Predictive factors of de novo overactive bladder in clinically localized prostate cancer patients after robot-assisted radical prostatectomy.

OBJECTIVES: To assess the postoperative status of clinically localized prostate cancer patients who underwent robot-assisted radical prostatectomy (RARP) with a focus on de novo overactive bladder (OAB). METHODS: The present study included 156 patients who did not have preoperative OAB and underwent RARP between December 2015 and April 2020 at our institution. Patients were divided into the de novo OAB group and non-OAB group based on the findings of overactive bladder symptoms score (OABSS) 6 months after RARP, and comparative assessments were performed between the two groups. RESULTS: Six months after RARP, de novo OAB was detected in 38 (24.4%) out of 156 patients. Body mass index (BMI) and the proportion of patients with hypertension were significantly higher in the de novo OAB group than in the non-OAB group. No significant differences were observed in the other characteristics examined. Furthermore, the preoperative findings of uroflowmetry and a urodynamic study did not significantly differ between the two groups. Despite the lack of significant differences in preoperative OABSS, total international prostate symptom score, the voiding symptom score, storage symptom score, and quality of life score between the two groups, all of these findings 6 months after RARP were significantly worse in the de novo OAB group than in the non-OAB group. Among the several factors examined, only BMI was independently associated with the development of de novo OAB 6 months after RARP. CONCLUSIONS: Patients with a high BMI may develop de novo OAB after RARP, resulting in the significant deterioration of lower urinary tract symptoms.

Comparison of perioperative outcomes among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy.

OBJECTIVES: It has been well documented that partial nephrectomy for completely endophytic renal tumors is a highly challenging procedure accompanied by several technical difficulties even with the assistance of a robotic surgical system. This study aimed to compare perioperative variables among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy. METHODS: This study retrospectively included 265 consecutive patients with localized small renal masses undergoing robot-assisted partial nephrectomy at our institution. In this study, completely endophytic tumor was defined as the mass totally covered by renal healthy parenchyma, and according to the points for the 'E' domain of RENAL nephrometry score based on preoperative computed tomography, subjects were classified into three groups as follows: exophytic, mesophytic, and endophytic tumor groups, and perioperative outcomes among these groups were compared. RESULTS: Of 265 patients, 127, 112, and 26 were classified into the exophytic, mesophytic, and endophytic tumor groups, respectively. A significantly smaller tumor diameter was observed in the endophytic group than in the other groups (P < 0.001), whereas the RENAL nephrometry score was significantly higher (P < 0.001). In addition, the warm ischemia time in the endophytic tumor group was significantly longer than that in other groups (P = 0.009); however, no significant difference in the trifecta achievement was noted among the three groups. CONCLUSIONS: This study suggests that robot-assisted partial nephrectomy for patients with completely endophytic tumors can be regarded as a feasible approach without marked impairment of perioperative outcomes; however, further investigation of the long-term functional and oncological outcomes in these patients is required.

Robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy: Initial experience in Japan.

Introduction: Open surgical approach remains the standard treatment for renal cell carcinoma with an inferior vena cava tumor thrombus. In recent years, however, robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy have emerged as minimally invasive alternatives to conventional open surgery. Case presentation: Here, we describe a 76-year-old female patient with right renal cell carcinoma with a level I inferior vena cava thrombus undergoing robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy, which was successfully completed with a purely robotic procedure, resulting in the following outcomes: console time,167 min; total operative time, 211 min; and estimated blood loss, 150 mL. To our knowledge, this is the first case managed by robot-assisted radical nephrectomy and inferior vena cava tumor thrombectomy in Japan. Conclusion: Based on our experience, it might be worthwhile to consider purely robotic surgery for the treatment of renal cell carcinoma with an inferior vena cava thrombus.

Significant impact of a history of prior or concomitant upper urinary tract cancer on the recurrence and progression of non-muscle invasive bladder cancer.

