[Advances in research on organ-at-risk protection in pelvic tumor external beam radiotherapy].

The simultaneous objectives of destroying tumor cells while protecting normal pelvic organs present a dual clinical and technical challenge within the realm of pelvic tumor radiotherapy. This article reviews the latest literatures, focusing on technological innovations in key aspects of radiotherapy such as positioning, planning, and delivery. These include positioning fixation techniques, organ-at-risk avoidance irradiation, non-coplanar irradiation techniques, as well as organ displacement protection and image-guided adaptive techniques. It summarizes and discusses the research progress made in the protection of critical organs during pelvic tumor radiotherapy. The paper emphasizes technological advancements in the protection of critical organs throughout the processes of radiotherapy positioning, planning, and implementation, aiming to provide references for further research on the protection of critical organs in the external irradiation treatment of pelvic tumors.

Novel positioning guiders accurately assist in situ acetabular reconstruction for patients undergoing pelvic bone tumor resection.

PURPOSE: Acetabular reconstruction in situ after extensive pelvic resection is technically challenging. The aim of this study was to investigate the feasibility of positioning guiders for acetabular reconstruction following pelvic tumor resection and the clinical benefit brought by the approach. METHODS: The study included patients who underwent acetabular reconstruction following periacetabular tumor resection using a modular hemipelvic prosthesis. In the guider-assisted group (n = 14), guiders were designed and applied to assist acetabular reconstruction. In the traditional operation group (n = 18), the patients underwent the same surgery but without the guiders. The displacement of the hip rotation center before and after surgery was calculated. The complications and the Musculoskeletal Tumor Society-93 scores were documented. RESULTS: The overall displacement of the hip rotation center was significantly reduced in the guider-assisted group compared with the traditional operation group (13.83 ± 4.06 vs. 22.95 ± 9.18 mm in P = 0.000, 95%CI 3.90-12.96), especially in the anteroposterior axis (3.77 ± 3.03 versus 13.51 ± 9.43 mm in P = 0.000, 95%CI 3.45-13.09). Guider-assisted acetabular reconstruction reduced the risk of prosthesis dislocation compared with the traditional operation (dislocation risks: 1/14, 7.1% vs. 4/18, 22.2%). CONCLUSION: Positioning guiders can effectively and conveniently help place the modular hemipelvic prosthesis at the native position, which might potentially reduce the risk of prosthesis dislocation. LEVEL OF EVIDENCE: Therapeutic level III.

Paraganglioma of the urinary bladder initially diagnosed as gastrointestinal stromal tumor requiring combined resection of the rectum: a case report.

BACKGROUND: Paraganglioma of the urinary bladder (Pub) is rare and presents with clinical symptoms caused by catecholamine production and release. The typical symptoms of Pub are hypertension, macroscopic hematuria, and a hypertensive crisis during micturition. The average size of detected Pubs is approximately 3 cm. Herein, we report a case of a large Pub in which the symptoms were masked by oral medication, precise preoperative diagnosis was difficult, and intraoperative confirmation of tumoral adhesion to the rectum resulted in hypertensive attacks during surgery. CASE PRESENTATION: A 64-year-old Japanese male with a history of hypertension and arrhythmia controlled with oral medication presented with a large tumor in the pelvic region, detected on examination for weight loss, with no clinical symptoms. Computed tomography and magnetic resonance imaging revealed a tumor measuring 77 mm in diameter in the posterior wall of the urinary bladder. The border with the rectum was unclear, and the tumor showed heterogeneous enhancement in the solid part with an enhancing hypodense lesion. Cystoscopy revealed compression of the bladder trigone by external masses; however, no tumor was visible in the lumen. Endoscopic ultrasonography-guided fine-needle aspiration revealed CD34-positive spindle-shaped cells in the fibrous tissue, suggestive of a mesenchymal neoplasm. The tumor was suspected to be a gastrointestinal stromal tumor, and surgery was performed. After laparotomy, we suspected that the tumor had invaded the rectum, and total cystectomy and anterior resection of the rectum were performed. Histologically, the tumor cells had granular or clear amphophilic cytoplasm with an oval nucleus and nests of cells delimited by connective tissue and vascular septations. Immunohistochemically, the tumor was positive for chromogranin A, CD56, and synaptophysin, and a diagnosis of paraganglioma of the urinary bladder was confirmed. There was no tumor recurrence at the 7-month follow-up. CONCLUSION: This case highlights the importance of careful examination of pelvic tumors, including endocrine testing, for detecting paraganglioma of the urinary bladder in patients with a history of hypertension or arrhythmia.

