Robotic-assisted partial nephrectomy for a neuroendocrine tumor in a horseshoe kidney: a case report.

Neuroendocrine tumors of the kidney are exceedingly rare. We report the first case of robotic-assisted partial nephrectomy for such tumors in horseshoe kidneys. A 65-year-old woman was incidentally found to have a 27 mm renal mass in the isthmus of her horseshoe kidney during computed tomography. Based on contrast-enhanced computed tomography results, we initially suspected renal cell carcinoma originating from the horseshoe kidney. Subsequently, robotic-assisted partial nephrectomy with isthmus transection was performed. Intraoperatively, we adjusted the port position for camera insertion and the patient's positioning to facilitate better visualization for dorsal isthmus and vessel dissection. Pathological examination and immunohistochemical analysis revealed a well-differentiated neuroendocrine tumor. Therefore, robotic-assisted partial nephrectomy is a safe and effective approach for managing neuroendocrine tumors in the isthmus of horseshoe kidneys. Given the nonspecific clinical presentation of renal neuroendocrine tumors and their rarity, the optimal management of these tumors remains controversial.

A case of successful treatment of Fournier's gangrene through conservative management and elective debridement.

Introduction: Fournier's gangrene refers to a necrotizing fasciitis that mainly affects the perineal region and a condition that requires immediate debridement. This case involved elective debridement of Fournier's gangrene after the general condition was improved through antibiotic treatment instead of requesting an emergency debridement. Case presentation: The patient was an 85-year-old man with a performance status of 4 admitted to a nursing home. He was transferred by ambulance with a fever. Blood tests showed a markedly elevated inflammatory response, and computed tomography revealed widespread aerodermectasia around the right testis to the lower abdomen. The patient was diagnosed with Fournier's gangrene. However, his family declined emergency surgical debridement. The patient's general condition was improved with antibiotics, and debridement was eventually performed. After 52 days of hospitalization, the patient was transferred to another hospital. Conclusion: This study describes the successful treatment of Fournier's gangrene through conservative treatment followed by elective debridement.

Association of lung immune prognostic index with survival outcomes in patients with metastatic renal cell carcinoma treated with nivolumab plus ipilimumab.

OBJECTIVE: Lung immune prognostic index is based on derived neutrophil-to-lymphocyte ratio and lactate dehydrogenase level. Lung immune prognostic index has reported association with survival outcomes in patients with various malignancies undergoing treatment with immune checkpoint inhibitors. However, the prognostic impact of pre-treatment lung immune prognostic index in patients with metastatic renal cell carcinoma receiving nivolumab plus ipilimumab treatment remains unclear. This study examines the association between lung immune prognostic index and outcomes in this setting. METHODS: We retrospectively evaluated 156 patients with metastatic renal cell carcinoma treated with nivolumab plus ipilimumab at eight institutions. We assessed the associations between pre-treatment lung immune prognostic index and survival outcomes including progression-free survival, second progression-free survival (PFS2), cancer-specific survival and overall survival. RESULTS: Patients were classified into good (n = 84, 54%), intermediate (n = 52, 33%) and poor (n = 20, 13%) lung immune prognostic index groups. Progression-free survival did not significantly differ between lung immune prognostic index groups, but there was significant difference in PFS2, cancer-specific survival and overall survival. In multivariable Cox proportional hazard analyses, high pre-treatment lung immune prognostic index was a significant predictor of poor PFS2 (vs. good group, intermediate group: P = 0.01 and poor group: P = 0.04) and poor overall survival (vs. good group, intermediate group: P = 0.01 and poor group: P < 0.01). Moreover, the patients with poor lung immune prognostic index had significantly poorer cancer-specific survival than those with good LIPI (P < 0.01). CONCLUSIONS: High pre-treatment LIPI is suggested by our results to be a significant independent predictor of poor prognosis in patients receiving nivolumab plus ipilimumab for metastatic renal cell carcinoma.

Effects of thienopyridine class antiplatelets on bleeding outcomes following robot-assisted radical prostatectomy.

This study aimed to assess the effects of thienopyridine-class antiplatelet agents (including ticlopidine, clopidogrel, and prasugrel) on bleeding complications in patients who underwent robot-assisted radical prostatectomy. This cohort study used a database for robot-assisted radical prostatectomy at 23 tertiary centers nationwide between 2011 and 2022. Patients who received thienopyridines (thienopyridine group) were compared with those who received aspirin monotherapy (aspirin group). The primary outcome was the incidence of bleeding complications. High-grade complications were defined as Clavien-Dindo grade III or higher. The risks of these outcomes were evaluated using inverse probability of treatment weighted regression models. The study results demonstrated that thienopyridine therapy was associated with a higher risk of overall bleeding complications (OR: 3.62, 95%CI 1.54-8.49). The increased risks of the thienopyridine group were detected for low-grade bleeding complications (OR: 3.20, 95%CI 1.23-8.30) but not for high-grade bleeding complications (OR: 5.23, 95%CI 0.78-34.9). The increased risk of bleeding complications was not observed when thienopyridine was discontinued (OR: 2.52, 95%CI 0.83-7.70); however, it became apparent when it was continued perioperatively (OR: 4.35, 95%CI 1.14-16.61). In conclusion, thienopyridine increased the incidence of bleeding complications, particularly low-grade bleeding complications, following robot-assisted radical prostatectomy. These bleeding effects emerged when thienopyridine was continued perioperatively.

