Robot-assisted nephroureterectomy using the GelPoint Platform with a focus on optimizing the port position and specimen retrieval.

INTRODUCTION: One of the factors that makes robot-assisted nephroureterectomy difficult is that the optimal port position differs between nephrectomy and bladder cuff excision. In addition, how best to retrieve the specimen after resection while minimizing the size of the wound is a challenge in robot-assisted surgery. To solve these problems, we designed a surgical technique for robot-assisted nephroureterectomy using the GelPoint Platform with a focus on port position optimization and specimen retrieval. This study describes the surgical technique of GelPoint robot-assisted nephroureterectomy and reports our initial experience with this technique. METHODS: Between January 2023 and May 2024, seven patients underwent robot-assisted nephroureterectomy using the GelPoint Platform and 11 underwent conventional robot-assisted nephroureterectomy. We compared the patients' characteristics and surgical outcomes between the two groups. RESULTS: Compared with the conventional robot-assisted nephroureterectomy group, the median operative time tended to be shorter in the GelPoint robot-assisted nephroureterectomy group (280 vs. 357 min, respectively; p = .135). The maximum incision length tended to be longer in the GelPoint robot-assisted nephroureterectomy group (7.0 vs. 6.0 cm, respectively; p = .078). The incidence of 30-day complications was similar between the two groups (28.5% vs. 18.2%, respectively; p = 1.000). No complications were associated with the use of the GelPoint Platform. CONCLUSION: The surgical outcomes of GelPoint robot-assisted nephroureterectomy are comparable to those of conventional robot-assisted nephroureterectomy, and it can be performed safely and effectively. GelPoint robot-assisted nephroureterectomy can be considered a feasible alternative for selected patients with upper tract urothelial carcinoma.

Efficacy of educational stepwise robot-assisted radical prostatectomy procedure for urology residents.

OBJECTIVE: To evaluate the effectiveness of an educational stepwise robot-assisted radical prostatectomy (RARP) procedure for urology residents. METHODS: We performed a detailed evaluation of 42 RARP procedures performed by a single urology resident from July 2019 to February 2022. The RARP procedures were divided into the following nine steps: (1) bladder dissection, (2) endopelvic fascia dissection, (3) bladder neck dissection, (4) seminal vesicle dissection, (5) Denonvilliers' fascia dissection, (6) dorsal vascular complex ligation, (7) dissection of the prostatic apex, (8) posterior anastomosis, and (9) urethro-vesical anastomosis. The procedures were further subcategorized as anatomical understanding, spatial recognition, and technical skills for evaluation of resident training. The surgeries were divided into first and second halves, and patient characteristics and operative outcomes were statistically analyzed. The operative time of each of the nine steps and the reasons for proctor intervention were compared. RESULTS: Among 42 patients, there were no significant differences in operative outcomes between the two groups. The median operative time was 169 min (164 vs. 179 min, p = .12), and the median console time was 128 min (127 vs. 130 min, p = .74). Although there were no significant differences in the time of the nine steps, the resident significantly overcame (7) dissection of the prostatic apex and (8) posterior anastomosis based on the evaluation of the proctored reasons for intervention. CONCLUSIONS: Urology residents can safely perform and efficiently learn RARP with this stepwise educational system. This educational stepwise RARP procedure can effectively help residents to develop their skills.

Micropapillary Variant of Urothelial Carcinoma in a Hemodialysis Patient.

The micropapillary variant of urothelial carcinoma (MPUC) is an aggressive form of urothelial carcinoma with high metastatic potential and a poor prognosis. Although various therapies have been reported, there is still no established treatment strategy for MPUC due to its rarity. The incidence of urinary tract malignancies is higher in patients undergoing hemodialysis (HD) than in healthy individuals. Here, we report the case of an 82-year-old man on HD with end-stage kidney disease who visited our hospital for macrohematuria. Cystoscopy followed by computed tomography and urine cytology revealed a sessile papillary tumor around the left bladder wall. We performed transurethral resection of the bladder tumor. Based on histopathological and imaging findings indicative of clinical-stage T3N0M0 MPUC, we performed radical cystectomy. Histopathology revealed a pathological stage T4aN0M0 MPUC. Two months after the cystectomy, the patient complained of constipation and painful defecation due to local recurrence and rectal invasion. While colostomy was performed to improve defecation 3 months after cystectomy, he did not receive any chemotherapy due to his progressively worsening general condition. Six months after cystectomy, he died following rapid metastases. Our findings, in this case, confirm that bladder cancer in HD patients tends to be pathologically more advanced. Therefore, regular screening is recommended for its early detection in HD patients.