[Retrograde intrarenal surgery for kidney diseases].

INTRODUCTION: Retrograde intrarenal surgery (RIRS) is being actively implemented in the treatment of renal stones and other diseases. If necessary, RIRS can be combined with percutaneous procedures. AIM: To study the results of RIRS in patients with nephrolithiasis and various renal disorders. MATERIALS AND METHODS: A total of 106 patients who undergone RIRS were included in the study. There were 66 men (63.4%) and 40 women (36.6%). Mean age was 46.8+/-15.6 years. The indication for RIRS in 84 (79.2%) patients was renal stones. Calculus in calyceal diverticulum were diagnosed in 6 (5.7%), encrusted stents in 8 (7.7%), urinary fistulas after partial nephrectomy in 5 (4.7%), pelvis tumors in 2 (1.9%), pelvis perforation after marsupialization of parapelvic cyst in 1 (0.9%) patient, respectively. Simultaneous retro- and antegrade procedures were performed in 27 (25.5%) cases. In those with nephrolithiasis and encrusted stents, lithotripsy was done with the removal of stone fragments. Two patients underwent endoscopic resection of the pelvis tumor. In six patients, the neck of the diverticulum was incised after lithotripsy, while in five cases retrograde endoscopically controlled percutaneous treatment urinary fistulae was performed. In one case, laser fulguration of the pelvis defect with stenting was done. RESULTS: RIRS was effective in 72 (85.7%) of 84 patients with renal stones. The operation time was 70.8+/-10.2 minutes. In 12 (14.3%) cases with residual fragments, extracorporeal shock-wave lithotripsy (n=7) and repeated RIRS (n=5) were performed. The efficiency of RIRS after two sessions was 91.7%. Complications were observed in 11 (10.4%) patients. With encrusted stents, the operation time was 95.0+/-16.5 min. After laser fragmentation of encrustations in the lower part of the stent, percutaneous lithotripsy was performed with antegrade removal of its upper half. The time for RIRS in those with diverticula was 60.0+/-8.5 min, the average stone size was 8 mm (from 6 to 10 mm). In all cases lithotripsy with mucosal fulguration was successfully done. The procedures for urinary fistulae were also effective (operation time was 45.0 +/- 20.5 minutes) and there were no complications. CONCLUSION: RIRS is a safe and effective treatment for patients with nephrolithiasis and other kidney disorders. Modern flexible ureteroscopes allows to examine the collecting system and to perform lithotripsy and removal of stone fragments.

High-intensity focused ultrasound ablation in the treatment of recurrent ovary cancer and metastatic pelvic tumors: a feasibility study.

