[Two Cases of Unilateral Multifocal Renal Cell Carcinoma Treated with Robot-Assisted Partial Nephrectomy].

Recently, robot-assisted laparoscopic partial nephrectomy (RAPN) has become a commonly performed surgical treatment for small renal tumors, but for difficult cases, such as those presenting with multiple tumors, there are few institutions with experience. We herein report two cases of unilateral multifocal renal cell carcinoma that were successfully treated with RAPN. Case 1: A 65-year-oldwoman was incidentally identified to have two right kidney tumors on imaging. RAPN under cold ischemia was performed. Pathological examinations revealed both tumors to be clear cell carcinoma. Case 2: A 56-year-oldman was incidentally found to have two left kidney tumors on imaging. RAPN under zero-ischemia and warm ischemia was performed. Pathological examinations revealed both tumors to be clear cell carcinoma. In both cases, no recurrence has been observed, and the decrease that occurred in the renal function was mild during the one-and-a half year follow-up.

[Treatment of Parastomal Hernia Following Robot-Assisted Radical Cystectomy and Cutaneous Ureterostomy : A Case Report].

The patient was an 82-year-old woman with localized muscle-invasive bladder cancer, who underwent robot-assisted radical cystectomy and cutaneous ureterostomy. On the 3rd day after the operation, she suddenly complained of abdominal pain. Abdominal computed tomographic scans revealed parastomal hernia. The patient underwent manual reduction of hernia, but had repeated recurrences of parastomal hernia within a few days. On the 14th day we performed a laparoscopic hernia repair. Observation of the stoma site revealed a laceration of the peritoneum and fascia, and the small intestine was prolapsed. We pulled the small intestine out and ligated the laceration with Mediflex® Suture Grasper Closure Device. After re-operation, there was no recurrence of bladder cancer and parastomal hernia, and the stoma appliances could be put on without any trouble.

[A Case of Robotic-Assisted Surgery for Simultaneous Triple Cancer of Rectum, Bladder, and Prostate].

The patient was a 70s man, whose chief complaint of Hematochezia. He visited neighborhood hospital and was diagnosed with lower rectal cancer by colonoscopy. Preoperative CT showed a mass in the bladder, which led to a diagnosis of multiple early stage bladder cancer after a thorough urological examination. We diagnosed that very low anterior resection was necessary for rectal cancer and total bladder resection was necessary for bladder cancer. The patient underwent robotic- assisted total pelvic exenteration with anal preservation. One year and three months have passed since the surgery, and no signs of recurrence have been observed.

[A Case of Sigmoid Colon Cancer with Bladder Invasion That Could Be Treated with Neoadjuvant Chemotherapy to Preserve the Bladder].

The patient was male, 50s. He visited his local doctor with complaints of hematochezia and hematuria. He underwent colonoscopy, which revealed a circumferential lesion in the sigmoid colon, and he was referred to our department for further examination and treatment. A urinalysis at the time of admission revealed leukocytes(3+)and bacteria(2+), suggesting that the sigmoid colon cancer was invading the bladder. The urologist performed cystoscopy, which showed internal invasion of the bladder, and at this point, including the CT findings, it was needed that a combined bladder resection was necessary. We decided to undergo neoadjuvant chemotherapy(NAC)with the possibility of bladder preservation. FOLFOXIRI plus bevacizumab was selected as the regimen, and a total of 6 courses were performed. After NAC, the effect was judged PR. The patient underwent laparoscopy-assisted resection of the sigmoid colon and partial resection of the bladder wall. The pathological diagnosis was ypStage Ⅱc. Postoperatively, the patient received 6 courses of FOLFOX as adjuvant chemotherapy. Currently, about 8 months after surgery, no recurrence has been observed.

[A Case of IgG4-Related Disease Diagnosed by Prostate Biopsy].

A 74 year-old man presented with complaints of dysuria and miction pain. Since the prostate volume was 43.5 ml, the patient was scheduled for surgical treatment of benign prostatic hyperplasia. However, prostate cancer was suspected from the magnetic resonance imaging findings and a prostate biopsy was performed. No malignant findings were observed in the pathological results, but numerous plasma cells stained positive for IgG4. Abdominal computed tomography showed pancreatic head enlargement with surrounding inflammatory changes and elevated serum IgG4 was also observed. The patient was diagnosed with IgG4-related disease (pancreatitis/prostatitis). Dysuria improved with induction of 30 mg prednisolone. The patient no longer needed to take the α1 blocker and 5α reductase inhibitor. The international prostate symptom score and urine flow measurement indicated that the patient remained in good condition at 18 months since the start of treatment.

