hospital for the treatment of VVF and pT1 invasive bladder cancer. Typical radical cystectomy procedures incising the vaginal wall are not suitable for her because of the high risk of disseminating tumors. Robot-assisted radical cystectomy with en bloc resection of the bladder, uterus, ovaries, and vagina was successfully performed without urine extravasation by dissecting the rectovaginal space to the pelvic floor, referencing the robot-assisted sacrocolpopexy technique. No evidence of recurrence was noted within 10 months after surgery.

Novel clipping procedure for preventing post-operative inguinal hernia in robot-assisted radical prostatectomy.

OBJECTIVES: Inguinal hernia (IH) is a common postoperative complication after robot-assisted radical prostatectomy (RARP). We developed a novel clipping technique for the prevention of IH developing after RARP. METHODS: This cohort included 759 consecutive patients who underwent RARP for prostate cancer at the University of Tokyo Hospital between January 2011 and December 2018. We reviewed clinical parameters and identified the risk factors of postoperative IH. The prophylactic preventive procedure of IH development was performed by clipping the peritoneum and underlying tissue around the internal inguinal ring using Hem-o-Lok clip to prevent the prolapse of the intestine through the internal inguinal ring. RESULTS: In total, 236 patients received the clipping procedure. The median follow-up time was 50 months. The incidence rate of IH was 10.8% (78/720). The median time to the diagnosis of IH was 10 months. Univariate analysis revealed that patients with higher age (age ≥ 63), low BMI (BMI < 25 kg/m2), and lower number of surgical experiences (Surgical experience < 40) showed a significantly higher odds ratio of developing IH. Multivariate analysis showed that "BMI < 25 kg/m2" and "Surgical experience < 40" were independent predictive factors of IH. Among the patients with a high risk of IH due to receiving surgery from inexperienced surgeons, there was a statistically significant preventive effect for the patients with "BMI ≥ 25 kg/m2" by the novel clipping procedure. CONCLUSIONS: The novel clipping procedure reduced the risk of post-operative IH in obese patients when the RARP was performed by inexperienced surgeons.

Oncologic and Functional Outcomes of Salvage Robot-Assisted Radical Prostatectomy: Report of the First 10 Cases.

BACKGROUND: Salvage robot-assisted radical prostatectomy (sRARP) after PSA failure in patients who underwent initial radiotherapy or focal therapy has rarely been reported in Japan. We aimed to report the oncologic and functional outcomes of the first 10 cases of sRARP. METHODS: Ten patients underwent sRARP after failing to respond to initial radiotherapy or focal therapy. Initial definitive treatment included volumetric modulated arc therapy, intensity-modulated radio therapy, stereotactic body radiotherapy, heavy-ion radiotherapy, low-dose-rate brachytherapy, and high-intensity focused ultrasound. We retrospectively investigated 10 cases on oncologic and functional outcomes of sRARP. RESULTS: The median PSA level at sRARP, amount of blood loss, and console time were 2.17 ng/mL, 100 mL, and 136 min, respectively. Positive surgical margins were found in half of the cases. Median follow-up was 1.1 years. There were no 30-day major complications. No patients had erections after sRARP. Urinary continence and biochemical recurrence (BCR) rate were 40% and 30% at 1 year after sRARP, respectively. CONCLUSIONS: Salvage RARP may be a feasible option after PSA failure in patients who underwent radiotherapy or focal therapy as initial treatment, showing acceptable BCR rate.

Reliability of superficial swab culture results compared with deep wound culture results in Fournier's gangrene: A retrospective study.

