High frequency of concomitant squamous metaplasia in bulbar urethral stricture and its association with reconstructive delay and urethral rest.

PURPOSE: To determine the prevalence of concomitant squamous metaplasia (SM), the initial histological change from normal urethra to urethral stricture, in bulbar urethral strictures and to investigate the associated clinical factors. METHODS: A retrospective review was conducted on 165 male patients with bulbar urethral strictures who underwent excision and primary anastomosis (EPA) between 2010 and 2020, for whom complete clinical data and excised urethral specimens were available. An experienced pathologist histologically evaluated concomitant SM in paraffin sections of the proximal end of the excised urethra blinded to the clinical data. Disease duration was calculated as the period from the initial diagnosis of urethral stricture to the date of EPA. The association between concomitant SM and clinical background was investigated. RESULTS: SM was identified in 86 (52.1%) patients. The median disease duration in patients with SM (38 months) was significantly longer than that in patients without SM (9 months, p < 0.0001). In multivariate analysis, the longer disease duration, non-traumatic stricture etiology, and failure to maintain urethral rest with urinary diversion via a suprapubic tube for more than 90 days were independent factors predicting concomitant SM. No significant difference was observed in success rates of EPA between patients with SM (93.2%) and those without SM (97.5%, p = 0.18). CONCLUSIONS: Reconstructive urologists need to be aware that concomitant SM is frequent in patients with bulbar urethral stricture, especially in those with long disease duration and those who were voiding volitionally during the period of urethral rest.

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults.

OBJECTIVES: We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes. METHODS: Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". RESULTS: The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction. CONCLUSIONS: Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

[A Case of Massive Prostate Abscess Treated by Transperineal Drainage].

The patient was an 81-year-old man who visited a clinic for fever and lower abdominal pain. He was subsequently diagnosed with prostatitis based on computed tomography (CT) findings that showed swelling of the prostate. Despite treatment with antibacterial therapy, his symptoms did not improve significantly. Since the patient also had myelodysplastic syndrome, he was transferred to our hospital and subsequently diagnosed with prostate abscess based on findings on magnetic resonance imaging (MRI). The abscess had spread widely from the dorsal side of the trigone of the bladder to anterior wall of the rectum. Transperineal drainage was performed to preserve the urethral mucosa of the prostatic urethra. Considering the shape of the abscess cavity, one pigtail catheter was placed in the prostate and another was placed transperineally on the dorsal side of the trigone of the bladder. Cystostomy was performed at the same time. Culture of the abscess revealed the presence of Staphylococcus aureus. As there was little exudate from the abscess 9 days after drainage, the pigtail catheter on the dorsal side of the trigone of the bladder was removed following an injection of minocycline into the abscess. CT showed shrinkage of the abscess 4 days later, and the remaining intraprostatic pigtail catheter was removed after an injection of minocycline. The cystostomy pigtail catheter was subsequently removed since the patient was able to urinate smoothly after clamping. MRI confirmed the disappearance of the abscess cavity 2 months later.

Increased nucleophosmin expression is a strong predictor of recurrence and prognosis in patients with N0M0 upper tract urothelial carcinoma undergoing radical nephroureterectomy.