[Two Cases of Urethral Clear Cell Adenocarcinoma with Suspected Recurrence of Uterine Cancer].

Herein, we report two cases of urethral clear cell carcinoma in two patients who had previously undergone radical hysterectomyfor utetine cancer. Case 1 presented with bloodyvaginal discharge and case 2 presented with acute urinaryretention. Magnetic resonance imaging revealed a periurethral tumor in both cases. Both cases were suspected to be recurrence at first. However, pathological findings of the transurethral resection-biopsyshowed clear cell adenocarcinoma in both cases. Subsequentlyradical cystourethrectomy and pelvic lymphadenectomy were performed in both cases. Surgical findings showed tumor invasion of the vaginal muscularis in case 1 and invasion of the anterior wall of the vagina and bladder neck in case 2. Although adjuvant postoperative therapywas not performed, there has been no evidence of recurrence to date.

[Clinical Outcome of Laparoscopic Partial Nephrectomy].

The purpose of this study was to evaluate the safety and feasibility of laparoscopic partial nephrectomy with a small renal tumor. Between September 2004 and October 2014, 69 patients who underwent laparoscopic partial nephrectomy in Kansai Rosai Hospial were examined. The mean patient age was 60.3 years, and the mean tumor size was 24.5 mm. The mean estimated blood loss was 111 cc. The mean cold ischemic time was 59.7 minutes, and the mean warm ischemic time was 31.3 minutes. There were 5 complications : intraoperative ureteral injury, blood transfusion, postoperative perinephric hematoma, portsite bleeding, urinary fistula, respectively. All of the cases were cured with non-surgical treatment except ureteral injury which was repaired intraoperatively. The postoperative eGFR loss was 11%. At present, no patients have developed local recurrence or distant metastasis. The initial outcome of laparoscopic partial nephrectomy in our hospital was satisfactory in terms of safety, renal function and cancer control.

Post-chemotherapy nerve-sparing laparoscopic retroperitoneal lymph node dissection in stage IIB testicular cancer.

We report our experience of extraperitoneal nerve-sparing laparoscopic retroperitoneal lymph node dissection after chemotherapy. Six patients were diagnosed with non-seminomatous germ cell tumor after orchiectomy and clinical stage IIB disease. Nerve-sparing laparoscopic retroperitoneal lymph node dissection was carried out for residual retroperitoneal tumors after cisplatin-based chemotherapy. The median tumor diameter was 2.95 cm before chemotherapy and 1.95 cm after chemotherapy. A modified left (n=1), right (n=1) and bilateral (n=4) template for the dissection area was used. Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Median operative time was 394 min (range 212-526 min). Median blood loss was 75 mL (range 10-238 mL). The overall complication rate was 33.3% (2/6). Two patients had prolonged lymphatic leakage (grade I), which was managed conservatively. Antegrade ejaculation was preserved in all six patients. The histopathological findings showed that two patients had mature teratoma and four patients had necrotic tissue. After a median follow up of 30 months (range 24-36), no recurrence of disease was observed. We can conclude that extraperitoneal nerve-sparing laparoscopic retroperitoneal lymph node dissection for residual tumors after chemotherapy is a feasible operation. The oncological outcomes need to be confirmed in a certain number of patients with longer follow up.

[Amyloidosis of the ureter arising secondarily to the systemic lupus erythematosus : a case report].

A 55-year-old man was referred to our department with the chief complaint of left flank pain. Computed tomography and magnetic resonance imaging demonstrated a left hydronephroureter due to the ureteral stenosis with a mass. We considered the possibility of a malignant neoplasm, and performed laparoscopic left total nephroureterectomy. Microscopic appearance showed ureteral wall thickening and perivascular deposition of heterogeneous amyloid. It stained positive by immune-histochemical staining using Congo-red. In addition, it stained positive by immune-histochemical staining with an anti-AA antibody. These findings indicated that the amyloid was type AA. AA amyloidosis is a systemic amyloidosis that arises secondarily to an inflammatory disease. He had been treated for systemic lupus erythematosus. It is compatible to secondary amyloidosis. Eighty seven months after diagnosis, he died of lung cancer. There were no signs or symptoms of deposition of the AA amyloid proteins.