OBJECTIVE: To explore the feasibility of high-intensity focused ultrasound (HIFU) ablation for treating metastatic pelvic tumors and recurrent ovary cancer. MATERIALS AND METHODS: Eight patients with metastatic pelvic tumors or recurrent ovary cancer were enrolled in this study. Among them, 5 patients had ovarian cancer, 1 had cervical cancer, 1 had endometrial cancer, and 1 had rectal cancer. Six of them received abdominal surgical operation for their primary cancer, no one received radiotherapy. HIFU treatment was performed under conscious sedation. Vital signs were monitored during the procedure, and adverse effects were recorded. Postoperative follow-up was performed to observe pain relief and the improvement of the patient's quality of life. RESULTS: The median age of the patients was 54 (range: 33-76) years, with a total of 12 lesions. The average volume of the lesions was 238.0 cm3. Six patients completed 12 months follow-up. Postoperative pain relief rate was 60% (3/5), and the quality of life improved in the short term. The main adverse effect of HIFU was pain in the treated area, with the pain score lower than 4, and all of which was self-relieved within 1 day after HIFU treatment. No serious complications such as skin burn, intestinal perforation, and nerve injury occurred. CONCLUSION: HIFU is feasible for the treatment of metastatic pelvic tumors or recurrent ovary cancer without serious complications. Therefore, HIFU seems a promising treatment for recurrent ovary cancer, metastatic pelvic tumors from cervical cancer, endometrial cancer, and rectal cancer.

Total Laparoscopic Excision of an Altman Type IV Sacrococcygeal Teratoma with the Assistance of Intraoperative Transrectal Sonography.

OBJECTIVE: To present the case of a young patient with an Altman type IV sacrococcygeal teratoma (Fig 1) managed exclusively with laparoscopy. DESIGN: A step-by-step demonstration of the technique. SETTING: A 24-year-old patient complaining of dysmenorrhea, deep dyspareunia, chronic constipation, dyschezia, and bladder atony was diagnosed with a 5-cm cystic tumor compressing the low rectum and overlying the left levator ani muscle. INTERVENTIONS: Laparoscopic excision of the tumor. At laparoscopy, significant bilateral pelvic venous congestion was found. The left medial and lateral pararectal fossa and the rectovaginal space were developed to the level of the pelvic floor. Several branches of the left internal artery and vein were dissected. The left hypogastric nerve and deep hypogastric plexus were dissected in an effort to preserve ipsilateral autonomic nerve supply to the rectum. Owing to the tumor's soft consistency and dense adherence to the surrounding structures, transrectal sonography facilitated dissection, which was performed medially to the mesorectal fascia and anteriorly to the presacral fascia. The middle sacral artery and peripheral branches of the internal iliac vasculature supplying the tumor were ligated. Part of the left levator ani had to be excised. The rectum was injured during the effort to detach the tumor from its lateral wall. The injury was repaired laparoscopically. The cut edge of the levator ani was used as a flap to reinforce the repair. CONCLUSION: Sacrococcygeal teratomas lying entirely in the pelvis (Altman type IV) are extremely rare [1,2]. Complete laparoscopic excision is challenging and potentially dangerous [3-5], but it is feasible with careful dissection.

Augmented Reality as a Tool to Guide PSI Placement in Pelvic Tumor Resections.

Patient-specific instruments (PSIs) have become a valuable tool for osteotomy guidance in complex surgical scenarios such as pelvic tumor resection. They provide similar accuracy to surgical navigation systems but are generally more convenient and faster. However, their correct placement can become challenging in some anatomical regions, and it cannot be verified objectively during the intervention. Incorrect installations can result in high deviations from the planned osteotomy, increasing the risk of positive resection margins. In this work, we propose to use augmented reality (AR) to guide and verify PSIs placement. We designed an experiment to assess the accuracy provided by the system using a smartphone and the HoloLens 2 and compared the results with the conventional freehand method. The results showed significant differences, where AR guidance prevented high osteotomy deviations, reducing maximal deviation of 54.03 mm for freehand placements to less than 5 mm with AR guidance. The experiment was performed in two versions of a plastic three-dimensional (3D) printed phantom, one including a silicone layer to simulate tissue, providing more realism. We also studied how differences in shape and location of PSIs affect their accuracy, concluding that those with smaller sizes and a homogeneous target surface are more prone to errors. Our study presents promising results that prove AR's potential to overcome the present limitations of PSIs conveniently and effectively.

