Initial outcomes and surgical techniques of prostatic urethral lift for benign prostatic hyperplasia in Japan.

OBJECTIVES: The prostatic urethral lift (PUL) has been used as a minimally invasive surgery for benign prostatic hyperplasia (BPH) since April 2022 in Japan. This study evaluated the initial outcomes and surgical techniques of PUL for BPH. METHODS: In this prospective, single-center study, indications were based on the proper use guidelines for PUL in Japan. Preoperative patient status, postoperative progress at 1 and 3 months, and perioperative complications were evaluated. The surgical technique was changed twice, and the subgroup analysis and technique were evaluated. RESULTS: Of the 50 patients who underwent surgeries performed by a single surgeon, the median age and prostate volume were 71 years and 42.0 mL, respectively. Furthermore, the median operative time and number of implants used were 20 min and 5, respectively. No postoperative fever or severe hematuria requiring reoperation occurred. All patients were discharged from the hospital the day following the PUL, as scheduled. Postoperative International Prostate Symptom Score, quality of life score, maximum flow rate, and postvoid residual volume at 1 and 3 months were significantly improved compared with the preoperative values. A significant improvement in maximum flow rate was observed in the subgroup analysis from 1 month postoperatively in the group with an anterior channel creation focus. CONCLUSIONS: PUL is effective and safe in cases with prostate volumes of <100 mL. Lifting the bladder neck is important for opening an anterior prostatic urethral channel and improving urinary function during the early postoperative period.

Perioperative changes in ganglioside monosialodihexosylganglioside (GM3) molecular species for benign prostatic hyperplasia: a preliminary report.

Benign prostatic hyperplasia (BPH) progresses with age and is associated with chronic inflammation. We focused on the relationship between BPH and ganglioside monosialodihexosylganglioside (GM3), a sialic acid-containing glycosphingolipid that is involved in chronic inflammation. GM3 molecular species would have a significant role in regulating inflammatory processes. In this prospective study, preoperative and postoperative serum samples were obtained from patients who underwent holmium laser enucleation of the prostate (HoLEP) for BPH. Preoperative and postoperative measurements of serum GM3 species were performed one month before and three months after HoLEP. Twenty-three patients were included in the study. The average patient age was 75 years, and the average prostate volume was 66 mL. The average weight of the surgically resected prostate tissue was 42 g. At three months after HoLEP, the serum concentration of GM3 species was found to have decreased after HoLEP compared with the preoperative concentration of GM3 species. Six GM3 species such as d18:1-17:0 [C17 acyl chain (-17:0) linked to a C18 sphingosine base with a double bond (d18:1-) by an amide linkage], were significantly reduced. The sample size was small; therefore, this study showed only preliminary results and could not evaluate prostate tissue inflammation. This study showed that the serum concentrations of several GM3 species, which indicate chronic inflammation, may be significantly reduced after BPH surgery.

Inhibition of platelet-derived growth factor pathway suppresses tubulointerstitial injury in renal congestion.

OBJECTIVE: Increased central venous pressure in congestive heart failure is responsible for renal dysfunction, which is mediated by renal venous congestion. Pericyte detachment from capillaries after renal congestion might trigger renal fibrogenesis via pericyte-myofibroblast transition (PMT). Platelet-derived growth factor receptors (PDGFRs), which are PMT indicators, were upregulated in our recently established renal congestion model. This study was designed to determine whether inhibition of the PDGFR pathway could suppress tubulointerstitial injury after renal congestion. METHODS: The inferior vena cava between the renal veins was ligated in male Sprague-Dawley rats, inducing congestion only in the left kidney. Imatinib mesylate or vehicle were injected intraperitoneally daily from 1 day before the operation. Three days after the surgery, the effect of imatinib was assessed by physiological, morphological and molecular methods. The inhibition of PDGFRs against transforming growth factor-ß1 (TGFB1)-induced fibrosis was also tested in human pericyte cell culture. RESULTS: Increased kidney weight and renal fibrosis were observed in the congested kidneys. Upstream inferior vena cava (IVC) pressure immediately increased to around 20 mmHg after IVC ligation in both the imatinib and saline groups. Although vasa recta dilatation and pericyte detachment under renal congestion were maintained, imatinib ameliorated the increased kidney weight and suppressed renal fibrosis around the vasa recta. TGFB1-induced elevation of fibrosis markers in human pericytes was suppressed by PDGFR inhibitors at the transcriptional level. CONCLUSION: The activation of the PDGFR pathway after renal congestion was responsible for renal congestion-induced fibrosis. This mechanism could be a candidate therapeutic target for renoprotection against renal congestion-induced tubulointerstitial injury.