PURPOSE: We aimed to evaluate whether increased nucleophosmin expression predicts recurrence and survival in upper tract urothelial carcinoma (UTUC). METHODS: Specimens from 101 patients with N0M0 UTUC undergoing radical nephroureterectomy were evaluated. Nucleophosmin expression was determined immunohistochemically and categorized into two groups according to nucleophosmin staining intensity. The association between nucleophosmin expression and various clinicopathological factors including Ki-67 expression was analyzed. Multivariate analyses were performed to identify the independent predictors of extraurothelial recurrence and cancer-specific survival. RESULTS: High nucleophosmin expression was significantly correlated with tumor location, pT ≥3, lymphovascular invasion, lymph node metastasis, and high Ki-67 expression. Patients whose tumors demonstrated high nucleophosmin expression had a significantly higher rate of extraurothelial recurrence and a lower survival rate than those with low nucleophosmin expression. Multivariate analysis showed that pT ≥3, lymph node metastasis, high nucleophosmin expression, and high Ki-67 expression were independent predictors of extraurothelial recurrence. When patients were stratified into three groups according to the number of risk factors, the 2-year extraurothelial recurrence-free survival rates were 92.9% in patients with 0 or 1 risk factor, 76.5% in patients with 2 risk factors, and 9.1% in patients with 3 or 4 risk factors. Regarding cancer-specific survival, lymphovascular invasion and high nucleophosmin expression were independent predictors. CONCLUSIONS: Increased nucleophosmin expression was a strong predictor of extraurothelial recurrence and cancer-specific survival in patients with N0M0 UTUC undergoing radical nephroureterectomy. Our risk stratification models integrating nucleophosmin expression may provide valuable information on disease recurrence and prognosis.

[A CASE OF METASTATIC BLADDER UROTHELIAL CARCINOMA WHOSE DISEASE WAS CONTROLLED FOR A RELATIVE LONG PERIOD BY MULTIDISCIPLINARY TREATMENT INCLUDING RADIATION TO A LUNG METASTASIS AND MULTIPLE COURSES OF CHEMOTHERAPY].

A 67-year-old woman complained of urinary frequency and gross hematuria. She was referred to our hospital with the diagnosis of bladder tumor. Transurethral resection of the bladder tumor (TURBT) was performed and pathological diagnosis was urothelial carcinoma (G2>G3) with muscular invasion. Because she hoped bladder preservation therapy, she received two courses of M-VAC (methotrexate, vinblastine, doxorubicin and cisplatin) therapy, one course of arterial infusion chemotherapy, and chemoradiotherapy with cisplatin. After those therapies she underwent 4 times of TURBT and two courses intravesical BCG therapy. However, solitary lung metastasis appeared 19 months after the initial TURBT. Multidisciplinary treatments including 25 courses of various multiagent chemotherapies, radiation therapy to the lung metastasis and surgical resection of a urethral recurrence were performed. Although a localized radiation pneumonitis was developed, the lung metastasis appeared to be controlled for 26 months after the radiation therapy to the lung. Bilateral ureteral and renal pelvic tumors appeared after the radiation therapy. Severe bleeding was occurred from renal pelvic tumors several times and she needed the hospital stay 2 times. Active bleeding stopped after the administration of chemotherapy each time. Although she died of occlusive jaundice due to the liver metastasis, she had been alive due to the multidisciplinary treatment for 67 months after lung metastasis appearance with relatively good performance status.

[CLINICAL ANALYSIS ABOUT PERCUTANEOUS NEEDLE BIOPSY FOR RENAL MASSES].

(Objective) We investigated the efficacy and safety of percutaneous renal mass biopsy retrospectively. (Methods) A retrospective review was performed of 44 patients (46 renal masses) who received ultrasound and/or computed tomography guided percutaneous biopsy of a solid renal mass between April 2004 and December 2012 in National Defense Medical College Hospital. (Results) The median renal mass size was 45 (range 15-140) mm with a median of 2 (1-5) cores taken. Thirteen masses were biopsied for differential diagnosis between RCC and other malignancies (or benign renal tumors), 11 were biopsied for differential diagnosis between RCC and renal pelvic urothelial carcinoma, 10 unresectable masses were biopsied to confirm the diagnosis pathologically before starting medication, and 12 small masses were biopsied before radio-frequency ablation. Of the initial 46 biopsies, 38 (82.6%) were diagnostic. The median lesion sizes in the diagnostic and nondiagnostic biopsy specimens were 45 (15-140) mm and 43 (17-128) mm. The median numbers of diagnostic and nondiagnostic cores were 2 (1-5) and 1.5 (1-4). These size and core number differences between the diagnostic and nondiagnostic biopsy specimens are not statistically significant. Of initial nondiagnostic 8 masses, 3 masses that were performed repeat biopsy resulted in determined diagnosis finally. There were mild postprocedural hematomas not requiring blood transfusion. There was no tumor dissemination after renal mass biopsy. (Conclusions) Percutaneous biopsy of renal masses is a safe procedure that provides diagnostic information.

