[Resumption of Enfortumab Vedotin Supported by Diagnosis of a Late- Onset Immune-Related Adverse Event in Metastatic Urothelial Carcinoma : A Case Report].

A 71-year-old man presented with exertional dyspnea. Chest radiography revealed multiple pulmonary nodules, and contrast-enhanced computed tomography showed findings suspicious of right renal pelvic cancer. Percutaneous lung tumor biopsy revealed a histological diagnosis of urothelial carcinoma, and right renal pelvic cancer cT3N2M1 was diagnosed. Favorable response was shown during primary chemotherapy with gemcitabine and cisplatin but resulted in tumor progression after four cycles. The patient was switched to a second-line treatment, pembrolizumab, which resulted in rapid tumor growth. Hyper-progression was suspected, and the patient was promptly switched to a third-line treatment, enfortumab vedotin. The tumor shrank significantly. After three treatment cycles, an adverse event of enteritis was observed. A biopsy of the intestinal mucosa led to a histopathologic diagnosis of late-onset immune-related adverse event; therefore, enfortumab vedotin could be continued.

[Rupture of Adrenal Artery Aneurysm : A Case Report].

A 45-year-old man with severe left flank pain was brought by ambulance to our hospital early in the morning. On arrival, his circulation dynamics were stable. His urinalysis results were normal, and ultrasonography showed no hydronephrosis. Abdominal dynamic computed tomography (CT) showed a huge retroperitoneal hematoma suspected of hemorrhage from a left adrenal artery aneurysm. After 3 hours of absolute bed rest, the patient experienced episodes of anemia, decreased blood pressure and increased pulse. Recheck of CT showed bleeding into the peritoneal cavity. Therefore, the patient was immediately treated with transcatheter arterial embolization.

[Clinical outcomes after non-ischemic partial nephrectomy for clinical T1 renal tumors using soft coagulation versus microwave tissue coagulation].

PURPOSE: We have performed non-ischemic partial nephrectomy for clinical T1 renal tumors using microwave tissue coagulation (MTC group) or soft coagulation (soft coagulation group). The clinical outcomes were retrospectively compared between the two groups. MATERIALS AND METHODS: A total of 36 patients were analyzed in this study (22 in the MTC group and 14 in the soft coagulation group). The anatomical characteristics of the renal tumors were assessed using the R.E.N.A.L Nephrometry Score. Renal function was assessed by the estimated glomerular filtration rate. RESULTS: The preoperative estimated glomerular filtration rate was 72.1 ml/min in the MTC group and 65.6 ml/min in the soft coagulation group (p = 0.05). The R.E.N.A.L Nephrometry Score was not significantly different between the two groups. Clavian grade > or = 2 postoperative complications occurred in one patient (4.5%) in the MTC group and one patient (7.1%) in the soft coagulation group. Postoperative local recurrence and distant metastasis occurred in one patient (8.3%) in the soft coagulation group and no patients in the MTC group, which was not a significant difference between the two groups. The median postoperative decrease in estimated glomerular filtration rate was 11.5% in the MTC group and 3.6% in the soft coagulation group. Postoperative renal preservation tended to be better in the soft coagulation group than in the MTC group, but this difference was not significant. CONCLUSION: The use of soft coagulation in non-ischemic partial nephrectomy for the treatment of clinical T1 renal tumors is as effective as that of MTC.

Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy.

This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.

Antimicrobial prophylaxis to prevent perioperative infection in urological surgery: a multicenter study.