OBJECTIVES: To compare isolates from deep wound and superficial swab cultures to evaluate the detectability of pathogens by each culture in Fournier's gangrene; and evaluate the association between microorganisms isolated from deep wounds and those isolated from blood or urine. METHODS: Patients with Fournier's gangrene who underwent debridement between October 2006 and January 2023 were retrospectively reviewed. In addition to comparing the isolates from deep wound cultures at initial debridement with those from superficial swab, blood, and urine cultures, the relationship between the traits of the organisms from deep wounds and patient disease severity and prognosis was examined. RESULTS: Among 25 patients, deep wound and superficial swab cultures were obtained from 25 to 18 patients, respectively. The frequency of anaerobic isolates was significantly lower in the superficial cultures than in the deep wound cultures (31/76 versus 13/56, p = 0.034). Bacteria not isolated from deep wounds were isolated from superficial cultures in 55.6 % of the patients; the concordance rate between deep and superficial cultures was 27.8 % (5/18). The positive rates of blood and urine cultures were 20.8 % and 35.7 %, respectively; all isolates from the urine and blood cultures reflected the results of the deep wound culture. No significant association was observed between the severity or mortality and the type of causative bacteria. CONCLUSIONS: Superficial swab cultures cannot be substituted for deep wound cultures in Fournier's gangrene. Although the positivity rates for blood and urine cultures were not high, they were helpful in determining antibiotic de-escalation.

Effectiveness of soft coagulation in robot-assisted partial nephrectomy in preventing pseudoaneurysms and its influence on renal function based on propensity score-matched analysis.

Background: Renal artery pseudoaneurysm (RAP) is one of the most stressful and life-threatening complications of partial nephrectomy, the standard treatment for small renal cell carcinoma. The use of a monopolar soft coagulation system for hemostasis during robot-assisted partial nephrectomy (RAPN) is expected to prevent post-surgical RAP development. In this study, we aimed to investigate how the use of a soft coagulation system in RAPN reduces postoperative pseudoaneurysms and changes renal function over time. Methods: The incidence of pseudoaneurysms and postoperative renal function were compared in 208 partial nephrectomies performed between May 2016 and March 2023 at a single institution, with propensity score matching to balance patient backgrounds. Outcomes were analyzed using multivariate logistic or linear regression analyses. Results: In total, 80 matched pairs were analyzed. One (1.2%) and eighteen (22.5%) pseudoaneurysms were found in the soft coagulation users and non-users, respectively (P<0.001). Compared to the non-user group, postoperative estimated glomerular filtration rates (eGFRs) in the user group were 89% vs. 96% (P<0.001), 87% vs. 93% (P=0.009), and 88% vs. 92% (P=0.15) at 1, 3, and 12 months, respectively. Subsequent multivariate analyses showed a lower incidence of pseudoaneurysms in the user group with an odds ratio of 0.05 [95% confidence interval (CI): 0.01 to 0.44; P=0.007], and no significant difference in the rate of change in renal function at 12 months postoperatively (-1.1%, 95% CI: -5.5% to 3.3%; P=0.61). Conclusions: The use of a soft coagulation system reduces pseudoaneurysm occurrence after partial nephrectomy. Although renal function decreased in the short-term for the use group, no long-term differences were observed.

Initial surgical performance in robot-assisted radical prostatectomy is associated with clinical outcomes and learning curves.

BACKGROUND: The association between surgical performance ratings and clinical outcomes in robotic surgery is poorly understood. Additionally, no studies have reported on the relationship between the surgeon's initial case-skill evaluation and the learning curve in robot-assisted surgery. We evaluated whether an objective surgical technique evaluation score for initial robot-assisted radical prostatectomy (RARP) was associated with clinical outcomes and surgeons' learning curves. METHODS: Six surgeons who were trained in and started to perform RARP at our institution were included. Anonymized, unedited videos of each surgeon's 10th RARP case were evaluated by three reviewers, using modified Objective Structured Assessment of Technical Skill (OSATS) scores. We then divided the surgeons into two groups on the basis of these OSATS scores. We retrospectively compared the clinical outcomes and learning curves of the console time of the two groups for consecutive RARPs, performed from March 2018 to July 2023. RESULTS: We analyzed 258 RARPs (43 cases/surgeon), including 129 cases performed by high-OSATS score surgeons (18.2-19.3 points) and 129 cases performed by low-OSATS score surgeons (11.9-16.0 points). Overall, the high-OSATS score group had significantly shorter operation and console times than the low-OSATS score group did (both P < 0.01) and their patients' rate of continence recovery by 3 months post-RARP was significantly higher (P = 0.03). However, complications, blood loss, and positive margins did not differ between the groups (P = 0.08, P = 0.51, and P = 0.90, respectively). The high-OSATS score group had a significantly shorter console time than the low-OSATS score group did after the 11-20 cases. CONCLUSIONS: The OSATS score in early RARP cases can predict subsequent surgical outcomes and surgeons' learning curves.

