Prepubertal testicular tumors: a 20-year experience with 40 cases.

Testicular tumors are rare in children. In addition, prepubertal testicular tumors (PTT) are fundamentally different from their postpubertal counterparts.We reviewed our 20-year experience with 40 cases to suggest an algorithm for the appropriate surgical approach for patients with PTT. All tumors ultrasonographically suspected of being benign were confirmed to be benign postoperatively. There was a significant difference between median preoperative a-fetoprotein (AFP) levels of infants with yolk sac tumor and teratoma. The majority of our cases were benign, with the most common histopathological subtype being teratoma, as recently reported. Testis-sparing surgery was carried out in five patients with teratoma and three patients with epidermoid cyst. Other than one patient with teratoma, none of the patients developed recurrence or testicular atrophy after testis-sparing surgery. When testis-sparing surgery is considered, our algorithm based on ultrasonographic findings and preoperative AFP levels might be helpful.

AST-120 treatment in pre-dialysis period affects the prognosis in patients on hemodialysis.

BACKGROUND/AIMS: An oral adsorbent, AST-120, has been shown to retard the deterioration of renal function in patients with chronic kidney disease (CKD) by decreasing serum nephrotoxic substances such as indoxyl sulfate. Recent studies have suggested that a high level of serum indoxyl sulfate may be one of the mechanisms underlying the progression of atherosclerotic lesion, which is the leading cause of cardiovascular event or death in dialysis patients. In this study, we examined retrospectively whether AST-120 given to patients in the pre-dialysis period influences the prognosis after the initiation of dialysis. METHODS: One hundred and ninety-two CKD patients on dialysis were studied. The survival and causes of death after the initiation of dialysis were compared between patients who were administrated AST-120 (AST-120 group, n = 101) and those not administrated AST-120 (non-AST-120 group, n = 91) prior to the initiation of dialysis. RESULTS: The five-year survival rate was 72.6% in the AST-120 group and 52.6% in the non-AST-120 group, and was significantly higher in the AST-120 group (p = 0.018). The risk of death was increased 1.91-fold in the non-AST-120 group. However, no difference in the causes of death was observed between two groups. CONCLUSION: This study suggests that AST-120 given prior to the initiation of dialysis improves the prognosis of CKD patients under dialysis, although there is no association between AST-120 treatment and death caused by cardiovascular diseases such as heart failure, myocardial infarction, and cerebral hemorrhage. Further studies are needed to elucidate the effect of AST-120 on cardiovascular events and the prognosis in dialysis patients.

AST-120, an oral adsorbent, delays the initiation of dialysis in patients with chronic kidney diseases.

The effects of an oral adsorbent, AST-120, in chronic kidney disease (CKD) patients was evaluated by the 24-month dialysis-free rate and 50% dialysis-free period. This study retrospectively analyzed 193 patients admitted to the Osaka Medical College Hospital between January 1994 and December 2001 because of CKD and who later started dialysis. The propensity score on multiple factors was used to match two groups of patients (AST-120 group, n = 78; non-AST-120 group, n = 78). Then, the proportion of patients remaining dialysis-free and the 50% dialysis-free period during the 24 months after starting treatment with or without AST-120 were analyzed. The impact of AST-120 on the risk of dialysis initiation was also determined by multivariate analysis. There were no significant differences in the clinical background and laboratory values after matching the two groups using the propensity score. The 50% dialysis-free period was significantly prolonged in the AST-120 group compared to the non-AST-120 group for all patients analyzed, as well as for the subgroup with diabetic or non-diabetic renal disease. When AST-120 treatment was started at a serum creatinine level below 3 mg/dL, the dialysis-free period was longer than 24 months in the AST-120 group, compared with 16.2 months in the non-AST-120 group. The 24-month dialysis-free rate was higher in the AST-120 group in every patient category. The risk of dialysis initiation was increased 3.48-fold in patients who were not administered AST-120. These results show that AST-120 delays the initiation of dialysis in CKD patients. Thus, AST-120 is an effective supplementary therapy to prevent the initiation of dialysis in CKD patients.

[Individualized treatment of undescended testis].

Undescended testis is one of the most common congenital anomalies requiring surgery. The guideline for the treatment of undescended testis was published by Japanese Society of Pediatric Urology in 2005. However, the management of undescended testis has been still controversial, particularly in case of impalpable testis including abdominal testis. In this article, we review our experience and published reports of orchiopexy for undescended testis and emphasize that the anatomical condition of undescended testis should be applied to individualized surgical treatment.