Impact of preoperative factors on catheter position in peritoneal dialysis: a prospective cohort study.

BACKGROUND: Peritoneal dialysis (PD) catheter malposition is one of the complications of renal replacement therapy. This study aimed to determine the preoperative factors that cause PD catheter malposition. METHODS: The prospective cohort study included patients who underwent PD catheter insertion surgery and had preoperative and postoperative computed tomography scans. We compared preoperative and intraoperative factors between the lower depth catheter group (group L) and upper depth catheter group (group U), and preoperative and intraoperative factors between the posterior catheter group (group P) and anterior catheter group (group A). In addition, PD catheter obstruction requiring surgical intervention in each group was followed up for 1 year. RESULTS: A total of 150 patients were categorized into groups L (n = 77) and U (n = 73), or groups P (n = 107) and A (n = 43). Body mass index (BMI; P = 0.02), subcutaneous fat area (P = 0.02), and rate of previous abdominal surgery (P = 0.01) were significantly lower in group L than in group U. In terms of anterior catheter position, females had more-anterior catheter positions. The time to PD catheter obstruction requiring surgical intervention (P = 0.03) was significantly lower in group U than in group L. CONCLUSIONS: High BMI, high subcutaneous fat area, high subcutaneous fat thickness, and previous abdominal surgery were identified as preoperative factors that cause the PD catheter to have an upper depth. Female sex was a preoperative influencing factor for the anterior PD catheter position.

Safety of peritoneal dialysis catheter surgery under dexmedetomidine and local anesthesia for elderly patients in Japan: a single-center prospective cohort study.

BACKGROUND: The number of patients aged ≥ 75 years and who need renal replacement therapy is steadily increasing. The study aimed to determine the safety of open surgery for peritoneal dialysis (PD) catheter placement in such patients. METHODS: This prospective cohort study included patients who underwent PD catheter placement by open surgery under dexmedetomidine (DEX) and local anesthesia at our institution from January 2015 to February 2021. Patients were divided into the following two groups according to age at the time of surgery: ≥ 75 years (group A) and < 75 years (group B). We compared the perioperative and postoperative complications (i.e., time to the first PD-related peritonitis and catheter obstruction requiring surgical intervention within 1 year) between the groups. RESULTS: A total of 118 patients were categorized into groups A (n = 65) and B (n = 53). No significant intergroup differences were observed in the postoperative fever, total duration of surgery, perioperative hemoglobin decrease, changes in the white blood cell count and C-reactive protein, postoperative catheter leakage, postoperative hospital stay, time to the first PD-related peritonitis, and catheter obstruction requiring surgical intervention within 1 year. CONCLUSIONS: The surgery for PD catheter placement by open surgery under DEX and local anesthesia in elderly patients is safe and effective.

The Impact of Preoperative Risk Factors on Peritoneal Dialysis-Related Peritonitis: A Single-Center Prospective Study in Japan.

Background and Objectives: Peritoneal dialysis (PD)-related peritonitis is a critical problem. However, preoperative risk factors for PD-related peritonitis have not been established. Thus, we aimed to determine the preoperative risk factors for PD-related peritonitis. Materials and Methods: This is a single-center prospective observational study. All peritonitis episodes during the study period were recorded, and preoperative and intraoperative clinical parameters were compared between patients with and without peritonitis to examine risk factors for PD-related peritonitis. Furthermore, subcutaneous and abdominal fat volumes were evaluated using computed tomography. Results: Among a total of 118 patients, 24 patients developed peritonitis. The proportion of male patients (83% vs. 61%, p = 0.04), body mass index (25 vs. 22 kg/m2, p = 0.04), and subcutaneous fat area (120 vs. 102 cm2, p = 0.01) were significantly higher and the proportion of patients living with family members (75% vs. 94%, p = 0.02) was significantly lower in the peritonitis group than in the non-peritonitis group. There were no significant differences in age, operation method, surgeon experience, previous abdominal surgery, medical history of diabetic nephropathy, serum albumin level, and renal function between the two groups. Conclusions: Male patients with high subcutaneous fat who are living alone might be at higher risk of PD-related peritonitis. These characteristics might be useful in risk assessment and patient education before PD induction.

Efficacy and safety of holmium laser enucleation of the prostate for elderly patients: surgical outcomes and King's Health Questionnaire.

BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) has been a widely utilized minimally invasive surgical procedure for benign prostate hyperplasia. The current study aimed to compare surgical outcomes and King's Health Questionnaire (KHQ) assessment scores following HoLEP between younger men and those aged ≥75 years. METHODS: This prospective single-center study compared perioperative complications, postoperative urinary conditions, and KHQ scores (nine categories) between men aged ≥75 years (group A) and men aged <75 years (group B) before and 1, 3, and 6 months after surgery. RESULTS: A total of 100 patients were included for analysis (group A, n=38 and group B, n=62). No differences in patient backgrounds, perioperative complications, such as perioperative decrease in hemoglobin, postoperative fever, postoperative indwelling catheterization duration, or postoperative hospitalization duration, and KHQ were observed between both groups. Both groups showed significantly better International Prostate Symptom Scores, quality of life, maximum urinary flow rate, and postvoid residual volume 1, 3, and 6 months after HoLEP compared to their respective preoperative levels (P<0.01). Regarding KHQ categories, both groups showed significantly better general health perceptions, impact on life, emotions, and sleep/energy 1 month after HoLEP; role limitations, physical limitations, and social limitations 3 months after HoLEP; and personal relationships and incontinence severity measures 6 months after HoLEP compared to their respective preoperative levels (P<0.05). CONCLUSIONS: HoLEP could be safe and effective even for men aged ≥75 years, comparing complications, urinary condition, and KHQ scores.

Fabry Nephropathy in a Young Female Patient Presenting with Only Urinary Mulberry Bodies Treated with Chaperone Therapy.

Fabry disease (FD) is an X-linked disorder of the sphingolipid metabolism, caused by deficiency or decreased activity of α-galactosidase A. We report a rare case of Fabry nephropathy (FN) in a 21-year-old Japanese female patient presenting with only urinary mulberry bodies; she was treated with pharmacological chaperone therapy (PCT) after renal biopsy. The patient underwent a detailed examination because her mother was diagnosed with FD in the Division of Community Medicine of our hospital. She did not have renal dysfunction or proteinuria, and only mulberry bodies were detected in the urine. The activity of α-galactosidase A was low, and genetic analysis revealed the R301Q mutation. A percutaneous renal biopsy was performed, and the findings revealed enlargement and vacuolation of glomerular podocytes by light microscopy, and myelin and zebra bodies were detected in podocytes by electron microscopy. She was diagnosed with FN by renal biopsy and gene analysis. PCT was selected as the treatment to prevent cardiac events and renal dysfunction. The present case suggests that renal biopsy may be necessary even for young women with only mulberry bodies for the diagnosis of FN. It could be useful to evaluate the effect of treatment using the counts of mulberry bodies in the urine. In addition, due to its oral administration, PCT may be suitable for patients who are unable to visit the hospital frequently.

Progressive plasmacytoid variant bladder cancer with retroperitoneal dissemination: An autopsy case report.

INTRODUCTION: Plasmacytoid urothelial carcinoma is a rare and aggressive variant of bladder cancer. CASE PRESENTATION: A 75-year-old woman presented with plasmacytoid urothelial carcinoma with retroperitoneal dissemination was treated with chemotherapy. After an unsuccessful first-line chemotherapy with gemcitabine and cisplatin, we assessed circulating tumor cells; one such cell was found to be positive for programmed death-ligand 1. The patient received second-line chemotherapy with pembrolizumab. However, the tumor extended to the retroperitoneal organs, and the patient eventually died. Autopsy revealed a widespread diffuse scirrhous infiltration of the carcinoma into the retroperitoneum. However, distant metastasis was not observed. CONCLUSION: The evaluation of circulating tumor cells and autopsy revealed a disease state of progressive plasmacytoid urothelial carcinoma treated with pembrolizumab.

One-surgeon basketing technique for stone extraction during flexible ureteroscopy for urolithiasis: A comparison between novice and expert surgeons.

OBJECTIVE: To determine the safety and efficacy of the one-surgeon basketing technique for stone extraction during flexible ureteroscopy when carried out by novice surgeons under instructor guidance. METHODS: We retrospectively compared perioperative results, complications and the "stone-free" rate (defined as ≤2 mm fragments on kidney-ureter-bladder imaging 1 month after flexible ureteroscopy) between experienced (group A, n = 50) and novice (group B, n = 50) surgeons using the one-surgeon basketing technique. RESULTS: Baseline patients' characteristics were similar between the two groups. There were no significant differences between groups A and B in operative time (mean 76 min vs 85 min, P = 0.46), stone-free rate (98% vs 92%, P = 0.36), postoperative fever events (4% vs 4%, P = 1.00) and postoperative hospital stay (24 h vs 24 h, P = 1.00). Clavien-Dindo grade IIIa complications (ureter injury) were only observed in two cases (4%) in group B. CONCLUSIONS: The one-surgeon basketing technique for the extraction of stone fragments during flexible ureteroscopy might be safely and effectively carried out by surgeons with no prior experience under proper guidance.

