Novel clinical diagnostic criteria based on noninvasive examination findings to predict the presence of urodynamic detrusor underactivity in men.

AIMS: To investigate the usefulness of novel clinical diagnostic criteria based on noninvasive examination findings to diagnose urodynamic detrusor underactivity (DU) in men. METHODS: We developed clinical diagnostic criteria to predict the presence of urodynamic DU in men as follows: (a) bladder voiding efficiency <70% on uroflowmetry, (b) existence of "sawtooth and interrupted waveforms" on uroflowmetry, and (c) ultrasonography-documented intravesical prostatic protrusion <10 mm. We analyzed the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these clinical criteria for diagnosing urodynamic DU in men aged 50 years or above with lower urinary tract symptoms who underwent urodynamic studies. RESULTS: Of the 314 men analyzed (mean age, 72.4 years; mean detrusor contraction index [DCI], 98.8; and mean bladder outlet obstruction index [BOOI], 43.9), 89 men met this clinical DU diagnostic criteria. Of these, 79 men (88.8%) had urodynamic DU (DCI < 100 and BOOI < 40), nine (10.1%) had DU + BOO (DCI < 100 and BOOI ≥ 40), and one (1.1%) had normal voiding functions. None of the men with urodynamic BOO (DCI ≥ 100 and BOOI ≥ 40) met the clinical DU diagnostic criteria. The sensitivity, specificity, PPV, and NPV of these clinical diagnostic criteria for urodynamic DU were 69.3%, 95.0%, 88.8%, and 84.4%, respectively. CONCLUSION: The proposed clinical DU diagnostic criteria showed a high PPV (88.8%) for diagnosing urodynamic DU. None of the patients with BOO met the clinical diagnostic criteria for DU. These clinical DU diagnostic criteria may be useful in identifying men with urodynamic DU in clinical practice.

Recent insights on the clinical, pathological, and molecular features of intraductal carcinoma of the prostate.

Intraductal carcinoma of the prostate, a unique histopathologic entity that is often observed (especially in advanced prostate cancer), is characterized by the proliferation of malignant cells within normal acini or ducts surrounded by a basement membrane. Intraductal carcinoma of the prostate is almost invariably associated with an adjacent high-grade carcinoma and is occasionally observed as an isolated subtype. Intraductal carcinoma of the prostate has been demonstrated to be an independent poor prognostic factor for all stages of cancer, whether localized, de novo metastatic, or castration-resistant. It also has a characteristic genetic profile, including high genomic instability. Recognizing and differentiating it from other pathologies is therefore important in patient management, and morphological diagnostic criteria for intraductal carcinoma of the prostate have been established. This review summarizes and outlines the clinical and pathological features, differential diagnosis, molecular aspects, and management of intraductal carcinoma of the prostate, as described in previous studies. We also present a discussion and future perspectives regarding intraductal carcinoma of the prostate.

Efficacy of the Addition of Robot-assisted Radical Cystectomy with Extracorporeal Urinary Diversion after an Enhanced Recovery Protocol.

PURPOSE: It is unclear if robotic radical cystectomy with extracorporeal urinary diversion (eRARC) provides additional benefit when performed along with enhanced recovery after surgery (ERAS). We assessed the additional efficacy of eRARC in terms of perioperative outcomes. MATERIALS AND METHODS: We retrospectively assessed 143 patients undergoing radical cystectomy with urinary diversion between June 2010 and December 2021 at a single center. The patients were assigned to three groups: open radical cystectomy (ORC) with conventional recovery after surgery (CRAS) [Group A], ORC with ERAS [Group B], and eRARC with ERAS [Group C]. A propensity score-matched analysis was performed to evaluate how ERAS and eRARC affected outcomes respectively. Meanwhile, multivariable analysis was used to detect the predictors of prolonged length of hospital stay (LOS). RESULTS: The median LOS was shorter after ERAS and eRARC. In the propensity score-matched analysis, ERAS was linked to a significantly shorter median LOS (28.0 vs. 20.0 days, P < .001), but eRARC was not associated with a shorter LOS (19.0 vs. 17.5 days, P = .21). Neither ERAS nor eRARC were connected with a reduce in complication rate. Following multivariable analysis, ERAS was found to be independently associated with shorter LOS (OR=0.23, P < .001), but eRARC demonstrated no such correlation (OR=0.29, P = .096). CONCLUSION: ERAS had strong association with shorter LOS, although eRARC did not contribute to additional efficacy. Neither ERAS nor eRARC decreased the complication rate.

