Cumulative incidence and risk factors for recurrence of upper tract urothelial carcinoma in patients undergoing radical cystectomy.

Objectives: This study aimed to evaluate the cumulative incidence of upper tract urothelial carcinoma (UTUC) recurrence and identify its risk factors in patients who underwent radical cystectomy (RC). Patients and methods: We performed RC on 385 patients between September 2002 and February 2020. After excluding 20 patients-13 with simultaneous nephroureterectomy, 6 with distal ureteral stump positivity and 1 with urachal cancer-365 patients were included in the analysis. To predict UTUC recurrence, we examined the cancer extension pattern in cystectomy specimens and categorized them into three types: cancer located only in the bladder (bladder-only type), cancer extending to the urethra or distal ureter (one-extension type) and cancer extending to both the urethra and distal ureter (both-extension type). We determined hazard ratios for UTUC recurrence for each covariate, including this cancer extension pattern. Results: Of the 365 patients, 60% had the bladder-only type, 30% had the one-extension type and 10% had the both-extension type. During a median follow-up period of 72 months for survivors, UTUC recurred in 25 of the 365 patients, with cumulative incidences of 3.7% at 5 years and 8.3% at 10 years. The median interval from cystectomy to recurrence was 65 months (interquartile range: 36-92 months). In the multivariate analysis, the extension pattern was a significant predictor of UTUC recurrence. The hazard ratios for UTUC recurrence were 3.12 (95% confidence interval [CI] = 1.15-8.43, p = 0.025) for the one-extension type and 5.96 (95% CI = 1.98-17.91, p = 0.001) for the both-extension type compared with the bladder-only type. Conclusions: The cancer extension pattern in cystectomy specimens is predictive of UTUC recurrence. A more extensive cancer extension in cystectomy specimens elevates the risk of subsequent UTUC recurrence. Intensive long-term monitoring is essential, particularly for patients with the both-extension type.

Epidermoid cyst of the testis: A report of three cases.

Testicular epidermoid cysts have characteristic findings. Testicular tumor markers are negative in patients with epidermoid cysts. Clear margins and sole and small testicular tumors (20 mm or less) suggest the possibility of epidermoid cyst. Testicular-sparing surgery with intraoperative frozen section examination should be performed when suspecting epidermoid cysts. Testicular epidermoid cysts are rare tumors that account for 1% of all testicular tumors and are often clinically misdiagnosed as malignant lesions. We report three cases of epidermoid cysts. The chief manifestations were scrotal induration in two patients and pruritus scrotum in one. The median age of the patients was 23 years (18-30). All tumors were determined to be sole lesions (<20 mm in diameter). Testing for tumor markers in all patients revealed negative results. We could not rule out malignancy; hence, we performed high inguinal orchiectomy in all cases. Histologically, the inner walls of the cysts were lined with stratified squamous epithelium; their contents were keratinized. All patients were diagnosed with epidermoid cysts.

Effectiveness of adjuvant chemotherapy for patients who undergo radical cystectomy without neoadjuvant chemotherapy: A retrospective cohort study of 115 advanced bladder cancer patients with pathological lymph node classification.

OBJECTIVES: We investigated the clinical outcomes of radical cystectomy without cisplatin-based neoadjuvant chemotherapy (NAC) and identified factors affecting the effectiveness of cisplatin-based adjuvant chemotherapy (AC). METHODS: Between September 2002 and February 2020, 288 bladder cancer patients who did not receive NAC underwent radical cystectomy. We retrospectively analyzed the recurrence rates, primary recurrence sites, recurrence-free survival (RFS), and overall survival (OS) of 115 advanced bladder cancer patients (pT3-4 or pN1-3) who were divided into the AC and observation groups. Subgroup analysis was performed, focusing on pathological stage. RESULTS: In total, 51 patients received AC, and 64 patients were observed. The median follow-up duration was 95 months. The recurrence rate was lower in the AC group than in the observation group (35.3% vs. 54.7%, p = 0.041). The rate of recurrences in the lymph node area (dissection site and proximal lymph nodes) was lower in the AC group (9.8% vs. 26.6%; p = 0.031). In the subgroup analysis of patients with pN1, the probability of RFS and OS was higher in the AC group than in the observation group. The hazard ratio for RFS and OS was 0.243 (95% confidence interval [CI]: 0.077-0.768) and 0.259 (95% CI: 0.082-0.816), respectively. The 5-year RFS and OS were significantly higher in the AC group (80.0% and 79.4%) than in the observation group (35.7% and 42.9%; p < 0.008 and p < 0.012, respectively). CONCLUSIONS: AC improved RFS and OS in patients with pN1 disease who did not receive NAC and should be considered for this population.

