[A Case of Subcutaneous Scrotal Metastasis from Primary Gastric Cancer].

Metastases to the subcutaneous scrotum are extremely rare. Here, we report a 78-year-old man who presented with pain to the scrotum and inguinal area. Two years ago, he underwent total gastrectomy for gastric cancer. The pain was attributed to increased scrotal wall thickness. Incisional biopsy of the thickened scrotal wall revealed diffused infiltration of the subcutaneous tissue by islands of scirrhous type malignant cells. Moreover, immunohistochemical studies showed that the tumor cells were positive for CK7, CK20, and CDX-2. These features suggested a metastatic adenocarcinoma of upper gastrointestinal origin. Although there were no visceral metastases, the tumor cells were too widely spread to be dissected curatively. Palliative chemotherapy with tegafur, gimeracil, and oteracil (S-1) was restarted, and local pain was subsequently ameliorated. Since scrotal metastasis is unlikely to occur it is difficult to diagnose. Therefore, in patients with groin discomfort or swelling and a history of gastric cancer, metastatic adenocarcinoma should be included in the differential diagnosis for early detection of a tumor.

[A Case of Consciousness Disturbance Due to Hyperammonemia Associated with Urinary Tract Infections].

We describe the case of a patient with hyperammonemia owing to urinary tract infections. The patient, a 66-year-old-woman, was previously diagnosed with bilateral hydronephrosis. She was admitted to the emergency room with macrohematuria and bilateral lumbar pain, which persisted for 2 days. She was hospitalized with the diagnosis of pyelonephritis. Despite antibiotic treatment, she developed sudden disturbance in consciousness on the 2nd day of illness. To improve the hyperammonemia and metabolic acidosis, we initiated continuous hemodiafiltration (CHDF) and urinary drainage by bilateral nephrostomy, after which her consciousness improved, and she was discharged on day 19. For patients with urinary tract infections and who are unaware of disturbance in consciousness, it is important to consider that obstructive urinary tract infections can cause hyperammonemia.

Development and external validation of a nomogram to predict high-grade papillary bladder cancer before first-time transurethral resection of the bladder tumor.

BACKGROUND: The aim of this study was to identify the clinical predictors related to the risk of high-grade papillary bladder cancer before first-time transurethral resection of a bladder tumor (TUR-Bt), and to develop and validate a nomogram predicting the risk of high-grade papillary bladder cancer. METHODS: A retrospective clinical study of consecutive patients who underwent first-time TUR-Bt for papillary bladder cancer was performed. Medical records were reviewed uniformly, and the following data were collected: age, sex, episodes of urinary symptoms, tumor size, number of tumors, location of the largest tumor (lateral walls, base, posterior wall, dome, and anterior wall), tumor appearance (papillary or non-papillary, pedunculated or sessile), and urinary cytology. Data from 254 patients (Group A) were used for the development of a nomogram, while data from 170 patients (Group B) were used for its external validation. RESULTS: High-grade papillary bladder cancer was pathologically diagnosed in 51.6 and 74.6% of Group A and Group B patients, respectively. Based on univariable analyses in Group A, macrohematuria, tumor size, multiple tumors, appearance, and positive urinary cytology were selected as variables to incorporate into a nomogram. The AUC value was 0.81 for the internal validation (Group A), and 0.78 for the external validation (Group B). This novel nomogram can predict high-grade papillary bladder cancer accurately. CONCLUSIONS: The present nomogram can help clinicians calculate the probability in patients with bladder cancer before TUR-Bt and decide on earlier intervention and priorities for the treatment of patients diagnosed with bladder cancer.

Clinical outcomes of second transurethral resection in non-muscle invasive high-grade bladder cancer: a retrospective, multi-institutional, collaborative study.