A case of clear cell adenocarcinoma arising from the urethral diverticulum: Utility of urinary cytology and immunohistochemistry.

Carcinomas rarely arise from the urethral diverticulum. In this report, we present a case of clear cell adenocarcinoma arising from the urethral diverticulum. A 42-year-old woman complained of bloody discharge and lower back pain. Imaging studies showed a tumor involving the region surrounding the urethra and cystourethroscopy showed papillary and villous tumors in the urethral diverticula. Cytology of the urine sediment showed papillary or spherical clusters of atypical cells, some of which had clear abundant cytoplasm and formed mirror ball-like clusters, suggesting adenocarcinoma. Although histological diagnosis was indeterminate by biopsy and transurethral resection (TUR) because of absence of stromal invasion, surgically resected specimen via cysturethrectomy revealed that the tumor was clear cell carcinoma. Urinary cytological findings and immunohistochemical analysis for CD15, Ki-67, and p53 might be useful for accurate diagnosis of clear cell adenocarcinoma that arises from the urethral diverticulum when sufficient materials are not available by biopsy and TUR.

A case of steroid-resistant cystitis as an immune-related adverse event during treatment with nivolumab for lung cancer, which was successfully treated with infliximab.

Introduction: Immune checkpoint inhibitors are widely used in various cancers as a standard treatment. However, while various immune-related adverse events related to immune checkpoint inhibitors have been reported, there are few reports of lower urinary tract symptoms. Case presentation: The patient was a 60-year-old man with primary lung cancer who was receiving long-term nivolumab therapy. He was referred to our department due to the sudden onset of glans penile pain and micturition pain. We suspected non-bacterial cystitis as an immune-related adverse event caused by nivolumab and were able to treat it by administering prednisolone. While his symptoms and findings on cystoscopy recurred during prednisolone therapy, we were able to treat him again by administering an additional dose of infliximab. Conclusion: A few reports have described cases of immune checkpoint inhibitor-induced cystitis for which prednisolone was effective. This report is the first to describe cystitis as a steroid-resistant immune-related adverse event.

Inflammatory pseudotumor of the retroperitoneum removed via a retroperitoneoscopic approach.

BACKGROUND: Inflammatory pseudotumors were mostly encountered in the lung. Retroperitoneal inflammatory pseudotumors are relatively rare. Although laparoscopic surgery with a modified flank position is widely performed for retroperitoneal tumors, we placed the patient in the supine position to maintain the normal anatomical view of the retroperitoneal space. We report a case of retroperitoneal inflammatory pseudotumor extracted via retroperitoneoscopic surgery in the supine position. METHODS AND RESULTS: A 53-year-old man presented with back pain and frequent urination. Ultrasonographic examination revealed a solid tumor above the urinary bladder. This tumor was diagnosed as a primary retroperitoneal tumor by computed tomography, magnetic resonance imaging, and angiography. The retroperitoneoscopic procedure was adopted to remove this tumor. Histopathologic examination revealed an inflammatory pseudotumor. There was no evidence of recurrence 5 years after surgery. CONCLUSIONS: The diagnosis of the inflammatory pseudotumor is rarely made before histologic examination. Only pathologic examination allows the correct diagnosis. Consequently, most patients undergo surgical treatment. A recurrence rate of 25% has been reported for inflammatory pseudotumors. Thus, radical resection is needed. The retroperitoneal laparoscopic approach with the patient in the supine position is useful for surgically treating these primary retroperitoneal tumors located below the level of the renal vessels.

[THE USE OF CT-GUIDED MARKING FOR THE LAPAROSCOPIC RESECTION OF A SOLITARY RETROPERITONEAL TUMOR].

When resecting small tumors or tumors with an irregular margin, a marking technique is conducted prior to the surgery. CT-guided marking techniques are common in pulmonary surgery, but it is rarely used in abdominal or urological surgery. We performed a marking technique for a small tumor that was undetectable by ultrasound using CT guidance prior to laparoscopic resection.A 63 year-old woman, two years after total hysterectomy for uterine stromal sarcoma, underwent combined right kidney resection and retroperitoneal tumor resection for a giant recurrence. Two months after the surgery, micro recurrence was observed in the vicinity of the right intestinal psoas muscle which upon follow up, the tumor size increased to 1 cm. Surgical resection of the small recurrent tumor was planned. Since it was difficult to detect by ultrasound, preoperative CT-guided marking was performed. Retroperitoneal laparoscopic resection was performed the following day. The histopathological diagnosis was endometrial stromal sarcoma.