BACKGROUND: The objective of the present study was to evaluate the prognostic impact of the upper urinary tract cancer status on recurrence-free survival and progression-free survival, and to develop risk stratification systems that include the upper urinary tract cancer status for patients with non-muscle invasive bladder cancer. PATIENTS AND METHODS: The present study included 40 (upper urinary tract cancer-non-muscle invasive bladder cancer group) and 285 (non-muscle invasive bladder cancer alone group) patients with and without a history of prior or concomitant upper urinary tract cancer, respectively. Nine clinicopathological findings between the two groups were compared, and risk stratification systems for the recurrence and progression of non-muscle invasive bladder cancer were developed. RESULTS: Recurrence-free survival and progression-free survival in the upper urinary tract cancer-non-muscle invasive bladder cancer group were significantly inferior to those in the NMIBC alone group (P < 0.001 and P = 0.006, respectively). Multivariate analyses identified the following independent prognosticators: multiplicity and upper urinary tract cancer status for recurrence-free survival, and pT category and upper urinary tract cancer status for progression-free survival. Significant differences were noted by the risk stratification systems based on the positive number of independent predictors of recurrence-free survival and progression-free survival (P < 0.001 and P = 0.007, respectively). The concordance indices of recurrence-free survival were 0.627, 0.588 and 0.499 in this study stratification, EORTC risk table and CUETO model, respectively. Those of progression-free survival were 0.752, 0.740 and 0.714, respectively. CONCLUSION: The present results suggest the significant impact of a history of prior or concomitant UUTC on recurrence-free survival and progression-free survival in non-muscle invasive bladder cancer patients, and risk stratification systems that include the upper urinary tract cancer status for the recurrence and progression of non-muscle invasive bladder cancer are promising tools for predicting the outcomes of these patients.

Limited impact of erectile function on health-related quality of life in Japanese men undergoing robot-assisted radical prostatectomy.

OBJECTIVE: To investigate the impact of erectile function on health-related quality of life in Japanese prostate cancer patients following robot-assisted radical prostatectomy. METHODS: Time-dependent changes in erectile function and health-related quality of life were assessed using the erection hardness score and Medical Outcomes Study 8-Item Short Form Health Survey, respectively, in 229 consecutive Japanese patients undergoing robot-assisted radical prostatectomy. In this series, patients with erection hardness score ≥2 were considered to those having a certain erectile function. RESULTS: Among the 229 patients examined, erection hardness score ≥2 was observed in 134 (58.5%) and 34 (14.9%) before and 12 months after robot-assisted radical prostatectomy, respectively. Prior to robot-assisted radical prostatectomy, all eight scale scores of 8-Item Short Form Health Survey were significantly superior in patients with erection hardness score ≥2 than in those with erection hardness score = 0 or 1. However, significant differences were observed in two scale scores between patients with erection hardness score ≥2 and those with erection hardness score = 0 or 1 at 12 months after robot-assisted radical prostatectomy. Furthermore, among patients with erection hardness score ≥2 before robot-assisted radical prostatectomy, no significant differences were noted in any of the eight scale scores between patients with erection hardness score ≥2 and erection hardness score = 0 or 1 at 12 months after robot-assisted radical prostatectomy. CONCLUSION: These findings suggest the limited impact of erectile function on postoperative health-related quality of life in Japanese patients undergoing robot-assisted radical prostatectomy.

Feasibility of interaortocaval clamping for renal artery during robot-assisted right partial nephrectomy: A propensity score-matching analysis.

AIM: To evaluate the impact of the interaortocaval clamping technique for the right renal artery on perioperative outcomes of patients who underwent robot-assisted partial nephrectomy (RAPN). METHODS: This study included 111 consecutive patients with right renal masses undergoing RAPN via the transperitoneal approach. In this series, standard and interaortocaval clamping techniques were defined as those for the right renal artery at the renal hilus and interaortocaval space, respectively. Based on the 3D images reconstructed from CT, interaortocaval clamping was preoperatively selected for patients in whom standard clamping of the main renal artery at the right hilum was judged to be technically difficult due to complicated vascular distribution, such as multiple branches of right renal arteries and veins and/or intertwining of these vessels. RESULTS: Of 111 patients, 95 and 16 were classified into the standard and interaortocaval clamping groups, respectively, and interaortocaval clamping was uneventfully performed as planned in all 16. After adjusting patient variables by 1:3 propensity score-matching, 33 and 11 patients were included in the respective groups, and there were no significant differences in major clinical characteristics between them, while the incidences of multiple branches of right renal vessels as well as their intertwining beside the right renal hilus were significantly higher in the interaortocaval clamping group. However, no significant difference was noted in any of the perioperative outcomes, including operative time or intraoperative blood loss, between the two groups. CONCLUSIONS: The interaortocaval clamping technique during RAPN is a feasible procedure with acceptable perioperative outcomes compared with standard hilar clamping, making it possible to more accurately resect renal tumors under clear visualization without unnecessary arterial bleeding from the tumor bed in patients with complex vascular distribution at the right renal hilus; however, special attention should be paid to the considerable individual variability of the interaortocaval anatomy.

Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases.

INTRODUCTION: To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan. METHODS: This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed. RESULTS: Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases. CONCLUSIONS: Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Prognostic assessments in patients with upper tract urothelial carcinoma undergoing radical nephroureterectomy and systematic regional lymph node dissection.

OBJECTIVES: Systematic regional lymph node dissection (LND) combined with radical nephroureterectomy (RNU) has been reported to improve the outcomes of upper tract urothelial carcinoma (UTUC) patients. The objective of the present study was to assess the prognostic outcomes of UTUC patients undergoing systematic regional LND combined with RNU. PATIENTS AND METHODS: We conducted a retrospective evaluation of prognostic outcomes of 68 consecutive UTUC patients treated with RUN and systematic regional LND. RESULTS: The median durations of recurrence-free survival (RFS) and overall survival (OS) were 45 and 166 months, respectively. Univariate analyses of several parameters showed that despite the lack of a significant predictor for RFS, the presence of lymph node metastasis correlated with poor OS. CONCLUSION: These results suggest that comparatively favorable outcomes are achievable in UTUC patients by RNU and systematic regional LND; however, special attention is needed for patients with nodal involvement even after systematic regional LND due to the adverse impact of this factor on OS.

Comparison of clinical outcomes between androgen deprivation therapy with up-front abiraterone and bicalutamide for Japanese patients with LATITUDE high-risk prostate cancer in a real-world retrospective analysis.

BACKGROUND: Combining abiraterone (Abi) with androgen deprivation therapy (ADT) improves overall survival, compared to ADT only, in patients with metastatic castration-sensitive prostate cancer (mCSPC). In Japan, bicalutamide (Bica) and ADT (combined androgen blockade: CAB) is frequently provided for mCSPC. Because these two treatments have not been compared, mCSPC patients who received either treatment were retrospectively analyzed. METHODS: Of 178 patients with LATITUDE high-risk mCSPC, 103 had received ADT plus upfront Abi (Abi group) and 75 had received ADT plus Bica (Bica group) in multiple institutions of the Tokai Urologic Oncology Research Seminar. Kaplan-Meir curves were used to retrospectively analyze survival and cancer recurrence. Univariate and multivariate Cox regression analyses identified potential prognostic factors for progression-free survival (PFS). RESULTS: Significant differences in major clinicopathological characteristics between the two groups were not observed. The rate of castration-resistant development was higher in the Bica compared to Abi group (50.6 vs. 25.2%, p < 0.001). The median PFS in the Bica group was 13.6 months {95% confidence interval [CI] 9.2-22.2}; however, in the Abi group, PFS did not reach the median {95% CI 18.5-not assessed [NA]; p < 0.001}. Time to second progression for the Abi group was superior (p = 0.07). Univariate and multivariate analyses revealed Gleason pattern 5, high alkaline phosphatase levels, and conventional CAB using Bica as significant prognostic factors for short PFS. CONCLUSIONS: In patients with LATITUDE high-risk mCSPC, upfront use of Abi combined with ADT resulted in favorable prognostic outcomes compared with conventional ADT with Bica.

Assessment of prognostic factors in previously treated Japanese patients with metastatic renal cell carcinoma who received nivolumab: An observational multi-institute study.

