Clinical questions in the Japanese Urological Association's 2024 clinical practice guidelines for urethral strictures.

Transurethral procedures such as direct vision internal urethrotomy and urethral dilation have been the traditional treatments for urethral strictures. However, transurethral procedures are associated with high recurrence rates, resulting in many uncured cases and prompting major international urological societies to recommend urethroplasty as the standard treatment owing to its high success rate. In contrast, many Japanese general urologists have little doubts about treating urethral strictures with transurethral treatment. Therefore, urethral stricture treatments in Japan are not in line with those used in other countries. To address this, the Trauma, Emergency Medicine, and Reconstruction Subcommittee of the Japanese Urological Association has developed guidelines to offer standardized treatment protocols for urethral stricture, based on international evidence and tailored to Japan's medical landscape. These guidelines target patients with a clinically suspected urethral stricture and are intended for urologists and general practitioners involved in its diagnosis and treatment. Following the Minds Clinical Practice Guideline Development Manual 2020, the committee identified eight critical clinical issues and formulated eight clinical questions using the "patient, intervention, comparison, and outcome" format. A comprehensive literature search was conducted. For six clinical questions addressed by the existing guidelines or systematic reviews, the level of evidence was determined by qualitative systematic reviews. Quantitative systematic reviews and meta-analyses were performed for the two unique clinical questions. The recommendation grades were determined using the Delphi method and consensus by the committee. These guidelines will be useful to clinicians in daily practice, especially those involved in the care of urethral strictures.

Recurrent left ventricular thrombus due to essential thrombocythemia complicated by COVID-19.

Essential thrombocythemia is a risk factor for thrombosis and hemorrhage. During the perioperative period of cardiac surgery, the risk of thrombosis and hemorrhage increases. Coronavirus disease 2019 (COVID-19) is also associated with thrombosis. We present the case of a 69-year-old man with essential thrombocythemia complicated by COVID-19 who developed a left ventricular thrombus. We performed thrombectomy, but the patient developed recurrent left ventricular thrombus 8 days after surgery. Emergency redo thrombectomy was performed followed by aggressive blood-thinning therapy. The postoperative course was complicated by cardiac tamponade requiring surgical drainage 8 days after the second surgery. The patient was discharged home 25 days after the second operation without any complications. Learning objective: Left ventricular thrombus is a rare but fatal complication associated with essential thrombocythemia. COVID-19 has also been reported to cause coagulopathy. This case suggested that after surgery for left ventricular thrombus complicated by multiple risk factors including essential thrombocythemia and COVID-19, aggressive blood-thinning therapy with combination of anticoagulation, antiplatelet, and metabolic antagonist may help prevent recurrent thrombosis.

Initial thickness of the crescent may not be a reliable predictor of complications in type A intramural haematoma.

OBJECTIVES: This study aimed to investigate changes in haematoma thickness during the early period and their association with disease progression in patients who received initial medical treatment for type A intramural haematoma (IMH). METHODS: Medical records and serial computed tomography angiography (CTA) images of patients who did not undergo emergency aortic repair for type A IMH upon presentation were retrospectively reviewed. The haematoma remodelling rate was determined using the following equation: thickness of the haematoma on the first CTA (mm) - thickness of the haematoma on the second CTA (mm)time between the first and second CTAs (h). RESULTS: Among the 40 patients included in this study, 38 were indicated for initial watch-and-wait strategy, whereas 2 were indicated for emergency aortic repair but declined it. During hospitalization, 10 patients developed disease progression, with 2 in-hospital mortality cases. Analysis of the haematoma remodelling rate in 39 patients revealed that such a rate was significantly associated with the reciprocal of the time from onset. Analysis of all 70 CTA examinations performed within 24 h after the onset of IMH showed that haematoma thickness was significantly associated with the logarithm of the time from onset. Initial regression of the haematoma was not necessarily associated with avoidance of disease progression. CONCLUSIONS: In type A IMH, the thickness of the haematoma in the ascending aorta tended to decrease in the very early period; however, prompt regression of the haematoma was not necessarily associated with avoidance of disease progression.

Watch-and-wait strategy for selected patients with type A intramural hematoma.