Complication rate, functional outcomes, and risk factors associated with carbon ion radiotherapy for patients with unresectable pelvic bone sarcoma.

BACKGROUND: To the authors' knowledge, carbon ion radiotherapy (CIRT) is one of the few curative treatments for unresectable pelvic bone sarcoma. The current study investigated the complications, functional outcomes, and risk factors of CIRT. METHODS: Of 112 patients who were treated with CIRT for unresectable pelvic bone sarcoma, the authors enrolled 29 patients who were without local disease recurrence or distant metastasis. The mean follow-up was 93 months. Complications, functional outcomes, and quality of life scores were assessed. Risk factors were analyzed, including the dose-volume histogram of the femoral head. RESULTS: Femoral head necrosis occurred in approximately 37% of patients, pelvic fractures were reported in 48% of patients, and neurological deficits were noted in 52% of patients. Femoral head necrosis was found to be significantly more prevalent among patients with periacetabular tumors (P = .018). The dose-volume histogram of the femoral head indicated tolerable volume percentages of the femoral head to be <33% for 40 grays (relative biological effectiveness) and 16% for 60 grays ( relative biological effectiveness). The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score were 53% and 64%, respectively, and the mean EuroQol 5 dimensions questionnaire index was 0.587. Patients aged >50 years and those with periacetabular tumors were found to have significantly lower Toronto Extremity Salvage Scores. CONCLUSIONS: Femoral head necrosis, pelvic fracture, and nerve damage are common complications with the use of CIRT for pelvic bone sarcoma. To prevent femoral head necrosis, the radiation dose to the femoral head should be kept below the estimated tolerance curve presented in the current study. The functional outcome is nearly equivalent to that of surgery. CIRT may be a promising alternative to surgery for patients with unresectable pelvic bone sarcoma.

Reconstruction with a novel combined hemipelvic endoprosthesis after resection of periacetabular tumors involving the sacroiliac joint: a report of 25 consecutive cases.

BACKGROUND: Our purpose was to examine the outcomes of patients who underwent extensive resection of periacetabular tumors involving the sacroiliac joint and joint reconstruction with a hemipelvic endoprosthesis. METHODS: The records of 25 consecutive patients diagnosed with Enneking type I/II/IV pelvic tumors from 2010 to 2016 who received resection and hemipelvic endoprosthesis reconstruction were retrospectively reviewed. RESULTS: The median follow-up period was 48 months. At the most recent follow-up, 11 patients were alive, with estimated 3- and 5-year survival rates of 45.6 and 38.0%, respectively. Fourteen patients died, with a mean survival of 20.8 months, and 8 patients had local recurrence at an average of 9.3 months after surgery. Distal metastases were detected in 11 patients at an average of 11.0 months after surgery. The total complication rate was 56.0%, and the most common complications were wound healing disturbances (28.0%) and deep infections (16.0%). The prosthesis-related complication rate was 24.0%; periprosthetic infections and aseptic loosening were most common. The estimated 1- and 3-year prosthesis survival rates were 81.2 and 63.2%, respectively. The mean Musculoskeletal Tumor Society score was 48.0%. Function and prosthesis-related complications did not differ significantly after adding an extra screw fixation to the first sacral vertebra. CONCLUSIONS: Reconstruction with the hemipelvic endoprosthesis described herein provides satisfactory function with a relatively low complication rate. Adding an extra screw fixation to the first sacral vertebra was not associated with any improvement in the clinical results after short-term follow-up. Improvement and further studies of this endoprosthesis are needed.

Combined Application of Modified Three-Dimensional Printed Anatomic Templates and Customized Cutting Blocks in Pelvic Reconstruction After Pelvic Tumor Resection.