Adiponectin can be a good predictor of urodynamic detrusor underactivity: a prospective study in men with lower urinary tract symptoms.

PURPOSE: To investigate whether circulating adiponectin, which is considered a possible marker of anti-atherogenic effects, is a useful predictor of bladder function, especially detrusor underactivity (DU), in men with lower urinary tract symptoms (LUTS). METHODS: A total of 130 treatment-naïve men with non-neurogenic LUTS were prospectively stratified into two groups (the DU and non-DU groups) based on the presence or absence of DU, where DU is defined as a bladder contractility index < 100 and bladder outlet obstruction index (BOOI) < 40. The impact of serum adiponectin levels on urodynamic function, including DU, was assessed using univariate, binomial logistic regression, and receiver operating characteristic (ROC) curve analyses. RESULTS: In total, data from 118 men were analyzed; 39 (33.0%) had DU (DU group) and 79 (67.0%) did not have DU (non-DU group). The median serum adiponectin in the DU group was significantly lower than in the non-DU group (6.2 vs 12.6 µg/mL, p < 0.001). In the binomial logistic regression analysis, lower adiponectin, smaller intravesical prostatic protrusion, and lower bladder voiding efficiency were significant factors related to DU. In the ROC analyses, serum adiponectin had the highest area under the curve value for DU diagnosis (0.849). Additionally, a cutoff value of 7.9 µg/mL for serum adiponectin level was identified for DU, which yielded a sensitivity and specificity of 79% and 90%, respectively. CONCLUSIONS: The serum adiponectin level was significantly associated with bladder function and may be a useful marker for predicting DU in men with LUTS.

Clinical utility of intraductal carcinoma of the prostate in treatment selection for metastatic hormone-sensitive prostate cancer.

BACKGROUND: In recent years, the usefulness of androgen receptor axis-targeted agents (ARATs) such as abiraterone, enzalutamide, and apalutamide for the upfront treatment of metastatic hormone-sensitive prostate cancer (mHSPC) has been demonstrated. However, it remains unclear which patients would truly benefit from these treatments. Furthermore, intraductal carcinoma of the prostate (IDC-P) is a known poor prognostic factor in patients with prostate cancer. We investigated the association between the presence of IDC-P and response to therapy in patients with mHSPC. METHODS: This retrospective analysis included 318 patients with mHSPC who received treatment at Nagoya University and its 12 affiliated institutions between 2014 and 2021. Their biopsy specimens were evaluated for the presence of IDC-P. The patients were classified according to their first-line treatment into the ARAT (n = 100, receiving a combination of androgen-deprivation therapy [ADT] and ARAT) or conventional therapy (n = 218, receiving ADT with or without standard antiandrogen agents) group. We compared the overall survival (OS) and second progression-free survival (PFS2) between the ARAT and conventional groups according to the presence of IDC-P to evaluate whether presence of IDC-P predicts the response to each treatment. PFS2 was defined as the period from mHSPC diagnosis to disease progression on second-line treatment or death. Propensity score matching with one-to-one nearest-neighbor matching was used to minimize the potential effects of selection bias and confounding factors. The clinicopathological variables of the patients were well-balanced after propensity score matching. RESULTS: Most patients in the ARAT (79%) and conventional therapy (71%) groups were ICD-P positive. In the propensity score-matched cohort, the OS and PFS2 of IDC-P-positive patients were significantly longer in the ARAT group than in the conventional group (OS: hazard ratio [HR], 0.36; p = 0.047; PFS2: HR, 0.30; p < 0.001). In contrast, no difference in OS and PFS2 was observed between the ARAT and conventional groups in IDC-P-negative patients (OS: HR, 1.09; p = 0.920; PFS2: HR, 0.40; p = 0.264). CONCLUSIONS: The findings highlight a high prevalence of IDC-P among patients with mHSPC and suggest that IDC-P positivity may be a reliable indicator that ARAT should be implemented as first-line treatment.

Two types of detrusor underactivity in men with nonneurogenic lower urinary tract symptoms.