OBJECTIVE: This single-center retrospective study evaluated early and midterm outcomes of 100 consecutive patients with type A intramural hematoma. METHODS: Initial watch-and-wait strategy was indicated if the maximum aortic diameter was < 50 mm, pain score was < 3/10 on the numerical rating scale, and no ulcer-like projection was observed in the ascending aorta. The primary endpoints of this study were all-cause and aorta-related deaths, and the secondary endpoint was aortic events. RESULTS: Initial watch-and-wait strategy was indicated in 52 patients. Emergency aortic repair was indicated in the remaining 48 patients; 2, 31, and 15 patients died before surgery, underwent emergency surgery, and declined emergency surgery, respectively. Among the watch-and-wait group, 11 (21%) patients underwent aortic repair during hospitalization. In-hospital mortality rates, 5-year survival rates, and 5-year freedom from aorta-related death were not significantly different between the initial watch-and-wait strategy and emergency surgery (2% vs. 6%, 92% vs. 82%, and 100% vs. 94%, respectively). In the initial watch-and-wait strategy group, 5-year freedom from aortic events and freedom from aortic events involving the ascending aorta were 60% and 66%, respectively. CONCLUSIONS: The early and midterm outcomes with the initial watch-and-wait strategy in patients with type A intramural hematoma with a maximum aortic diameter of ≤ 50 mm, pain score of ≤ 3/10, and no ulcer-like projection in the ascending aorta were favorable with no aorta-related death.

The Japanese Urological Association's clinical practice guidelines for urotrauma 2023.

The Japanese Urological Association's guidelines for the treatment of renal trauma were published in 2016. In conjunction with its revision, herein, we present the new guidelines for overall urotrauma. Its purpose is to provide standard diagnostic and treatment recommendations for urotrauma, including iatrogenic trauma, to preserve organ function and minimize complications and fatality. The guidelines committee comprised urologists with experience in urotrauma care, selected by the Trauma and Emergency Medicine Subcommittee of the Specialty Area Committee of the Japanese Urological Association, and specialists recommended by the Japanese Association for the Surgery of Trauma and the Japanese Society of Interventional Radiology. The guidelines committee established the domains of renal and ureteral, bladder, urethral, and genital trauma, and determined the lead person for each domain. A total of 30 clinical questions (CQs) were established for all domains; 15 for renal and ureteral trauma and five each for the other domains. An extensive literature search was conducted for studies published between January 1, 1983 and July 16, 2020, based on the preset keywords for each CQ. Since only few randomized controlled trials or meta-analyses were found on urotrauma clinical practice, conducting a systematic review and summarizing the evidence proved challenging; hence, the grade of recommendation was determined according to the 2007 "Minds Handbook for Clinical Practice Guidelines" based on a consensus reached by the guidelines committee. We hope that these guidelines will be useful for clinicians in their daily practice, especially those involved in urotrauma care.

[Distal Gastrectomy under Management of Intra-Aortic Balloon Pumping Therapy for an Elderly Patient with Carcinomatous Pyloric Stenosis Complicated by Severe Coronary Stenosis].

This case involved an 82-year-old man with a history of diabetes mellitus and myocardial infarction. He was undergoing treatment with 2 oral antiplatelet agents. The patient presented to our hospital for carcinomatous pyloric stenosis caused by type 4 advanced gastric cancer. Although distal gastrectomy was planned, preoperative coronary angiography revealed triple- vessel coronary artery disease. Therefore, surgery was performed under management of intra-aortic balloon pumping (IABP)therapy. The patient's hemodynamics at the time of the operation were stable, and no perioperative cardiovascular complications occurred. However, the patient was not able to start an oral diet because of impaired swallowing function. Although he underwent daily swallowing rehabilitation, he died of aspiration pneumonia 40 days postoperatively. There are many reports of cancer resection under IABP management for patients with severe heart disease. Because the perioperative hemodynamics were stable in all 21 reported cases of digestive malignant tumor resections in Japan, an IABP is suggested to be very effective for patients with severe heart disease. However, early death has also occurred, as in the present case. Close attention to the indications for IABP therapy is needed, especially in elderly patients, in consideration of not only cancer and heart disease but also preoperative activities of daily living.

