Gastrointestinal cancer and bilateral hydronephrosis resulted in a high risk of ureteral stent failure.

BACKGROUND: Urologists frequently encounter malignant ureteral obstruction (MUO) caused by advanced urological or non-urological malignant disease, but the treatment policy is unclear. The present study examined the risk factors for predicting ureteral stent failure in patients with MUO after ureteral stent insertion and the change in the renal function after retrograde ureteral stent insertion in cases of bilateral hydronephrosis. METHODS: A total of 39 patients who required ureteral stent placement for MUO at Yokohama City University Medical Center (Yokohama, Japan) between February 2007 and May 2016 were included in this study. The age, gender, type of cancer, hydronephrosis side, pre-stenting estimated glomerular filtration rate (eGFR), and eGFR increase were assessed as predictive factors for stent failure. Among these 39 patients, 25 showed bilateral hydronephrosis. Thirteen of these patients had bilateral ureteral stents placed, and the remaining 12 had a unilateral ureteral stent placed. The renal function and overall survival (OS) were analyzed between these two groups. RESULTS: Among all 39 patients, 9 (23.1%) had stent failure. A univariate analysis revealed that causative disease (gastrointestinal cancer vs. others; p = 0.045) and laterality of hydronephrosis (bilateral vs. unilateral; p = 0.05) were associated with stent failure. A multivariate analysis revealed that only age (hazard ratio, 0.938; 95% confidence interval, 0.883-0.996; p = 0.038) was associated with stent failure. A Kaplan-Meier analysis and log-rank test indicated that having a unilateral ureteral stent placed was not correlated with a lower OS rate than having bilateral ureteral stents placed (p = 0.563). Among patients with bilateral hydronephrosis, the increase in the eGFR of those who had bilateral ureteral stents placed was not significantly different from that of those who had a unilateral ureteral stent placed (p = 0.152). CONCLUSIONS: We revealed that age > 60 years was helpful for predicting stent failure. MUO due to gastrointestinal cancer and bilateral hydronephrosis may be predictive of stent failure. These factors may help urologists decide the optimal time to perform early percutaneous nephrostomy. These findings suggest that patients with bilateral hydronephrosis do not necessarily need to have a ureteral stent placed into both sides of the hydronephrosis.

The neutrophil-to-lymphocyte ratio (NLR) predicts adrenocortical carcinoma and is correlated with the prognosis.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) is reported as a biomarker for some solid malignant diseases. Thus far, however, no reports of the relationship between the NLR and adrenal tumors have been published. We analyzed the utility of the preoperative NLR as a biomarker for predicting the prognosis or diagnosis of malignant disease. METHODS: A total of 59 patients with adrenal tumors (13 cases of malignant disease and 46 with benign disease) were analyzed in this study from February 2004 to June 2015 at our institute. The NLR was obtained just before adrenalectomy. The diagnosis of adrenal tumor was confirmed by a pathological examination of surgical specimens. RESULTS: The NLR in malignant adrenal tumor specimens was significantly higher than in non-malignant specimens (p = 0.028). Adrenocortical carcinoma (ACC) showed the highest NLR among all adrenal tumors. In ACC, the higher NLR group (NLR ≥ 5) showed a significantly poorer overall survival than the lower NLR group (NLR < 5) (p = 0.032). CONCLUSIONS: In adrenal tumors, a higher NLR indicates a higher incidence of malignancy. The NLR might be a new biomarker for predicting the prognosis of adrenal tumor patients.

A low psoas muscle volume correlates with a longer hospitalization after radical cystectomy.