Clinical significance of p21-activated kinase 1 expression level in patients with upper urinary tract urothelial carcinoma.

OBJECTIVE: The p21-activated kinase serine/threonine kinases have been outlined as the main cytoskeletal remolding regulators. The same holds true for cell proliferation and motility. They additionally have a part in cellular invasion and carcinogenesis, but the effect of p21-activated kinase 1 expression on the progression of upper urinary tract urothelial carcinoma remains unclear. Therefore, we assessed the relation of p21-activated kinase 1 positivity level to clinicopathological features in patients with upper urinary tract urothelial carcinoma. METHODS: Immunohistochemical staining was performed using formalin-fixed and paraffin-embedded specimens, which were all from 124 patients with upper urinary tract urothelial carcinoma. The determination of staining level was based on the intensity of the staining along with portion of cells stained. Correlation of p21-activated kinase 1 positivity with clinicopathological parameters, including disease-specific or extravesical-recurrence-free survival, was evaluated. RESULTS: Statistically significant association was observed between moderate or more than moderate p21-activated kinase 1 positivity and higher tumor grade, pathological T stage, lymphovascular invasion, history of adjuvant chemotherapy and extravesical recurrence. Positivity for p21-activated kinase 1 had a significant association with shortened disease-specific survival in a multivariate analysis among clinicopathological parameters. Strongly positive p21-activated kinase 1 expression was also one of the independent factors for shortened extravesical-recurrence-free survival time in N0M0 upper urinary tract urothelial carcinoma patients in another multivariate analysis as well as histology and lymphovascular invasion (P = 0.0304, hazard ratio = 4.425). CONCLUSIONS: We conclude that our findings can help us continue a careful follow-up for upper urinary tract urothelial carcinoma patients with high p21-activated kinase 1 expression in surgical specimens.

Preoperative risk factors for extraurothelial recurrence in patients with ureteral cancer treated with radical nephroureterectomy.

PURPOSE: Recent studies have suggested that lymph node dissection may improve the prognosis in patients with upper tract urothelial carcinoma. Therefore, patients who will benefit from lymph node dissection need to be selected before surgery. Because patients who have extraurothelial recurrence theoretically include those whose prognoses are improved by lymph node dissection, we conducted this study to determine the preoperative predictors of extraurothelial recurrence in patients with ureteral cancer. MATERIALS AND METHODS: Because it is not appropriate to categorize the preoperative radiologic findings of ureteral cancer and those of renal pelvic cancer using the same classification criteria, we focused on ureteral cancer. We reviewed preoperative factors in 70 patients with ureteral cancer treated with radical nephroureterectomy. Laboratory tests including inflammatory indices, tumor markers and estimated glomerular filtration rate, along with radiologic findings, were evaluated. Multivariate analyses were performed to determine independent factors predicting extraurothelial recurrence in patients with ureteral cancer. RESULTS: Positive cytology, cT stage 3 or greater, length of ureteral cancer 3 cm or greater and estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 were independent predictors of extraurothelial recurrence on multivariate analysis. When patients were stratified into 3 groups according to the number of risk factors, the 3-year extraurothelial recurrence-free survival rates were 95.2% in the low risk group, 75.8% in the intermediate risk group and 25.1% in the high risk group. CONCLUSIONS: Positive cytology, cT stage 3 or greater, length of ureteral cancer 3 cm or greater and estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 were preoperative predictive factors of extraurothelial recurrence in patients with ureteral cancer and lymph node dissection may be omitted for low risk patients.