Gluteal Blood Flow Monitoring in Endovascular Aneurysm Repair With Internal Iliac Artery Embolization.

BACKGROUND: When an internal iliac artery (IIA) has to be embolized during endovascular aneurysm repair (EVAR), buttock claudication sometimes poses problems. However, there is no established method to evaluate intraoperative blood flow to the gluteal muscles.Methods and Results:Gluteal regional oxygen saturation (rSO2) was monitored using near-infrared spectroscopy (NIRS) during surgery, and changes in rSO2were compared with treatment results. Twenty-seven patients who underwent EVAR and IIA embolization at our institution between April 2019 and May 2020 were included in this study. The association between intraoperative changes in rSO2and postoperative incidence of buttock claudication was analyzed. Furthermore, the presence or absence of communication between the superior and inferior gluteal arteries and the intraoperative changes in rSO2were compared to ascertain whether rSO2reflects blood flow change. Postoperative buttock claudication occurred in 4 of 19 patients (21%) with unilateral occlusion of IIA and in 4 of 8 patients (50%) with bilateral occlusion of IIAs. rSO2was found to decrease significantly further in patients with buttock claudication than in patients without buttock claudication (-15±12% vs. -4±16%, P<0.05). In addition, rSO2was predominantly lower in patients without the communication between the superior and inferior gluteal arteries than in those with the communication. CONCLUSIONS: Gluteal rSO2is useful as an indicator of intraoperative gluteal blood flow.

Watch-and-wait strategy for type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta: a Japanese single-centre experience.

OBJECTIVES: In this study, we investigated the early and midterm outcomes of initial watch-and-wait strategy for Stanford type A intramural haematoma and acute aortic dissection with thrombosed false lumen of the ascending aorta in patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection in the ascending aorta. METHODS: Inpatient and outpatient records were retrospectively reviewed. RESULTS: Of the 81 patients with type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta between April 2011 and April 2019, a watch-and-wait strategy was selected in 46 patients. The mean age of the patients was 68 years, and 22 (48%) patients were female. Ten patients underwent emergency pericardial drainage for cardiac tamponade at the time of presentation and 8 patients underwent aortic repair during hospitalization for new ulcer-like projection, re-dissection or rupture. In-hospital mortality occurred in 2 (4%) patients. During follow-up, survival at 1 and 2 years was 95% and 92%, respectively. There was no significant difference in survival or aortic events between patients in whom the watch-and-wait strategy and emergency surgical treatment were indicated. CONCLUSIONS: The early and midterm outcomes of the initial watch-and-wait strategy were favourable for type A intramural haematoma and acute aortic dissection with the thrombosed false lumen of the ascending aorta in Japanese patients with a maximum aortic diameter of ≤50 mm, pain score of ≤3/10 and no ulcer-like projection. Further study is required to show the safety of this strategy.

[Partial penectomy for penile cancer in a centenarian man].

A 100-year-old man visited our hospital with a complaint of penile tumor formation with bleeding and pain. The tumor was 5cm in long diameter with an irregular surface, and extended from the glans via the coronal sulcus to the dorsal surface of the preputium. The clinical diagnosis was stage I penile cancer, and partial penectomy was performed. The pathological diagnosis was well-differentiated squamous cell carcinoma (pT1bcN0M0). To our knowledge, including foreign references, this is the oldest penile cancer patient in the literature. On discussing the operative course in very elderly patients, appropriate preoperative examination for circulatory and respiratory risks and evaluation of cognitive ability are considered essential. Although it is not difficult to conclude that only this operative procedure reveals enough radicality, we believe that it was the appropriate selection for relief of the patient's pain with full consideration of the invasiveness and risks.

[A case report of urinary extravasation by renal trauma Grade III successfully managed by percutaneous drainage].

A 30-year-old man was diagnosed with renal trauma Grade a and hospitalized on February 22, 2009. There was no apparent stenosis from the renal pelvis to ureter on pyelography, but computed tomography demonstrated urinary extravasation on March 2. An indwelling drainage catheter was placed percutaneously by an ultrasound-guided approach. An incidental ureter-obstructing blood clot prolonged the indwelling period of the drainage catheter, but we succeeded in avoiding open surgery. Although ureteral stenting might be generally selected for the primary management of traumatic urinary extravasation, it should be remembered that percutaneous drainage is effective in some cases. We consider it important to select the optimal treatment based on an accurate diagnosis of each case.