AIMS: To clarify the clinical features of men with nonneurogenic detrusor underactivity (DU) by focusing on storage dysfunction (SD). METHODS: We retrospectively reviewed the clinical and urodynamic data of men with nonneurogenic DU. Patients were divided into two groups according to the presence or absence of SD, such as detrusor overactivity (DO) and reduced bladder compliance (BC). Patient characteristics, lower urinary tract symptoms (LUTS), and urodynamic parameters were compared. DU was defined as bladder contractility index (BCI) ≤ 100 and bladder outlet obstruction index (BOOI) ≤ 40. RESULTS: Of 212 men with DU, 123 (58.0%) had concomitant SD (SD + DU group), and 89 (42.0%) had only DU (DU-only group). Age, prostate volume, and severity of storage symptoms were significantly higher in the SD + DU group. Particularly, >80% of men in the SD + DU group met the diagnostic criteria for overactive bladder in Japan, which was significantly higher than the 26% of men in the DU-only group. The frequency of urinary urgency incontinence (UUI) was also significantly higher in the SD + DU group (65% vs. 12% in DU-only group). In contrast, voiding symptoms, including straining, were more severe in the DU-only group. Regarding the urodynamic parameters, compared to the DU-only group, bladder capacity was significantly smaller and BOOI and BCI were significantly higher in the SD + DU group. However, there was no significant difference in the maximum flow rate and bladder voiding efficiency. CONCLUSIONS: Approximately 60% of men with DU had SD, such as DO and/or reduced BC, whereas the remaining 40% had increased bladder capacity without an increase in detrusor pressure during the storage phase. There were significant differences in the storage and voiding symptoms between the groups. It is important to divide patients with DU based on SD to accurately clarify the clinical picture of DU.

A case of undifferentiated carcinoma of the bladder treated by combination therapy of surgery, local radiation, and immune checkpoint inhibitors.

Undifferentiated carcinoma of the bladder is a rare malignancy with a poor prognosis. We present the case of an 81-year-old woman complaining of bladder irritation. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a bulky bladder tumor, which was diagnosed as cT4aN0M0. A transurethral resection of the bladder tumor revealed pT2 or higher urothelial carcinoma. The patient underwent total cystectomy with an ileal conduit diversion. Histological examination revealed a primary undifferentiated bladder carcinoma with a sarcoma component, pT3aN0M0. Postoperative adjuvant chemotherapy with gemcitabine plus carboplatin was administered. However, this regimen was discontinued after one course due to significant myelosuppression. Four months after total cystectomy, a pelvic tumor with suspected local recurrence was detected on CT. The patient was diagnosed with recurrent undifferentiated carcinoma with a sarcoma component by a transperineal ultrasound-guided biopsy. Local radiation therapy and immunotherapy with immune checkpoint inhibitors were prescribed. After three courses of immunotherapy with pembrolizumab, the primary tumor disappeared. Upon continuing immune checkpoint inhibitor treatment, the patient has maintained a complete response without tumor recurrence in the following six months.

Urodynamic risk factors of asymptomatic bacteriuria in men with non-neurogenic lower urinary tract symptoms.

PURPOSE: To investigate the prevalence of asymptomatic bacteriuria (ASB) in middle-aged and older men with non-neurogenic lower urinary tract symptoms (LUTS) and clarify urodynamic factors related to the presence of ASB. METHODS: We retrospectively reviewed the clinical data of men with LUTS who underwent urine culture examination, LUTS severity assessment, and urodynamic studies. The patients were allocated into two groups (the ASB + LUTS and LUTS-only) according to presence or absence of ASB. The patients' characteristics and urodynamic factors related to the development of ASB were assessed using univariate, binomial logistic regression, and receiver-operating characteristic (ROC) curve analyses. RESULTS: Of 440 men, 93 (21.1%) had ASB. Parameters related to voiding functions, such as maximum flow rate, post-void residual urine volume, bladder voiding efficiency (BVE), and bladder contractility index (BCI), were significantly reduced in the ASB + LUTS group, while bladder outlet obstruction index was not different between the groups. Binomial logistic regression analysis showed that the presence of diabetes, lower BCI, and lower BVE were significantly associated with the presence of ASB. In addition, ROC analysis identified 55% as the optimal cutoff value of BVE for the presence of ASB, with a sensitivity of 84% and specificity of 83%. CONCLUSIONS: ASB was found in > 20% of men with non-neurogenic LUTS and was associated with decreased bladder contractility and decreased BVE. BVE could predict presence of ASB with high sensitivity and specificity.