Robotic versus open and laparoscopic pelvic exenterations for pelvic cancer: a multicenter propensity-matched analysis in Japan.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors. METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias. RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002). CONCLUSION: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

Fourth national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from patients with complicated urinary tract infections.

INTRODUCTION: Antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using the national surveillance data, comprising 793 bacterial strains from eight clinically relevant species. MATERIALS AND METHODS: Data were collected for the fourth national surveillance project from July 2020 to December 2021 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was supervised with the cooperation of 43 medical institutions throughout Japan. RESULTS: Fluoroquinolone required a minimum inhibitory concentration (MIC) of 2-64 mg/L to inhibit the 330 tested Escherichia coli strains. The proportion of levofloxacin-resistant E. coli strains increased from 28.6% in 2008 to 29.6% in 2011, 38.5% in 2015, and 44.5% in 2021. The proportion of levofloxacin-resistant strains of Pseudomonas aeruginosa also increased from previous survey results, showing a continuing downward trend. Conversely, the proportion of levofloxacin-resistant strains of Enterococcus faecalis decreased relative to previous reports. Neither multidrug-resistant P. aeruginosa nor carbapenem-resistant Enterobacteriaceae were detected. For methicillin-resistant Staphylococcus aureus (MRSA), the proportion of vancomycin-susceptible strains (MIC of 2 µg/mL) decreased from 14.7% to 7.7%. DISCUSSION: Bacterial strains that produced extended-spectrum ß-lactamase included E. coli (82/330 strains, 24.8%), Klebsiella pneumoniae (11/68 strains, 16.2%), and Proteus mirabilis (4/26 strains, 15.4%). As compared to previous surveillance reports, these strains showed an increase in proportion over the years.

A Safer Method for Disinfection of Bacillus Calmette-Guerin-Containing Urine: A Prospective, Randomized Study.

INTRODUCTION: The aim of the study was to examine whether disinfection of bacillus Calmette-Guerin-containing urine with etaprocohol® (ethanol 76.9-81.4 vol % and isopropanol as an additive) is safer than disinfection with sodium hypochlorite. METHOD: In prospective research, safety and efficacy was analyzed in 5 patients in the etaprocohol® disinfection group and 5 patients in the sodium hypochlorite disinfection group. The primary endpoint was the temperature change after disinfection and the secondary endpoint was the unpleasantness of the odor caused by disinfection. Additionally, concentration of gas produced was also examined. Sensory tests were taken from staff who performed urine disinfection and the odor generated by disinfection was evaluated. As a safety protocol, post-BCG-treated urine is cultured to verify the negativity for mycobacteria. RESULTS: Mycobacteria were disinfected in all cases. The temperature rise following disinfection was significantly higher in the sodium hypochlorite group. The sensory test outcomes were significantly worse in the group disinfected with sodium hypochlorite. The concentration of gas generated immediately after disinfection in both groups reached the maximum value and declined quickly. CONCLUSIONS: Disinfection of bacillus Calmette-Guerin-containing urine with etaprocohol® was safer than disinfection with sodium hypochlorite, and an equivalent disinfection effect was achieved.

Upper extremity contact pressure measurement in robot-assisted pelvic surgery.

