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.

[Post-Operative Immediate Single Instillation of Chemotherapy as Prevention of Recurrence after Transurethral Resection of Intermediate-High Risk Non-Muscle-Invasive Bladder Cancer].

We retrospectively evaluated the efficacy of immediate single instillation (SI) of pirarubicine hydrochloride (THP) in the chemoprevention of intermediate and high risk patients with non-muscle-invasive bladder cancer (NMIBC). The study population consisted of 256 intermediate and high risk patients with NMIBC who underwent Bacillus Calmette-Guerin (BCG) induction therapy or delayed intravesical chemotherapy between 1999 and 2014. We introduced SI of 30 mg THP in 30 ml normal saline for all cases in 2010, and thus earlier cases could be considered as historical controls. As BCG induction therapy, patients received 80 mg of BCG Tokyo strain 2 weeks after transurethral resection of bladder tumor (TURBT), and the instillations were repeated weekly for 8 weeks. On the other hand, as delayed intravesical chemotherapy, patients received 30 mg THP in 30 ml normal saline over a period of 6 months starting 2 weeks after TURBT. The instillation schedule was once a week for 1 month, every other week for 1 month and once a month for 4 months. The patients were followed with cystoscopy and urine cytology every 3 months for the first 2 years and every 6 months thereafter. The 3-, and 5-year non-recurrence rates were 80. 3 and 80.3%, respectively, in the single immediate instillation group and 69.7 and 64.5%, respectively, in the control group. Univariate analysis revealed a significant difference between the SI group and the control group (P=0. 025). Multivariate analysis showed that there was an independent and significant recurrence risk factor in selecting chemotherapy instead of BCG in additional intravesical instillation therapy and not to perform SI. Limitations of our study are its retrospective and nonrandomized nature with a limited number of patients.

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.

[Post-Operative Single Immediate Intravesical Instillation Chemotherapy as Prophylaxis for Reccurence after Transurethral Resection of Low Risk Non-Muscle-Invasive Bladder Cancer].

We evaluated the efficacy of single-dose instillation of pirarubicine hydrochloride (THP) in the chemoprophylaxis of non-muscle-invasive bladder cancer(NMIBC). In a retrospective study, 135 evaluable patients were assigned to three groups after transurethral resection of bladder tumors (TURBT). In group 1, patients received no adjuvant therapy after TURBT. In group 2, patients received a single-dose of 30 mg THP in 30 ml normal saline immediately after TURBT. In group 3, patients received 30 mg THP in 30 ml normal saline 2 weeks after TURBT , and the instillations were repeated for 4 weeks, then every other week twice and successively monthly for 6 months. Patients were followed with cystoscopy and urine cytology every 3 months for the first 2 years and every 6 months thereafter. The 3- and 5-year non-recurrence rates were 66.9%, and 66.0%, respectively, in group 1, 85.6%, and 85.6%, respectively, in group 2, and 93.6%, and 77.9%, respectively, in group 3. There was a significant difference only between group 1 and group2 (P ＝0.048). With respect to the recurrence per month, there was a significant difference between the 3 groups (P＝0.014) for the first 2 years. However, there was no significant difference thereafter. Limitations of our study are its retrospective and nonrandomized nature with a limited number of patients.

Increased neutrophil-to-lymphocyte ratio is associated with disease-specific mortality in patients with penile cancer.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR), a simple marker of the systemic inflammatory response, has been demonstrated to correlate with patient outcomes for various solid malignancies. We investigated the utility of the pretreatment NLR as a prognosticator in patients who presented with penile cancer. METHODS: A total of 41 patients who underwent complete blood count with differential and subsequent radical penectomy from 1988 to 2014 were analyzed. We assessed the correlation between the NLR and the prognosis of penile cancer. RESULTS: The median and mean (± SD) NLRs in 41 penile cancer patients were 3.42 and 5.03 ± 4.99, respectively. Based on the area under receiver operator characteristic curve, the cut-off value of NLR was determined to be 2.82. Patients with a high NLR (≥2.82) showed a significantly poorer cancer-specific survival (p = 0.023) than those with a low NLR. CONCLUSIONS: The pretreatment NLR may function as a biomarker that precisely predicts the prognosis in patients with penile cancer.