BACKGROUND: Recently, sarcopenia has been reported as a new predictor for patient outcomes or likelihood of post-operative complications. The purpose of this study was to evaluate the association of the psoas muscle volume with the length of hospitalization among patients undergoing radical cystectomy. METHODS: A total of 63 (80.8%) male patients and 15 (19.2%) female patients who underwent radical cystectomy for their bladder cancer in our institution from 2000 to 2015 were analyzed. The psoas muscle index (PMI) was calculated by normalizing the psoas muscle area calculated using axial computed tomography at the level of the umbilicus (cm2) by the square of the body height (m2). Longer hospitalization was defined as hospitalization exceeding 30 days after surgery. RESULTS: The median PMIs (mean ± standard deviation) were 391 (394 ± 92.1) and 271 (278 ± 92.6) cm2/m2 in men and women, respectively. Thus, the PMIs of male patients were significantly larger than those of females (p < 0.001). Based on the differences in gender, we analyzed 63 male patients for a further analysis. In male patients, those hospitalized longer showed a significantly smaller PMI than those normally discharged (377 ± 93.1 vs. 425 ± 83.4; p = 0.04). Similarly, male patients with a small PMI (<400) had a significantly worse overall survival (p = 0.02) than those with a large PMI (≥400). CONCLUSIONS: The presence of sarcopenia was found to be associated with significantly longer hospitalization after radical cystectomy in male patients. Furthermore, in men, a PMI <400 may suggest a significantly worse prognosis.

Clinical application of neutrophil CD64 quantification for differential diagnosis of acute scrotum.

The management of acute scrotum can be challenging, especially in infants or patients with a neurological or neurodevelopmental disorder in whom presentation, diagnosis and definitive management tends to be delayed. This leads to poor outcomes, such as loss of the affected testis. Here we present two cases of testicular torsion in patients with neurodevelopmental disorders, and a further two cases of epidydimo-orchitis in whom measurement of CD64 expression on neutrophils was helpful for differential diagnosis. These data suggest that the levels of expression of CD64 by neutrophils, known as a marker of infection, could also be useful for differentiating between testicular torsion and infection in acute scrotum.

[Severe Hyponatremia after Cisplatin-Based Chemotherapy : Two Case Reports].

Hyponatremia is one of the common electrolyte disorders associated with cisplatin (CDDP) administration. We report here two cases of hyponatremia associated with CDDP. Case 1 : A 75-year-old man with urothelial carcinoma of bladder (cT3N1M0) underwent neoadjuvant chemotherapy with CDDP and gemcitabine. He lost consciousness on the eighth day after the chemotherapy. Blood tests showed severe hyponatremia (Na 113 mEq/l), low plasma osmolality and high level of plasma vasopressin. Urine tests showed low osmolality. These findings were consistent with the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH). His consciousness level was improved after saline infusion and fluid restriction. Case 2 : A 54-year-old man with penile cancer (cT3N2M0) underwent neoadjuvant chemotherapy with CDDP, paclitaxel and fluorouracil. He lost consciousness on the seventh day after the chemotherapy. Blood tests showed hyponatremia(Na 121 mEq/l) with renal dysfunction. We concluded that the hyponatremia is due to the renal salt wasting syndrome (RSWS) based on renal dysfunction and high urinary sodium excretion. His consciousness level was improved after saline infusion. Although it is difficult to distinguish between SIADH and RSWS, correct evaluation is necessary for appropriate management of hyponatremia after CDDP administration.

[Unilateral adrenal tuberculosis: a case report].

Computed tomography (CT) performed for a 75-year-old man as a follow-up examination for deep vein thrombosis in October 2010 revealed a left adrenal mass (diameter, 8 mm). In December 2012, the adrenal mass increased to 28 mm in diameter, and he was referred to our department. Several blood examinations revealed that the adrenal mass was non-functioning, and only peripheral lesions were observed to be enhanced by using CT in the arterial phase. Malignancy was suspected due to the irregular shape and growth of the mass, and left adrenalectomy was performed in February 2013. The histopathological diagnosis was adrenal mycobacteriosis, and clinical diagnosis was adrenal tuberculosis. No other tuberculosis infection-related lesion was detected, and the patient was treated with multidrug antituberculous chemotherapy.

[Malignant priapism due to metastatic papillary renal cell carcinoma : a case report].