BACKGROUND: Common three-dimensional (3D)-printed anatomic templates have generally been used to reconstruct the pelvis after zone II and III borderline pelvic tumor resection. However, gradual increases in postoperative implant complications and the tumor recurrence rate have been observed. This study aimed to introduce the innovative application of a modified 3D-printed anatomic template with a customized cutting block for pelvic reconstruction and to comparatively analyze the common and modified 3D-printed anatomic templates. METHODS: A total of 38 patients were included in this study and were allocated to 2 groups (19 patients/group). Group A received innovative therapy, and Group B received traditional therapy. All patients were questioned in detail about age, location, and duration of the mass and associated symptoms, and routine blood tests, such as serological tests, were administered. RESULTS: We found that the modified 3D-printed anatomic template with a customized cutting block resulted in a shorter operating time, smaller bleeding loss, and simpler operation than the common 3D-printed anatomic template. Additionally, the tumor recurrence rate was lower and the accuracy of tumor resection was much greater for the modified 3D-printed anatomic template with a customized cutting block. However, compared with the traditional therapy, the innovative therapy had a significantly higher rate of implant loosening. CONCLUSION: The innovative therapy can increase surgical safety and reduce recurrence after tumor resection relative to the traditional therapy. Additionally, the innovative therapy reconstructs the pelvis of zone III to improve the quality of patient life. However, the innovative therapy with implant loosening should be improved.

Utility of pediatric female fertility preservation discussions following pelvic radiation.

INTRODUCTION: While many childhood cancers are curable with therapy, adverse consequences in fertility exist. We sought to assess the number of female patients with pelvic tumors receiving radiation therapy, and the proportion that undergo measures for fertility preservation (FP). METHODS: A total of 53 female patients treated with pelvic tumors from 2000 to 2016 were retrospectively identified. RESULTS: 19 (34%) of these patients underwent pelvic radiation therapy (pXRT). Three of the patients received pXRT for palliative treatment. Of the 19 female patients receiving pXRT, six (31%) were prepubertal and 13 (68%) were postpubertal. Three patients (16%) had documentation of a discussion of FP measures prior to pXRT. One was prepubertal and the others were post-pubertal. Six patients (32%) were evaluated by endocrinology after radiation therapy, diagnosed with ovarian failure, and placed on hormone therapy. Current guidelines recommend discussion of FP in pre-and postpubertal patients with cancer. This 16-year retrospective review of female patients that underwent pXRT for pelvic tumors demonstrated < 17% of patients have documentation of a discussion of FP measures. CONCLUSION: Female pediatric patients who underwent chemotherapy and pXRT suffer a high rate of premature ovarian failure, high morbidity and mortality as well as low rates of documented FP discussions. Based on these findings we have established a multi-disciplinary fertility preservation team available for consultation and a protocol for discussing and documenting the impact of pXRT, along with other treatments, on fertility. LEVEL OF EVIDENCE: III.

Clinical practice patterns for upper tract urothelial carcinoma: a nationwide survey in Japan.

OBJECTIVE: A comprehensive survey has not yet been conducted to investigate care patterns by urologists for the management of upper tract urothelial carcinoma. METHODS: We conducted a nationwide survey for urologists treating upper tract urothelial carcinoma patients. The questionnaire was approved by the Japanese Urological Association and sent by mail in February 2014 to 1119 institutes in Japan. We identified 627 responders for this study. RESULTS: Our survey demonstrated that (i) the mean number of radical nephroureterectomy cases per institution in 2013 was 7.6, (ii) the main detecting tool for upper tract urothelial carcinoma is contrast-enhanced computed tomography, (iii) the need for ureteroscopic evaluations is highly dependent on voiding urine cytology results, (iv) 67% of urologists always or often perform radical nephroureterectomy by laparoscopic surgery, (v) more than half of the urologists do not aggressively perform lymph node dissection, (vi) 75% of the urologists perform bladder cuff incision through an extravesical approach, (vii) urologists perform kidney-sparing surgery following various indications, (viii) 59% of the urologists always perform adjuvant systemic chemotherapy for high-risk upper tract urothelial carcinoma patients, (ix) the combination of gemcitabine and cisplatin is the most frequent chemo-regimen for metastatic upper tract urothelial carcinoma, and gemcitabine and cisplatin with dose reductions is also the first choice even in patients with impaired renal function and (x) 10.5% of urologists always or sometimes perform single intravesical chemotherapy immediately after radical nephroureterectomy. CONCLUSIONS: The management strategy for upper tract urothelial carcinoma has changed with the introduction of new devices and development of instruments. The lack of clear evidence for relatively uncommon upper tract urothelial carcinoma affects the consistency of its treatment strategies.