The aim of the present study was to evaluate the prognosis of Japanese patients with metastatic renal cell carcinoma (mRCC) receiving nivolumab and to identify factors predicting the overall survival (OS) in this cohort of patients. This study retrospectively assessed the outcomes of 77 consecutive Japanese patients with mRCC who were treated using either 1 or 2 molecular-targeted agents followed by nivolumab in routine clinical practice. The best responses to nivolumab observed were as follows: Complete response in 3 patients, partial response in 27, stable disease in 33 and progressive disease in 14; therefore, the objective response rate in the 77 patients was 39.0%. During the median follow-up period of 11 months after the introduction of nivolumab, the median progression-free survival and OS were 7 months and not reached, respectively. On multivariate analysis of several parameters, age, Karnofsky Performance Status (KPS) and neutrophil counts were demonstrated to be independently associated with OS in the 77 patients. By dividing these patients into 3 groups according to 3 risk factors, it was possible to stratify the OS; however, the International Metastatic Renal Cell Carcinoma Database Consortium model was unable to classify the OS. These results suggested that age, KPS and neutrophil counts were useful predictors of OS in previously treated patients with mRCC who received nivolumab.

Useful predictors of progression-free survival for Japanese patients with LATITUDE-high-risk metastatic castration-sensitive prostate cancer who received upfront abiraterone acetate.

OBJECTIVE: Recently, hormonal therapy using abiraterone acetate, a second-generation androgen receptor axis-targeted agent, was reported to improve overall survival and progression-free survival in men with LATITUDE-high-risk metastatic castration-sensitive prostate cancer. This observational multicenter study aimed to assess the efficacy of upfront abiraterone acetate in Japanese patients with LATITUDE-high-risk metastatic castration-sensitive prostate cancer. METHODS: The present study included 112 Japanese patients with LATITUDE-high-risk metastatic castration-sensitive prostate cancer who received upfront abiraterone acetate at four institutions belonging to the Tokai Urologic Oncology Research Seminar group, between January 2018 and September 2020. Progression-free survival and overall survival were assessed, and Cox regression analyses were carried out to evaluate the prognostic significance of upfront abiraterone acetate for progression-free survival. RESULTS: Within a median follow-up period of 13 months, the progression-free survival and overall survival rates were 76.8% and 89.3%, respectively. Both univariate and multivariable Cox regression analyses showed that the presence of Gleason pattern 5, performance status and hemoglobin were independent predictors of progression-free survival. The patients were subsequently divided into three groups as follows: group 1, 17 patients negative for these three independent progression-free survival predictors; group 2, 49 patients with one positive independent progression-free survival predictor; and group 3, 45 patients with two or three independent progression-free survival predictors. Progression-free survival was significantly different among these three groups (P < 0.001). CONCLUSION: Upfront abiraterone acetate might provide satisfactory outcomes for Japanese patients with LATITUDE-high-risk metastatic castration-sensitive prostate cancer. Gleason pattern 5, performance status and hemoglobin are potential predictors of progression-free survival in Japanese patients with LATITUDE-high-risk metastatic castration-sensitive prostate cancer who received upfront abiraterone acetate.

Prognostic significance of third-line treatment for patients with metastatic castration-resistant prostate cancer: comparative assessments between cabazitaxel and other agents.

BACKGROUND: Cabazitaxel has played an important role in the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC); however, several types of sequential therapy against mCRPC have been performed in routine clinical practice. The objective of this study was to investigate the impact of third-line treatment on prognostic outcomes of mCRPC patients. METHODS: This study retrospectively analyzed the clinical outcomes of 166 patients who received 3 agents following the diagnosis of mCRPC, consisting of 81 sequentially treated with either abiraterone or enzalutamide and then docetaxel, followed by third-line cabazitaxel (group A) and 85 treated with 3 agents, including abiraterone, enzalutamide, and docetaxel (group B). RESULTS: There were no significant differences in major characteristics at the introduction of the third-line agent between these 2 groups. The proportion of patients with prostate-specific antigen (PSA) reduction > 50% by cabazitaxel in group A was significantly greater than that by either third-line agent in group B. Both PSA progression-free survival (PFS) and overall survival (OS) following third-line therapy in group A were significantly longer than those in group B. Furthermore, OS after the diagnosis of mCRPC in group A was significantly longer than that in group B. Multivariate analysis identified independent predictors of favorable prognostic outcomes after third-line therapy as follows: high-performance status (PS), low PSA level and third-line cabazitaxel for PSA PFS, and high PS, low lactate dehydrogenase level and third-line cabazitaxel for OS. CONCLUSIONS: The introduction of cabazitaxel as a third-line agent could markedly improve the prognostic outcomes of mCRPC patients.