[Investigation of prognostic factors for occult inguinal lymph node metastasis in penile cancer patients with no palpable or visibly enlarged inguinal lymph node (cN0)].

We investigated the incidence of inguinal lymph node metastasis in 66 penile cancer patients with no palpable or visibly enlarged inguinal lymph nodes (cN0). Median follow up interval was 35. 7 months. During follow up, 14 patients (21.2%) had inguinal lymph node metastasis and 6 patients died of cancer. Five-year disease-free survival was 77.3%. Univariate analysis demonstrated that local tumor staging (T), differentiation, lymphovascular invasion (LVI), and tumor infiltration pattern (INF, Yamamoto-Kohama grading system) were associated with the incidence of inguinal lymphnode metastasis. Multivariate analysis demonstrated that only LVI was associated with incidence of inguinal lymph node metastasis (p = 0.008, Hazard ratio 17.947). According to EAU risk classification, the incidence of inguinal lymph node metastasis in the low-risk group, intermediate risk group and high-risk group was 12.0, 17.6 and 55.6%, respectively. In conclusion, LVI is an independent prognostic factor for inguinal lymph node metastasis in cN0 penile cancer. Furthermore, EAU risk classification is valid judging from our cases and in incidence of inguinal lymph node metastasis. Either sentinel node biopsy or inguinal lymph node dissection is recommended in high and intermediate risk patient.

[A case of complete disappearance of paraneoplestic syndrome after curative resection of bone metastasis in renal cell carcinoma].

A case of renal cell carcinoma presenting with paraneoplastic syndrome is reported. A 69-year-old man with uncontrolled diabetes was incidentally found to have a left thoracic tumor and a right renal tumor. He had intermittent fever of 39℃ or more and laboratory data showed diabetes and high C-reactive protein level. A radical nephrectomy was performed, but the neoplastic syndrome did not improve. After a second surgery consisting of complete resection of solitary bone metastasis the symptoms resolved immediately. At 6 months postoperatively, he had no reoccurence. Generally prognosis of patients with bone metastasis from renal cell carcinoma has been said to be poor, but surgical control of bone metastasis may be a key factor for the prognosis of patient with metastatic RCC in the era of targeted therapy.

[Sharing information of urological cancer patient in terminal stage using Cybozulive® for home medical care].

It is very important to share patient information because home patient care involves several different specialties of care. We introduced Cybozulive ® , a cloud-based free groupware, for 14 terminal-stage patients with urological cancer to share information among doctors and co-medical staff. This system enables access to patient information regardless of time and place. Of the 14 patients (mean age 74.4 years), 11 died of cancer. The average period in which Cybozulive® was used for the patients was 210 days. The average number of entries to the electronic bulletin board in this period was 88.4. We were able to obtain more information about the patients from the website. There was no difference in the average number of times that the patient consulted the out patient clinic before and after the introduction of Cybozulive® (before 7.0 ; after 6.3). After introduction of this system, eleven patients were hospitalized in our department 21 times. Eighteen of these 21 times, since we had acquired patient information from the website beforehand, there was a quick response for management of the emergency admission. This system could be used to construct a network for home care and may be helpful for sharing patient information in homecare.

[Neoadjuvant and adjuvant chemotherapy with paclitaxel, cisplatin and 5-fluorouracil for advanced penile cancer: a case report].