Prognostic impact of fatty acid synthase expression in upper urinary tract urothelial carcinoma.

OBJECTIVE: Fatty acid synthase has been shown to be highly expressed in various types of cancers with increased tumour aggressiveness. In this study we examined the level of fatty acid synthase expression in surgically resected upper urinary tract urothelial carcinoma specimens and evaluated the relations between fatty acid synthase expression and the patients' pathological features and clinical outcomes. METHODS: Sections of paraffin-embedded tumour specimens from 113 patients who underwent surgical treatment for upper urinary tract urothelial carcinoma were immunostained with a polyclonal fatty acid synthase antibody, and a tumour was considered to have high fatty acid synthase expression if >50% of the cancer cells stained with moderate-to-strong intensity. Associations between fatty acid synthase expression and the patients' pathological parameters and survival were analyzed statistically. RESULTS: During the follow-up time (median: 46.8 months), 61 patients (54.0%) had recurrence and 17 (15.0%) died of upper urinary tract urothelial carcinoma. High fatty acid synthase expression was significantly associated with high tumour grade (P = 0.0273). Patients with high fatty acid synthase expression had significantly worse recurrence-free survival and extravesical-recurrence-free survival than those with low fatty acid synthase expression (P = 0.0171, P = 0.0228, respectively). In multivariate analysis, high fatty acid synthase expression was an independent predictor of shortened recurrence-free survival (P = 0.0220, hazard ratio (HR) = 1.970). CONCLUSIONS: Fatty acid synthase expression in upper urinary tract urothelial carcinoma is an independent predictor for tumour recurrence. Patients with high fatty acid synthase expression in upper urinary tract urothelial carcinoma should be followed carefully and adjuvant therapy for them should be considered.

[The diagnostic value of pre-biopsy magnetic resonance imaging for precise detection of clinically localized prostate cancer compared to post-biopsy setting].

A total of 136 patients who underwent radical prostatectomy following histological diagnosis of prostate cancer by transrectal biopsy and 3-Tesla magnetic resonance imaging (MRI) were evaluated. MRI was performed on 26 patients before prostate biopsy (pre-biopsy group) and on 110 patients after prostate biopsy (post-biopsy group). We defined the largest tumor focus in a radical prostatectomy specimen as the index cancer. We compared the accuracy of MRI in detecting and localizing the index cancer in the groups. The sensitivity of detecting the index cancer by MRI was significantly (p = 0.012) higher in the pre-biopsy group (96.2%) than in the post-biopsy group (77. 3%). The negative predictive value of extracapsular invasion was 84.6% in the pre-biopsy group and 80.7% in the post-biopsy group. The average interval between biopsy and MRI was 42.8 days. Artifacts due to post-biopsy hemorrhage were observed in 32 (29.1%) of the patients in the post-biopsy group. The sensitivity of detecting the index cancer by MRI was significantly (p = 0.022) higher in 78 patients without artifacts due to hemorrhage (83.3%) than in the 32 patients with artifacts due to hemorrhage (62.5%). Even if MRI is delayed until after prostate biopsy,the artifact due to hemorrhage markedly interferes with the accuracy of MRI. Although pre-biopsy MRI is more accurate than post-biopsy MRI,there are some problems to be solved,such as cost effectiveness and the detectability of low-malignant and small cancers.

[Causes and salvage of failed urethroplasties for traumatic urethral injury].