A 70-year-old man presented in December, 2010 with priapism persistent for over a month. The patient had no history of medications for erectile dysfunction, penis trauma, or traumatic sexual activities. A blood gas measurement of the cavernosum was performed, but only fibrosis tissue was aspirated and no blood was obtained. Color-flow Doppler imaging of the penis revealed blood flow in the corpora cavernosa of the penis, suggesting the occurrence of nonischemic priapism. Enhanced chest and abdominal computed tomography revealed a left renal cyst, and the wall of the cyst showed contrast enhancement. No other obvious obstructive mass or tumor was detected in the pelvic cavity. Gradually, necrotic changes of the glans penis appeared, and total penectomy was performed. Histopathological examination of penectomy tissue specimens suggested papillary renal cell carcinoma metastases to the penis. Consequently, open left radical nephrectomy was performed. Pathological diagnosis revealed papillary renal cell carcinoma pT2, and the patient was diagnosed with stage IV (pT2N0M1) renal cell carcinoma. Treatment was provided by intravenous temsirolimus therapy that resulted in partial remission and stable disease, which in turn relieved cancer pain.

A case of allograft ureteral stone successfully treated with antegrade ureteroscopic lithotripsy: use of a 3D-printed model to determine the ideal approach.

We present the case of a 46-year-old man who underwent successful antegrade ureteroscopy for lithiasis in his allograft ureter. At a scheduled follow-up 15 years after transplantation, computed tomography (CT) detected a 12-mm renal stone in the renal pelvis of the transplanted kidney. During his follow-up, gross hematuria was seen; the stone moved to the ureter, causing hydronephrosis. Ultrasound and non-contrast CT revealed hydronephrosis and a 15-mm stone in the transplanted ureter. Considering the stone size, location, and the difficulty of the access to the anastomosed ureteral orifice, percutaneous ureteroscopic approach was planned. Due to the anatomical difficulty regarding his allograft kidney, we planned to prepare a 3D image and model for selecting the best percutaneous approach. The procedure was performed and a stone-free status was acquired without complication. Under precise simulation, we performed successful antegrade ureteroscopy for lithiasis in the allograft ureter supported by 3D imaging. Use of a 3D printed model may aid in a safe and effective procedure for lithiasis in the allograft kidney and ureter.

Expression of PD-L1 and CTLA-4 in female urethral carcinoma.

INTRODUCTION: Although the tumors are often easily detected, a considerable number of patients with female urethral carcinoma are diagnosed in an advance stage. Thus, no evidence-based therapeutic approach has been established. We herein report our experience in the treatment of three female patients with urethral carcinoma. We also examined the expression of PD-L1 and CTLA-4. CASE PRESENTATION: Three female patients pathologically diagnosed with urethral carcinoma, including urothelial carcinoma, squamous cell carcinoma, and adenocarcinoma, between 2013 and 2017 were analyzed in this study. Two patients underwent urethrectomy with cystostomy. Immunohistochemistry was performed to assess the levels of PD-L1 and CTLA-4 expression in patients with urethral carcinoma. Eleven control cases of urethral carcinoma tissue were also stained. CONCLUSION: This study revealed the expression of PD-L1 and CTLA-4 in female urethral carcinomas.

Spontaneous adrenal hemorrhage with dehydroepiandrosterone-sulfate elevation in a patient with suspected adrenal cortical carcinoma.

INTRODUCTION: Spontaneous adrenal hemorrhage is a relatively rare disease that is sometimes difficult to differentiate from adrenal cortical carcinoma. We herein report a case of spontaneous adrenal hemorrhage with dehydroepiandrosterone-sulfate elevation. CASE PRESENTATION: The patient was a 78-year-old man with an adrenal tumor that had increased in size to 42 mm. With the exception of an elevated dehydroepiandrosterone-sulfate level (2281 ng/mL), the results of a hormone analysis were almost normal. Laparoscopic adrenal tumor resection was performed. The pathological diagnosis was adrenal hematoma. CONCLUSION: We reported a case of spontaneous adrenal hemorrhage in a patient with dehydroepiandrosterone-sulfate elevation.

Successful treatment of ureteral stricture after total hysterectomy: An antegrade ureteroscopic approach facilitates the insertion of a guidewire for endoscopic dilation.

INTRODUCTION: Iatrogenic ureteral injury is sometimes seen in daily clinical practice, and gynecological surgery carries the highest risk of ureteral injury among iatrogenic surgical ureteral injury. CASE PRESENTATION: A 61-year-old woman was referred to our department for right ureteral stricture and hydronephrosis after total hysterectomy. We initially attempted ureteral stenting, but hydronephrosis redeveloped 1 month after ureteral stent removal. We performed ureteroscopy via an antegrade approach and successfully incised and dilated the ureter. CONCLUSION: We encountered a case of severe ureteral stenosis after total hysterectomy that was successfully treated endoscopically using ureteroscopy via an antegrade approach.