Impact of Bladder Neck Angle Measured by Postoperative Magnetic Resonance Imaging on Midterm Recovery of Urinary Continence in Prostate Cancer Patients Undergoing Robot-Assisted Radical Prostatectomy.

Introduction: MRI has helped clarify the relationship between pelvic anatomical structures and functional outcomes after robot-assisted radical prostatectomy (RARP). The objective of this study was to assess the impact of the bladder neck angle (BNA) measured by postoperative MRI on midterm recovery of urinary continence (UC) in patients undergoing RARP. Patients and Methods: This study retrospectively included 200 consecutive patients with prostate cancer who were treated by RARP and received MRI 3 months after RARP. Based on postoperative MRI, the BNA was measured as the angle between the anterior and posterior bladder walls. The midterm recovery of UC was defined as the use of either no pad or an occasional security pad at 6 months after RARP. Results: One hundred forty-four of the 200 patients (72.0%) achieved midterm recovery of UC and the median BNA was 70°. There were no significant differences in several parameters, including age, body mass index, total prostate volume, preservation of the neurovascular bundle, and postoperative membranous urethral length (MUL), between patients with BNA ≥70° and <70°. Of these parameters, only the BNA and postoperative MUL were independently associated with the midterm recovery of UC. The optimal cutoff points of the BNA and MUL (65° and 9 mm, respectively) were calculated by the receiver operating characteristics curve, and a scoring model for the prediction of midterm recovery of UC was developed according to the logistic regression analysis. This scoring model was demonstrated to be satisfactorily calibrated (p for Hosmer-Lemeshow test = 0.49) and provide good discrimination (area under the curve: 0.723; p < 0.001). Conclusions: These findings suggest that midterm recovery of UC after RARP is favorably affected by the large BNA and long postoperative MUL, and our scoring model can be used as a reliable tool for predicting the midterm continence status after RARP.

Health-Related Quality of Life in Patients with Small Renal Mass Who Underwent Robot-Assisted Partial Nephrectomy: A Prospective Evaluation.

Introduction: There have been insufficient data regarding the impact of partial nephrectomy (PN) with minimal invasive approaches, including robot-assisted PN (RAPN), on postoperative quality of life (QOL) in patients with small renal mass (SRM). The objective of this study was to investigate the changes in health-related QOL (HR-QOL) outcomes in patients with SRM who underwent RAPN. Patients and Methods: We performed a prospective observational study including 100 consecutive patients with SRM who underwent RAPN at our institution between April 2016 and August 2018. A single surgeon performed RAPN for all 100 cases using the da Vinci Xi. HR-QOL in these patients was assessed using the Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8) before and 3, 6, and 12 months after RAPN. Results: Mean age in the 100 patients was 63 years, and diabetes mellitus, hypertension, and chronic kidney disease were preoperatively detected in 22, 44, and 30 patients, respectively. Mean values of tumor diameter and R.E.N.A.L. nephrometry score were 25 mm and 7, respectively. Console and warm ischemia times during RAPN were 115 and 15 minutes, respectively. Of eight subscale scores of the SF-8 survey, three subscale scores before RAPN, bodily pain, role emotional, and mental health (MH), were significantly improved after RAPN. Furthermore, of two summary scores, mental health component summary (MCS), but not physical health component summary (PCS), showed a significant improvement postoperatively. Multivariate analyses of several factors revealed that despite the lack of factors associated with improved PCS, younger age (<65 years) had an independent impact on improved MCS. Conclusions: These findings suggest that patients undergoing RAPN could result in the achievement of favorable HR-QOL, particularly that reflecting MH status in younger patients.

Renal allograft rejection after treatment with nivolumab in patients with metastatic renal cell carcinoma.