Laparoscopic adrenalectomy: troublesome cases.

Among 143 cases of laparoscopic adrenalectomy carried out from 1993 to the present, 13 patients in whom the surgical manipulation presented problems were examined. Problems occurred due to the condition of the adrenal tumors themselves in six patients, whereas problems occurred due to the operative history in four patients. There were three patients with no operative history but with strong intraperitoneal adhesion. In patients with a history of laparotomy in other fields such as open cholecystectomy, gastrectomy or colostomy, operations were possible in most patients by examining the trocar site preoperatively. Patients with strong adhesion even without a history of surgery could be handled by full separation of the adhesion during surgery. In patients with bleeding in the adrenal tumors, large adrenal tumors, or tumors impacted in the liver, methods such as changing the sequence of separation procedures were required. In patients with a history of renal subcapsular hematomas due to extracorporeal shock wave lithotripsy (ESWL), it was not possible to understand the conditions of adrenal or perinephritic adhesion in preoperative imaging diagnosis, but resection was possible by changing the order of separation procedures and by using optimal instruments and devices. As with any surgery, including open surgeries, it is necessary to obtain knowledge on how to deal with variations in laparoscopic adrenalectomy to assure safe outcomes and to always consider effective methods for coping with unexpected difficulties.

How to use laparoscopic surgical instruments safely.

The development of laparoscopic surgery has been accompanied by a rapid increase in the number of laparoscopic surgical procedures carried out in the field of urology. In 2002 laparoscopic nephrectomy was approved for coverage under Japanese national health insurance, and in 2003 there were over 1000 registered cases in which this procedure was carried out. This suggests that laparoscopic nephrectomy, a procedure formerly conducted at only a few institutions, is now spreading to hospitals across Japan. Laparoscopic surgery involves the use of specialized instruments within a restricted field of vision, and risky surgical techniques can potentially result in visceral or vascular damage. In order to promote the use of safe laparoscopic surgery procedures, the Japanese Urological Association and the Japanese Society of Endourology and Extracorporeal Shock Wave Lithotripsy (ESWL) have inaugurated a certification program for urologic laparoscopy. This program not only encourages development in this field of surgery and provides technical certification to ensure appropriate levels of expertise, but also reviews methods for the correct use of instruments such as trocars and hemostats. The purpose of this video is to present correct methods for the use of a variety of laparoscopic instruments, in order to increase the safety of this procedure. The video has been designed to be useful not only for practitioners who are just beginning laparoscopy, but also for those who already have extensive laparoscopic experience. The video discusses five laparoscopic instruments (trocar, electric surgical devices, ultrasonic surgery devices, clips and clip appliers and endo-staplers), and demonstrates their correct use. In addition, animal models are used to illustrate the potential complications that can be associated with some methods of use.

The Use of CT-Guided Marking for the Laparoscopic Resection of a Solitary Retroperitoneal Metastasis of Colon Cancer.

Background: CT-guided marking technique is rarely used in abdominal or urologic surgery. We developed and performed a marking technique for a small tumor, undetectable by ultrasound, using CT guidance before laparoscopic resection of the tumor. Case Presentation: A 73-year-old woman with a history of breast cancer underwent right colectomy with D3 lymph node dissection for ascending colon cancer. Five years after the operation, a solitary tumor was found in the right pararenal region of the retroperitoneal space on enhanced abdominal CT. The tumor was 20 mm in diameter and undetectable by ultrasound, so we performed a marking technique using CT guidance before the operation. Placing the patient in a prone position on the CT table, a 22-gauge needle was inserted into the Gerota's fascia percutaneously and a mixed fluid containing India ink and Iopamidol was injected para to the tumor by the radiologist. During the surgery, the marker was clearly identified and the cutting line was determined to ensure a sufficient surgical margin. The tumor was laparoscopically resected as planned. The histopathologic diagnosis was adenocarcinoma, compatible with metastasis of colon cancer. The postoperative course was uneventful and the patient remained free of disease at 10 months after surgery. Conclusion: When resecting small tumors or tumors with an irregular margin, a marking technique is conducted before the surgery. But, preoperative CT-guided marking has not been applied generally for resection of intraabdominal lesion yet. CT-guided marking can be effective when performing minimally invasive and curable surgery on small tumors. This is the first report of an effective CT-guided marking before retroperitoneal laparoscopic tumorectomy. We believe that this technique provides an important therapeutic option for small tumors that may be undetectable by ultrasound.

