[Clinical Study of Bladder Tamponade at Takeda Hospital].

This retrospective study examined bladder tamponade in 58 patients (male, n＝36 ; female, n＝22 ; average age, 78.5 years old) at Takeda Hospital between 2006 and 2016. Twenty-four of the patients were prescribed anticoagulants, and 18 had an indwelling urethral catheter. The underlying diseases comprised of cystitis (male, n＝7; female, n＝19), iatrogenic lower urinary tract injury (male, n＝13), bladder neoplasms (male, n＝6 ; female, n＝1), prostatic hemorrhage (male, n＝7), renal cell carcinoma (male, n＝1 ; female, n＝1), and bladder stone (male, n＝2 ; female, n＝1). The ratios of cystitis and iatrogenic injury were significantly higher in females and males, respectively (p＜0.0001). Elderly women in particular might be more in need of care due to a tendency towards bladder tamponade. Continuous bladder irrigation and transurethral coagulation were required more frequently for males than females. Radiation cystitis was not the cause of bladder tamponade in any of our patients, indicating that the incidence of bladder tamponade due to radiation cystitis has sharply decreased in Japan over the past 10 years.

[CHYLOUS LEAKAGE AFTER LAPAROSCOPIC RENAL AND ADRENAL SURGERY].

(Objectives) It is recognized that Chylous leakage is a rare complication but is a relevant clinical problem after major abdominal surgery. It was occasionally reported in urologic surgery, but the data about its incidence and treatment outcome is still lacking. In this study, we reviewed our cases of chylous leakage after laparoscopic adrenalectomy or nephrectomy. (Patients and methods) From January 2005 to September 2014, laparoscopic adrenalectomies or nephrectomies were performed in 300 patients. The factors that affected the development of chylous leakage were analyzed. (Results) The overall incidence of chylous leakage was 4.3% (13 of 300 cases). All chylous leakage was seen on the left side, and it was commonly developed in patients with lymph node dissection or excessive hilar dissection around the left renal pedicle. Importantly, all cases were successfully managed conservatively by a low fat diet with or without octreotide. (Conclusions) Our results suggest that chylous leakage is not a rare complication after laparoscopic adrenalectomy or nephrectomy, but most cases can be treated conservatively. Chylous leakage can occur in patients with lymphadenectomy or hilar dissection on the left side.

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR RENAL TUMOR>7CM.

(Objectives) Laparoscopic radical nephrectomy (LRN) is now a standard care for the treatment of renal tumors, but the limitation of LRN for large tumors remains to be elucidated. In this study, we examined the safety and efficacy of LRN for >7 cm renal tumors including tumors >10 cm. (Patients and methods) From March 2001 to September 2014, 167 patients received laparoscopic surgery for renal tumors at our institution. Of these, 126 patients (≤4.0 cm: 64 cases, 4.1-7.0 cm: 40 cases, 7.1-10.0 cm: 12 cases, >10.0 cm: 10 cases) underwent LRN. Treatment outcomes including surgical and oncological outcomes among each stage were compared. (Results) Operating time for 7.1-10.0 cm tumors were similar to that <7 cm tumors but that for >10 cm tumors was significantly longer than that <10 cm tumors. There was no significant difference among each stage in terms of complication rate. As expected, recurrence-free survival rate for >10 cm tumors were worse than <10 cm tumors. (Conclusions) Our data suggests that LRN for large tumors >7 cm can be performed safely, but LRN for >10 cm tumors are technically demanding and require longer operation time.

MID-TERM ONCOLOGICAL OUTCOME AND TECHNICAL MODIFICATIONS FOR LAPAROSCOPIC RADICAL CYSTECTOMY AT OUR INSTITUTION: 60 CASES ANALYSIS.

(Objective) Although laparoscopic radical cystectomy (LRC) is becoming a standard care for invasive and high-risk non-invasive bladder cancer in Japan, the data about mid-and long-term oncological outcome is still lacking. We previously reported our initial experience of LRC compared to open radical cystectomy. In this study, we evaluated mid-term oncological outcome for LRC by updating our clinical data. In addition, we evaluated the effect of technical modifications for LRC. (Patients and methods) From March 2005 to September 2015, 60 patients underwent LRC at our institution. Treatment outcomes including surgical and oncological outcomes were analyzed. We also assessed the effect of technical modifications between first 30 cases and second 30 cases as to blood loss, operating time and complication rate. (Results) The overall complication rate was 47%, including 18% serious complications (Clavien score 3 or greater). The 5-year recurrence-free survival, cancer-specific survival, and overall survival were 56.2%, 74.4%, and 63.6%, respectively. The recurrence occurred in 19 (32%) cases, including distant metastasis in 12 (20%) cases, local recurrence in 6 (10%) cases, and both in 1 (2%) cases. As for the effect of technical modifications for LRC, the blood loss decreased and postoperative recovery was faster in second 30 cases. (Conclusion) These results indicate that LRC could be performed safely with acceptable oncological outcomes.