Clinical features and urodynamic findings in elderly men with chronic prostatitis.

OBJECTIVES: To investigate the complication rate of chronic prostatitis/chronic pelvic pain syndrome in men with lower urinary tract symptoms, and to clarify their clinical features and urodynamic findings. METHODS: We retrospectively reviewed the clinical data of treatment-naïve men with lower urinary tract symptoms. Patients were divided into two groups (chronic prostatitis/chronic pelvic pain syndrome + lower urinary tract symptoms and lower urinary tract symptoms only) according to the presence or absence of chronic prostatitis/chronic pelvic pain syndrome, and the patient characteristics as well as the parameters of lower urinary tract symptoms and lower urinary tract function assessed by urodynamics were compared. The diagnostic criteria for chronic prostatitis/chronic pelvic pain syndrome included a complaint of pelvic pain for ≥3 months, National Institutes of Health Chronic Prostatitis Symptom Index pain subscore ≥4, and negative culture of a urine specimen collected after prostate massage. RESULTS: Out of 386 men, 123 (31.9%) had chronic prostatitis/chronic pelvic pain syndrome. Parameters of lower urinary tract symptoms and National Institutes of Health Chronic Prostatitis Symptom Index scores were significantly higher in the chronic prostatitis/chronic pelvic pain syndrome + lower urinary tract symptoms group. Although there were no significant intergroup differences in voiding parameters such as maximum flow rate and bladder outlet obstruction index, storage functions such as the incidence of detrusor overactivity and bladder compliance were significantly reduced in the chronic prostatitis/chronic pelvic pain syndrome + lower urinary tract symptoms group. The multivariable regression analysis revealed that a low serum total testosterone level (<3.5 ng/mL), complications of hyperlipidemia, and presence of overactive bladder and detrusor overactivity were significantly associated with the development of chronic prostatitis/chronic pelvic pain syndrome. CONCLUSIONS: Chronic prostatitis causes a significant decrease in storage function, such as an increase in detrusor overactivity. Additionally, low serum testosterone levels and hyperlipidemia were found to be significantly associated with the development of chronic prostatitis/chronic pelvic pain syndrome in men with lower urinary tract symptoms.

Grade group 2 (10% ≥ GP4) patients have very similar malignant potential with grade group 1 patients, given the risk of intraductal carcinoma of the prostate.

BACKGROUND: It has been argued that grade group 2 (GG2) with a low Gleason pattern 4 (GP4) proportion should be an indication for active surveillance (AS) of prostate cancer (PCa). However, the cut-off GP4 proportion for AS remains unclear. Here, we evaluated the effect of GP4 proportion and IDC-P on cancer recurrence following radical prostatectomy (RP) in GG1 and GG2 patients, and identified candidates for AS. METHODS: We retrospectively evaluated 646 patients with PCa who underwent RP between 2005 and 2014, and whose specimens were of GG1 or GG2 status. RESULTS: The GGs were as follows: GG1, 25.2% (n = 163); GG2 (5% ≥ GP4), 11.4% (n = 74); GG2 (5% < GP4 ≤ 10%), 25.9% (n = 167); and GG2 (20% ≤ GP4), 37.5% (n = 242). IDC-P was detected in 26 patients (4%), i.e., in 2/167 GG2 (5% < GP4 ≤ 10%; 1%) cases and 24/242 GG2 (20% ≤ GP4; 10%) cases. GG2 patients with IDC-P exhibited a significantly poorer prognosis than did those without IDC-P (P < 0.0001), as did GG2 (20% ≤ GP4) patients without IDC-P (P < 0.05). The GG2 (5% ≥ GP4) and (5% < GP4 ≤ 10%) groups exhibited prognoses similar to those of the GG1 patients. In multivariate analysis, GG2 (20% ≤ GP4) without IDC-P, the presence of IDC-P, and the prostate-specific antigen level at diagnosis significantly predicted prognosis (P < 0.05, < 0.0001, and < 0.0001, respectively). CONCLUSION: Our findings suggest that GG2 (GP4 ≤ 10%) patients could be indicated for AS, similar to GG1 patients, given the risk of IDC-P tumors.