In recent years, immune checkpoint inhibitors (ICIs), such as nivolumab, pembrolizumab and ipilimumab, have been introduced into routine clinical practice for treating patients with several types of advanced cancer, including renal cell carcinoma (RCC). However, activation of the immune system against cancer cells by the use of ICIs could result in the induction of allograft rejection in organ transplant patients, and to date, the safety of treatment for organ transplant patients with ICIs has not been well-investigated. Here, we report a case of renal allograft rejection in a kidney transplant recipient with metastatic RCC (mRCC) after the administration of nivolumab. Four weeks after initiating treatment with nivolumab, the renal function, in this case, was markedly impaired, and pathological findings of renal biopsy specimens showed acute rejection characterized by marked infiltration of inflammatory cells. Steroid pulse therapy was performed in this case, and despite the lack of improvement in the renal function, his graft was salvaged. Collectively, these findings suggest that it is necessary to pay special attention to the potential for allograft rejection when introducing ICIs for solid organ transplant recipients.

Frequency of pre-treatment may not increase the immune-related adverse events of RCC patients treated with nivolumab.

ABSTRACT: Nivolumab has shown good prognosis in renal cell carcinoma (RCC) patients previously treated with targeted therapy. We aimed to study irAE (immune-related adverse event) due to nivolumab and numbers of previous treatment lines in RCC patients. Between October 2016 and November 2019, 114 patients were treated with nivolumab as second- and later-line therapy. Among them, 110 patients with complete data were evaluated in this retrospective observational study. The primary endpoint was the relation between irAE and numbers of previous targeted therapies. Secondary endpoints were the relation of irAE with the duration of nivolumab treatment and with best overall response. For the primary analysis, proportional odds logistic regression was used to assess the effect of the number of prior therapies on the grade of any irAE as the ordinal variable. For the secondary analysis, binomial logistic regression models adjusted for the covariates were prepared to confirm the association between the incidence of irAE and the number of courses, number of nivolumab treatments and best overall response. Overall, 69, 66, 33, 13, 9 and 9 patients were treated with sunitinib, axitinib, pazopanib, sorafenib, temsirolimus and everolimus, respectively, prior to nivolumab. In total, 60 adverse events (Grade 1, 21; Grade 2, 21; Grade 3, 14; Grade 4, 2; not evaluated, 2) were identified in the patients treated with nivolumab. Ordered logistic regression analysis showed that the adjusted odds ratios of numbers of prior treatment for grade of irAE were 1.12 (numbers of prior treatment: 2 to 1) and 1.31 (3 to 1). Odds ratios of the numbers of nivolumab treatments and best overall response for the incidence of irAE were not significant. No statistically significant relations were found between grade of irAE and numbers of treatments prior to nivolumab. Patients treated with nivolumab should be closely monitored for irAE regardless number of previous therapies.

Significance of 5-Aminolevulinic Acid-mediated Photodynamic Diagnosis Following Standard Transurethral Resection in Non-muscle Invasive Bladder Cancer.

Background/Aim: Transurethral resection of bladder tumors (TURBT) guided by photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA) has been shown to be superior to conventional white light (WL) cystoscopy with regard to diagnostic accuracy, for non-muscle invasive bladder cancer (NMIBC); however, PDD is usually performed prior to WL TURBT. The objective of this study was to investigate the diagnostic significance of 5-ALA-mediated PDD following TUR of NMIBC. Patients and Methods: In 83 NMIBC patients, all visible tumors were completely resected under the conventional WL guidance followed by additional resection if fluorescent lesions were observed under the blue light (BL) guidance, and random biopsy was further conducted. Results: With the BL source, 39 (47.0%) patients were judged to have fluorescent lesions. Twenty (51.3%) of the 39 patients with positive findings by PDD were diagnosed with residual cancer by additional resection, while random biopsy detected cancers in 2 (4.5%) of the 44 patients with negative findings by PDD. Accordingly, the sensitivity, specificity, positive predictive value and negative predictive value in diagnosing residual cancer by our PDD system were 90.9, 68.9, 51.3 and 95.5%, respectively. Univariate analysis showed that the presence of residual cancers shown by WL TURBT was significantly associated with the preoperative findings of urinary cytology, tumor multiplicity, pathological T stage and tumor grade, of which only the preoperative finding on urinary cytology was shown to have an independent impact on the diagnosis of residual cancer. Conclusion: 5-ALA-mediated PDD following standard WL TURBT could improve the diagnostic accuracy in NMIBC patients, particularly those who are positive for preoperative urinary cytology.