OBJECTIVES: Salvage urethroplasty after failed repair of traumatic urethral injury is a urological challenge, and we herein describe our experience with it. METHODS: From October 2010 to January 2012, five patients underwent salvage repair of failed urethroplasties for traumatic urethral injuries: three bulbar straddle injuries and two pelvic fracture urethral injuries. One of the three failed urethroplasties for bulbar straddle injuries was a stricture excision and primary anastomosis, and its failure was due to periurethral abscess formation. Another was an augmented anastomotic urethroplasty using buccal mucosa, and its failure was due to periurethral abscess formation. The third was a tube graft urethroplasty using buccal mucosa, and its failure was due to a stricture at the anastomotic site. Two failed urethroplasties for pelvic fracture urethral injuries were perineal anastomotic repairs combined with corporal separation and inferior pubectomy, and the failures of both were due to ischemic bulbar necrosis. The urethral gap lengths estimated from urethrograms ranged from 12 to 45 mm (mean = 26 mm). RESULTS: Urethroplasties in all patients with bulbar straddle injuries were salvaged by stricture excision and primary anastomosis with corporal separation, and urethroplasties in both patients with pelvic fracture urethral injuries were salvaged by abdominal transpubic perineal urethroplasty. Although the patients who underwent transpubic urethroplasty had transient pelvic girdle pain, no severe complications were observed. All patients were for 10 to 25 months postoperatively (mean = 16 months) able to void satisfactorily without additional treatment. CONCLUSIONS: Failed urethroplasties for traumatic urethral injuries can be salvaged with a second reconstruction surgery. The procedure of choice for this salvage is anastomotic urethroplasty with techniques for tension-free anastomosis.

Prediction of biochemical recurrence after radical prostatectomy using peritumoral lymphatic vessel density in biopsy specimens in patients with localized prostate cancer.

INTRODUCTION: Lymphatic invasion has been associated with biochemical recurrence (BCR), and many patients with postoperative elevation of prostate-specific antigen (PSA) develop distant metastases within several years. We previously found peritumoral lymphatic vessel density (PTLD) in biopsy cores to be an independent predictor of lymphatic invasion in radical prostatectomy specimens, so we speculate that PTLD parameters in biopsy specimens could also be independent predictors of BCR after surgery. PATIENTS AND METHODS: We obtained positive biopsy cores from 110 patients who underwent radical prostatectomy at our institution. Biopsy cores were immunostained with the D2-40 monoclonal antibody, which specifically and selectively detects lymphatic endothelium. We evaluated differences between the BCR-free survival rates and used univariate and multivariate analyses to detect independent predictors of BCR. RESULTS: The results of a Cox proportional hazards model showed that lymphatic invasion in prostatectomy specimens was one of the independent postoperative prognostic factors for BCR (p = 0.0338). An additional model showed that one PTLD parameter, maximal PTLD, was among the independent preoperative predictors of lower BCR-free survival rates (p = 0.0200). CONCLUSIONS: Information about PTLD in prostate biopsy specimens could be helpful for selecting patients as radical prostatectomy candidates, and patients with high PTLD values should be carefully monitored after surgery.

Prognostic factors for upper urinary tract urothelial carcinoma after nephroureterectomy.

INTRODUCTION: The purpose of this study was to evaluate prognostic factors for patients with upper urinary tract urothelial carcinoma (UUT-UC) after nephroureterectomy and to seek a better way of finding more favorable clinical results for these patients. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 121 UUT-UC patients who underwent a nephroureterectomy at our institution, and analyzed the prognostic significance of various clinicopathological parameters for progression-free and disease-specific survival rates by using univariate and multivariate analysis. RESULTS: A Cox proportional hazards model showed that extravesical tumor recurrence after surgery was an independent prognostic factor for disease-specific survival (p < 0.0001). An additional model showed that lymphovascular invasion (LVI) was one of the independent predictors of lower extravesical-recurrence-free survival rates (p = 0.0004). Our final finding was that pathological tumor stage and positive surgical margin were significantly associated with the presence of LVI (p < 0.0001 and p = 0.0029, respectively). CONCLUSIONS: We conclude that there is a high possibility of LVI in patients with large tumors. Our findings should be helpful in terms of determining whether or not to perform neoadjuvant chemotherapy for patients with large tumors, given the fact that we frequently find a severe reduction in renal function after nephroureterectomy.