Retinal Nerve Fiber Layer Thickness Progression after Robotic-Assisted Laparoscopic Radical Prostatectomy in Glaucoma Patients.

PURPOSE: To investigate the effect of the steep Trendelenburg position surgical procedure on the retinal structure and function during robotic-assisted laparoscopic radical prostatectomy (RALP) in glaucoma patients. METHODS: At 1 month and 1 day before and at 1 and 2 months after the RALP operation, 10 glaucoma patients underwent standard automated perimetry and optical coherence tomography. After placing patients in a supine position, intraocular pressure (IOP) was measured at 5 min after intubation under general anesthesia (T1), at 5 discrete time points (5, 30, 60, 120, and 180 min; T2-6) and at 5 min after returning to a horizontal supine position (T7). The Guided Progression Analysis software program was used to assess serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression. RESULTS: Eight additional patients were newly diagnosed in addition to the two previous glaucoma patients. Average IOP (mmHg) at each time point was as follows: T1 = 11.2 ± 3.8, T2 = 19.0 ± 4.4, T3 = 23.3 ± 6.3, T4 = 25.1 ± 4.3, T5 = 25.5 ± 5.1, T6 = 28.3 ± 4.8, and T7 = 22.6 ± 5.4. IOP significantly increased during RALP. RNFL thickness progressed in two eyes of two patients after the surgery, even though there was no progression of the visual field. CONCLUSIONS: Two eyes of two patients exhibited significant RNFL thickness progression. Since an increased IOP during the surgery was the probable cause of the changes, ophthalmologic examinations should be performed before and after RALP, especially in glaucoma patients.

The Effect of Steep Trendelenburg Positioning on Retinal Structure and Function during Robotic-Assisted Laparoscopic Procedures.

PURPOSE: Robotic-assisted laparoscopic radical prostatectomy (RALP) has become a standard treatment choice for localized prostate cancer. RALP requires a steep Trendelenburg position, which leads to a significant increase in intraocular pressure (IOP). This study evaluated the effect on the retinal structure and function in patients undergoing RALP. METHODS: Standard automated perimetry (SAP) and optical coherence tomography (OCT) were performed in 20 males scheduled for RALP at 1 month and 1 day before the operation and at 1 and 3 months after the operation. IOP measurements were made in the supine position at 5 min after intubation under general anesthesia (T1), at 6 discrete time points (5, 30, 60, 120, 180, and 240 min; T2-7), and at 5 min after returning to a horizontal supine position (T8). Serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression were assessed using the guided progression analysis software program. RNFL thickness progression and visual field progression were evaluated by event analysis. RESULTS: Average IOP (mmHg) for each time point was as follows: T1 = 12.3 ± 2.6, T2 = 20.4 ± 4.2, T3 = 23.3 ± 3.8, T4 = 24.0 ± 3.2, T5 = 24.3 ± 3.4, T6 = 27.1 ± 7.2, T7 = 29.8 ± 8.7, and T8 = 20.1 ± 4.4. During RALP, IOP significantly increased. There was no progression of the visual field and RNFL thickness after surgery or any other ocular complications found. CONCLUSIONS: Although IOP significantly increased during RALP, there were no significant changes in the retinal structure and function between the pre- and postoperation observations.

[PROSTATE CANCER DETECTION ON INITIAL TRANSRECTAL PROSTATE BIOPSY IN RELATION TO PROSTATE-SPECIFIC ANTIGEN LEVELS].

(Objective) The prostate cancer detection rates on initial transrectal ultrasound guided prostate biopsies were investigated and the clinicopathological features of prostate cancer patients were examined. (Methods) A retrospective review was performed. From 2003 to 2015, 2,246 patients received initial prostate biopsy in Tochigi Cancer Center. Prostate cancer detection rates and clinicopathological features of the prostate cancer patients in relation to prostate-specific antigen levels were evaluated. (Results) Of the biopsies, 1,294 cases (57.6%) were diagnosed as prostate cancer. The prostate cancer detection rates were 27.8%, 39.8%, 53.6%, 67.4%, 88.4%, 100% in the groups with PSA levels 0.0-3.0, 3.1-4.0, 4.1-10.0, 10.1-20.0, 20.1-100.0, >100.0 ng/ml, respectively. Of all 1,294 cases in prostate cancer, patients rates with the low risk were 0%, 30%, 22%, 0%, 0%, 0% in the groups with PSA levels 0.0-3.0, 3.1-4.0, 4.1-10.0, 10.1-20.0, 20.1-100.0, >100.0 ng/ml, respectively. (Conclusions) From the results of the prostate cancer detection rates and the low risk rates, it seems difficult to determine diagnosis and treatment of prostate cancer only with PSA values.