Successful Resection of Cisplatin-Resistant Renal Pelvic Cancer after the Administration of Pembrolizumab as Second-Line Therapy.

Pembrolizumab has been used as a second-line systemic therapy for urothelial carcinoma. We herein report a case of cisplatin-resistant renal-pelvic urothelial carcinoma that was successfully resected after pembrolizumab treatment. A 74-year-old woman was referred to our hospital for further examination for gross hematuria and a renal-pelvis tumor. Retrograde pyelography showed a defect lesion in her renal pelvis and urinary cytology of the renal pelvis showed class V. Because staging CT could not deny lung metastasis, we planned to perform nephro-ureterectomy after evaluating the response to neoadjuvant chemotherapy. After three courses of gemcitabine and cisplatin chemotherapy, the original site showed progression; thus, nephro-ureterectomy was cancelled. We introduced pembrolizumab as a second-line therapy. After four courses of pembrolizumab treatment, the size of the original lesion was significantly decreased. During these therapies the lung tumor size was unchanged; thus, we determined that the lung tumor was not metastatic and performed nephro-ureterectomy. A pathological examination demonstrated that the tumor was completely resected with a negative surgical margin. We described the first case in which cisplatin-resistant renal pelvic tumor was successfully resected after pembrolizumab treatment.

Management of urethral stricture: High-pressure balloon dilation versus optical internal urethrotomy.

OBJECTIVE: Urethral stenosis is a disease in which the lumen of the urethra becomes constricted by fibrosis. Such stenoses have been treated by urethral dilation using a bougie and optical internal urethrotomy (OIU). Recently, high-pressure balloon dilation (BD) has been developed as a new treatment method for urethral stenosis. The present study compared the effectiveness of urethral dilation by BD and OIU. METHODS: Twenty-two patients of urethral stenosis were treated at Yokohama City University Medical Center between 2005 and 2015. Of these, 13 underwent BD, whereas OIU was performed in 9. BD was performed at 30 atm twice for 5 min each time. In OIU, an endoscopic knife was used to cut out the stenotic lesion in 3 directions. The endpoint was set as restenosis, which required additional surgical treatment, including BD, OIU, and the use of a urethral bougie. RESULTS: The causes of urethral stricture were endoscopic surgery (n = 7; 31.8%), development after total prostatectomy (n = 4; 18.2%), iatrogenic reasons associated with catheter insertion (n = 5; 22.7%), development after a prostate needle biopsy (n = 3; 13.6%), and unknown (n = 3; 13.6%). The site of the stenotic lesion site was the anastomosis (n = 3; 13.6%), bladder neck (n = 6; 27.3%), prostatic urethra (n = 4; 18.2%), anterior urethra (n = 7; 31.8%), and membranous urethra (n = 2; 9.1%). The stenosis-free rate was 84% for those undergoing BD and 22% for those receiving OIU. The median stenosis-free time was significantly longer after BD than OIU (1675 vs. 244 days, respectively; P < .01). CONCLUSION: The stenosis-free time was significantly longer after BD than OIU.

High orchiectomy and ipsilateral testicular sperm extraction in a man with a testicular tumor and Klinefelter syndrome: A case report.

INTRODUCTION: Testicular epidermal cysts in Klinefelter syndrome are very rare. We report a case of Klinefelter syndrome associated with a testicular epidermal cyst. To our knowledge, this is the first report showing successful spermatozoa retrieval from the affected testis. CASE PRESENTATION: A 25-year-old married man was referred to our hospital with right scrotal induration, which was in lower pole of the right testis. Testicular cancer tumor markers were normal; endocrinological findings indicated hypergonadotropic hypogonadism. Semen analyses revealed azoospermia. Preoperative chromosome test result: 47, XXY karyotype; ultrasonography report: 1.9-cm internal heterogeneous echoic mass in the right testis (malignancy not discarded). Because the patient hoped for children, he underwent high orchiectomy with ipsilateral testicular sperm extraction (200 spermatozoa from normal testicular tissue) for future fertilization procedures. Tumor pathology was an epidermal cyst. CONCLUSION: While performing orchiectomy for testicular tumors, sperm retrieval should be attempted from normal tissues in patients planning for children.