[The efficacy of direct vision internal urethrotomy for male urethral stricture].

OBJECTIVE: Direct vision internal urethrotomy (DVIU) has been considered to be a low invasive and widely used therapeutic modality for male urethral stricture. However, its efficacy is still controversial. We herein evaluated the efficacy of DVIU for male urethral stricture. PATIENTS AND METHODS: Nineteen patients 27 to 78 years old (median age = 59) underwent DVIU for urethral strictures at our hospital were included in this study. Strictures were at bulbar urethra in 17 patients, membranous urethra in 1 patient, and pendulous urethra in 1 patient. The stricture lengths estimated on retrograde urethrography were less than 1 cm in 13 patients, 1-2 cm in 2 patients, and more than 2 cm in 4 patients. The etiology of stricture was straddle injury in 7 patients, post transurethral surgery in 7 patients, pelvic fracture in 1 patient, and unknown in 4 patients. The operation was done by cold knife incision using guidewire. The duration of postoperative urethral catheterization was 5 to 35 days (mean 12.8 days). Follow up duration ranged from 1 month to 139 months (mean 48.2 months). The definition of postoperative re-stricture was the confirmation of re-stricture on retrograde urethrography or deterioration of symptom. RESULTS: While no severe complication was observed, postoperative re-stricture was seen in 13 patients. Stricture-free rates at 3 months, 6 months, and 5 years after the first DVIU were 44.4%, 38.1%, 20.3% respectively. Although second DVIU was done for 7 patients with re-stricture, six patients resulted in failure. Stricture-free rates at 3 months, 6 months, and 5 years after the second DVIU were 42.2%, 28.6%, 14.3% respectively. Though the third DVIU was done for two of them, they were unable to void just immediately after the removal of urethral catheters. Stricture-free rate in stricture less than 1 cm was higher than that in 1 cm or longer, though it did not reach significant difference (p = 0.1813). CONCLUSION: The efficacy of DVIU is lesser than we expected. DVIU seems to be excessively applied to male urethral strictures and should not be performed for long and recurrent urethral stricture.

Impact of postoperative C-reactive protein level on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma.

PURPOSE: Preoperative C-reactive protein is a strong predictor of recurrence and prognosis in patients with renal cell carcinoma while postoperative C-reactive protein reportedly predicts survival in patients with metastatic renal cell carcinoma. We evaluated the impact of postoperative C-reactive protein on recurrence and prognosis in patients with N0M0 clear cell renal cell carcinoma. MATERIALS AND METHODS: We defined increased preoperative C-reactive protein as 1 mg/dl or greater and postoperative C-reactive protein normalization as at least 1 postoperative measurement of less than 0.3 mg/dl. We reviewed the records of 263 patients with N0M0 clear cell renal cell carcinoma who underwent nephrectomy, and in whom preoperative and postoperative C-reactive protein values were available. We used multivariate analysis to identify independent factors predicting recurrence and prognosis. We also evaluated C-reactive protein at recurrence and its impact on survival. RESULTS: Increased preoperative C-reactive protein and nonnormalization of postoperative C-reactive protein were associated with worse clinicopathological factors. Postoperative C-reactive protein nonnormalization, increased preoperative C-reactive protein, microvascular invasion and histological tumor necrosis were independent predictors for recurrence. Risk stratification using these factors effectively predicted the possibility of recurrence. Anemia, thrombocytosis and postoperative C-reactive protein nonnormalization were independent predictors of overall survival. Postoperative followup revealed recurrence in 50 patients. The 3-year survival rate in patients with C-reactive protein 0.3 mg/dl or greater at recurrence was significantly lower than that in patients with less than 0.3 mg/dl at recurrence (47.3% vs 81.6%). CONCLUSIONS: Nonnormalization of postoperative C-reactive protein is a strong predictor of recurrence and prognosis. Patients with C-reactive protein 0.3 mg/dl or greater at recurrence might not survive as long as those with C-reactive protein less than 0.3 mg/dl at recurrence.

