Intravesical bacillus Calmette-Guerin therapy after second transurethral resection for primary T1 bladder cancer.

BACKGROUND: To evaluate the effect of intravesical bacillus Calmette-Guerin (BCG) instillation therapy after second transurethral resection (TUR) on primary T1 bladder cancer. METHODS: The subjects were 180 patients diagnosed with T1 bladder cancer at our university and at affiliated hospitals between January 1990 and December 2015. Tumor residual rate, intravesical recurrence rate, and risk factors for intravesical recurrence were investigated. RESULTS: The median follow-up period was 26 (1-175) months. Of the 180 patients, 78 (43%) underwent a second TUR. Residual tumors were detected in 42 patients (53.8%), and no up-staging cases were observed. Within the whole group, 42 patients were treated with intravesical BCG therapy following a second TUR (group 1), 36 were treated with second TUR alone (group 2), 28 were treated with intravesical BCG therapy alone (group 3), and 74 were treated without second TUR or intravesical BCG therapy (group 4). The 1- and 5-year recurrence-free survival rates of the four groups were 80.7 and 59.7% (group 1), 69.0 and 26.3% (group 2), 76.3 and 56.6% (group 3), 64.6 and 48.6% (group 4), respectively. There was no significant difference between group 1 and group 3 (p = 0.401). Intravesical BCG therapy was the only factor preventing intravesical recurrence (p = 0.013). CONCLUSIONS: Intravesical BCG therapy alone showed a significant preventive effect with regard to intravesical recurrence. In our cohort, however, second TUR did not improve recurrence-free survival in those individuals who underwent BCG instillation.

[A Female Paraurethral Leiomyoma Causing Urinary Retention: A Case Report].

Leiomyoma is a benign smooth muscle tumor which is rarely found in the paraurethral region. We report a case of paraurethral leiomyoma in a 44-year-old female who visited a clinic complaining of urinary retention. Magnetic resonance imaging revealed a 9 cm mass adjacent to the urethra. She was referred to our department. Transvaginal needle biopsy was performed and the histopathological diagnosis was leiomyoma. The mass was completely excised transperitoneally and transvaginally. The resected specimen was 8 × 7 × 4.5 cm in size and 194 g in weight. Histopathological diagnosis was leiomyoma and the tumor cells demonstrated immunoreactivity for estrogen receptors and progesterone receptors. Herpost operative course was uneventful and she gained normal voiding function. In a follow-up after 3 months, there was no evidence of recurrence. We discuss the clinical and pathological features of the paraurethral leiomyoma.

[Psoas abscess after ureteral stent exchange for cutaneous ureterostomy: report of a case].

A 69-year-old man underwent a radical cystectomy and cutaneous ureterostomy for carcinoma in situ of the urinary bladder. The ureteral stents were exchanged for cutaneous ureterostomy 35 days after the operation. The patient suffered from high fever with chills a few hours after the stent exchange, and was readmitted to our hospital. High fever was not improved by treatment with Ceftriaxone for 5 days. Five days after the stent exchange, computed tomography (CT) revealed a right psoas abscess. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the blood culture. Urine culture showed MRSA, Pseudomonas aeruginosa and Enterococcus faecium. Computed tomography-guided percutaneous catheter drainage and treatment consisting of vancomycin, minocycline and ciprofloxacin were performed for the psoas abscess. This treatment significantly reduced the size of the abscess and high fever was improved. The catheter was removed 22 days after the drainage. However, magnetic resonance imaging revealed a spondylitis at L4 and L5. Therefore, antibiotics treatment was continued for about 3 months. There has been no sign of recurrence of bladder cancer and psoas abscess at 23 months after the operation.

[Incidence and risk factors of early postoperative paralytic ileus after radical cystectomy and cutaneous ureterostomy with a unilateral and parallel stoma].

To identify the incidence and risk factors for developing early postoperative paralytic ileus (POPI) after radical cystectomy and cutaneous ureterostomy with a unilateral and parallel stoma, we retrospectively reviewed 21 patients (mean age 73.0, 19 males and 2 females) with a minimum of 3 months of follow-up. POPI occurred in 4 patients (19.0%), who did not need surgical treatment and the insertion of a nasogastric tube. Age and past history of abdominal surgery influenced the occurrence of POPI. The patients with and without POPI had a mean age of 82.3±7.4 and 70.8±6.3 years old, respectively (p＝0.0025), and 75.0% (3/4) and 11.8% (2/17) of the patients, respectively, had a past history of abdominal surgery (p＝ 0.0276). There were no significant differences between patients with and without POPI in any of the following factors examined : sex, body mass index, American Society of Anesthesiologists score, pT-category, neoadjuvant chemotherapy, preoperative serum levels of hemoglobin, creatinine, total protein, and albumin, operative time, blood loss, transfusion volume, stomal side, postoperative day of ambulation, and removal of epidural anesthesia tube. In conclusion, our results showed that increasing age and a past history of abdominal surgery were significantly associated with the occurrence of POPI after radical cystectomy and cutaneous ureterostomy.