Malignant pheochromocytoma with IVC thrombus.

A 61-year-old man presented with feeling of bloating, remarkable sweating, and body weight loss. We diagnosed right pheochromocytoma with inferior vena cava (IVC) thrombus by some plasma and urine catecholamine and their metabolites data and imaging findings. The patient underwent right adrenalectomy and IVC thrombectomy without use of cardiopulmonary bypass. Pathological finding showed potentially malignant pheochromocytoma. After operation, his subjective symptom disappeared, and abnormal plasma and urine catecholamine and their metabolites data fell to normal range. It is very important to get preoperative information of the exact location of tumor thrombus for the safe surgical management of pheochromocytoma with IVC thrombus. Magnetic resonance imaging (MRI) and ultrasound imaging more useful for diagnosis of the exact location of IVC thrombus.

[Laparoscopic pyeloplasty for ureteropelvic junction obstruction].

PURPOSE: We performed laparoscopic pyeloplasty in 11 patients with ureteropelvic junction (UPJ) obstruction and evaluated the clinical outcomes of this surgery. MATERIALS AND METHODS: Between August 2001 and February 2004, 11 patients with UPJ obstruction underwent laparoscopic pyeloplasty in our institute. In all patients, symptoms were presented and UPJ obstruction was confirmed by radiographic examinations. Ten patients had primary obstruction, while one patient had secondary obstruction. Retroperitoneal approach was applied in all but one patient who needed intraperitoneal approach due to secondary obstruction. We performed Anderson-Hynes dismembered pyeloplasty, Hellström technique and Fenger plasty in 8, 2 and 1 patient, respectively. Nephropexy was performed in 2 patients with nephroptosis, and isthmusectomy was performed in 1 patient with horseshoe kidney, simultaneously. RESULTS: The mean operative time was 312 minutes (210-371) and the mean blood loss (including urine) was 75 ml. No blood transfusion was required, and all procedures were performed safely. Crossing vessels were found in 5 patients (45%). Pyelonephritis was the only postoperative complication, managed by the administration of antibiotics. Symptoms were disappeared without recurrences in all patients at mean follow up time of 18 months (6-36). ( CONCLUSION: Although the number of cases was small with relatively short follow up period, the clinical outcomes of laparoscopic pyeloplasty in our institute were almost satisfied, as previously reported by other investigators. Laparoscopic pyeloplasty might be one of the standard treatments for patients with UPJ obstruction, although we should carefully consider about indication, approach and operation method.

[Inflammatory pseudotumor of the urinary bladder diagnosed using 3D-CT cystoscopy].

Inflammatory pseudotumor of the urinary bladder is a rare benign entity of the submucosal stroma that can easily be mistaken for a malignant neoplasm both clinically and histologically. We report a case of an inflammatory pseudotumor of the urinary bladder in which 3D-CT cystoscopy aided in the diagnosis. A 38-year-old man presented with persistent miction pain, penile pain, and dysuria despite symptomatic treatment at another hospital. Cystoscopic examination, MRI and 3D-CT cystoscopy revealed a 3.0 X 3.0 cm wide-based nonpapillary tumor located at the anterior dome of the urinary bladder. Transabdominal biopsy and transurethral resection were performed and the tumor was suspected to be transitional cell carcinoma. A partial cystectomy and urachus excision were then performed for suspected urachal tumor based upon the radiological examinations. Careful examination of the specimen revealed an inflammatory pseudotumor. We discuss 20 cases of inflammatory pseudotumor of the urinary bladder including ours.

[Laparoscopic pyeloplasty for a secondary ureteropelvic junction obstruction after renal trauma: a case report].

We report a case of secondary ureteropelvic junction obstruction due to renal trauma treated by laparoscopic pyeloplasty. A 25-year-old man, who had renal trauma due to a traffic accident, complained of left lumbago and was diagnosed with left ureteropelvic junction obstruction. Endoscopic balloon dilation was performed twice, but the hydronephrosis did not change. Subsequently, laparoscopic pyeloplasty was performed with no complications. After operation, lumbago disappeared and hydronephrosis and renal function improved. Secondary ureteropelvic junction obstruction is rare, and this case seems to be the first case managed by laparoscopy in Japan.