Glucose-regulated protein 78 positivity as a predictor of poor survival in patients with renal cell carcinoma.

INTRODUCTION: Glucose-regulated protein 78 (GRP78), a chaperone for newly formed proteins during folding and glycosylation, is associated with resistance to apoptosis in some forms of cancer. We assessed GRP78 expression and its correlation with clinicopathological parameters and survival. PATIENTS AND METHODS: Immunohistochemistry was performed using formalin-fixed, paraffin-embedded specimens: 128 primary renal cell carcinoma (RCC) specimens (120 conventional and 8 other cell types) and 9 metastatic specimens. GRP78 positivity was determined based on intensity of staining and percentage of cells stained. Correlation of GRP78 positivity with clinicopathological parameters including patients' survival was evaluated. RESULTS: A statistically significant association was found between GRP78 positivity and higher tumor grade (G3; p <0.0001), advanced T stage (≥pT3; p = 0.0002), lymphovascular invasion (positive; p <0.0001), regional nodal involvement (≥N1; p = 0.0086), and distant metastases at presentation (M1; p = 0.001). Positivity of GRP78 expression was significantly associated with shorter disease-specific survival and shorter progression-free survival. Cox proportional hazard model showed that strong GRP78 positivity was an independent predictor of shortened progression-free survival in N0M0 RCC patients. CONCLUSIONS: There was a significant relationship between GRP78 expression levels and aggressiveness of RCC. Increased expression of GRP78 might be a useful parameter to predict shortened survival in patients with RCC.

[Clinical experience of 52 patients undergoing laparoscopic radical prostatectomy].

Perioperative results and oncological and functional results were evaluated for 52 patients who underwent laparoscopic radical prostatectomy (LRP). Median operative time was 341 minutes and median blood loss was 828 ml. The intraoperative complications were hemorrhage exceeding 3,000 ml (five cases), ureteral injury (two cases), and rectal injury (one case). The median day of catheter removal was postoperative day 7. Postoperative complications were temporal arrhythmia, mild hydronephrosis, port site hernia, urethral stricture, and a giant lymphocele. When surgical results were compared between the firsthalf cases and second-half cases who were operated on by a single surgeon, median operative time and intraoperative hemorrhage did not differ significantly between the two halves but the day of catheter removal after LRP was significantly earlier for the second-half group. The pathological stage was pT3 in 41.2% of the patients and the negative surgical margin rate was 62.7%. The 3-year PSA-failure-free survival rate was 64. 1%. Pad-free status (0-1 pad/day) was achieved in 84.4% of the patients. Erectile function was preserved in 58.3% of patients undergoing nerve-sparing LRP. Although the complication rate and the quality of operative procedures gradually improved, efforts to improve the oncological and functional outcomes of LRP must continue.

Preoperative risk stratification using plasma fibrinogen levels can predict lymphovascular invasion and poor prognosis in patients with upper urinary tract urothelial carcinoma.

It has been previously indicated that preoperative plasma fibrinogen levels can correlate with cancer progression and be used as a useful predictor of lymph node metastasis or its premetastatic status such as lymphovascular invasion (LVI). In the present study, how preoperative plasma fibrinogen levels, considered in conjunction with other clinicopathological factors, can predict the presence of LVI and prognosisin patients with upper urinary tract urothelial carcinoma (UTUC) was examined. Medical records of 145 patients with UTUC who underwent radical nephroureterectomy (RNU) were retrospectively reviewed. The current study evaluated systemic inflammatory response markers including levels of plasma fibrinogen and other clinicopathological factors in orderto determine independent predictors of LVI and prognosis. The Cox proportional hazards model indicated that positive surgical margins and LVI were independent factors for poor cancer-specific survival (CSS) rates and extraurothelial recurrence-free survival (ERFS) rates. In addition, positive cytology, the presence of hydronephrosis and plasma fibrinogen levels were significant preoperative predictors of LVI. Furthermore, patients exhibiting two or more of higher fibrinogen levels (≥400 mg/dl), positive urine cytology and the presence of hydronephrosis were indicated to exhibit worse CSS or ERFS rates compared with patients exhibiting only one of the aforementioned factors or those with none of the three aforementioned factors in the multivariate analysis of the Cox proportional hazards model. In conclusion, hyperfibrinogenemia can be an independent predictor of the presence of LVI, and stratifying preoperative risk using fibrinogen levels, urine cytology and hydronephrosis can serve as the basis for selecting candidates for additional therapy before and/or after RNU in patients with UTUC.