We prospectively investigated the rates of incidence of surgical site infection (SSI), urinary tract infection (UTI), and remote infection (RI) in 4,677 patients who underwent urological surgery from January to December 2010, including 2,507 endourological cases, 1,276 clean cases, 807 clean-contaminated cases, and 87 contaminated cases involving bowel segments. A single dose of antimicrobial prophylaxis (AMP) was administered in the endourological, clean, and clean-contaminated surgery cases, except for patients who underwent transurethral resection of the prostate (TURP) or percutaneous nephrolithotripsy (PNL). AMP was administered within 72 h in TURP and PNL, and AMP was administered within 48 h in contaminated surgery cases. In cases of endourological surgery, UTI was observed in 4% and RI in 0%, and SSI, UTI, and RI were seen in 1%, 1%, and 1%, respectively, of clean surgery cases, in 3%, 3%, and 2%, respectively, of clean-contaminated surgery cases, and in 17%, 30%, and 10%, respectively, of contaminated surgery cases. In multivariate analysis of the risk factors for infection, operative time was a significant risk factor for UTI in endourological surgery, and American Society of Anesthesiologists score and operative time were significant risk factors for RI in clean surgery. No significant risk factor was found in analyses of clean-contaminated and contaminated surgery cases. A single-dose AMP regimen was shown to be effective and feasible for prevention of perioperative infection in urological surgery.

[Primitive neuroectodermal tumor of kidney : a case report].

A 16-year-old man was referred to our hospital for asymptomatic gross hematuria. The findings of abdominal ultrasonography were normal. A month later, gross hematuria disappeared, and he was not followed after that. A month later, the patient was taken to our hospital in an ambulance for severe back pain and recurring gross hematuria. Computed tomography (CT) revealed a large right renal tumor with tumor thrombus penetrating inside the inferior vena cava. The patient underwent radical nephrectomy and embolectomy. The pathological diagnosis of the tumor was diagnosed as primitive neuroectodermal tumor (PNET) of kidney by immunostaining and gene analysis. We started adjuvant chemotherapy soon after the operation. However, at 10 months after, multiple pulmonary metastases were detected. The patient was treated with salvage chemotherapy, surgery and irradiation therapy as combined modality therapy. Nevertheless, he died 18 months after the diagnosis.

Thermodynamic control of asymmetric amplification in amino acid catalysis.

Ever since Pasteur noticed that tartrate crystals exist in two non-superimposable forms that are mirror images of one another--as are left and right hands--the phenomenon of chirality has intrigued scientists. On the molecular level, chirality often has a profound impact on recognition and interaction events and is thus important to biochemistry and pharmacology. In chemical synthesis, much effort has been directed towards developing asymmetric synthesis strategies that yield product molecules with a significant excess of either the left-handed or right-handed enantiomer. This is usually achieved by making use of chiral auxiliaries or catalysts that influence the course of a reaction, with the enantiomeric excess (ee) of the product linearly related to the ee of the auxiliary or catalyst used. In recent years, however, an increasing number of asymmetric reactions have been documented where this relationship is nonlinear, an effect that can lead to asymmetric amplification. Theoretical models have long suggested that autocatalytic processes can result in kinetically controlled asymmetric amplification, a prediction that has now been verified experimentally and rationalized mechanistically for an autocatalytic alkylation reaction. Here we show an alternative mechanism that gives rise to asymmetric amplification based on the equilibrium solid-liquid phase behaviour of amino acids in solution. This amplification mechanism is robust and can operate in aqueous systems, making it an appealing proposition for explaining one of the most tantalizing examples of asymmetric amplification-the development of high enantiomeric excess in biomolecules from a presumably racemic prebiotic world.

Echocardiographic assessment of the effects of mitral valve repair on mitral valve geometry in rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: While mitral valve replacement is generally considered as the standard surgical treatment for rheumatic mitral stenosis (MS), mitral valve repair may be an alternative therapeutic option. Several techniques have been used to overcome the anatomic difficulties involved in the repair of a rheumatic mitral valve. In the present study, quantitative echocardiography was used to investigate the effects of mitral valve repair and the influence of surgical procedures on mitral valve geometry in patients with rheumatic MS. METHODS: Mitral valve repair was successfully performed in seven patients with MS, by the same surgeon. Ring annuloplasty and slicing of the anterior mitral leaflet (AML) were performed in all patients. Concomitant surgical techniques included commissurotomy, decalcification, chordal resection, and division of the papillary muscles. The preoperative and postoperative echocardiographic findings in these patients were compared. RESULTS: The thickness of both the AML and posterior mitral leaflet (PML) (p = 0.01 for both), the opening angles of the AML (p = 0.02) and PML (p = 0.01), and the closing angle of the PML, the extent of calcification in the AML, and the pressure half-time (PHT) (p = 0.03 for all three parameters) were all significantly improved after mitral valve repair. CONCLUSION: In the present study, the transmitral peak velocity and mean pressure gradient were not significantly changed after mitral valve repair, whereas the PHT showed a marked improvement. Hence, the PHT may represent a suitable marker for evaluating the efficacy of mitral valve repair for MS.