Upper extremity complications are often a problem in robot-assisted pelvic surgery (RAPS) with the lithotomy-Trendelenburg position (LT-position). This study focused on upper extremity contact pressure (UEP) and examined the relationship between UEP and upper extremity complications. From May 2020 to April 2022 at the University of Tokyo Hospital, UEP was measured in 155 patients undergoing RARP and 20 patients undergoing RARC. A total of 350 sets of UEP were investigated in this study. UEP was measured using a portable interface pressure sensor (Palm Q, Cape CO., Kanagawa, Japan) in the preoperative lithotripsy position (L-position), preoperative LT-position, and postoperative L-position. UEP was increased in the preoperative LT-position than in the preoperative L-position (right side 5.2 mmHg vs. 17.1 mmHg, left side 5.3 mmHg vs. 17.1 mmHg, P < 0.001, respectively), and was decreased in the postoperative L-position than in preoperative LT-position (right side 17.1 mmHg vs. 10.8 mmHg, left side 17.1 mmHg vs. 10.6 mmHg, P < 0.001, respectively). Eleven upper extremities developed shoulder pain. UEP of the preoperative LT-position tended to be higher in the upper extremity exhibiting shoulder pain (25.6 mmHg (15.4-30.3) vs. 17.1 mmHg (12.0-24.4) P = 0.0901). UEP measurements may help prevent postoperative shoulder pain.

Factors affecting the use of a three-dimensional model during robot-assisted partial nephrectomy.

INTRODUCTION: This study aimed to identify cases that require a three-dimensional-printed kidney model in robot-assisted partial nephrectomy. METHODS: We enrolled 93 patients undergoing robot-assisted partial nephrectomy for renal tumors at a single institution between November 2018 and May 2021. The endpoints were how often and how long the surgeon consulted the three-dimensional-printed model, determined using intraoperative video. Multivariate analyses of the endpoints were adjusted by preoperative patient and kidney characteristics, including renal vascular complexity that was defined as the number of vascular branches penetrating the surface tangential to the ventral side of the kidney. RESULTS: Of the 93 cases, the median frequency and duration of intraoperative three-dimensional-printed model consultation were four times and 39 s, respectively. The multivariate linear regression analyses showed that the frequency of intraoperative three-dimensional-printed model consultation by the surgeon was significantly related to the complexity of the arterial structure (≥4 branches), presence of hilar tumor, and high Mayo Adhesive Probability score; the regression coefficients were 1.81, 2.79, and 1.34, respectively. All p-values were ≤.03. The duration of the three-dimensional-printed model consultation was significantly related to the complexity of the arterial structure (≥4 branches) and the presence of hilar tumor; the regression coefficients were 21.6, and 29.0 s, respectively. All p-values were <.01. CONCLUSION: During robot-assisted partial nephrectomy, a three-dimensional-printed model would be helpful in cases with a complex arterial structure or hilar tumor.

Development of risk-score model in patients with negative surgical margin after robot-assisted radical prostatectomy.

A total of 739 patients underwent RARP as initial treatment for PCa from November 2011 to October 2018. Data on BCR status, clinical and pathological parameters were collected from the clinical records. After excluding cases with neoadjuvant and/or adjuvant therapies, presence of lymph node or distant metastasis, and positive SM, a total of 537 cases were eligible for the final analysis. The median follow-up of experimental cohort was 28.0 (interquartile: 18.0-43.0) months. We identified the presence of International Society of Urological Pathology grade group (ISUP-GG) ≥ 4 (Hazard ratio (HR) 3.20, 95% Confidence Interval (95% CI) 1.70-6.03, P < 0.001), lymphovascular invasion (HR 2.03, 95% CI 1.00-4.12, P = 0.049), perineural invasion (HR 10.7, 95% CI 1.45-79.9, P = 0.020), and maximum tumor diameter (MTD) > 20 mm (HR 1.9, 95% CI 1.01-3.70, P = 0.047) as significant factors of BCR in the multivariate analysis. We further developed a risk model according to these factors. Based on this model, 1-year, 3-year, and 5-year BCR-free survival were 100%, 98.9%, 98.9% in the low-risk group; 99.1%, 94.1%, 86.5% in the intermediate-risk group; 93.9%, 84.6%, 58.1% in the high-risk group. Internal validation using the bootstrap method showed a c-index of 0.742 and an optimism-corrected c-index level of 0.731. External validation was also carried out using an integrated database derived from 3 other independent institutions including a total of 387 patients for the final analysis. External validation showed a c-index of 0.655. In conclusion, we identified risk factors of biochemical failure in patients showing negative surgical margin after RARP and further developed a risk model using these risk factors.

Current status of robot-assisted total pelvic exenteration focusing on the field of urology: a clinical practice review.