BACKGROUND: A retrospective, multi-institutional collaborative study was conducted to evaluate the impact of second transurethral resection (TUR) on the clinical outcome of non-muscle invasive high-grade bladder cancer and to identify predictors of invasion to the lamina propria (pT1) or deeper and residual tumor at the second TUR. METHODS: The clinical and pathological features of 198 patients with non-muscle invasive high-grade bladder cancer treated in five medical institutions from April 1990 to March 2013 were reviewed retrospectively. All patients underwent a second TUR within a mean of 1.5 months after the first resection. Clinicopathological findings of the first and second TURs were compared. Cancer-specific survival and recurrence-free survival were evaluated. Univariate and multivariate analyses for predictors of residual cancer at the second TUR were performed using a logistic regression model. RESULTS: At the second TUR, no tumor was found in 111 (56 %) patients, and 87 (44 %) had residual cancer. At the first TUR, five pT1 patients (3 %) were upstaged to pT2, one pTa patient (1 %) was upstaged to pT1, and 12 G2 patients (6 %) had their tumor upgraded to G3. Patients the group with less than stage pT1 cancer at the second TUR had significantly better survival than those in the group with stage pT1 or deeper cancer. Tumor multiplicity at the first resection was an independent risk factor for pT1 or deeper tumor at the second TUR. CONCLUSION: A second TUR is a valuable diagnostic procedure for accurate staging of non-muscle invasive high-grade bladder cancer. Tumor multiplicity at the first TUR was a significant independent predictor of pT1 or deeper tumor at the second TUR.

[Comparison of the Conventional Centrifuged and Filtrated Preparations in Urine Cytology].

The urine cytology test is one of the most important tools for the diagnosis of malignant urinary tract tumors. This test is also of great value for predicting malignancy. However, the sensitivity of this test is not high enough to screen for malignant cells. In our laboratory, we were able to attain a high sensitivity of urine cytology tests after changing the preparation method of urine samples. The differences in the cytodiagnosis between the two methods are discussed here. From January 2012 to June 2013, 2,031 urine samples were prepared using the conventional centrifuge method (C method) ; and from September 2013 to March 2015, 2,453 urine samples were prepared using the filtration method (F method) for the cytology test. When the samples included in category 4 or 5, were defined as cytological positive, the sensitivities of this test with samples prepared using the F method were significantly high compared with samples prepared using the C method (72% vs 28%, p＜0.001). The number of cells on the glass slides prepared by the F method was significantly higher than that of the samples prepared by the C method (p＜0.001). After introduction of the F method, the number of f alse negative cases was decreased in the urine cytology test because a larger number of cells was seen and easily detected as atypical or malignant epithelial cells. Therefore, this method has a higher sensitivity than the conventional C method as the sensitivity of urine cytology tests relies partially on the number of cells visualized in the prepared samples.

External validation and comparison of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology in two patient populations: a retrospective cohort study.

The aim of this study is to validate and compare the predictive accuracy of two nomograms predicting the probability of Gleason sum upgrading between biopsy and radical prostatectomy pathology among representative patients with prostate cancer. We previously developed a nomogram, as did Chun et al. In this validation study, patients originated from two centers: Toho University Sakura Medical Center (n = 214) and Chibaken Saiseikai Narashino Hospital (n = 216). We assessed predictive accuracy using area under the curve values and constructed calibration plots to grasp the tendency for each institution. Both nomograms showed a high predictive accuracy in each institution, although the constructed calibration plots of the two nomograms underestimated the actual probability in Toho University Sakura Medical Center. Clinicians need to use calibration plots for each institution to correctly understand the tendency of each nomogram for their patients, even if each nomogram has a good predictive accuracy.

[An infected renal cyst communicating with the urinary tract: a case report].

A 36-year-old man presented with fever and right backache. Abdominal computed tomographic scan revealed a right renal cyst, with a maximum diameter of 12 cm, and surrounded by a hyperdense area of perirenal fat tissue. The cyst appeared to be infected. Accordingly, we performed a percutaneous puncture of this cyst, and drained the fluid. The brown and cloudy fluid gradually became clear, the fluid volume increased a few days after the drainage. A communication between the infected cyst and urinary tract was suspected ; retrograde pyelography confirmed the presence of fistulas. The urine was drained, ＞ 600 ml per day, for four weeks. Surgical resection of the cyst wall and closure of the fistulas were performed as an additional treatment. A year after the open surgical procedure, the renal cyst did not recur, and his renal function has been normal.

[Clinical impact of peripheral lymphocyte counts for metastatic urothelial carcinoma patients treated with chemotherapy].