A quantitative study on splice variants of N-acylethanolamine acid amidase in human prostate cancer cells and other cells.

N-Acylethanolamine acid amidase (NAAA) is a lysosomal enzyme, hydrolyzing various bioactive N-acylethanolamines with a preference for palmitoylethanolamide. Human NAAA mRNA was previously reported to consist of multiple 3'-end splice variants. However, their tissue distributions and roles have not been examined yet. In the present study, we first identified four major splice variants (tentatively referred to as a1, a2, b2, and c2) in a human prostate cancer cell line LNCaP, which were composed of exons 1-11, exons 1-10 and 12, exons 1-9 and 12, and exons 1-8 and 12, respectively. We next developed quantitative polymerase chain reaction methods to individually quantify these NAAA variants as well as collectively measure all the variants. Among various human prostate cancer cells, the total levels of NAAA mRNAs in androgen-sensitive cells like LNCaP were higher than those in androgen-insensitive cells. In all of these prostate cells and other human cells, variants a1 and b2 showed the highest and lowest expression levels, respectively, among the four variants. Interestingly, ratios of the four variants were different by cell type. Variants a1 and a2 encoded the same full-length NAAA protein, which was catalytically active, while b2 and c2 were translated to C-terminally truncated proteins. As expressed in HEK293 cells these truncated forms were detected as catalytically inactive precursor proteins, but not as mature forms. These results revealed wide distribution of multiple variants of NAAA mRNA in various human cells and suggested that the proteins from some variants are catalytically inactive.

Villous Tumor of the Urinary Bladder Resembling Low-grade Mucinous Neoplasm of the Appendix.

Mucinous neoplasms of the urinary tract are very rare. We present a 63-year-old-women who had a sessile papillary villous tumor in urinary bladder. Although transurethral resection of the bladder tumor (TURBT) was performed, the villous tumor repetitively recurred and gradually spread to the entire surface of bladder lumen. Histopathologic and immunohistochemical examination showed that the lesion was very similar to low-grade mucinous neoplasm arising in appendix vermiformis. There are no reports on appendiceal metaplasia of urinary bladder mucosa. In this case, we describe this unprecedented neoplasm as "villous tumor of the urinary bladder resembling low-grade mucinous neoplasm of the appendix."

Case of vascular air embolism during holmium laser enucleation of the prostate.

Vascular air embolism is a rare complication during transurethral surgery. A case of air embolism during holmium laser enucleation of the prostate in a 76-year-old man is presented. During the step of morcellation, the patient's blood pressure suddenly oscillated up and down, and end-tidal CO2 and arterial saturation decreased. Transesophageal and transthoracic echocardiography showed air collection in the right atrium. It was also discovered that incorrect assembly of the tube from the morcellator caused rapid entrainment of air into the vein. Computed tomography and abdominal X-ray showed niveau formation in the femoral vein and air collection in the pelvic retroperitoneal space. The patient recovered with careful observation and was discharged 7 days after the operation with no sequelae. This report is presented to remind urologists of this unusual complication that can occur during holmium laser enucleation of the prostate procedures.

[Effect of change to flutamide for prostate cancer patient who developed breast pain during bicalutamide treatment (BIP-F study)].

In Japan, prostate cancer is treated with non-steroidal anti-androgen (flutamide and bicalutamide). Development of breast pain during bicalutamide treatment, in prostate cancer patients reduces their quality of life (QOL) and treatment compliance. We studied the safety and effectiveness of switching from bicalutamide to flutamide in 13 prostate cancer patients who developed breast pain during bicalutamide treatment. We estimated the change in breast pain using a face scale and the Expanded Prostate Cancer Index Composite (EPIC) and EPIC-hormone domain (HD) score. The switch to flutamide relieved breast pain in nine patients, had no effect in one patient, and increased breast pain in two patients. One patient dropped out. Furthermore, summary score and hormone function were improved with a significant difference in the EPIC-HD score. Switching to flutamide in prostate cancer patients who develop breast pain during bicalutamide is safe and effective.

[An ileal neobladder-enteric fistula 10 years after a radical cystectomy with ileal neobladder construction].