The clinical benefit of sequential therapy with androgen receptor axis-targeted agents alone in patients with castration-resistant prostate cancer: A propensity score-matched comparison study.

BACKGROUND: The optimal sequential therapy for castration-resistant prostate cancer (CRPC) remains unknown. In recent years, some doubts have emerged regarding the clinical benefit of sequential therapy with androgen receptor axis-targeted agents (ART) such as abiraterone (ABI) or enzalutamide (ENZ) for patients with CRPC. We compared the effect of ART-to-ART (AA) sequential therapy after castration resistance with that of docetaxel (DTX)-combined sequential therapy (ART to DTX or DTX to ART) in patients with CRPC. METHODS: We retrospectively identified and analyzed the data of 315 patients with CRPC treated in our seven affiliated institutions between 2009 and 2019. All patients received either DTX or ART (ABI or ENZ) as the first- or second-line therapy after castration resistance. We compared the overall survival (OS) and the second progression-free survival (PFS2), calculated from the initiation of first-line therapy after castration resistance, between the AA sequence group and the DTX-combined sequence group. PFS2 was defined as the period from the start of first-line treatment after castration resistance to progression on second-line treatment. To minimize selection bias from possible confounders, we performed propensity score matching using one-to-one nearest neighbor matching without replacement. RESULTS: Overall, 106 and 209 patients were administered the AA sequential therapy and DTX-combined sequential therapy, respectively. The clinicopathological variables of patients were well balanced after propensity score matching, and there were no significant differences between the two groups. In the propensity score-matched cohort, OS was not significantly different between the two groups (median, 37.9 vs. 45.4 months; hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.68-1.79; p = .701), while PFS2 was significantly shorter in the AA group than in the DTX-combined group (median, 12.9 vs. 21.6 months; HR, 1.70; 95% CI, 1.16-2.48; p = .007). CONCLUSIONS: Certain patients with CRPC can benefit from ART-to-ART sequential therapy in a daily clinical setting.

Effect of core needle biopsy number on intraductal carcinoma of the prostate (IDC-P) diagnosis in patients with metastatic hormone-sensitive prostate cancer.

BACKGROUND: The number of core needle biopsies in metastatic prostate cancer cases are sometimes reduced to avoid various complications. We analyzed whether core needle biopsy number influence IDC-P detection rate in patients with metastatic castration-sensitive prostate cancer (mHSPC). METHODS: We retrospectively evaluated data from 150 patients diagnosed with mHSPC. Subjects were allocated to three groups according to the number of core biopsies performed: ≤ 5, 6-9, and ≥ 10. The study endpoints were the cancer-specific survival (CSS) and overall survival (OS) rates. RESULTS: For patients who underwent ≥ 10 core biopsies, a significant difference on CSS was detected between with or without IDC-P (P = 0.016). On the other hand, the difference decreased as the number of core biopsies became smaller (6-9; P = 0.322 and ≤ 5; P = 0.815). A similar trend was identified for the OS outcome. A significant difference on OS was also found between with or without IDC-P in patients who underwent ≥ 10 and 6-9 core needle biopsies (P = 0.0002 and 0.017, respectively), but not in those who underwent ≤ 5 core biopsies (P = 0.341). IDC-P served as a stronger prognostic marker for CSS and OS than did the other factors included in the multivariate analysis for patients had ≥ 10 core biopsies (P = 0.016, and P = 0.0014, respectively). CONCLUSIONS: Given the IDC-P detection and its value as a prognostic marker, we propose the performance of ≥ 10 core biopsy procedures in patients diagnosed with mHSPC to minimize the sampling error of the IDC-P.

Comparison of cernitin pollen extract vs tadalafil therapy for refractory chronic prostatitis/chronic pelvic pain syndrome: A randomized, prospective study.