[Cae of double cancer involving of the bladder and prostate which was treated by radical cystectomy 8 years after radical prostatectomy].

A 66-year-old man was diagnosed as having prostate cancer (T2aN0M0) and neoadjuvant hormone therapy was started from 17 February 1995. During observation, superficial bladder cancer was incidentally found and the first transurethral resection was carried out on 21 June 1995. Radical prostatectomy was performed on 8 May 1996. Thereafter, bladder cancer demonstrated repeated recurrence. At the time of the third recurrence, malignant trasformation was recognized as TCC G3 T2 or more invasive, and radical cystectomy with ileal conduit was performed on 12 May 2004 when the patient was 74 years old. From the perspective of double cancer, the frequency of diagnosing localized prostate cancer with superficial bladder cancer is expected to increase because PSA screening is being increasingly performed recently. Because of the possibility of malignant transformation in patients with superficial bladder cancer, in cases of coincident of cancers, it remains controversial which treatment should be selected for the previously diagnosed prostate cancer. Here, we report the clinical course and discuss this issue to some extent.

[Primary malignant lymphoma of the urinary bladder: a case report].

We report a case of primary malignant lymphoma of the urinary bladder. A 72-year old woman complaining of low abdominal pain was admitted to the Tone Central Hospital in February, 2001. Macrohematuria appeared, and the submucosal tumor was observed by cystoscopy, and A Transurethral bladder biopsy led to a histopathological diagnosis of non-Hodgkin's malignant lymphoma (diffuse lymphoma, large-sized cell type, B-cell type). Clinical stage was IE, but as soon, she was get bilateral hydronephrosis and bladder-ileum fistula. The administration of 6-course CHOP chemotherapy had an excellent effect of disappearing the tumor, bilateral hydronephrosis, and bladder-ileum fistula. She remained free of disease until now.

Autopsy findings of patients with urological neoplasms.

BACKGROUND: A study was carried out to gain extensive understanding of the disease status in patients who had suffered and died of urological neoplasms. METHODS: The subjects were 524 patients who had died at the Department of Urology of Gunma Cancer Center. The autopsy rate for each urological, neoplasm, the extent of the disease, and incidental diseases were analyzed. RESULTS: Autopsies were performed in 27.1% (142/524) of the patients. Frequent metastatic sites were the lymph nodes, bone, and lung in prostate neoplasms; the lymph nodes, liver, and lung in bladder neoplasms; and the lymph nodes, lung, and bone in kidney neoplasms. In the 116 patients with these three major urological neoplasms, the autopsy findings of all patients were compatible with progression of the disease, except for 5 cases (acute myocardial infarction in 2 and liver failure in 3). Multiple primary cancers were seen in 21.6% (25/116), and other cancers that caused death, apart from those at urological sites, were confirmed in 7 patients (pancreas in 2, and esophagus, lung, gallbladder, liver, and uterus in 1 patient each). CONCLUSION: Autopsies revealed the macroscopic and microscopic extent of the disease and the presence of incidental disease beyond the diagnosis made in the patient's lifetime.

Tumor-associated tissue eosinophilia of penile cancer.

BACKGROUND: Tumor-associated tissue eosinophilia (TATE) occurs in many kinds of cancer. This study analyzed whether TATE improves the survival of penile cancer patients. METHODS: In 17 patients with penile cancer, survival was compared between the TATE-positive group and the TATE-negative group. Tissue eosinophils were observed by transmission electron microscopy. RESULTS: In all cases, 5-year survival was 72.9% in the TATE-positive group (n = 8) and 38.9% in the TATE-negative group (n = 9; P = 0.131). In stage III and IV, it was 60% in the TATE-positive group (n = 5) and 0% in the TATE-negative group (n = 5; P = 0.058). Transmission electron microscopy images revealed the vigorous infiltration of tissue eosinophils. CONCLUSIONS: It is suggested that TATE improves the survival of patients with advanced penile cancer. However, a greater number of subjects is needed to prove statistical significance.