Single Short Retention Instillation of Pirarubicin Prevents Intravesical Recurrence of Low-risk Non Muscle Invasive Bladder Cancer.

BACKGROUND: This study evaluated the efficacy of a single instillation of pirarubicin with a short retention time for preventing intravesical recurrence of low-risk non-muscle-invasive bladder cancer. PATIENTS AND METHODS: We analyzed 165 patients with low-risk non-muscle-invasive bladder cancer who underwent transurethral surgery. Single instillation of pirarubicin with 15-min retention time immediate after surgery was performed in 47 (28%) patients. The other patients (118, 72%) were treated without instillation therapy. The primary endpoint was recurrence-free survival. RESULTS: Median overall follow-up was 50 (range=6-134) months. Recurrence-free survival at 1 and 5 years was 91% and 72%, and 79% and 54% in the group treated with pirarubicin, and that treated with surgery alone, respectively (p=0.031). Cox's hazard analysis revealed lack of instillation and larger tumor size (>10 mm) as significant factors for risk of recurrence. No adverse events regarding intravesical chemotherapy were observed. CONCLUSION: Pirarubicin instillation with 15-min retention time can prevent intravesical recurrence of low-risk bladder tumors.

[Clinical study of tubeless cutaneous ureterostomy].

We constructed Toyoda cutaneous ureterostomy with fixation between the anterior and posterior rectus sheath by four interrupted sutures to maintain the stability of the abdominal wall tunnel for the ureters. After the operation, the stent catheters were placed in the renal pelvis through the stoma, and exchanged every 4 weeks. The stent catheters were removed 3 months after the operation, because the stomal conditions were unstable and obstructive in the early phase after the operation. Fifteen patients (27 renal units) with at least 6 months of follow-up were enrolled in this study. The follow-up period was 6 to 33 months (average 14.0 +/- 7.9). Radical cystectomy was performed for bladder cancer in these patients. There were 12 men and 3 women with an average age of 73.3 +/- 7.2 years. At the operation, the ureters were intact in all 27 renal units. Six months after operation, 26 (96.3%) of 27 renal units achieved a tubeless condition, and 25 renal units (92.6%) had no hydronephrosis. Acute pyelonephritis had developed 2 (13.3%) of the 15 patients both within 3 months after the operation and after this period. In conclusion, our operative modification of cutaneous ureterostomy achieved a high catheter-free rate.

Computed tomography detected pyelovenous backflow associated with complete ureteral obstruction.

INTRODUCTION: Pyelovenous backflow is a rare condition resulting from an increase in pressure in the renal pelvis due to urinary obstruction. CASE PRESENTATION: A 49-year-old woman developed high-grade fever and right-sided hydronephrosis after undergoing hysterectomy. Although the hydronephrosis was mild, retrograde pyelography revealed complete obstruction of the right ureter. Excretory phase scans of contrast-enhanced computed tomography showed pyelovenous backflow, which presumably decompressed the hydronephrosis. The pyelovenous backflow immediately disappeared after ureteroneocystostomy. CONCLUSION: We were presented with a patient showing pyelovenous backflow detected by contrast-enhanced computed tomography, which completely disappeared after ureteral obstruction release.

[A case of locally advanced prostate cancer with low serum testosterone associated with intake of an androgenic medicine].

A 74-year-old man was referred to our clinic for the work-up of digitally hard and irregularly surfaced prostate and elevated serum prostate-specific antigen (PSA). His serum PSA was elevated to 41 ng/ml, but testosterone and LH level were decreased to 23.5 ng/dl and 0.5 mIU/ml, respectively. He had a history of taking an androgenic medicine containing methyl-testosterone 2 to 3 times a week for 2 year and 6 months. Transrectal sextant prostatic biopsy revealed moderately differentiated adenocarcinoma (Gleason score: 3 + 4) in 6 of 6 specimens and CT scan of the abdomen showed an enlarged obturator lymph-node (15 mm), resulting in the diagnosis of stage D1 (T3aN1M0) prostate cancer. Since serum testosterone level seemed to recover around the normal level after discontinuation of the exogenous androgen, we treated him with combination androgen blockade with LHRH agonist and bicaltamide, although his testosterone level was very low. Indeed, serum PSA decreased to 0.09 ng/ml and the right obturator node was markedly reduced by the hormone treatment. After the neoadjuvant therapy of 6 months duration, radical prostatectomy and limited pelvic lymph node dissection was carried out. Histologically, viable cancer cells were not found in any of resected lymph nodes, but they remained in bilateral lobes of the prostate (pT2bN0). The histological effect of the neoadjuvant hormone therapy according to General rule for Clinical and Pathological Studies on Prostate Cancer (3rd ed.) was grade 2. The patient has been well with undetectable PSA and no evidence of clinical failure for more than 12 months, though serum testosterone level recovered to near normal (288 ng/dl) 8 months after the cessation of the hormone treatment following the operation. Combination androgen blockade or non-steroidal anti-androgen agent appears to be effective for the treatment of prostatic cancer patients who takes exogenous androgenic medicine, even with a suppressed low serum testosterone level.