Lateral lumbar vertebral body screw predisposes to neuralgia after limb-salvage surgery for pelvic tumors: a single-center, retrospective study of 349 cases.

PURPOSE: To investigate the incidence and risk factors of neuralgia after limb-salvage surgery for pelvic tumors with focus on the reconstruction methods. METHODS: We included 349 cases of pelvic tumors treated with internal hemipelvectomy and reconstruction in our center from January 2009 to May 2015. None of these cases had major lumbosacral nerves invaded by the tumors. Demographic and medical data were reviewed and documented for statistical analyses. The locations of lateral lumbar vertebral body screws (LLVBSs) were evaluated in 26 cases. RESULTS: The overall incidence of post-operative neuralgia was 8.3 %. Pre-admission requirement of analgesics (OR 4.089; 95 % CI 1.711-9.774) and application of LLVBS (OR 11.848; 95 % CI 4.369-32.129) were independent risk factors of neuralgia. The horizontal location of LLVBS did not affect the incidence of neuralgia when it was placed near the midline of the vertebra. CONCLUSIONS: The incidence of post-operative neuralgia was 8.3 % in this study cohort. The LLVBS technique could increase the risk of post-operative neuralgia.

Palliative treatment of pelvic bone tumors using radioiodine (125I) brachytherapy.

BACKGROUND: Complete resection of pelvic bone tumors, especially recurrent and metastatic ones, is often impossible to achieve using conventional surgery. This study aimed to assess the benefits and adverse effects of computed tomography (CT)-guided radioiodine (125I) brachytherapy for inoperable recurrent and metastatic bone tumors of the pelvis. METHODS: This was a retrospective study of 22 patients with confirmed pelvic bone tumors (10 females and 12 males; 15-84 years; 21 with primary pelvic tumor and one with pelvic metastasis). CT-guided 125I brachytherapy was performed using 9-21 125I seeds (radioactivity of 0.5-0.7 mCi). Seed implantation was validated by postoperative CT scanning. Complications, pain, survival, and CT-estimated tumor size were carried out to evaluate the therapeutic benefits. RESULTS: Postoperative CT scans revealed satisfactory 125I seed implantation, and the radiation dose delivered to 90% of the target area (D90) was higher than the prescription dose (PD). No obvious complications were observed. Pain was reported by 19 of 22 patients, but 17 reported pain relief after implantation. Follow-up ranged 8-27 (median, 19) months. Tumor size was reduced in 11 patients within 1 month after surgery, nine patients showed no change, and tumor size increased in two patients. Finally, 1- and 2-year survival was 81.8 and 45.5%, respectively; 1- and 2-year local tumor control rates were 59.1 and 36.4%, respectively. CONCLUSIONS: 125I seed implantation significantly reduced bone tumor size and relieved pain, with a low complication rate. These findings suggest that 125I brachytherapy treatment could be a useful palliative approach for pelvic bone tumor treatment.

Transitional cell carcinoma with extension of the renal vein and IVC tumor thrombus: report of three cases and literature review.