[Ureter cancer of complete double renal pelvis and ureter: a case report].

A 66-year-old man presented at our hospital with left back pain. Intravenous pyelography, computerized tomography and magnetic resonance imaging revealed ureteral tumors of the complete left double renal pelvis and the ureter. An endoscopic examination disclosed a papillary tumor from the left ureteral orifice of the lower pole of the kidney. A transurethral resection of the tumor was done, and the pathological features revealed transitional cell carcinoma (PTa, grade 2). A left nephroureterectomy and a partial cystectomy were also carried out; macroscopic examinations showed a non-papillary tumor on the middle portion of the left ureter originating from the upper pole of the kidney. Microscopic examinations revealed transitional cell carcinoma (PT3, grade 3, PL1, PV1). Adjuvant chemotherapy (M-VAC) was administered but discontinued because of severe side effects. Dispite recurrence with retro-peritoneal lymph node metastasis, the patient is alive and again undergoing M-VAC chemotherapy 22 months after the initial surgery. However, the evaluation of the chemotherapy was "no change".

Effect of a novel bladder preservation therapy, BOAI-CDDP-radiation (OMC-regimen).

We have developed a novel form of bladder preservation therapy [OMC (Osaka Medical College)-regimen] involving balloon-occluded-arterial-infusion (BOAI) of an anticancer agent (cisplatin/gemcitabine), used concomitantly with hemodialysis, which delivers an extremely high concentration of anticancer agent to the site of a tumor without systemic adverse effects, along with concurrent radiation. We previously reported that the OMC-regimen elicited a complete response (CR) in >90% of patients with organ confined tumors, while LN(+), T4 tumors and a non-UC histological type were statistically significant risk factors for treatment failure and patient survival. In this study, we investigated the effects of the OMC-regimen in patients with organ confined urothelial cancer tumors and the outcomes were compared to those with total cystectomy. Three hundred and one patients were assigned to receive either the OMC-regimen (n=162) or total cystectomy (n=139). Patients in the OMC-regimen group who failed to achieve CR underwent cystectomy, or secondary BOAI with an increased amount of CDDP or gemcitabine (1600 mg). The OMC-regimen yielded 98.1% of clinical response; CR in 93.8% (152/162) of patients; PR in 4.3% (7/162). More than 96% of the CR patients (146/152) were alive with no evidence of recurrence after a mean follow-up of 166 (range 23-960) weeks. No patients suffered grade III toxicity; all patients successfully completed this therapy. The patient survival was significantly better compared to the cystectomy group; the overall 5-, 10- and 15-year survival rates were 87.3, 79.6 and 59.7%, respectively. Moreover, the 5-, 10- and 15-year bladder intact survival rates, the most important issue for bladder preservation therapy, were 85.7, 78.4 and 58.8%, respectively. In conclusion, the OMC-regimen is a useful bladder-preservation strategy, not only in those for whom cystectomy is indicated, but also in patients whose condition is not amenable to curative treatment and for whom palliation would otherwise seem the only option.

A great option for elderly patients with locally invasive bladder cancer, BOAI-CDDP-radiation (OMC regimen).

We have developed a novel bladder preservation therapy, balloon-occluded arterial infusion (BOAI) of cisplatin/gemcitabine, concomitantly with hemodialysis, along with concurrent irradiation [the so-called 'OMC (Osaka Medical College) regimen']. The OMC regimen delivers an extremely high concentration of anticancer agent to the site of a tumor without systemic adverse effects, since more than 95% of free Pt was efficiently eliminated by hemodialysis, which enables short hospital stay. In this study, we investigated the efficiency of OMC regimen in patients aged over 70 years with muscle-invasive bladder cancer without metastasis. A total of 134 such patients were assigned to receive either the OMC regimen (n=89) or cystectomy (n=45). OMC regimen patients who failed to achieve CR underwent cystectomy, or secondary BOAI with gemcitabine (1,600 mg). The OMC regimen, which delivers an extremely high concentration of anticancer agent to the tumor site without systemic adverse effects, yielded CR in >91% (81/89) of patients. More than 96% (78/81) of the CR patients survived without recurrence with intact bladder after a mean follow-up of 164 (range 16-818) weeks. The 5- and 10-year bladder intact survival rates were 87.2 and 69.8%, and overall survival rates were 88.4 and 70.7% (vs. 59.9 and 33.3% for cystectomy, p=0.0002), respectively, although the median age in the OMC regimen group was significantly greater than in the cystectomy group (median, range = 77, 70-98 vs. 74, 70-89; p=0.0003). No patients suffered grade II or more severe toxicities; the oldest patient, aged 91 years, successfully completed this therapy. In conclusion, the OMC regimen is a useful bladder preservation strategy for elderly patients with locally invasive bladder cancer, not only in those for whom cystectomy is indicated, but also in patients whose condition is not amenable to curative treatment and for whom palliation would otherwise seem the only option.