A mechanistic rationalization of unusual kinetic behavior in proline-mediated C-O and C-N bond-forming reactions.

Kinetic evidence supports the role of the reaction product in the catalytic cycle of proline-mediated alpha-aminoxylation and alpha-amination reactions, providing both design principles as well as a model for the evolution of efficiency in catalysis.

[Squamous cell carcinoma of the bladder presenting with bladder rupture: a case report].

A 71-year-old woman with pan-peritonitis was transferred to our hospital. Imaging studies showed the extravasation of contrast medium from the bladder to the intraperitoneal cavity, the right non-visualizing kidney and the left hydronephrosis. Cystoscopy revealed bladder stones and a fistula at the posterior wall of the bladder. A histological examination of specimen around the fistula revealed squamous cell carcinoma(SCC) with stromal invasion. Symptoms of peritonitis subsided following the placement of bilateral ureteral catheters and a urethral catheter. Because a laparotomy revealed peritonitis-carcinomatosa, she underwent bilateral ureterocutaneostomies, the removal of the bladder stones and the primary closure of the fistula. She died on the 42nd day after surgery.

[Clinical review of conservative management of upper urinary tract transitional cell carcinoma].

We reviewed 18 patients with transitional cell carcinoma of the renal pelvis and ureter undergoing nephron-sparing surgery between April 1990 and Febrary 2003. The mean age of the patients, 17 males and one female, was 69 years (range 33-88 years). The tumor site was the renal pelvis in 2, ureter in 13 and ureteral orfice in 2. Six of them were imperative cases and 12 were elective. Eight patients underwent endourological treatment and 10 patients open surgery including partial ureterectomy performed on 8 patient. The follow up period was 3 to 104 months (mean 37 months). Among those defined as imperative, the histopathological stage was pT1 in one, pT2 in one, pT3 in 3 and one in pT4. Among the elective cases, the histopathological stage was pTa in 7, pT1 in 2, pT2 in one, pT3 in 2 patients. Of the three defired as elective with tumors cT2 or higher, two died of disease. The 5-year survival rate was 50% and 68% in the imperative and elective cases, respectively. In the patients with tumors pT2 or higher and/or grade 3, the prognosis was poor which suggests the need for intensive therapy including lymph node dissection and/or adjuvant chemotherapy. It is necessary to consider the possibility of selecting nephron-sparing surgery for locally advanced tumors.

[Laparoscopic radical nephrectomy for renal cell carcinoma at Kobe City General Hospital].

Between April 2002 and March 2004, 21 patients with clinical T1-T3a renal cell carcinoma underwent laparoscopic radical nephrectomy at the Kobe City General Hospital. A transperitoneal approach was chosen in 9 patients with clinical T2 stage, tumors more than 5 cm in diameter at the upper pole of the kidney, and posteriorly protruded tumors at the middle portion. Otherwise, a retroperitoneal approach was chosen in 12 patients. The mean (range) operative time for the transperitonal and retroperitoneal approaches was 355 (290-410) min and 342 (275-490) min, respectively. There were no major intraoperative complications. Postoperatively, one patient underwent emergency operation due to the perforation of duodenal ulcer. In the mean follow-up of 15.9 months, lung metastasis was seen in one patient under adjuvant immunotherapy. Significant differences between transperitoneal and retroperitoneal approaches were seen in mean time to renal artery clipping (170 versus 85 min, p < 0.01), mean blood loss (548 versus 281 ml, p < 0.05) and concurrent adrenalectomy (66.7 versus 16.7%, p < 0.05). Laparoscopic radical nephrectomy is a safe and feasible procedure when suitable approaches are chosen depending on tumor size and location.