Poor Outcome due to the Plasmacytoid Variant of Urothelial Carcinoma.

A 72-year-old man visited our hospital due to pollakiuria and lower abdominal pain. Urinary cytology was positive, and cystoscopy revealed diffuse edematous nonpapillary tumor. We performed transurethral biopsy, and clinical stage T3 plasmacytoid variant of urothelial carcinoma (PUC) was diagnosed. Although we planned for radical cystectomy, peritoneal dissemination and lung and pelvic lymph node metastases appeared 3 weeks after the initial visit. We also planned for chemotherapy; however, the metastases rapidly progressed, and he died 7 weeks after the biopsy. PUC is rare and shows an aggressive clinical course and poor prognosis.

The patient-side surgeon plays a key role in facilitating robot-assisted intracorporeal ileal conduit urinary diversion in men.

The influence of the console surgeon on the feasibility and outcome of various robot-assisted surgeries has been evaluated. These variables may be partially affected by the skills of the patient-side surgeon (PSS), but this has not been evaluated using objective data. This study aimed to describe the surgical techniques of the PSS in robot-assisted radical cystectomy (RARC) and intracorporeal ileal conduit (ICIC) urinary diversion and objectively examine the changes in surgical outcomes with increasing PSS experience. During a 3-year period, 28 men underwent RARC and ICIC urinary diversion. Clinical characteristics and surgical outcomes were compared between patients who underwent surgery early (first half group) or late in the study period (second half group). The pre-docking incision enabled easy specimen removal. The glove port technique widened the working space of the PSS. The stay suture allowed the PSS to control the distal portion of the conduit, facilitating the passage of the ureteral stents. During stoma creation, pneumoperitoneum pressure was lost by opening the abdominal cavity. To overcome this problem, the robotic arm was used to lift the abdominal wall to maintain the surgical field and facilitate the PSS procedure. Compared with the first half group, the second half group had significantly shorter times for urinary diversion (202 min vs 148 min, p < 0.001), ileal isolation and anastomosis (73 min vs 45 min, p < 0.001), and stenting (23.0 min vs 6.5 min, p < 0.001). As the experience of the PSS increased, the time of the PSS procedures decreased.

Sepsis-associated purpura fulminans caused by emphysematous cystitis.

INTRODUCTION: Emphysematous cystitis is a rare pathology characterized by gas bubbles within the bladder wall and lumen from gas-producing bacteria. Sepsis-associated purpura fulminans is also rare and shows poor clinical outcomes. CASE PRESENTATION: A 73-year-old man was hospitalized at a nearby hospital due to chronic subdural hematoma, symptomatic epilepsy, and diabetes mellitus. He was transferred to our hospital with fever, low blood pressure, and cyanosis of the legs, and was diagnosed with septic shock due to emphysematous cystitis with purpura fulminans. He underwent intensive treatment, including retroperitoneal drainage. Urine culture was positive for Citrobacter freundii. His general condition gradually improved and diffuse air decreased after surgery, but progressive purpuric skin necrosis became evident on the legs, which could not be salvaged. He died on the 25th hospital day. CONCLUSION: Sepsis-associated purpura fulminans caused by emphysematous cystitis shows a very poor prognosis irrespective of intensive treatment, including retroperitoneal drainage.

Complete response to pembrolizumab in recurrent nested variant of urothelial carcinoma.

INTRODUCTION: The nested variant of urothelial carcinoma is rare and shows poor prognosis. We report a case of complete response to pembrolizumab in recurrent nested variant. CASE PRESENTATION: A 50-year-old man visited another hospital with hematuria and weight loss. Clinical stage T4aN0M0 bladder cancer and acute renal failure were diagnosed. He was referred to our hospital and underwent radical cystectomy. Histological examination showed pathological stage T4aN2 nested variant of urothelial carcinoma. He received 3 cycles of gemcitabine and carboplatin adjuvant chemotherapy. However, para-aortic lymph node metastasis appeared 7 months after cystectomy. He received pembrolizumab as systemic chemotherapy. After 10 cycles, the lesion remained undetectable and we evaluated the response as complete. He has received 18 cycles in total and no recurrences or metastases have been observed. CONCLUSION: Pembrolizumab may offer effective treatment for nested variant of urothelial carcinoma.

[A CASE OF ILEAL CONDUIT-ENTERIC FISTULA AFTER ROBOTIC INTRACORPOREAL ILEAL CONDUIT URINARY DIVERSION].