54-year-old male was introduced to our hospital in January 2012 for surgical treatment and chemotherapy. The pathological examination revealed well differentiated squamous cell carcinoma of the penis. Computed tomography and magnetic resonance imaging indicated right inguinal and pelvic lymphadenopathy. We diagnosed the tumor to be unresectable radically and administered paclitaxel, cisplatin and 5-fluorouracil (TPF) as neoadjuvant chemotherapy. After 3 courses of chemotherapy, the size of lymphadenopathy had become small enough to allow curative surgical treatment. Partial penectomy and lymph node dissection were performed after neoadjuvant chemotherapy. For 12 months after this radical treatment, the patient has been healthy with no local resurrence and no distant metastatic lesion. TPF chemotherapy for unresectable nodal metastasis from squamous cell carcinoma of penis was suggested to be effective.

Comparison of Urinary Liver Fatty Acid Binding Protein Level and Pathologic Biopsy Findings 1 Year After Kidney Transplantation.

BACKGROUND: For the early detection of abnormal findings considering for therapeutic intervention, we regularly undertake protocol renal allograft biopsy at 1 year after kidney transplantation (KT). We examined whether urinary liver fatty acid binding protein (L-FABP) level predicts some pathologic findings of renal allograft. METHODS: We retrospectively enrolled recipients with stable graft function who routinely were biopsied renal allograft specimens 1 year after KT between January 2015 and May 2021 in our center. We assessed the association urinary L-FABP level with pathologic findings of renal allograft biopsies. RESULTS: We enrolled 56 recipients in this study. Their median age at KT was 49.5 and their median serum creatinine at 1 year after KT was 1.22 mg/dL. In 9 of 56 patients, abnormal high value of urinary L-FABP were observed. All of them had abnormal findings pathologically in the renal allografts (border line change 3, medullary ray injury [MRI] with calcineurin inhibitor toxicity [CNI-T] 1, MRI without CNI-T 1, CNI-T with IgA deposition 1, and BK virus nephropathy 3). On the other hand, 30 of 47 patients with normal value of urinary LFABP had no pathologically abnormal findings. Both specificity and positive predictive value of urinary L-FABP for pathologic findings were 100.0༅. CONCLUSIONS: Our results suggest that patients with renal transplant with elevated urinary L-FABP levels might benefit from renal allograft biopsy. Comparison of urinary liver fatty acid binding protein level and pathologic biopsy findings 1 year after KT.

Testicular sperm extraction for fertility preservation in young patients with cancer.

Background: Cancer survivors in the adolescent and young adult generation often experience marriage, pregnancy, and childbirth after treatment; thus, fertility preservation is very important. In male patients, testicular sperm extraction (TESE) is sometimes performed due to azoospermia. Such a procedure is called oncological TESE (onco-TESE). In the present study, we aimed to define onco-TESE as TESE for fertility preservation in cancer patients, including those receiving gonadotoxic treatment. Methods: Seventeen male patients with cancer who had undergone onco-TESE for fertility preservation at Yokohama City University Medical Center between April 2014 and March 2023 were included in the study. Results: Motile testicular sperm were acquired by TESE in 9 out of 17 cases. Among patients who had initiated chemotherapy before surgery, Motile sperm could be acquired by onco-TESE in 3 out of 9 cases. In chemotherapy-naive patients, Motile sperm were acquired by onco-TESE in 6 out of 8 cases. In the end, sperm cryopreservation was performed in 10 patients. Cryopreserved sperm were used in 2 of the 10 cases, and live birth was achieved after intracytoplasmic sperm injection in both cases. Conclusions: Before starting gonadotoxic treatment, it is important to confirm whether the patient desires to bear children. If having a baby is desired, a referral to a reproductive medicine doctor is recommended. Fertility preservation before starting gonadotoxic treatment is preferable, but fertility preservation could be considered even after such a treatment.

Clinical case of 45,X/46,XY mosaic male with ejaculatory disorder associated with seminal vesicle dysplasia: a case report.