THE FACTORS THAT AFFECT THE DECISION TO PERFORM LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR SMALL RENAL TUMOR.

(Objectives) Nephron sparing surgery (NSS) is strongly recommended for patients with T1a renal cell carcinoma (RCC) whenever surgically feasible. However, partial nephrectomy, particularly laparoscopic approach, remains underutilized in Japan compared to laparoscopic radical nephrectomy (LRN). In this study, we examined the safety and efficacy of laparoscopic partial nephrectomy (LPN) for T1a RCC compared to LRN. We also assessed the factors that affect the decision to perform LPN or LRN. (Patients and methods) From March 2001 to September 2014, 112 patients with T1a renal tumors received renal surgery at our institution. Of these, 100 patients (LPN: 36 patients, LRN: 64 patients) underwent laparoscopic surgery. Treatment outcomes including surgical and oncological outcomes among each approach were compared. In addition, multivariate analysis was performed to reveal the factors that affect the decision on surgical approach. (Results) The ratio of patients more than 75 years old and the RENAL nephrometry score were higher in LRN group than those in LPN group. Operating time was longer but renal function was well preserved in LPN group. Importantly, blood loss, intraoperative and postoperative complication rate, and oncological outcome (recurrence-free survival and overall survival) were similar in both groups. Multivariate analysis revealed that age (≥75 years old), high RENAL nephrometry score, operation period (before 2011), and the absence of Endoscopic Surgical Skill Qualification (ESSQ) in surgeon were independent predictive factors that select LRN. (Conclusions) Our data suggests that LPN for T1a renal tumor could be performed safely and the decision whether LPN or LRN were performed were associated with technical factors such as the presence of ESSQ or operation period, as well as patient's factor such as age and tumor factor such as tumor complexity.

[Treatment outcome of laparoscopic radical cystectomy at a single institution].

OBJECTIVE: The standard care for invasive bladder cancer is radical cystectomy with urinary diversion, but laparoscopic radical cystectomy (LRC) is still being evaluated. We describe our initial experience of laparoscopic radical cystectomy compared to open radical cystectomy (ORC). PATIENTS AND METHODS: From January 2000 to June 2012, 84 patients underwent radical cystectomy by ORC (n = 54) or LRC (n = 30). Treatment outcomes including surgical and oncological outcomes between LRC and ORC were compared. We also assessed learning curve during LRC as to blood loss, operating time and complication rate. RESULTS: The patients' characteristics were similar in LRC and ORC groups except for ASA score. Importantly, Operating time during LRC was longer but complication rate of LRC was lower than that of ORC (586 min vs 424 min and 40% vs 69%, respectively). In addition, pathological stage or outcomes were similar in both groups and there were no significant difference between LRC and ORC groups in terms of overall and recurrence free survival rate. As for learning curve of LRC, operating time and blood loss tended to decrease with increased experience. CONCLUSION: These results indicate that LRC could be performed safely with decreased complication rate and similar oncological outcomes compared to ORC.

Antimicrobial prophylaxis to prevent perioperative infection in urological surgery: a multicenter study.

We prospectively investigated the rates of incidence of surgical site infection (SSI), urinary tract infection (UTI), and remote infection (RI) in 4,677 patients who underwent urological surgery from January to December 2010, including 2,507 endourological cases, 1,276 clean cases, 807 clean-contaminated cases, and 87 contaminated cases involving bowel segments. A single dose of antimicrobial prophylaxis (AMP) was administered in the endourological, clean, and clean-contaminated surgery cases, except for patients who underwent transurethral resection of the prostate (TURP) or percutaneous nephrolithotripsy (PNL). AMP was administered within 72 h in TURP and PNL, and AMP was administered within 48 h in contaminated surgery cases. In cases of endourological surgery, UTI was observed in 4% and RI in 0%, and SSI, UTI, and RI were seen in 1%, 1%, and 1%, respectively, of clean surgery cases, in 3%, 3%, and 2%, respectively, of clean-contaminated surgery cases, and in 17%, 30%, and 10%, respectively, of contaminated surgery cases. In multivariate analysis of the risk factors for infection, operative time was a significant risk factor for UTI in endourological surgery, and American Society of Anesthesiologists score and operative time were significant risk factors for RI in clean surgery. No significant risk factor was found in analyses of clean-contaminated and contaminated surgery cases. A single-dose AMP regimen was shown to be effective and feasible for prevention of perioperative infection in urological surgery.