BACKGROUND: Transitional cell carcinoma (TCC) originating from the renal pelvis with a venous tumor thrombus is a rare entity. However, clinicians should be aware of it because of its high malignancy and poor prognosis. CASE PRESENTATION: Here, we report three cases of pathologically confirmed TCC originating from the renal pelvis with extension into the renal vein or inferior vena cava (IVC). Of these patients, two are males and one is female (58~73 years old). Their main symptom is flank pain; besides, gross hematuria and weight loss is observed in one of the patients. Computed tomography (CT) scan of the first patient revealed multiple space-occupying lesions in the left renal pelvis and left medium and lower ureter with a tumor thrombus in the left renal vein. CT scan of the second patient revealed a right renal mass and extension into the IVC. Abdominal magnetic resonance imaging (MRI) of the third patient showed a soft tissue mass in the region of the left renal sinus, and the signal of the soft tissue was observed in the left renal vein. The preoperative diagnoses of the first and third patient were TCC, while the second patient was renal cell carcinoma (RCC). Two patients with the preoperative diagnosis of TCC underwent laparoscopic radical nephroureterectomy with thrombectomy, and the other patient underwent radical nephrectomy with thrombectomy. The surgeries were successful. Although two of our patients underwent chemotherapy and radiotherapy, they died 2 and 19 months after the surgery, respectively. The other patient refused any adjuvant therapy and died 3 months after the operation. CONCLUSIONS: Compared to the extension of RCC to the renal vein or IVC, extension of TCC to the renal vein or IVC is rare. TCC with a venous tumor thrombus is often misdiagnosed as RCC. However, a correct preoperative or intraoperative diagnosis is of great importance to decide surgical strategy. Laparoscopic radical nephroureterectomy with thrombectomy may be a safe and feasible operative method in treatment of TCC with a renal vein thrombus. The prognosis of such cases is poor even if chemotherapy and radiotherapy are scheduled.

Vascular Lipoleiomyoma of the Uterus: an Unusual Case.

INTRODUCTION: Uterine lipoleiomyomas are a rare type of uterine myomas, which have been seldom diagnosed and are less known and still unusual. Histologically they are composed of smooth muscle cells with multiple fat cells and fibrous tissue. Their pathogenesis is still a stigmata and their preoperative diagnosis is still questionable. CASE REPORT HISTORY: A 39-year old woman presented at the University clinic for obstetrics and gynecology with complaints of a mild low abdominal and pelvic pain, increased frequency of vaginal bleeding and abdominal distension. Ultrasound examination showed dislocated uterus by a large semisolid tumor, located between the uterus and the urinary bladder. This mass was not well defined and had great vascularity. Pelvic computerized tomography revealed a large heterogeneous tumor located behind the bladder, measuring 8.5x7.5cm in size, making compression on the other pelvic organs. CONCLUSION: We should pay more attention on the preoperative imaging studies, in order to select patients who require surgery and further treatment more appropriately.

Evidenced-based clinical practice guideline for upper tract urothelial carcinoma (summary--Japanese Urological Association, 2014 edition).

Upper tract urothelial carcinoma is more rare than bladder cancer, although they are both categorized as urothelial carcinoma. Because of the low incidence, little clinical evidence is available regarding the treatment of the former. However, recently such evidence has slowly begun to accumulate. The guideline presented herein was compiled for the purpose of ensuring proper diagnosis and treatment by physicians involved in the treatment of upper tract urothelial carcinoma. We carefully selected 16 clinical questions essential for daily clinical practice and grouped them into four major categories: epidemiology, diagnosis, surgery and systemic chemotherapy/other matters. Related literature was searched using PubMed and Japan Medical Abstracts Society databases for articles published between 1987 and 2013. If the judgment was made on the basis of insufficient or inadequate evidence, the grade of recommendation was determined on the basis of committee discussions and resultant consensus statements. Here, we present a short English version of the original guideline, and overview its key clinical issues.

Tailor-made treatment combined with proton beam therapy for children with genitourinary/pelvic rhabdomyosarcoma.