The complications of ileal conduit urinary diversion were reported to be urinary tract infections, bowel obstruction, and delayed wound healing, but ileal conduit-enteric fistula is rare. We report a case of ileal conduit-enteric fistula after robotic intracorporeal ileal conduit urinary diversion. An 81-year-old man with muscle-invasive bladder cancer underwent robot-assisted radical cystectomy and intracorporeal ileal conduit urinary diversion. Twenty-two days after the surgery, we identified the presence of fecaluria. Loopography revealed an ileal conduit-enteric fistula. He underwent conservative treatment with fasting and intravenous hyperalimentation. Loopography was performed 48 days after the surgery. However, the fistula remained. Therefore, fistula closure surgery was performed 51 days after the surgery. Here we review the characteristics of 4 ileal conduit-enteric fistula cases reported in Japan.

Urothelial carcinoma of the urinary bladder related to a migrated mesh after inguinal hernioplasty: A case report.

INTRODUCTION: Mesh migration into the urinary bladder following repair of inguinal hernia and bladder cancer caused by a foreign body are extremely rare. We hereby report a rare case of urothelial carcinoma of the bladder related to a migrated mesh following inguinal hernioplasty. CASE PRESENTATION: A 70-year-old Japanese woman who underwent surgery for left inguinal hernia 5 years previously presented with gross hematuria. Cystoscopy and computed tomography revealed stone formed in the mesh migrated into the urinary bladder. Mesh removal surgery and partial cystectomy were performed; and pathological findings revealed muscle invasive bladder cancer. Neoadjuvant chemotherapy and radical cystectomy were performed. The pathological diagnosis was high-grade urothelial carcinoma, stage pT3a with positive lymph nodes, stage pN3. To date, 3 months after surgery, the patient has received adjuvant chemotherapy. CONCLUSION: To our knowledge, this is the first report of urothelial carcinoma related to a migrated mesh after inguinal hernioplasty.

[SUCCESSFUL TREATMENT OF SEVERE EMPHYSEMATOUS CYSTITIS USING RETROPENITONEAL DRAINAGE: A CASE REPORT].

Emphysematous cystitis is a rare disease involving infection caused by gas-producing bacteria is characterized by air storage in the bladder wall and lumen. Approximately 90% of the affected cases are treated using medical therapy alone, and approximately 10% require combined surgical treatment. Here we report a case of emphysematous cystitis with septic shock that could be treated using multimodal therapy with retroperitoneal drainage. A 76-year-old woman was hospitalized at a nearby hospital owing to lumbar compression fracture. She was transferred to our hospital owing to altered consciousness and low blood pressure. She was diagnosed with emphysematous cystitis, and conservative treatment was performed using an indwelling bladder catheter and by administering antibiotics or vasopressors. The patient had septic shock; hence, retroperitoneal drainage was performed. After surgery, the patient's general condition improved. In this study, we review the characteristics of five cases of emphysematous cystitis requiring surgical treatment in Japan.

[INITIAL EXPERIENCE WITH ROBOT-ASSISTED RADICAL CYSTECTOMY AND INTRACORPOREAL URINARY DIVERSION ~COMPARISON WITH THE CONVENTIONAL METHOD~].

(Objectives) While robot assisted radical cystectomy (RARC) has been associated with improved perioperative outcomes such as blood loss, hospital stay, and improved convalescence, much of the criticism has been attributable to the longer operative time. Opinions are divided regarding whether intracorporeal urinary diversion (ICUD) or extracorporeal urinary diversion (ECUD) should be performed. The aim of this study is to evaluate the utility of RARC and ICUD by comparing with the conventional method. (Patients and methods) From December 2014 to July 2018, 14 patients underwent laparoscopic radical cystectomy (LRC) and 16 patients underwent RARC at our institution. Among the 30 patients, 23 underwent ileal conduit or orthotopic bladder; these patients were divided into two groups: an ICUD patient group (n=10) and an ECUD patient group (n=13). Treatment outcomes were compared between groups. (Results) Compared to patients who underwent LRC those treated with RARC had older (75 vs. 67, P=0.031). There was a trend of high-risk cases (American Society of Anesthesiologists' physical status classification ≥3) more frequently (31.3% vs. 7.1%, P=0.176). Patient treated with RARC had less blood loss (150 vs. 544 ml, P=0.003). There was no significant difference in the intra- and postoperative complication rates (12.5% vs. 21.4%, P=0.642). Compared to patients who underwent ECUD, those treated with ICUD included a longer operative time for urinary diversion (222 vs. 181 minutes, P=0.007) but less maximal incision length without perineal incision (3.0 vs. 6.0 cm, P=0.002). (Conclusions) Our data suggests that RARC is a safe procedure with potential advantages in terms of reduced blood loss. ICUD has longer operative time but is a procedure with excellent cosmetic results.