Total pelvic exenteration (TPE) is a highly invasive surgery associated with high rates of perioperative morbidity and mortality and is commonly performed for several types of locally advanced or recurrent pelvic cancers. It involves multivisceral resection, including the rectum, sigmoid colon, bladder, prostate, uterus, vagina, or ovaries, and urologists normally perform radical cystectomy or radical prostatectomy and urinary diversion in collaboration with colorectal surgeons and gynecologists. In the urological field, robot-assisted surgeries have been widely performed as one of the main minimally invasive procedures because of their superior perioperative or oncological outcomes compared to open or laparoscopic surgeries. In pelvic exenteration (PE) surgery, laparoscopic surgeries have shown superior rates of mortality, morbidity, and R0 resection compared to open surgeries. Robot-assisted TPE for the treatment of locally advanced rectal cancer was first reported in 2014, and reports of its safety and usefulness have gradually increased. Robot-assisted PE, in which multivisceral resection in a narrow pelvic space is easier, will eventually be a standard minimally invasive procedure, although evidence has been limited to date. This clinical practice review summarizes the indications for surgery, perioperative complications, and oncological outcomes of robot-assisted TPE and highlights the current status of robot-assisted TPE for patients with urological malignancies and its surgical technique, focusing on the manipulation of urological organs.

Six-year outcomes of robot-assisted radical prostatectomy versus volumetric modulated arc therapy for localized prostate cancer: A propensity score-matched analysis.

BACKGROUND: Although robot-assisted radical prostatectomy (RARP) and intensity-modulated radiotherapy are the leading respective techniques of prostatectomy and radiotherapy for localized prostate cancer, almost no study has directly compared their outcomes; none have compared mortality outcomes. METHODS: We compared 6­year outcomes of RARP (n = 500) and volumetric modulated arc therapy (VMAT, a rotational intensity-modulated radiotherapy, n = 360) in patients with cT1-4N0M0 prostate cancer. We assessed oncological outcomes, namely overall survival (OS), cancer-specific survival (CSS), radiological recurrence-free survival (rRFS), and biochemical recurrence-free survival (bRFS), using propensity score matching (PSM). We also assessed treatment-related complication outcomes of prostatectomy and radiotherapy. RESULTS: The median follow-up duration was 79 months (> 6 years). PSM generated a matched cohort of 260 patients (130 per treatment group). In the matched cohort, RARP and VMAT showed equivalent results for OS, CSS, and rRFS: both achieved excellent 6­year outcomes for OS (> 96%), CSS (> 98%), and rRFS (> 91%). VMAT had significantly longer bRFS than RARP, albeit based on different definitions of biochemical recurrence. Regarding complication outcomes, patients who underwent RARP had minimal (2.6%) severe perioperative complications and achieved excellent continence recovery (91.6 and 68.8% of the patients achieved ≤ 1 pad/day and pad-free, respectively). Patients who underwent VMAT had an acceptable rate (20.0%) of grade ≥ 2 genitourinary complications and a very low rate (4.4%) of grade ≥ 2 gastrointestinal complications. CONCLUSION: On the basis of PSM after a 6-year follow-up, RARP and VMAT showed equivalent and excellent oncological outcomes, as well as acceptable complication profiles.

Early recovery of urinary continence after robot-assisted radical prostatectomy is associated with membranous urethra and neurovascular bundle preservation.

OBJECTIVES: We investigated the correlation between surgical outcomes and postoperative urinary continence recovery in robot-assisted radical prostatectomy (RARP). METHODS: Patients who underwent RARP in our institution (n = 195) were included in this study. Preserved urethral length (PUL) was assessed during the procedure. Other outcomes of the surgical procedure were collected from operative records. Kaplan-Meier analysis with log-rank test was used to compare urinary continence recovery rate with the PUL, sparing of the neurovascular bundle (NVB), and other surgical procedures. Univariate and multivariate analyses were performed using Cox proportional hazards model, and p-values of <0.05 were considered significant. RESULTS: Patients with a PUL ≥26 mm had 10.0%, 24.7%, 36.6%, and 89.0% continence recovery rates at 30, 60, 90, and 365 days after surgery, respectively, while patients with a PUL <26 mm had 0%, 17.8%, 26.1%, and 80.9% recovery rates, respectively. Kaplan-Meier curves showed significantly better postoperative urinary continence recovery at 30 days after RARP in patients with a PUL ≥26 mm than those with a PUL <26 mm (p = 0.0028) and in patients with NVB preservation than those with no NVB preservation (p = 0.014). Urinary continence recovery within 30, 60, and 90 days after surgery was 90.6% for patients with a PUL of ≥26 mm and NVB preservation, while only 82.3% for patients with a PUL of <26 mm or no NVB preservation. CONCLUSION: Our results suggest that a PUL ≥26 mm and NVB preservation after RARP correlate with a significantly higher postoperative rate of recovery of urinary continence.