Pre-chemotherapeutic factors to assess the prognosis of patients with advanced urothelial carcinoma have not yet been completely established. The immune response of the host to the tumor is lymphocyte dependent. However, the effect of lymphocytes on chemotherapy prognosis is unknown. In this study, we investigated the correlation between pre-chemotherapeutic lymphocyte counts and the clinical characteristics of urothelial carcinoma and determined the effectiveness of lymphocytes as a prognostic predictor for metastatic urothelial carcinoma treated with chemotherapy. Between April 2003 and March 2011, data from 34 patients with unresectable or metastatic urothelial carcinoma were retrospectively subjected to multivariate regression analysis to determine the patient characteristics with independent prognostic significance for survival. The median patient age was 71 ; 21 patients were male and 13 female. The number of primary tumors in the pelvis, ureter, and bladder were four, six, and 24, respectively. Seventeen patients underwent prior curative resections, and visceral metastases at chemotherapy were detected in 14 patients. The median lymphocyte count at chemotherapy was 1,292/ml. Cancer-specific survival was significantly lower in patients with lymphocyte counts ＜1,000/ml than in patients with lymphocyte counts ≥1,000/µl (p＝0. 001). During multivariate analysis, visceral metastasis and lymphocyte counts were independent factors for predicting poor prognosis. In addition, lymphocyte counts of ＜1, 000/ml or positive visceral metastases also affected survival. This information may be useful for identifying patients who are likely to benefit from chemotherapy.

[Syphilitic orchitis: a case report].

Tertiary syphilis is recently a rare disease in Japan. In this paper, we report a rare case of syphilitic orchitis. The patient was in his early forties. The left scrotal contents were swelling and a low echoic nodule measuring about 30 mm in diameter was detected on ultrasonography. Serum alpha fetoprotein, lactate dehydrogenase, and beta subunit of human chorionic gonadotropin were within the normal range, whereas Treponema pallidum hemagglutination assay and rapid plasma reagin were strongly positive. High orchiectomy was performed for suspicion of testicular tumor. Histological findings showed the non-specific inflammatory granuloma with lympho-plasmatic infiltration. It was diagnosed as granulomatous inflammation of left testis caused by syphilis.

[A case of carcinosarcoma of the urinary bladder].

A 66-year-old woman visited our hospital complaining of painful, irritative urinary symptoms and macroscopic hematuria. Cystoscopy revealed a non-papillary tumor covered with necrotic tissue on the right side of the posterior wall of the bladder. Transurethral resection was performed ; histologically, the tumor was found to be composed of carcinomatous and sarcomatous elements. The carcinomatous element consisted of urothelial and squamous cell carcinomas. The sarcomatous element was composed of osteosarcoma, chondrosarcoma and spindle cell sarcoma. Immunohistochemical examination showed that the carcinomatous component was positive for cytokeratin and the sarcomatous component was positive for S-100 protein. The patient underwent total cystectomy with ileal conduit under the diagnosis of carcinosarcoma. Pathological examination showed no residual tumor. She was followed up with no signs of recurrence or metastasis. Computed tomography (CT) at nine months following surgery showed no evidence of recurrence. However, thirteen months after the operation, she complained of lower abdominal pain, and CT demonstrated a bulky intrapelvic tumor and right hydronephrosis. Her condition worsened rapidly and she died one month later.

[A case of urachal carcinoma treated with S-1/CDDP combination chemotherapy].

No established treatment exists for urachal carcinoma,except curative resection,and its prognosis is poor. More than 80% of urachal carcinomas are adenocarcinomas. We report a case of advanced urachal carcinoma treated with S-1 and cisplatin combination (S-1/CDDP) chemotherapy. The patient,a 61-year-old woman,presented with macroscopic hematuria. A tumor was detected on the bladder dome and transurethral resection was performed. Histopathological findings indicated poorly differentiated adenocarcinoma. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels were 3.5 ng/ml and 140 U/ml respectively. Magnetic resonance images indicated an extension of this tumor to the retroperioneal space. Metastasis to her right ischium was suspected from bone scintigraphy results. The tumor was diagnosed as stage IVB (Sheldon's category) urachal carcinoma. After one cycle of S-1/CDDP chemotherapy,the size of the tumor on the bladder dome decreased,after which total cystectomy was performed. The surgical margin of the cystectomy specimen was negative for malignant cells,although poorly differentiated adenocarcinoma was still observed in this specimen. The findings of this study indicate that this therapy might be beneficial for treating advanced urachal carcinomas. This is the second report of successful treatment of advanced urachal carcinoma with S-1/CDDP chemotherapy.

Left ileal conduit: A case report.