Anteroposterior dissection three-lobe technique: an effective surgical method for inexperienced surgeons performing holmium laser enucleation of the prostate.

PURPOSE: To evaluate the effectiveness of anteroposterior dissection three-lobe technique for surgeons with no prior experience of holmium laser enucleation of the prostate (HoLEP) METHODS: In this retrospective single-center study, we compared perioperative complications and postoperative urinary conditions between an experienced surgeon and surgeons with no prior experience of HoLEP. Forty patients were operated by one experienced surgeon (group A), and another 40 patients were operated by four inexperienced surgeons (group B) under the guidance of the instructor. The enucleation procedure was performed by anteroposterior dissection three-lobe technique. RESULTS: Patient characteristics were comparable in the two groups in age, body mass index, and preoperative prostate volume. The enucleation efficiency rate [0.96 vs 0.56 g/min (P < 0.001)] was significantly different between groups A and B. However, there were no significant differences in enucleate prostate weight, hemoglobin decrease, or postoperative catheter-indwelling period between the two groups. There were no significant differences with respect to postoperative urinary incontinence rate at 1 month [43 vs 50% (P = 0.65)], 3 months [13 vs 20% (P = 0.55)], and 6 months [0 vs 3% (P = 1.00)] between the two groups. Both groups showed a significant improvement in the maximum flow rate and postvoid residual volume after HoLEP compared with baseline levels (P < 0.01). CONCLUSION: Anteroposterior dissection HoLEP three-lobe technique was found to be a safe and effective enucleation method for surgeons with no prior experience of HoLEP under the guidance of the instructor.

Preoperative pelvic floor muscle exercise for early continence after holmium laser enucleation of the prostate: a randomized controlled study.

BACKGROUND: Transient postoperative urinary incontinence is a bothersome complication of holmium laser enucleation of the prostate (HoLEP). The effects of preoperative pelvic floor muscle exercise (PFME) for early recovery of continence after HoLEP have never been elucidated. The aim of this study was to determine the benefit of preoperatively started PFME for early recovery of continence after HoLEP. METHODS: We randomly assigned patients to start PFME preoperatively and continue postoperatively (group A) or start PFME no earlier than the postoperative period (group B). The primary outcome was time to complete urinary control, defined as no pad usage. The secondary outcome was measured using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score. Univariate and multivariate analyses were performed to identify parameters associated with recovery of continence after HoLEP. RESULTS: Seventy patients were randomized across groups A (n = 35) and B (n = 35). Patients' characteristics were not different between groups A and B. The postoperative urinary incontinence rate significantly decreased in group A compared with that in group B at 3 months postoperatively [3% vs. 26% (P = 0.01)]. However, there were no significant differences between groups A and B at 3 days [40% vs. 54% (P = 0.34)], 1 month [37% vs. 51% (P = 0.34)], and 6 months [0% vs. 3% (P = 1.00)] postoperatively, respectively. The postoperative ICIQ-SF score was not significantly different between groups A and B at any time point postoperatively. In univariate analysis, patients who performed preoperative PFME had a 0.56-fold lower risk of urinary incontinence 1 month after HoLEP and a 0.08-fold lower risk of urinary incontinence 3 months after HoLEP. CONCLUSIONS: Preoperatively started PFME appears to facilitate improvement of early urinary continence after HoLEP. TRIAL REGISTRATION: The study was registered with the University Hospital Medical Information Network Clinical Trials Registry in Japan (UMIN000034713); registration date: 31 October 2018. Retrospectively registered.

Nerves in the Areas Posterior to the Prostate Base Contribute to Erectile Function: An Intraoperative Electrical Stimulation Assessment.