Introduction: 45,X/46,XY mosaicism is a rare anomaly in sexual differentiation, presenting with diverse phenotypes and often leading to infertility due to abnormal gonadal development. Aims: This report aims to present a case study of a 45,X/46,XY mosaic male patient with an ejaculatory disorder attributed to seminal vesicle dysplasia. Methods: In this case study, diagnostic procedures encompassed blood tests, semen analysis, chromosomal examination, and imaging studies to assess gonadal morphology. Treatment strategies included attempted varicocelectomy, pharmacological intervention with amoxapine, and surgical testicular sperm extraction. Additionally, the patient underwent assisted reproductive techniques, specifically intracytoplasmic sperm injection (ICSI), to facilitate pregnancy for his wife. Results: A 32-year-old man could not ejaculate, with post-orgasmic urinalysis revealing minimal sperm presence. Chromosomal analysis confirmed 45,X/46,XY mosaicism. Despite undergoing microsurgical varicocelectomy for clinical varicocele and receiving tricyclic antidepressants, no improvement in semen volume occurred. Imaging studies indicated ejaculatory disorder due to prostate and seminal vesicle aplasia. Consequently, surgical retrieval of testicular sperm was performed, leading to successful pregnancy via ICSI for his wife. Conclusion: Our approach has effectively addressed ejaculatory disorder in 45,X/46,XY mosaic men, resulting in successful pregnancy.

Prostate ductal adenocarcinoma exhibiting a late recurrence in the anterior urethra 13 years post-total prostatectomy: a case report.

BACKGROUND: Prostate ductal adenocarcinoma, a rare histology observed in 0.4-0.8% of all prostate cancers, is treated similarly to acinar adenocarcinoma but tends to have a higher likelihood of metastasis, recurrence, and poorer prognosis. CASE PRESENTATION: A 73-year-old Asian-Japanese male presented with gross hematuria, with investigations revealing a prostate ductal adenocarcinoma. Subsequent radical prostatectomy indicated a Gleason score of 8 with no lymph node metastasis. Despite initial prostate-specific antigen level reductions post-prostatectomy and salvage radiation therapy due to recurring elevated prostate-specific antigen levels, no recurrence was evident until 13 years later. A tumor in the anterior urethra was identified as metastasis of his prostate ductal adenocarcinoma. CONCLUSION: This report presents an uncommon case of prostate ductal adenocarcinoma exhibiting a late recurrence in the anterior urethra 13 years post-radical prostatectomy.

[A suspected case of extra-gonadal germ cell tumor complicated with choriocarcinoma syndrome].

Our patient was a 31-year-old man who presented with right flank pain. Computed tomography revealed multiple tumors in the liver and lungs, with marked elevation of serum human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) levels. In addition, no testicular abnormalities were detected by palpation or ultrasonography. On the bases of these results, the patient was diagnosed with extragonadal germ cell tumor and was therefore started on chemotherapy with bleomycin, etoposide, and cisplatin (BEP). However, the result of a subsequent blood test showed marked pancytopenia at the initial stage of treatment. We speculated that the cause of anemia was not only bone marrow suppression but also intratumoral hemorrhage, collectively termed choriocarcinoma syndrome. After conservative treatment involving blood transfusion and administration of granulocyte colony-stimulating factor, he recovered. After several chemotherapy sessions, the levels of all tumor markers returned to normal. Finally, the patient underwent hepatectomy for residual tumors ; but, the resected specimen showed no viable cancer cells. Currently, the patient is free from disease since the last chemotherapy session, administered 5 months ago.

A Case of Kidney Transplantation from a Deceased Donor with Acute Kidney Injury due to Rhabdomyolysis.