BACKGROUND: Rhabdomyosarcoma (RMS) is one of the most common soft tissue sarcomas among children. Patients who developed genitourinary/pelvic rhabdomyosarcoma (GU/P-RMS) have a higher complication ratio and relatively poorer event free survival, with local therapy being very important. While proton beam therapy (PBT) is expected to reduce co-morbidity, especially for children, this lacks firm evidence and analysis. We analyzed GU/P-RMS children who had undergone multimodal therapy combined with PBT at a single institution. METHOD: We retrospectively reviewed charts of children with GU/P-RMS treated from January 2007 to May 2013 at the University of Tsukuba Hospital who had undergone multimodal therapy with PBT. RESULTS: There were 5 children and their median age at diagnosis was 2.8 years (0.6-4.4 years). Primary sites were the bladder (2) and the prostate (3). All received neo-adjuvant chemotherapy and 3 underwent chemotherapy during PBT (Group Cx). All patients of Group Cx developed leukocytopenia (WBC <1000/µL). The median dose of PBT was 47.7 GyE (41.4-50.4 GyE). All patients survived by their last hospital visit (median, 36 months). CONCLUSIONS: We analyzed multimodal treatment combined with PBT applied for GU/P-RMS. PBT was well tolerated and could be a plausible choice instead of photon therapy for this population.

Mastering bladder paraganglioma for optimal treatment: a case report of robot-assisted surgery.

Bladder paraganglioma is a rare neuroendocrine neoplasm, either functional or non-functional, arising from the urinary bladder. Functional variants present with catecholamine-related symptoms, while non-functional variants pose diagnostic challenges, mimicking urothelial carcinoma. Misdiagnosis risks underscore the importance of accurate identification for appropriate patient management. In this case, a 52-year-old man, diagnosed incidentally with hypertension and reported occasional post-micturition tachycardia, underwent abdominal ultrasound for known hepatic cyst follow-up, revealing an oval hypoechoic bladder mass. Initial consideration of bladder urothelial carcinoma prompted further investigation with contrast-enhanced CT scan and cystoscopy that confirmed extrinsic mass nature, and subsequent robotic-assisted partial cystectomy was performed. Histologically, the removed mass exhibited characteristic features of bladder paraganglioma. Postoperative recovery was uneventful, with resolution of post-micturition tachycardia at 1 month. Follow-up includes endocrinological evaluation and a 6-month CT scan. In conclusion, bladder paraganglioma should be considered in para-vesical mass differentials. This case highlights the importance of meticulous history collection, even in asymptomatic patients, the need for a multidisciplinary approach for accurate diagnosis and management of this rare condition, and the robotic approach as a viable option.

Clinical evaluation for lower abdominal aorta balloon occluding in the pelvic and sacral tumor resection.

OBJECTIVE: To investigate the values of clinical application of lower abdominal aorta balloon occluding in the pelvic and sacral tumor resection. METHOD: From January 2004 to January 2010, 137 patients were diagnosed as sacral or pelvic tumors and underwent surgery in our institution. Forty-five patients underwent resection combined with lower abdominal aorta balloon occluding to control hemorrhage (balloon occluding group), the remaining 92 patients underwent conventional resection (conventional therapy group). We compared operative time, intraoperative hemorrhage, the amount of blood transfusion, postoperative complications, mean hospital stay as well as rates of tumor recurrence or metastasis at 3 years. RESULTS: En-bloc resection was performed in 93.3% (42/45) patients in balloon occluding group while the conventional therapy group was 78.2% (79/92). The balloon occluding group showed significantly shorter mean operating time, lower blood loss, lower blood transfusion, and lower postoperative drainage volume than did the conventional therapy group. The two treatment groups showed no significant difference in mean hospital stay, frequency of postoperative complications or rates of tumor recurrence or metastasis at 3 years. CONCLUSION: The application of lower abdominal aorta balloon occluding to control hemorrhage during the surgery contributes to a more clear operation field, less operation time as well as less blood loss and blood transfusion. Moderate prolong of the occluding duration can improve the safety of the surgery and contribute to more radical resection of the tumor without increase of the risks for complications.