Nephrectomy and upper pole heminephrectomy for poorly functioning kidney: Is total ureterectomy necessary?

OBJECTIVE: We analyzed our experience with nephrectomy and upper pole heminephrectomy combined with subtotal ureterectomy to determine the incidence of the problems associated with the distal ureteral stump. MATERIALS AND METHODS: The records of 48 children who underwent nephrectomy or upper pole heminephrectomy with subtotal ureterectomy for a poorly functioning kidney were reviewed. RESULTS: No patient who underwent nephrectomy for a poorly functioning single-system kidney required secondary surgery. No secondary surgery was required in any patient who underwent upper pole heminephrectomy for ectopic ureter, while secondary surgery was required in five of 17 patients (29%) who underwent upper pole heminephrectomy for ectopic ureterocele. All five patients presented with recurrent febrile urinary tract infection after upper pole heminephrectomy. They also had reflux into the ipsilateral lower moiety, contralateral kidney, or distal ureteral stump. Our results and data from other reports suggest that recurrent urinary tract infections after upper pole heminephrectomy were treatment outcomes based on the initial surgical approach to ectopic ureterocele rather than isolated problems associated with the distal ureteral stump. CONCLUSION: We consider that total ureterectomy is unnecessary at the time of nephrectomy or heminephrectomy for a poorly functioning kidney because the distal ureteral stump rarely causes a problem.

Urinary continence following laparoscopic radical prostatectomy: Association with postoperative membranous urethral length measured using real-time intraoperative transrectal ultrasonography.

Urinary incontinence is a major complication following radical prostatectomy. The aim of the present study was to assess the association between urinary continence following laparoscopic radical prostatectomy (LRP) and various factors measured using real-time intraoperative transrectal ultrasonography (TRUS). Patients (n=53) with localized prostate cancer underwent LRP in combination with real-time intraoperative TRUS navigation and were evaluated for urinary continence for more than 6 months following LRP. Prostate size, membranous urethral length (MUL) and bladder-urethra angle were measured using real-time intraoperative TRUS immediately before and after surgery. Urinary continence was regained by 4, 15 and 27 patients 1, 3 and 6 months after LRP, respectively. Longer postoperative MUL was significantly correlated with recovery of urinary continence 1, 3 and 6 months after LRP. In addition, an increase in difference between preoperative and postoperative MUL was also associated with superior continence. No correlation was observed between postoperative MUL and the rate of tumor-positive surgical margins. Larger prostate volume was correlated to postoperative continence 6 months after surgery. Shorter operation time and less blood loss resulted in postoperative urinary continence 1 month after LRP. Preoperative MUL, bladder-urethra angle, age and body mass index had no correlation with urinary continence. Postoperative MUL was the most significant factor for early recovery of urinary continence following LRP. These results indicate that preservation of longer urethra during surgery may be recommended without tumor-positive surgical margins.

Familial transverse testicular ectopia unrelated to persistent Müllerian duct syndrome.

Transverse testicular ectopia (TTE) is rare. Although several familial cases of TTE have been reported, most of them were associated with persistent Mullerian duct syndrome (PMDS), which may be inherited as an autosomal-recessive or X-linked recessive trait. We experienced two brothers with TTE unrelated to PMDS. A genetic etiology may be involved even in TTE unrelated to PMDS.

A case of bilateral abdominoscrotal hydroceles without communication with the peritoneum.

Abdominoscrotal hydrocele (ASH) is an uncommon entity. Although various theories on the development of ASH have been proposed, its etiology is still unclear. According to several etiological theories, it is necessary that ASH have communication with the peritoneum. We present a case of bilateral ASH that had no communication with the peritoneum.