OBJECTIVE: To confirm the distribution of functional nerves involved in erectile function at the posterior of the prostate base, intraoperative nerve stimulation was performed during robot-assisted radical prostatectomy (RARP) METHODS: Several points at the posterior of the prostate and the posterolateral typical neurovascular bundle (NVB) were electrically stimulated at the level of the prostate base during RARP in patients with clinically localized prostate cancer. The prostate pedicle (PP), medial side of the PP (MPP), Denonvilliers' fascia (DF), and typical NVB were stimulated using bipolar electrodes. The changes in pressure at the middle of the urethra were measured using an inserted balloon-catheter to detect the increase in cavernosal pressure. RESULTS: Although the study included only 12 patients, each stimulation of the PP, MPP, and NVB induced evident urethral pressure responses in all patients. The median amplitude of the pressure responses was 5.49 (IQR 3.11-8.42), 6.00 (IQR 3.70-8.30), and 3.22 (IQR 2.48-7.19) cm H2O at the PP, MPP, and NVB, respectively. The amplitude of responses at the PP and MPP was not small compared with the responses at the typical NVB. Stimulations at the DF induced unstable weak urethral response alone or no response in all patients. CONCLUSION: We showed that electrostimulation of the PP and MPP increases the cavernosal pressure similar to the typical NVB stimulation. These findings indicate that maximal preservation of the tissues at the posterior area of the prostate base can contribute to optimal recovery of postoperative erectile function after nerve-sparing RARP.

Laparoscopic radical nephrectomy for a right renal tumor with renal vein tumor thrombus in a patient with situs inversus totalis.

Situs inversus totalis (SIT) is a rare congenital anomaly characterized by complete inversion of the thoracic and abdominal organs. Many intra-abdominal and vessel anomalies have been reported in association with SIT. However, there have been no reports on the use of laparoscopic radical nephrectomy with thrombectomy for renal vein thrombus, which is considered as a safe and feasible procedure, in patients with SIT. We herein present the case of an 80-year-old man with SIT who was preoperatively diagnosed with a right renal tumor and renal vein tumor thrombus. The patient underwent laparoscopic right nephrectomy and tumor thrombectomy with no intraoperative complications. To ensure a safe procedure, the anatomy and vessels were carefully evaluated preoperatively using 3-D multiplanar reconstructed CT imaging. Assessing anatomical structures leads to safer laparoscopic radical nephrectomy for renal cell carcinoma with venous tumor thrombus in patients with SIT.

Renal Transplantation with Simultaneous Aortoiliac Reconstruction Using a Polytetrafluoroethylene Vascular Graft for Severe Atherosclerosis.

Studies on aortoiliac reconstruction for severe atherosclerosis with renal transplantation are limited. Here, we report a rare experience of the simultaneous reconstruction of the external iliac artery caused by severe atherosclerosis with polytetrafluoroethylene vascular graft and renal transplantation in a 55-year-old female; she was unable to undergo standard renal artery anastomosis to the right external iliac artery because of severe atherosclerosis, which would result in complete occlusion. Next, we directly anastomosed the donor renal artery to the polytetrafluoroethylene graft. After transplantation, delayed graft function occurred; therefore, the patient had to undergo hemodialysis. On day 7 after transplantation, her creatine level started to decrease. She was discharged from the hospital on the 14th day after transplantation. After 1 month, her serum creatinine level reduced to 1.12 mg/dL. After 3 years of transplantation, her serum creatinine level was 1.2 mg/dL. The simultaneous implantation of the polytetrafluoroethylene graft and renal transplantation was feasible as well as safe, with no infectious complications and stable renal function noted on long time follow-up. Although our case was rare, it emphasizes the need for transplant surgeons to gain surgical skills for vascular surgery using vascular grafts.

Evaluation of Tumor Viability for Primary and Bone Metastases in Metastatic Castration-Resistant Prostate Cancer Using Whole-Body Magnetic Resonance Imaging.

In contrast to bone scan and computed tomography (CT), which depend on osteoblastic response to detect bone metastasis, whole-body magnetic resonance imaging (WB-MRI) may be able to directly detect viable tumors. A 75-year-old male who had progressive metastatic prostate cancer during primary androgen deprivation therapy was referred to our hospital. Although bone scan and CT showed multiple bone metastases, WB-MRI suggested nonviable bone metastasis and viable tumor of the primary lesion. Prostate needle biopsy demonstrated viable prostate cancer cells from 10 of 12 cores. In contrast, CT-guided needle biopsy from bone metastasis of the lumbar vertebra revealed no malignant cells. Based on these findings, we reasoned that viable tumor cells inducing disease progression may primarily exist in the primary lesions and not in the metastatic lesions, and combined prostate radiotherapy and systemic hormonal therapy resulted in successful clinical response and disease control. The use of WB-MRI to detect viable disease lesions may enable us to design optimal treatment strategies for patients with metastatic castration-resistant prostate cancer.