Mercaptoacetyltriglycine-3 renogram is not superior to estimated glomerular filtration rate measurement for the prediction of long-term renal function after nephrectomy.

OBJECTIVE: To evaluate the clinical usefulness of effective renal plasma flow (ERPF) measured using preoperative mercaptoacetyltriglycine-3 (MAG3) renogram for the prediction of chronic renal insufficiency after nephrectomy. METHODS: A total of 47 patients underwent preoperative MAG3 renal scintigraphy and subsequent unilateral nephrectomy. Correlations between the 5-year postoperative estimated glomerular filtration rate (eGFR) and the preoperative ERPF of the contralateral kidney (cERPF), ERPF of the diseased kidney (dERPF), total ERPF (tERPF), cERPF to dERPF ratio, serum creatinine (sCr) level, eGFR, as well as the influence of preoperative comorbidities (diabetes, hypertension) on the postoperative eGFR, were evaluated with both univariate and multivariate analyses. RESULTS: Multiple linear regression analysis showed that preoperative cERPF significantly correlated with postoperative eGFR. However, a much stronger correlation was observed between the preoperative and postoperative eGFR. Multiple logistic regression analysis showed that only preoperative eGFR was a significant predicator of the development of advanced-stage chronic kidney disease (CKD). CONCLUSIONS: Preoperative MAG3 renogram is not superior to eGFR measurement as a prognostic indicator of long-term renal function after unilateral nephrectomy.

[Case of carcinoembryogenic antigen-producing renal pelvic cancer].

A 58-year-old man with a chief complaint of exertional dyspnea was admitted to our hospital. One year earlier, he had visited another hospital for the evaluation of gross hematuria, and had undergone right nephro-ureterectomy with a diagnosis of right renal pelvic cancer. Blood chemistry revealed an elevated level of carcinoembryogenic antigen (CEA) (134.5 ng/ml). Computed tomographic scans showed multiple metastases to the liver and sternum. No primary lesion was detected, and immuno-histochemical findings of the specimen were CEA-positive. Thus, we diagnosed this case as CEA-producing renal pelvic cancer. Chemotherapy was ineffective. The patient committed suicide 10 months after admission.

Extraperitoneal laparoscopic ureterolithotomy in the supine position for impacted ureteral stones.

We describe initial experiences with extraperitoneal laparoscopic ureterolithotomy in the supine position. This method can provide adequate working space without the risk of mechanical bowel injury and nerve stretching specific to the flank position.

Complications and the learning curve for a laparoscopic nephrectomy at a single institution.

BACKGROUND: We assessed our experiences in performing a laparoscopic nephrectomy, with regard to complications and the learning curve, during a 4-year period. METHODS: Between November 2000 and October 2004, a total of 78 laparoscopic nephrectomies were performed at our institution (37 radical nephrectomies, 30 nephroureterectomies and 11 simple nephrectomies). The patient charts were retrospectively reviewed to identify any operative and postoperative complications, and also to evaluate the operating time. RESULTS: A total of eleven complications (14.1%) occurred in our series (nine operative and two postoperative complications). All operative complications were due to vascular injuries (n=9), five (2.6%) of which required an open conversion. The operating time and the rates of complications decreased significantly as the surgeons' experiences increased. CONCLUSION: A laparoscopic nephrectomy could be performed as safely as previously reported. In addition, the learning curve for a laparoscopic nephrectomy appeared to be good over the initial 50 procedures at our institution.

Facilitating the technique of laparoscopic running urethrovesical anastomosis using Lapra-ty absorbable suture clips.

We herein describe a simplified technique for performing laparoscopic running urethrovesical anastomosis using Lapra-ty absorbable suture clips (Ethicon, Somerville, NJ, USA) during a laparoscopic radical prostatectomy (LRP). Using two 20 cm absorbable sutures tied together and locked with Lapra-ty at their tail ends, the initiating mattress sutures are placed in the 5:30-6:30-o'clock area between the urethra and the bladder neck. The left and right running sutures are then made clockwise from the 6:30-12-o'clock position and counterclockwise from the 5:30-12-o'clock position, respectively. Both sutures are locked with proper tension by Lapra-ty at the 3, 9 and 12-o'clock positions, and then they are intracorporeally tied together just at the 12-o'clock position. In the initial 20 cases, this anastomosis took 22.5 min on average to perform. We experienced no major urine extravasation and no anastomotic stricture to date.

[Surgical management of inflammatory granuloma which developed following subcutaneous injection of leuprorelin acetate: a case report].