AIMS: To compare the efficacy of cernitin pollen extract (cernitin) or tadalafil for treating persistent chronic pelvic pain despite α1-blocker monotherapy in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and lower urinary tract symptoms (LUTS). METHODS: A total of 100 patients with refractory CP/CPPS despite ongoing α1-blocker monotherapy were randomized to receive add-on therapy with either cernitin (4 capsules/day) or tadalafil (5 mg/d) for 12 weeks. At week 12, changes from baseline in the patients' CP/CPPS, LUTS, and voiding function, as assessed using the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), the International Prostate Symptom Score (IPSS), and uroflowmetry, respectively, were compared between the groups. RESULTS: The final analysis included 42 and 45 patients in the cernitin and tadalafil groups, respectively. Although the NIH-CPSI total, NIH-CPSI pain sub-score, and NIH-CPSI quality of life sub-score significantly improved in both groups, the cernitin (vs tadalafil) group showed significantly greater improvements in the NIH-CPSI total score (-6.8 vs -4.6; P = .02) and NIH-CPSI pain sub-score (-4.1 vs -1.5; P < .001). Half (50%) of the patients in the cernitin group showed a reduction greater than 50% in their NIH-CPSI pain sub-score; in the tadalafil group, only four patients (8.9%) showed ≥50% improvement (P < .001). In contrast, the improvement in LUTS was significantly superior in the tadalafil group. CONCLUSION: Both cernitin and tadalafil significantly ameliorated chronic pelvic pain in patients with refractory CP/CPPS. The add-on of cernitin was more effective than tadalafil for pelvic pain and discomfort.

[ADOPTION OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL FOR THE MANAGEMENT OF PATIENTS UNDERGOING RADICAL CYSTECTOMY IN JAPAN].

(Objectives) The Enhanced Recovery After Surgery (ERAS) protocols are standardized and multimodal perioperative care pathways designed to improve surgical outcomes by minimizing stress response and inflammation following surgery. First adopted in colorectal surgery, ERAS is now being employed in various other types of surgeries, most recently in patients undergoing radical cystectomy (RC). Implementation of ERAS protocols resulted in reductions in perioperative complication rates and length of hospital stay (LOS). However, information on the adoption of ERAS in patients undergoing RC in Japan is limited. The objective of this study was to evaluate the safety and efficacy of ERAS implemented in the Toyohashi Municipal Hospital in 2017 for the management of patients with RC. (Patients and methods) This was a retrospective study of 103 patients who underwent RC and urinary diversion from January 2012 to March 2019. Of the 103 patients, 71 underwent surgery prior to the introduction of the ERAS were allocated to the 'traditional' group, while 32 were exposed to the ERAS protocol were allocated to the 'ERAS' group. In this study, ERAS included no bowel preparation, preoperative carbohydrate loading, preoperative fluid reduction, preoperative fasting, reduced drainage use, no nasogastric intubation, and early postoperative drinking and eating. A comparative analysis was performed to evaluate LOS and postoperative complication rate (Clavien classification ≥2) after RC between the 'traditional' and 'ERAS' groups. (Results) Patient characteristics and intraoperative variables such as median age, sex, body mass index, clinical and pathological cancer stage, amount of bleeding, need for transfusion, and technique of urinary diversion did not differ between groups. However, duration of surgery was significantly shorter in the ERAS group than in the traditional group (402 min vs. 470 min; P = 0.03). Further, rate of complication was significantly lower (43.8% vs. 67.6%; P=0.03) and LOS after RC was significantly shorter (21 days vs. 28 days; P<0.001) in the ERAS group compared to the traditional group. Moreover, ERAS was an independent factor affecting shorter LOS after RC (OR, 5.22; 95% CI, 1.52-17.90; P = 0.009) in multivariate analyses. (Conclusions) It is possible that the ERAS protocol adopted in this study reduced the LOS and postoperative complication rate after RC at this site in Japan.

Propensity score-matched comparison of docetaxel and androgen receptor axis-targeted agents in patients with castration-resistant intraductal carcinoma of the prostate.