Acute kidney injury (AKI) due to rhabdomyolysis occurs because of renal ischemia or acute tubular necrosis due to the deposition of myoglobin casts in the renal tubules. Donors with AKI due to rhabdomyolysis are not contraindication for transplantation. However, the dark red kidney raises concerns about renal hypofunction or primary nonfunction after transplantation. We report the case of a 34-year-old man with a 15-year history of hemodialysis for chronic renal failure due to congenital anomalies of the kidney and urinary tract. The patient received a renal allograft from a young woman who suffered cardiac death. The serum creatinine (sCre) level of the donor at the time of transport was 0.6 mg/dL, and renal ultrasonography revealed no abnormalities in renal morphology or blood flow. Her serum creatinine kinase level increased to 57,000 IU/L 58 h after femoral artery cannulation and sCre level worsened to 1.4 mg/dL, suggesting AKI due to rhabdomyolysis. However, since the urine output of the donor was maintained, the sCre elevation was thought to be nonproblematic. The allograft had a dark red appearance at the time of procurement. The perfusion of the isolated kidney was good, but the dark red color did not improve. A 0-h biopsy showed flattening of the renal tubular epithelium and absence of the brush border and myoglobin casts in 30% of the renal tubules. Rhabdomyolysis-related tubular damage was diagnosed. Hemodialysis was discontinued on postoperative day 14. Twenty-four days after the operation, the transplanted kidney function progressed favorably (sCre 1.18 mg/dL), and the patient was discharged. Protocol biopsy 1 month after transplantation showed disappearance of myoglobin casts and improvement in renal tubular epithelial damage. The patient's sCre level was approximately 1.0 mg/dL 24 months after transplantation, and he is doing well without complications.

Comparison of Humoral Response in Kidney Transplant Recipients and Donors and Healthy Volunteers Following Second Dose of SARS-CoV-2 mRNA Vaccine.

PURPOSE: To investigate the kinetics and durability of anti-spike glycoprotein (S) immunoglobulin G (IgG) after the second dose of mRNA-based SARS-CoV-2 vaccine in kidney transplant recipients (recipients) compared with those in kidney donors (donors) and healthy volunteers (HVs) and identify factors negatively associated with SARS-CoV-2 vaccine effectiveness in recipients. METHODS: We enrolled 378 recipients with no history of COVID-19 and no anti-S-IgG before the first vaccine and who received a second mRNA-based vaccine dose. Antibodies were detected using an immunoassay more than 4 weeks after the second vaccine dose. Anti-S-IgG <0.8, ≥0.8 to 15, and ≥15 U/mL were considered negative, weak positive, and strongly positive, respectively, whereas anti-nucleocapsid protein IgG was negative. Anti-S-IgG titer was determined in 990 HVs and 102 donors. RESULTS: Anti-S-IgG titers were 154, 2475, and 1181 U/mL in the recipient, HV, and donor groups, respectively, with values significantly lower in recipients. The anti-S-IgG-positivity rate of recipients gradually increased following the second vaccination, suggesting that recipients had a delayed response compared with the HV and donor groups, who had a 100% positivity rate at an earlier time point. Anti-S-IgG titers decreased in donors and HVs, whereas they remained stable in recipients, although at a significantly lower level. Independent negative factors associated with anti-S-IgG titers in recipients were age >60 years and lymphocytopenia (odds ratio: 2.35 and 2.44, respectively). CONCLUSIONS: Kidney transplant recipients demonstrate delayed and attenuated responses, with lower SARS-CoV-2 antibody titers after the second dose of the mRNA-based COVID-19 vaccine.

[A case of long-term survivor after combined modality therapy for brain metastasis of bladder carcinoma].

A 75-year-old man with advanced bladder cancer (cT4N1M0) received three courses of systemic chemotherapy with Methotrexate, Epirubicin and Nedaplatin (MEN). His metastatic lymph node completely disappeared. We performed total cystectomy. Three months after the surgery, he complained of neck pain and nausea. Brain magnetic resonance imaging (MRI) revealed a 3 cm tumor in his right cerebella and a 5 mm tumor in left parietal lobe. He underwent surgical resection of the right cerebellar tumor and a gamma knife therapy for the left parietal tumor. Pathological diagnosis was metastatic urothelial carcinoma. We performed three additional courses of chemotherapy of MEN. He has been well without local recurrence or distant metastasis for 18 months.