A case of granuloma which developed following a subcutaneous injection of leuprorelin acetate is presented. A prominent induration developed at the site of injection with a three-month type preparation, and radical retropubic prostatectomy and simultaneous excision of the granulomas were requested by the patient since they were large, infectious and painful. Our experience may indicate the necessity of conversion from leuprorelin acetate to other drugs (e.g., goserelin acetate, castration) if a local induration, caused by a subcutaneous injection of leuprorelin acetate, has developed to a large granuloma.

Laparoscopic partial nephrectomy for a renal tumor with tumor-feeding artery ligation: left renal cell carcinoma in the posterior mid zone.

The most serious problem regarding a laparoscopic partial nephrectomy is how to perform bloodless excision without causing renal ischemia in a limited working space. We report the case of a 65-year-old man with left small renal cell carcinoma in the posterior mid zone who underwent a laparoscopic partial nephrectomy through a retroperitoneal approach by carrying out the ligation of the tumor-feeding artery, but without clamping the renal pedicle. Both preoperative abdominal computed tomography (CT) and intraoperative ultrasonography revealed the tumor to be fully encapsulated. The tumor-feeding artery could be exposed by dissection from the renal hilum and, after an arterial ligation, tumor resection with a safety margin was smoothly performed with minimal bleeding. Postoperatively, CT revealed a limited defect of the renal parenchyma and excretory pyelography showed no urine leakage or urinary tract obstruction. The preoperative and postoperative creatinine levels were 0.66 and 0.69 mg/dL, respectively. As a result, a tumor-feeding artery ligation with a laparoscopic partial nephrectomy for left renal cell carcinoma in the posterior mid zone is considered to be an effective surgical modality which avoids renal ischemia and pelvic heat injury.

Accumulation of 99mTc-PMT in renal metastasis of hepatocellular carcinoma.

We describe here a case in which 99mTc-Sn-N-pyridoxy-5-methyltryptophan (99mTc-PMT) scintigraphy was useful in diagnosing renal metastasis of hepatocellular carcinoma (HCC). A 62-year-old man who had undergone hepatectomy for HCC presented 6 years after initial diagnosis with left flank pain and was found on CT and MRI to have a tumor in the left kidney. Hepatobiliary scintigraphy using 99Tc-PMT was performed, and 99mTc-PMT accumulation was found in the tumor. Nephrectomy was performed and metastasis of HCC was confirmed.

[A case of renal cell carcinoma in a horseshoe kidney].

A-50-year-old patient visited our hospital to have further examination for left renal mass. Drip infusion pyelography revealed a cluster of calculi in the upper pole of the left kidney. Computed tomography and magnetic resonance imaging revealed a heterogeneous mass on the left side of a horseshoe kidney. Left nephrectomy was performed through an abdominal transperitoneal approach. An operation for dividing isthmus was simultaneously done using a microwave tissue coagulator. Histopathological findings showed grade 1 > 2, pT1aN0M0, clear cell subtype, renal cell carcinoma. Convalescence was uneventful and the patient was free of tumor at one year postoperatively.

[A case of extensive Fournier's gangrene].

A 52-year-old man was admitted to our hospital complaining of high grade fever and painful swelling of the scrotum. Although debridement of the scrotum and inguinal region was immediately carried out, the inflammation extended to the right abdominal region 2 days later. We tunneled the newly infected areas and placed Penrose drains through the tunnels, so that complete drainage was achieved with minimal tissue loss. The infection was controlled by frequent irrigation of the wound and antibiotic administration. Forty days after the admission the defect of the skin was reconstructed by using a meshed skin graft, and the patient was discharged on the 68th hospital day. We concluded that limited debridement with placement of through-and-through drains might have produced a good result with minimal tissue loss.

[A case of adrenal cortical carcinoma].

We report a case of left adrenocortical carcinoma in a 23-year-old man. His chief complaints were spike fever attack and general malaise. Imaging examination revealed a heterogeneously enhanced mass at the site of the left adrenal gland. Non-functional adrenocortical carcinoma was suspected from hormonal studies. The mass was removed together with the left kidney because of severe adhesion to the renal pedicle. The histopathological findings showed adrenocortical carcinoma (pT3N0M0). Three months after surgery, local recurrence appeared and the tumor grew larger rapidly. Spike fever attack reappeared. No distant metastasis was detected. Two courses of systemic chemotherapy with o, p'-DDD, VP-16, adriamycin and cisplatinum were performed. Computed tomography after the chemotherapy showed progression. Although o, p'-DDD was administered continuously, the patient died of cancerous cachexia 8 months after the surgery. Autopsy could not be done.