Development of novel ACN (albumin, C-reactive protein and neutrophil-to-lymphocyte ratio) prognostication model for patients with metastatic renal cell carcinoma receiving first-line molecular-targeted therapy.

PURPOSE: The objective of this study was to develop a novel prognostication model in patients with treatment-naïve metastatic renal cell carcinoma (mRCC). METHODS: This study included 325 consecutive mRCC patients receiving first-line molecular-targeted therapy at 4 institutions. Potential parameters associated with overall survival (OS) in these patients were investigated to develop a novel stratification model. RESULTS: Median OS of the 325 patients was 38 months. A multivariable analysis of several factors identified independent predictors associated with unfavorable OS as follows: no previous nephrectomy, Karnofsky performance status <80%, albumin (Alb) ≤3.5 g/dl, C-reactive protein (CRP) >0.5 mg/dl and neutrophil-to-lymphocyte ratio (NLR) >3. Of these 5 independent OS predictors, 3 numeric factors were used to develop the ACN (Alb, CRP, and NLR) model by dividing patients into 3 groups according to the positive numbers of these 3 numeric risk factors. Median OS durations were 63, 37, and 11 months in the favorable (n = 105, 32.3%, without risk factors), intermediate (n = 88, 27.1%, with a single risk factor), and poor (n = 132, 40.6%, with multiple risk factors) risk groups, respectively. The ACN model as a prognostication tool was shown to be superior to the Memorial Sloan Kettering Cancer Center (MSKCC) and the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) models by both the concordance index and decision curve analysis. CONCLUSIONS: The ACN model could stratify the prognostic risk of mRCC patients receiving first-line targeted therapy more accurately than the MSKCC and IMDC models.

Perioperative outcomes in patients undergoing robot-assisted partial nephrectomy: Comparative assessments between complex and non-complex renal tumors.

INTRODUCTION: The aim of this study was to investigate the effects of renal tumor complexity on perioperative outcomes in patients receiving robot-assisted partial nephrectomy (RAPN). METHODS: This study included 153 consecutive patients with cT1 renal masses undergoing RAPN and analyzed their perioperative outcomes, particularly tumor complexity. In this series, cT1b, completely endophytic, hilar, and cystic tumors were considered complex tumors. Patients with tumors that met at least one of the complex criterion were placed in the complex tumor group; patients with tumors that did not meet any of the complex criteria were placed in the non-complex tumor group. RESULTS: Of the 153 patients, 54 (35.3%) had complex tumors; specifically, 18 (11.8%) had cT1b tumors, 15 (9.8%) had completely endophytic tumors, 28 (18.3%) had hilar tumors, and 8 (5.2%) had cystic tumors. The non-complex group included 99 patients (64.7%). The complex tumor group had significantly longer warm ischemia and console times than the non-complex tumor group, but there was no significant difference between them in the achievement of the trifecta. Both warm ischemia and console times were significantly correlated with the number of complex factors. Multivariate analyses of complex factors demonstrated that completely endophytic and cT1b tumors were independently associated with warm ischemia time and console time, respectively. CONCLUSIONS: For patients with complex tumors, RAPN may be a feasible procedure with acceptable perioperative outcomes. However, special attention should be paid to long warm ischemia and console times, particularly in those with completely endophytic and/or cT1b tumors.

Kidney transplantation from a living donor with renal artery fibromuscular dysplasia: A case report on arterial grafting of the donor renal artery.

INTRODUCTION: Renal artery fibromuscular dysplasia is generally considered a contraindication of kidney transplantation, since fibromuscular dysplasia occasionally induces hypertension or renal insufficiency in the recipient and/or donor. To date, limited information remains available with respect to whether kidneys with renal arterial fibromuscular dysplasia can be successfully transplanted. CASE PRESENTATION: A 53-year-old potential donor was diagnosed with fibromuscular dysplasia of the right renal artery. Laparoscopic right nephrectomy was performed, and the affected portion was resected and reconstructed using the harvested internal iliac artery. Transplantation was successful and the serum creatinine level was <2 mg/dL for 3 years after surgery. CONCLUSION: If reconstruction of the diseased artery could be safely performed, transplantation using a kidney from a donor with renal artery fibromuscular dysplasia may be considered.