Tumor budding in upper urinary tract urothelial carcinoma: a putative prognostic factor for extraurothelial recurrence and overall survival.

Tumor budding, defined as a single cancer cell or clusters of fewer than five cancer cells observed at the tumor invasion front, has been reported to be associated with poor prognosis in various types of cancers. However, limited information regarding the pathological and prognostic significance of tumor budding in upper urinary tract urothelial carcinoma (UUTUC) is available. We investigated 135 consecutive patients with newly diagnosed invasive UUTUCs (73 with renal pelvic cancers and 62 with ureteral cancers) treated with nephroureterectomy or partial ureterectomy between 1999 and 2018 in our hospital. Under a × 200 magnification, tumors with 10 or more budding foci were defined as "high tumor budding". The median follow-up period was 53.6 months. Among the 135 patients, 41 (30%; 16 with renal pelvic cancers and 25 with ureteral cancers) showed high tumor budding. High tumor budding was related to adjuvant chemotherapy status, higher pathological T stage, lymphovascular invasion, lymph node metastasis, tumor location, concomitant variant histology, and non-papillary gross finding. The multivariate Cox analysis revealed that LVI and high tumor budding were independent predictors for extraurothelial recurrence (P = 0.039 and 0.014, hazard ratio = 2.50 and 2.88, respectively), and high tumor budding was an independent predictor for overall survival (P = 0.024, hazard ratio = 2.33). Tumor budding can be easily introduced in clinical practice with no need for immunohistochemical analysis, may be an important clinicopathological factor of UUTUC, and is suggested to be useful as a novel predictive prognostic factor of patients with invasive UUTUC.

[CLINICAL ANALYSIS OF 95 CASES OF PERCUTANEOUS CYSTOSTOMY].

(Introduction) Percutaneous cystostomy is a standard urological procedure; however, very few reports have focused on the many cases of this procedure performed in Japan. We analyzed the background of the procedure and its approach as well as the incidence of its complications at our institution. (Material and methods) We examined 95 patients who underwent percutaneous cystostomy between April 2010 and March 2019. A comparative analysis was conducted for each type of procedure performed. Furthermore, cases that experienced accidental catheter extraction before the first catheter replacement were analyzed, and the three patient groups were compared based on the type of procedure performed and cases that needed another operation. (Result) The indications for cystostomy were urethral stricture (56.3%), neuropathic bladder (13.5%), and prostatic hyperplasia (11.5%). The complications included hemorrhage, peritoneal injury, urinary tract infection, and catheter damage caused by a puncture needle. The overall complication rate was 10.5%. Based on type of the procedure performed, the incidence of hemorrhage was found to be as high as 25% in patients who underwent the procedure using a cannula puncture needle. Accidental catheter extraction before the first catheter replacement occurred most frequently in patients treated with Seldinger technique (17.0%). The rate of complications including accidental catheter extraction ranged from 25.0% to 25.4% among the three groups. (Conclusion) We prefer the Seldinger technique for the first placement of the cystostomy catheter because of its low rate of hemorrhage, but a cannula puncture needle may also be used by using exploratory puncture if vascular damage and accidental catheter extraction are avoided.