Lower bleeding volume contributes to decreasing surgical site infection in radical cystectomy: A propensity score-matched comparison of open versus robot-assisted radical cystectomy.

OBJECTIVES: To compare the incidence of surgical site infections (SSI) between robot-assisted and open radical cystectomies and investigate the risk factors for SSI after radical cystectomies. METHODS: Consecutive patients who underwent radical cystectomy between July 2008 and December 2022 were retrospectively reviewed. The prevalence and characteristics of SSI after open and robot-assisted radical cystectomies were compared, and the risk factors for SSI were investigated using propensity score matching. RESULTS: This study enrolled 231 patients (open: 145, robot-assisted: 86). In the robot-assisted group, urinary diversion was performed using an intracorporeal approach. SSI occurred in 34 (open: 28, robot-assisted: 6) patients, and the incidence was significantly lower in the robot-assisted group (19.3% vs. 7.0%, p = 0.007). After propensity score matching cohort (open: 34, robot-assisted: 34), increased bleeding volume, blood transfusion, and delayed postoperative oral feeding were significantly associated with SSI. Only increased bleeding volume remained a significant risk factor in the multivariate regression analysis (odds ratio, 1.13 [per 100 mL increase]; 95% confidence interval: 1.02-1.25; p = 0.001). The cutoff bleeding volume for predicting SSI was 1630 mL with an area under the receiver operating characteristic curve, sensitivity, and specificity of 0.773, 0.73, and 0.75, respectively. CONCLUSIONS: The incidence of SSI after robot-assisted radical cystectomy was significantly lower than that after the open procedure. However, decreased bleeding volume, which was significantly associated with robot-assisted procedures, was an independent and more significant factor for reducing SSI after radical cystectomy than the differences of the surgical procedure even after propensity score matching.

A new training model using the self-healing properties of supramolecular hydrogels for endoscopic combined intrarenal surgery.

The combination of hydronephrosis formation, ureteroscopic imaging, and ultrasound delineation has not been included in any non-biological training model of percutaneous nephrolithotomy or endoscopic combined intrarenal surgery. We aimed to develop a realistic kidney phantom using the self-healing properties of supramolecular hydrogels for percutaneous nephrolithotomy and endoscopic combined intrarenal surgery and evaluate its suitability as a training model.Expert and resident urologists performed ultrasound-guided renal pelvic punctures and flexible ureteroscopies for endoscopic combined intrarenal surgery using a training model. Subsequently, the training model was evaluated using a 17-item Likert scale questionnaire (range, 1-5 points). After being filled with carrageenan, the collecting system was inflated, and the relationship between the collecting system volume and collecting system pressure was determined. The durability of the model was verified by repeatedly inserting a 16-Fr access sheath. Five novices and seven urology experts performed the procedure. The mean questionnaire score was 4.25 (standard deviation, 0.37). The model was able to hold 50 mL of air, and the pressure in the collecting system ranged from 6 to 33 mmHg. Repeated punctures were possible even when a 16-Fr access sheath was inserted. Our new training model included the self-healing properties of supramolecular hydrogels, which are tough and flexible and can be evaluated using ultrasonography. According to the questionnaire score, the model was highly satisfactory and has potential as a new educational tool.

Identification of DNA damage response-related genes as biomarkers for castration-resistant prostate cancer.