[Mucinous Tubular and Spindle Cell Carcinoma in a Patient on Hemodialysis : A Case Report].

Although patients on long-term hemodialysis frequently develop renal cell carcinoma, mucinous tubular and spindle cell carcinoma (MTSCC) is rare in incidence. Here, we report a case of MTSCC occurring in a patient under hemodialysis. The patient was a 72-year-old man with end stage renal failure due to diabetic nephropathy. Hemodialysis was initiated in 2003. He presented with macrohematuria. Contrastenhanced computed tomography (CT) revealed a right renal tumor. Laparoscopic right nephrectomy was performed accordingly in June 2017. Pathologically, the tumor was diagnosed as MTSCC. Six months after the surgery, the patient remains free of recurrence and metastasis. Here we review the characteristics of 5 MTSCC cases in patients on hemodialysis reported in Japan.

Testicular nocardiosis accompanied by cutaneous lesions in an immunocompetent man.

We herein report the case of a 77-year-old man admitted for an acute cutaneous infection and persistent fever. A physical examination revealed systemic small blisters and scrotal swelling. He was suspected of having complications from chickenpox or bullous impetigo as the initial diagnosis. Nocardia was detected on an aspiration biopsy of the small blisters and the surgically removed testis at a later date. Testicular nocardiosis is a rare condition; however, we should consider nocardiosis in the differential diagnosis because delay in providing treatment may worsen a patient's general condition.

[Two cases of primary female urethral cancer].

Herein, we report two cases of female urethral cancer. Case 1 presented with acute urinary retention and case 2 presented with a painful perineal mass. Magnetic resonance imaging (MRI) revealed a urethral tumor in both cases. Histopathological examination of transperineal biopsy specimens from both patients suggested clear cell adenocarcinoma in case 1 and squamous cell carcinoma in case 2. Both cases underwent total urethrectomy with partial resection of the vaginal wall and cystostomy urinary diversion. With reference to case 1, obturator lymph node metastases were observed during surgery, and treatment comprised combined radiotherapy to 60 Gy and chemotherapy with 5-fluorouracil and cisplatin following surgery. However, metastases appeared in the lung 6 months after initial treatment and she died 20 months after surgery. For case 2, tumor marker failure was observed 5 months after surgery. The same combined treatment was performed and a complete response was obtained. At 19 months after surgery, the patient showed no evidence of recurrence.

Prognostic significance of matrix metalloproteinases-2 activation ratio in renal cell carcinoma.

BACKGROUND: Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases. MMP-2 and MMP-9 have been reported to be closely associated with tumor invasion and metastasis in various human carcinomas. METHODS: Tissue samples were obtained from 57 patients with renal cell carcinoma (RCC) who underwent radical nephrectomy in our hospital. We examined the expression of MMPs by gelatin zymography and assessed correlations with clinico-pathological parameters and clinical outcomes. RESULTS: We detected bands corresponding to MMP-9, proMMP-2 and active MMP-2. The expression of active MMP-2 and MMP-2 activation ratio (active MMP-2/[proMMP-2 and active MMP-2]) were higher in T3 tumors than in T1 and T2 tumors. There were no significant differences in the expression of proMMP-2, active MMP-2 or MMP-9 for any of the clinico-pathological parameters. Patients with high MMP-2 activation ratio or high MMP-9 had significantly worse cause-specific survival. Interestingly, among patients with stage III RCC, those with high MMP-2 activation ratio or high active MMP-2 had significantly worse cause-specific survival. Univariate analysis showed that histological grade (P = 0.0001), histologic type (P = 0.0005), MMP-2 activation ratio (P = 0.0159), stage (P = 0.0001), MMP-9 (P = 0.0316), and T (primary tumor) category of TNM (primary tumor, lymph node, metastasis) classification (P = 0.0021) were significant predictors of clinical outcome. Multivariate analysis showed that only histological grade (P = 0.002) and stage (P = 0.0099) were independently significant predictors of clinical outcome. CONCLUSION: Activation of MMP-2 appears to play important roles in initiating metastasis, as shown by results obtained with stage III RCC patients. However, further study is needed to confirm this.