The Use of a Metal Stent in the Treatment of Ureteral Stricture in a Patient Who Had Undergone Radical Cystectomy with the Creation of an Ileal Conduit.

Approximately 9.2% of patients who undergo radical cystectomy are reported to develop ureteral stricture as a result of both benign and malignant conditions. A metallic stent is a continuous, unfenestrated all-metal double-pigtail ureteric stent with no end or side holes. The patient was a 74-year-old man who underwent radial cystectomy with the creation of an ileal conduit due to advanced bladder cancer 7 years previously. Although he had no radiographic recurrence, he developed bilateral hydronephrosis. We herein report the first case of a patient with ureteral stricture after radial cystectomy with the creation of an ileal conduit who was successfully treated by the insertion of a metal stent by a combined antegrade and retrograde approach.

Skene duct adenocarcinoma in a patient with an elevated serum prostate-specific antigen level: a case report.

BACKGROUND: Female urethral carcinoma is a very rare disease that accounts for 0.02% of malignant diseases in female patients. CASE PRESENTATION: A 70-year-old Asian Japanese woman with a urethral tumor was referred to our hospital to undergo further examination. Biopsy specimens showed urethral adenocarcinoma that was positive for prostate-specific antigen. Her serum prostate-specific antigen level before surgery was 34.4 ng/ml. Urethral tumor resection with pelvic lymph node resection was performed. Her serum prostate-specific antigen level decreased to < 0.01 ng/ml after surgery. CONCLUSIONS: We report a very rare case of Skene duct adenocarcinoma in a female patient with serum prostate-specific antigen elevation.

Neutrophil-to-Lymphocyte Ratio in Renal Transplant Patients.

OBJECTIVES: Because of recent developments in immunosuppressive therapy, renal transplant outcomes have improved. Although reports on the association between immunosuppressive therapy and malignant disease are available, the results are controversial. The neutrophil-to-lymphocyte ratio has been reported as an easy tumor marker for predicting the prognoses of some solid tumors. In the present study, we examined changes in neutrophil-to-lymphocyte ratio after renal transplant and discussed cases in which malignant disease developed after renal transplant. MATERIALS AND METHODS: Our study included 137 patients who underwent renal transplant between August 2001 and September 2015. Four of these patients (2.9%) developed malignant disease. The neutrophil-to-lymphocyte ratio was calculated based on the numbers of neutrophils and lymphocytes in the complete blood count and evaluated before and at 1, 3, 6, and 12 months and at 3 years after renal transplant. RESULTS: The neutrophil-to-lymphocyte ratio was markedly high at 1 week and 1 month after renal transplant and gradually decreased until it became stable at 3 months posttransplant. In patients with malignant disease, there was a gradual increase in the neutrophil-to-Iymphocyte ratio after renal transplant. CONCLUSIONS: We observed dramatic differences in the neutrophil-to-lymphocyte ratio at 1 and 3 months after renal transplant. The neutrophil-to-lymphocyte ratio of patients with malignant disease after renal transplant continued to increase.

Fluorescent Light-Guided Cystoscopy with 5-ALA Aids in Accurate Surgical Margin Detection for TURBO: A Case Report.

Recent studies have revealed that transurethral resection in one piece (TURBO) has several benefits over standard transurethral resection of bladder tumor (TUR-Bt), including a higher rate of containing the bladder muscle tissue and single-block resection. Five-aminolevulinic acid (5-ALA) was approved for the detection of bladder tumor treated with TUR-Bt. A 71-year-old male patient who received right nephroureterectomy developed bladder tumor recurrence on routine cystoscopy follow-up. We planned TURBO using fluorescent light-guided cystoscopy with 5-ALA. We herein report a case of bladder tumor successfully treated with TURBO using fluorescent light-guided cystoscopy with 5-ALA to detect the tumor surgical margin.