INTRODUCTION: When ileal conduit construction is performed for urinary tract drainage during radical cystectomy, the conduit is usually constructed in the right lower abdomen. However, no reports have described ileal conduit construction in the left lower abdomen when it cannot be performed on the right side. In addition, some ingenuity is necessary for construction on the left. CASE PRESENTATION: A 75-year-old woman visited our hospital with chief complaint of gross hematuria. Computed tomography and cystoscopy showed a huge bladder tumor, and blood analysis showed anemia. The patient was treated by radical cystectomy with ileal conduit construction. An ileal conduit was constructed in the left lower abdomen; it was impossible to construct in the right lower abdomen because of the abdominal wall scar hernia due to the past open surgery. CONCLUSION: We herein reported a patient who underwent ileal conduit for urinary diversion on the left side of low abdominal wall.

Incidence of inguinal hernia after prostate surgery: open radical retropubic prostatectomy versus open simple prostatectomy versus transurethral resection of the prostate.

Our objective was to determine the incidence of inguinal hernia (IH) after surgery for prostatic diseases. Medical records of 395 patients who underwent radical retropubic prostatectomy (RRP; n = 155), open simple prostatectomy (OP; n = 35), or transurethral resection of the prostate (TURP; n = 205) at the Chibaken Saiseikai Narashino Hospital from April 2000 to March 2007 were retrospectively evaluated. The incidence of IH was 23.9% in the RRP group, 18.9% in the OP group, and 2% in the TURP group. Overall, 91.9% in the RRP and 83.3% in the OP group developed an IH within 2 years postoperatively. The laterality of IH after open surgery was mainly on the right side. Subclinical IH were seen in 25% of RRP cases. The existence of subclinical IH was the only significant risk factor for postoperative IH in this analysis. Furthermore, OP and RRP procedures significantly increased the risk of postoperative IH compared with TURP. The hernia-free ratios were significantly lower after RRP and OP than after TURP (vs RRP: P < 0.001; vs OP: P < 0.001). Our findings confirm that a lower abdominal incision itself is associated with postoperative IH in patients undergoing prostate surgery. Attention must be paid to pre-existing subclinical IH through careful preoperative assessment. Patients should be followed for more than 2 years due to the high incidence of postoperative IH.

External validation and head-to-head comparison of Japanese and Western prostate biopsy nomograms using Japanese data sets.

The objective of this study was to perform external validation of a previously developed prostate biopsy nomogram (the CHIBA nomogram) and to compare it with previously published nomograms developed in Japanese and overseas populations. Two different cohorts of patients were used: one from the Chiba Cancer Center (n = 392) in which transperineal 16-core biopsy was performed, and another from Chibaken Saiseikai Narashino Hospital (n = 269) in which transrectal 16-core biopsy was carried out. All patients were Japanese men with serum prostate-specific antigen levels less than 10 ng/mL. The predictive accuracy of our CHIBA nomogram and of four other published nomograms (Finne's sextant biopsy-based logistic regression model, Karakiewicz's sextant biopsy-based nomogram, Chun's 10-core biopsy-based nomogram and Kawakami's three-dimensional biopsy-based nomogram) was quantified based on area under the curve derived from receiver operating characteristic curves. Head-to-head comparison of area under the curve values demonstrated that our nomogram was significantly more accurate than all other models except Chun's (P = 0.012 vs Finne's, P = 0.000 vs Karakiewicz's, and P = 0.003 vs Kawakami's). Our nomogram appears to be more useful for the Japanese population than Western models. Moreover, external validation demonstrates that its predictive accuracy does not vary according to biopsy approach. This is the first report to demonstrate that the predictive accuracy of a nomogram is independent from the biopsy method.

Repeated spontaneous migration of ureteral stent in hemiplegia patient during ureteral stone treatment.

A 48-year-old man with a history of cerebral infarction presented with gross hematuria. The patient's limping accompanies twisting trunk on his walking. The diagnosis was right upper ureteral stone. Prior to Extracorporeal shockwave lithotripsy (ESWL) ureteral stent was inserted. After the second ESWL ureteral stent was displaced upwardly without patient's unknown. Retrograde intrarenal surgery (RIRS) was performed for both removal of ureteral stent and fragmentation of residual stone. Spontaneously, post RIRS ureteral stent was migrated upwardly to the same position. Ureteral stent migration is uncommon. Twisting walk may cause the position of ureteral stent upwardly.

[Clinical impact of body mass index on prostate biopsy in patients with intermediate PSA levels].