[Retroperitoneoscopic partial nephrectomy for renal cell carcinoma: our initial experience and review of the literature].

PURPOSE: We report our initial experiences of retroperitoneoscopic partial nephrectomy for renal cell carcinoma. MATERIALS AND METHODS: From April 2002 to October 2003, we performed 11 retroperitoneoscopic partial nephrectomy for renal cell carcinoma. Our indication was T1N0M0 renal tumors which sizes were about 4 cm or less and were exophytic and were not situated at the renal hilum. First we inserted single J catheter to the renal pelvis cystoscopically. under fluoroscopic guidance. Next 4 trocars were set at pneumoretroperitoneum and the renal artery and vein were clamped individually after cold saline was circulated from the single J catheter. Renal parenchyma was sharply cut with scissors and vessels were coagulated with bipolar coagulator. When renal collecting system was opened, cariceal suture repair was performed. We used the microwave tissue coagulator without clamping the renal pedicle when the tumor was 2 cm or less in diameter and the distance from the tumor edge to the renal collecting system was more than 1cm. RESULTS: In 9 cases renal pedicles were clamped and in 2 cases were not. Mean tumor size was 27.5 +/- 8.9 mm and mean operative time was 350 +/- 92 minutes and mean estimated blood loss was 743 +/- 998 ml, and mean warm ischemic time was 70 +/- 30 minutes. In one case bleeding from cut surface was uncontrollable, so open conversion was needed. In this case the renal artery and vein were clamed but another artery exited. The surgical margins were all negative, and no other complications were happened. Post operative serum creatinine raised soon after the operation but finally downed, and the mean up level was 0.07 ng/ml only. But RI examination revealed the residual renal damages were in proportioned to the warm ischemic times. During a mean followup of 8 months no patients has had local recurrence or metastatic disease. CONCLUSIONS: Retroperitoneoscopic partial nephrectomy for renal cell carcinoma is effective for select patients. But better cooling method and earlier suture technique and more long follow-up periods will be necessary for establishment.

[Mixed epithelial and stromal tumor growing with polypoid pattern in the renal pelvis].

A 68-year-old woman was found incidentally to have right hydronephrosis and a renal pelvic mass by abdominal ultrasonography. Radiographic examinations revealed a heterogeneous renal pelvic tumor, and right nephroureterectomy was performed. The tumor was well circumscribed yellow-whitish solid mass with scattered cysts. Histologically, the tumor was composed of both mesenchymal and epithelial components. The mesenchymal elements consisted of fibroblasts and smooth muscle cells, and the epithelial elements of cystic and tubular structures lined by cuboidal epithelium. Atypia and mitoses were not identified. The patient was free of recurrence 42 months postoperatively. Mixed epithelial and stromal tumor of the kidney is a recently recognized neoplasm that occurs almost exclusively in perimenopausal woman. Similar tumors have been reported previously under various names, including adult mesoblastic nephroma and cystic hamartoma of the renal pelvis. Histogenesis of the tumor is still controversial.

[Change of serum adrenal androgens in prostatic cancer patients after bilateral orchidectomy or LHRH agonist treatment].