OBJECTIVE: To evaluate the efficacy of docetaxel and androgen receptor axis-targeted (ARAT) agents in patients with castration-resistant prostate cancer (CRPC) with intraductal carcinoma of the prostate (IDC-P) using a propensity score-matched analysis. PATIENTS AND METHODS: We retrospectively identified 309 patients with CRPC from February 2007 to February 2016 at Nagoya University and its affiliated hospitals. All patients received initial androgen-deprivation therapy (ADT). After progression to CRPC, they received docetaxel or ARAT (abiraterone or enzalutamide) as first-line life-prolonging therapy. Docetaxel (70-75 mg/m2 ) every 3 weeks vs enzalutamide (160 mg) once daily orally or abiraterone (1 g) once daily plus prednisone (5 mg) twice daily orally was administered. The primary outcome of interest was overall survival (OS) from the time of CRPC diagnosis. A propensity score analysis with a 1:1 ratio using an optimal matching algorithm was used to adjust for confounding factors. RESULTS: Overall, 234 patients were analysed. Propensity score-matching identified 85 patients in each group. There were no significant differences in patient characteristics between the groups. The median OS in the docetaxel group was 38.2 vs 58.3 months in the ARAT group (P = 0.03). For patients with IDC-P, OS was significantly longer in the ARAT group than the docetaxel group (P = 0.01), and there was no significant difference in each group, as in patients without IDC-P (P = 0.67). A multivariate analysis showed that the presence of IDC-P, duration of primary ADT, visceral metastasis, and administration of ARAT as the first-line treatment for CRPC were independent prognostic factors for OS. CONCLUSION: Administration of ARAT as the first-line treatment for CRPC may prolong OS more than that of docetaxel, especially in patients with IDC-P.

[Coronary Artery Bypass Grafting in an Elderly Patient with Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery].

We report a case of a 73-year-old woman who was diagnosed with anomalous origin of the left coronary artery(LCA) from the pulmonary artery(ALCAPA) by coronary angiography. Drug stress myocardial perfusion scintigraphy demonstrated myocardial ischemia in the left anterior descending coronary artery (LAD) region. She underwent single coronary artery bypass grafting to LAD using left internal thoracic artery (LITA) and direct closure of the origin of the anomalous LCA. Postoperative coronary catheterization revealed a patent graft showing no residual shunt from the pulmonary artery into the left coronary artery. Myocardial scintigraphy proved improvement of the ischemia. In general, once ALCAPA is diagnosed, early surgical intervention is recommended. However, since there are few reports regarding surgical treatment for ALCAPA in elderly patients, the optimal treatment strategy is not completely established. Therefore careful long-term follow-up is mandatory.

Efficacy of zoledronic acid in older prostate cancer patients undergoing androgen deprivation therapy.

OBJECTIVES: The purpose of this study is to evaluate the efficacy of annual zoledronic acid treatment in Japanese patients with nonmetastatic prostate cancer during androgen deprivation therapy (ADT). METHODS: This is a single institution 12-month study. Between 2016 and 2019, patients aged 70 years or older on ADT for nonmetastatic prostate cancer had bone mineral density (BMD) measured and 10-year probability of fracture calculated using fracture risk assessment tool (FRAX). Patients who showed osteopenia or had a 10-year hip fracture risk ≥ 3% or a 10-year probability of major osteoporotic fracture ≥ 20% were offered treatment with zoledronic acid 5 mg intravenously (ZA group). The patients who did not receive treatment were set as the control group. Lumbar and hip BMD were measured 6 and 12 months after treatment in the ZA group and 12 months after baseline in the control group. The yearly BMD change of both groups was compared. RESULTS: The mean ages of the ZA group (n = 26) and control group (n = 12) were 80.5 ± 9.1 and 76.1 ± 6.7 years, respectively. In the ZA group, lumbar and hip BMD changes at 12 months were +2.1% and +0.8%, respectively. In the control group, lumbar and hip BMD changes were -0.9% and -4.9%, respectively. There were statistically significant differences between the 2 groups in BMD percent changes (P < 0.05). CONCLUSIONS: Without intervention, BMD tends to continue to decrease during ADT. Our findings suggest that administration of zoledronic acid enables maintenance of BMD in the older adults.

[A CASE OF RETROPERITONEAL HEMORRHAGE CAUSED BY THE INSERTION OF A URETERAL ACCESS SHEATH. A RARE COMPLICATION ASSOCIATED WITH FLEXIBLE TRANSURETHRAL LITHOTRIPSY (fTUL)].

A 77-year-old man with a right kidney stone was admitted to our hospital. A ureteroscope was introduced into the ureter without dilation under direct vision. We then performed flexible transurethral lithotripsy (f-TUL) using a ureteral access sheath and successfully fragmented the stone and extracted almost all the stone fragments without any complications. Just 3 hours after the operation, he suddenly developed right abdominal pain with a decrease in hemoglobin. A CT scan showed a retroperitoneal hemorrhage around the lower ureter. We herein describe a rare complication associated with flexible transurethral lithotripsy.