From April 2005 to September 2007, 480 patients underwent transrectal prostate biopsy at our institution. The clinical data including age, serum prostate specific antigen (PSA) level, prostate volume and body mass index (BMI) were obtained, and the cancer detection rates and pathological findings were evaluated in 305 cases with a PSA concentration of 4.0 to 10.0 ng/ml. Prostate volume was calculated from magnetic resonance imaging (MRI) findings. The 305 patients were categorized according to their BMI into three groups (normal, less than 22 kg/m2 ; overweight, 22-25 kg/m2 ; and obese, more than 25 kg/m2). Cancer detection rates and histopathologic findings were compared between the groups. Multivariate logistic regression analysis was also performed. Prostate cancer was detected in 127 patients. No significant differences in BMI were observed between biopsy-positive and biopsy-negative cases (p = 0.965), and the detection rates of prostate cancer observed in the three groups were not significantly different. There was a significant association between BMI and the findings of high Gleason score (more than 4+3) (p = 0.048). BMI was not a contributory factor of prostate cancer detection for cases with intermediate PSA levels; however, patients with high BMI may have high-grade malignancy features.

[Regression of mucosa-associated lymphoid tissue lymphoma of the bladder after antibiotic therapy: a case report].

A 69-year-old woman presented with macroscopic hematuria and severe anemia. Cystoscopy revealed flat edematous mucosa with continuous bleeding. Transurethral coagulation and a biopsy of the urinary bladder were performed. Histopathological examination of the biopsy revealed non-Hodgkin's lymphoma of the mucosa-associated lymphoid tissue (MALT) type. Results of a computed tomography scan and gallium scintigraphy suggested that it was a primary malignant lymphoma of the urinary bladder. A urinary tract infection was found and she was treated with antibiotics for 2 weeks. Because of the detection of a Helicobacter pylori (HP) infection in the gastric mucosal biopsy specimens, the patient was subsequently administered HP eradication therapy. Consequently, the lymphoma disappeared and the woman has had no tumor recurrence for the past 25 months.

[Predicting blood loss during radical prostatectomy using internal pelvimetry].

We retrospectively evaluated the possibility of predicting estimated blood loss (EBL) in 39 consecutive patients undergoing retropubic radical prostatectomy (RRP) using pelvimetry under a single surgeon at our institution from April 2004 to March 2006. For pelvimetry, the area of pelvic entrance (APE) and view of prostatic apex (VPA) were evaluated using preoperative images. Other perioperative data were also recorded, including the patient's age, prostate specific antigen (PSA), body mass index (BMI), use of neoadjuvant hormonal therapy, operative time and pathological data (such as pathological T factor and specimen weight). The relationship between these factors and EBL was analyzed. Average EBL was 761 ml (ranging from 232 to 2,149) and autologous blood transfusion was not performed. There was no statistically significant correlation or difference between EBL and perioperative parameters excluding APE, VPA and BMI. Multivariate analysis showed that the most influential factor for EBL was VPA (p = 0.001). A significantly lower EBL was seen in patients with a wide APE (125 or more), good VPA, and acceptable BMI (less than 25 kg/m2) versus other patients (429 +/- 137 ml vs 934 +/- 358 ml, p < 0.0001). Our findings demonstrate the potential of pelvimetric analysis such as the measurement of APE and the evaluation of VPA, as a useful tool for predicting blood loss during RRP. Moreover, these data also indicate that blood preparation may be spared in patients with acceptable BMI, wide APE, and good VPA.

[Ileovesical fistula caused by bladder cancer with bladder stone].

Enterovesical fistula is a very rare complication of primary urological malignancies. A case of ileovesical fistula caused by a bladder carcinoma is presented. A 66-year-old male was referred with complaints of urinary pain. On admission, fecaluria and urinary tract infection with bladder stone were detected. Cystography revealed the passage of contrast medium into the small bowel. Under the diagnosis ofileovesical fistula due to suspected inflammatory disease, sigmoidectomy and segmental small bowel resection with partial cystectomy were performed. Histological evaluation revealed a poorly differentiated urothelial carcinoma. Without further treatment, the patient died from cancer five months after operation. However, it is hard to assess the effect of fistulas on prognosis. Since it has been reported that about 40% of the patients with T4 bladder tumors could be potentially cured with radical resection, we recommend a thorough examination to confirm the diagnosis of primary disease to obtain the best results.