Bilateral orchidectomy (ORX) or administration of luteinizing hormone releasing hormone agonist (LHRH) for prostatic cancer patients causes suppression of testicular androgens. However, the suppression of adrenal androgens by these treatments is controversial. We measured serum concentrations of testosterone (T), 4-androstene-3, 17-dione (A-dione), dehydroepiandrosterone (DHEA), LH, follicle-stimulating hormone (FSH), adrenocorticotropic hormone (ACTH) and cortisol before and after 3-12 months of the first hormonal treatment in 17 prostatic cancer patients who had received ORX (8 cases) or LHRH (9 cases). ORX and LHRH decreased serum T to the castration level significantly (ORX: p < 0.001, LHRH: p < 0.0001). ORX increased serum LH and FSH significantly (LH: p < 0.001, FSH: p < 0.001), whereas LHRH decreased LH and FSH significantly (LH: p < 0.05, FSH: p < 0.05). Neither treatment caused any significant change in ACTH or cortisol. ORX and LHRH decreased the serum A-dione significantly (ORX: p < 0.01, LHRH: p < 0.001). LHRH decreased the serum DHEA significantly (p < 0.01), whereas ORX did not decrease serum DHEA. These data suggest that "medical" and "surgical" castration, especially LHRH agonist, may decrease not only testicular androgens but also adrenal androgens.

Reconsiderations of mitral stenosis: rheumatic mitral valve repair and the Wilkins score.

BACKGROUND: Mitral valve repair is a feasible treatment option in patients with rheumatic mitral valve disease, but it is not always successful. Mitral valve replacement is generally the surgical treatment of choice in such patients. We aimed to examine whether the Wilkins score can predict the feasibility of surgical repair in such patients. METHODS: Mitral valve surgery was performed on 14 patients by the same surgeon (A.A.). Five patients underwent mitral valve repair (group I), and nine patients underwent mitral valve replacement (group II). The Wilkins scores were determined by assessing echocardiography findings. The selection of mitral valve repair or replacement was based on the intraoperative findings and the preferences of the same surgeon (A.A.). In group I, we performed chordal reconstruction, augmentation of the posterior leaflet, resection of chordae, decalcification of the commissure, commissurotomy, slicing of the anterior leaflet, division of the papillary muscle, and ring annuloplasty in various combinations. RESULTS: There were no significant differences between the two groups with regard to any component of the preoperative Wilkins score. There was no significant difference in the pre- and postoperative scores in group I; however, the mitral valve orifice area was significantly improved after the operation (pre- and postoperative mean values: 1.3 ± 0.3 and 2.0 ± 0.4, P < 0.05). CONCLUSION: Mitral valve repair is effective in treating rheumatic mitral stenosis. However, the Wilkins score may not be useful in predicting the feasibility of mitral repair.

Metabolic syndrome is an independent risk factor for stroke and acute renal failure after coronary artery bypass grafting.

OBJECTIVES: Metabolic syndrome is common among patients having coronary artery bypass grafting. However, it remains unclear whether it has a significant impact on postoperative complications. We aimed to determine whether metabolic syndrome negatively influences the postoperative outcomes of coronary artery bypass grafting. METHODS: We enrolled 1183 patients who had coronary artery bypass grafting at Juntendo University Hospital between 1984 and 1992. Patients were categorized by the presence or absence of metabolic syndrome using the modified National Cholesterol Education Program Adult Treatment Panel III definition with body mass index in the place of waist circumference. Multivariate analysis was performed to assess the relationships between preoperative presence of metabolic syndrome and postoperative outcomes. RESULTS: Metabolic syndrome was present in 551 (46.6%) patients and absent in 632 (53.4%). Postoperative stroke occurred in 4.7% of patients with metabolic syndrome and 2.1% of patients without metabolic syndrome (P < .0001). Postoperative acute renal failure occurred in 3.8% of patients with metabolic syndrome and 1.1% of patients without metabolic syndrome. On multivariate analysis, metabolic syndrome had odds ratios of 2.47 (95% confidence interval 1.22-4.99; P = .012) for postoperative stroke and 3.81 (95% confidence interval 1.42-10.3; P = .008) for postoperative acute renal failure. CONCLUSIONS: This study showed the clinical importance of metabolic syndrome with respect to postoperative stroke and acute renal failure in patients having coronary artery bypass grafting. Like many established risk factors for postoperative complications, metabolic syndrome should be recognized as a novel risk factor for adverse events.