Although hormone therapy is effective for the treatment of prostate cancer (Pca), many patients develop a lethal type of Pca called castration-resistant prostate cancer (CRPC). Dysregulation of DNA damage response (DDR)-related genes leads to Pca progression. Here, we explored DDR-related signals upregulated in CRPC tissues. We analyzed the gene expression profiles in our RNA-sequence (RNA-seq) dataset containing benign prostate, primary Pca, and CRPC samples. We identified six DDR-related genes (Ribonuclease H2 Subunit A (RNASEH2A), replication factor C subunit 2 (RFC2), RFC4, DNA Ligase 1 (LIG1), DNA polymerase D1 (POLD1), and DNA polymerase E4 (POLE4)) that were upregulated in CRPC compared with Pca tissues. By analyzing public databases and validation studies, we focused on RFC2 as a new biomarker. Functional analysis demonstrated that silencing of RFC2 expression inhibited cell proliferation and induced the expression of DNA damage and apoptosis markers in CRPC model cells. Furthermore, immunohistochemical (IHC) analysis revealed that high expression of RFC2 protein correlated with poor prognosis in patients with Pca and increased expression in CRPC tissues compared with localized Pca. Thus, our study suggests that six DDR-related genes would be important for Pca progression. RFC2 could be a useful biomarker associated with poor outcomes of patients with Pca.

Enfortumab vedotin versus platinum rechallenge in post-platinum, post-pembrolizumab advanced urothelial carcinoma: A multicenter propensity score-matched study.

OBJECTIVE: Enfortumab vedotin (EV) was approved for advanced urothelial carcinoma (UC) in 2021 after the EV-301 trial showed its superiority to non-platinum-based chemotherapy as later-line treatment after platinum-based chemotherapy and immune checkpoint inhibitors including pembrolizumab. However, no study has compared EV with rechallenging platinum-based chemotherapy (i.e., "platinum rechallenge") in that setting. METHODS: In total, 283 patients received pembrolizumab for advanced UC after platinum-based chemotherapy between 2018 and 2023. Of them, 41 and 25 patients received EV and platinum rechallenge, respectively, as later-line treatment after pembrolizumab. After excluding two patients with EV without imaging evaluation, we compared oncological outcomes, including progression-free survival (PFS) and overall survival (OS), between the EV (n = 39) and platinum rechallenge groups (n = 25) using propensity score matching (PSM). RESULTS: Analyses on crude data (n = 64) showed no significant differences between the two groups regarding patients' baseline characteristics. PFS (5 months) and OS (11 months) in the EV group were comparable to those (8 and 12 months, respectively) in the platinum rechallenge group. After PSM (n = 36), the baseline characteristics between the two groups became more balanced, and PFS (not reached) and OS (not reached) in the EV group were comparable to those (8 and 11 months, respectively) in the platinum rechallenge group. CONCLUSIONS: EV and platinum rechallenge showed equivalent oncological outcomes, even after PSM, and both treatments should therefore be effective treatment options for post-platinum, post-pembrolizumab advanced UC.

Left testicular and pulmonary metastases of mucinous adenocarcinoma of the prostate after robot-assisted radical prostatectomy.

Introduction: We present a case of mucinous adenocarcinoma of the prostate with testicular and lung metastases following robot-assisted radical prostatectomy, androgen deprivation therapy, and radiotherapy. Case presentation: A 73-year-old man with a prostate-specific antigen level of 4.3 ng/mL was diagnosed with prostate cancer. Following the robot-assisted radical prostatectomy, the pathological diagnosis was mucinous adenocarcinoma of the prostate (pT3bpN0, Gleason score of 4 + 4). Salvage hormonal therapy and irradiation were performed after the prostatectomy. Enlargement of the left testis was noted, and 28 months after prostatectomy, computed tomography detected a left testicular tumor and nodular lesions in the bilateral lungs. The histopathological diagnosis of left high orchiectomy was metastasis of a mucinous adenocarcinoma of the prostate. Chemotherapy with docetaxel followed by cabazitaxel was initiated. Conclusion: Mucinous prostate adenocarcinoma with distal metastases following prostatectomy has been managed for longer than 3 years with multiple treatments.