A 67-year-old male underwent a radical cystectomy and ileal neobladder construction in September 2002. He developed adhesive ileus postoperatively and underwent an intestine-ascending colon bypass operation with a side-to-side anastomosis in December of 2002. Subsequently, the patient developed ileus frequently, which improved with conservative management. In February 2013, he had fecaluria and was diagnosed with an ileal neobladder-enteric fistula based on computed tomography 2 hours after contrast medium injection. He underwent closure of the intestinal anal side of the anastomosis between the intestine and ascending colon. The fecaluria disappeared and he is making steady progress. An ileal neobladderenteric fistula as a long-term postoperative complication of ileal neobladder construction is extremely rare, with no other reports to our knowledge. Here, we discuss its cause, diagnosis and treatment, with reference to previous reports.

[A case report of Cowper's syringocele in an adult treated with transurethral unroofing].

We present an adult case of Cowper's syringocele. A 19-year-old male presented with the chief complaint of persistent post-voiding dribbling 5 months after onset. Urethroscopy demonstrated a thin membrane with a small orifice on the ventral aspect distal to the external sphincter. Magnetic resonance imaging showed a restiform shadow on the left side of the corpus spongiosum. Retrograde urethrogram showed filling of diverticulum-like structure in the region of urethral bulb terminating in the urogenital diaphragm. Considering the results mentioned above, we diagnosed the patient with Cowper's syringocele. Transurethral unroofing of the Cowper's syringocele was performed with a cold knife, and the excessive tissue on the edge of syringocele was electroresected to avoid recurrence. His post-voiding dribbling resolved completely after the procedure and has not recurred in 13 months postoperatively. Cowper's syringocele is typically diagnosed presenting with hematuria, urinary tract infection, and disuria in male infants and children. Adult cases of Cowper's syringocele are rare, and only 32 cases including the present case have been reported. Proper awareness of this entity and careful evaluation are important if patients present with persistent adult-onset voiding dysfunction.

[Usefulness of MRI prior to prostate needle biopsy in PSA gray zone].

To evaluate the diagnostic accuracy of prostate magnetic resonance imaging (MRI), we compared MRI findings with the results of biopsy as well as findings from specimens following total prostatectomy. The subjects consisted of 260 males who showed a prostate specific antigen (PSA) level in the gray zone (4 ng/ml ≤PSA <10 ng/ml) and also underwent digital rectal examination (DRE), transrectal ultrasound (TRUS), and MRI prior to prostate biopsy between April 2005 and December 2009. In Evaluation 1, the results of DRE/TRUS/MRI were compared with those of prostate biopsy. The biopsy-positive rate was higher in males positive in each examination. However, 24.8% of males negative in all examinations were biopsypositive. Thus, these examinations were considered to be inappropriate for secondary screening. In evaluation 2, the prostate was divided into 4 regions, and the findings from specimens following total prostatectomy were compared with MRI findings in each region. For the region containing prostate cancer, MRI showed a sensitivity of 26.0%, specificity of 98.3%, positive predictive value of 96.2%, and negative predictive value of 44. 4%. In patients with a Gleason score ≥7, cancer foci were more frequently detectable using MRI. MRI prior to prostate biopsy in patients in the PSA gray zone is inappropriate for secondary screening due to its low sensitivity. However, by virtue of its high positive predictive value, MRI is useful for determining patients indicated for biopsy, as well as DRE and TRUS. Accurate evaluation of the localization of all cancer lesions is difficult using MRI. However, when MRI findings are present, they frequently indicate the cancer lesion, which may be useful information for treatment.

[Risk factors for falls and fractures at night in relation to lower urinary tract symptoms: a survey of outpatients and inpatients at a general hospital].

We investigated potential risk factors, including factors related to lower urinary tract symptoms (LUTS), for falls and fractures at night among outpatients and inpatients in a general hospital, via a questionnaire. The questionnaire included items to record the age, sex, number of consulting doctors, history of 11 particular medical diseases, LUTS, sleep, and falls and fractures at night. We distributed the questionnaire to 1,334 patients 51 years old or older in our hospital. Of the questionnaires completed, 96.9% were valid for analysis. Multivariate analyses revealed that "drinking water before bedtime or while in bed" was the strongest risk factor (odds ratio＝7.499) for bone fractures while "postural syncope" was the strongest risk factor (odds ratio＝5.041, except past medical history) for falls. In terms of LUTS, urge incontinence was a significant risk factor for falls.