[The result of VIP chemotherapy as an induction therapy in 6 patients with non-seminomatous extragonadal germ cell tumor].

We treated 6 patients with non-seminomatous extragonadal germ cell tumor (NSEGCT) by VP-16 + ifosfamide + cisplatin (VIP) chemotherapy as an induction therapy to investigate the effectiveness and safety. Primary lesions were located at the mediastinum in 4 patients and the retroperitoneum in 2 patients. As a rule, all patients were treated with VIP chemotherapy of 4 courses with or without second-line treatment such as chemotherapy, residual tumor resection and/or radiation. Following the induction therapy (VIP), 4 of 6 patients (67%) achieved complete or partial responses. After salvage therapy, 4 patients (67%) achieved complete responses and two other patients also achieved partial responses. However, only 2 of the 5 patients who had been follow-up for more than 2 years have remained disease free. The effects of VIP chemotherapy on non-seminomatous extragonadal germ cell tumor appeared to be similar to those of the conventional chemotherapies though the number of patients was small in the current study. It appears to be necessary to design more effective regimen.

Miliary tuberculosis following transrectal ultrasonography (TRUS)-guided prostate biopsy.

Miliary tuberculosis (TB) after transrectal ultrasonography (TRUS)-guided prostate biopsy is an extremely rare complication. A 75-year-old patient who presented with high fever and cough following TRUS-guided prostate biopsy for his high serum prostate-specific antigen (PSA) level (13.104 ng/ml) was diagnosed with miliary TB after clinical, laboratory, and radiological assessments. Histopathological examination of the prostate revealed TB with acid-fast bacilli. He was treated with chemotherapy for 9 months. The patient is now symptom-free, and his post-treatment PSA level was 5.023 ng/ml. This case is reported to acknowledge the possibility that miliary TB can occur as a complication of prostate biopsy if the patient suffers from prostate TB.

Evaluation of hydronephrosis with tubeless cutaneous ureterostomy using Tc-99m MAG3 diuretic renography.

PURPOSE: To assess hydronephrosis of tubeless cutaneous ureterostomy using Tc-99m mercaptoacetyltriglycine (MAG3) diuretic renogram. MATERIALS AND METHODS: Cutaneous ureterostomy with a unilateral stomal creation was performed in 15 patients (27 renal units) with a minimum follow-up period of 6 months. Stomal obstruction was evaluated with Tc-99m MAG3 diuretic renography 3 months after the surgery. The data analyses were performed with half-times to tracer clearance (T1/2) after furosemide (0.5 mg/kg) administration. RESULTS: T1/2 means were 7.27 +/- 7.11, 5.69 +/- 4.63, and 8.96 +/- 8.37 minutes for total, ipsilateral, and contralateral kidneys, respectively, in side relationships between ureter and stoma. There were no statistical differences among the groups. Six months after the surgery, of 26 renal units (96.3%) that had achieved a tubeless condition, and 25 renal units (92.6%) had no hydronephrosis. T1/2 was within 20 minutes in these 25 renal units, and of 25 renal units 23 (92%) revealed less than 15 minutes in T1/2, suggesting that the upper limit of T1/2 for nonobstructed systems after construction of a cutaneous ureterostomy might be 15 minutes. Mild hydronephrosis without the need for intervention was present in 1 renal unit (T1/2, 31.70 minutes). Catheterization was performed in one renal unit (T1/2, 21.04 minutes) due to acute pyelonephritis and persistence of grade 2 hydronephrosis 5 months after the surgery. Only these 2 renal units showed more than 20 minutes in T1/2, resulting in an obstructive pattern on diuretic renography. CONCLUSION: Tc-99m MAG3 diuretic renography with T1/2 assessment is useful to evaluate stomal stenosis in tubeless cutaneous ureterostomy.

Torsion of spermatocele: a rare manifestation.

Torsion of a spermatocele on its pedicle is an extremely rare clinical condition that mimics acute testicular torsion. This rare condition has not been well characterized. Here, we report a case of torsion of a spermatocele. The present case is the 5th case of torsion of a spermatocele and the first report in a patient with a history of scrotal trauma. A tender cystic mass adjacent to the normally appearing testicle in the scrotum is highly significant for the differentiation from other types of acute scrotum. Torsion of a spermatocele should be considered a differential diagnosis of acute scrotum in adolescents and adults.