A case of one-stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury associated with infected urinoma.

Introduction: Iatrogenic ureteral injury is a rare but often encountered complication of abdominal and gynecological surgery. This is a case of iatrogenic ureteral injury with infected urinoma treated with one-stage laparoscopic drainage and ureterocystoneostomy. Case presentation: An 80-year-old man with rectal cancer had robot-assisted low anterior rectum resection and left lateral lymph node dissection after colostomy and preoperative chemoradiotherapy. On the 14th postoperative day, he had a fever, and a noncontrast-enhanced computed tomography scan revealed a low-density polycystic area in the left pelvic cavity. Retrograde pyelography revealed contrast medium leaking from the left lower ureter, preventing ureteral stent placement. We identified it as a delayed ureteral injury with infected urinoma and performed laparoscopic one-stage drainage and ureterocystoneostomy. Conclusion: This study reported a case of one-stage laparoscopic drainage and ureterocystoneostomy for iatrogenic ureteral injury with infected urinoma.

Volatile Sulfur Compounds Produced by the Anaerobic Bacteria Porphyromonas spp. Isolated from the Oral Cavities of Dogs.

Porphyromonas spp. are oral anaerobic Gram-negative bacteria that form black-pigmented colonies on blood agar and produce volatile sulfur compounds (VSCs), such as hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide ((CH3)2S), which cause halitosis and the destruction of periodontal tissues. P. gulae is considered the main pathogen involved in periodontal disease in dogs. However, the characteristics of the VSCs produced by P. gulae are unknown. In the present study, VSCs were measured in 26 isolates of P. gulae and some isolates of the other Porphyromonas spp. obtained from the oral cavities of dogs with periodontal disease using an in vitro assay with an Oral ChromaTM gas chromatograph. The results demonstrated that P. gulae was able to produce large amounts of H2S and CH3SH, and the dominant product was CH3SH (CH3SH/H2S was approximately 2.2). Other Porphyromonas spp. that were also obtained from the oral cavities of dogs with periodontal disease indicated similar levels of production of H2S and CH3SH to those of P. gulae. It is strongly suggested that the high levels of H2S and CH3SH produced by P. gulae and other Porphyromonas spp. contribute to halitosis and the destruction of periodontal tissues during the progression of periodontal disease in dogs.

Bladder paraganglioma: A case of acute respiratory distress syndrome triggered by large bladder tumor transurethral resection with mild symptoms and atypical imaging.

Introduction: Bladder paraganglioma is exceedingly rare, accounting for <0.05% of bladder tumors. This is a case of paraganglioma with no symptom other than palpitations during urination, with atypical imaging, resulting in acute respiratory distress syndrome after transurethral resection of the bladder tumor. Case presentation: A 46-year-old man underwent transurethral resection of the bladder tumor for a bladder tumor 61 × 52 mm in size on contrast-enhanced computed tomography. The patient only had micturition attacks and was suspected to have urothelial carcinoma on magnetic resonance imaging. The patient had acute respiratory distress syndrome after the operation which improved conservatively. The 123Iodine metaiodobenzylguanidine scintigraphy, urinalysis, and pathological examination revealed bladder paraganglioma. Robot-assisted radical cystectomy and ileal neobladder reconstruction were performed. Conclusion: This study reported bladder paraganglioma with no symptoms other than micturition attacks in which acute respiratory distress syndrome occurred after transurethral resection of the bladder tumor.

Molecular prevalence and zoonotic potential of trichomonads from oral cavities in household dogs.

This study investigated the molecular prevalence of oral trichomonads in household dogs. Of the 144 dogs, 21 (14.6%, 21/144) tested positive for oral trichomonads. The prevalence was significantly higher in dogs with severe gingivitis (gingival index 3: 30.0%, 8/26) than that in normal dogs (gingival index 0: 2.7%, 1/37). Therefore, an interaction between oral trichomonads and the development of periodontal disease is suggested. Of the 21 positive samples, 16 isolates were T. brixi, four isolates were T. tenax, and one was Tetratrichomonas sp. Considering T. tenax is recognized as a zoonotic agent, transmission between dogs and humans cannot be neglected.

[Needle Lost during Robot-Assisted Laparoscopic Radical Prostatectomy : A Case Report].

A 66-year-old man, who presented with prostate cancer, underwent robot-assisted laparoscopic radical prostatectomy. During surgery, a suture needle was lost after an assistant surgeon removed it from the AirSeal® access port. We were not able to find the needle using a portable radiograph with no contrast optimization. After disassembling the device, the needle was found in the groove of the port top. It should be acknowledged that the needle can become stuck in the AirSeal® port, even though it does not have a valve structure. An X-ray radiograph, with an appropriate gradation setting could be useful to retrieve suture needles.

[Spontaneous Resolution of Renal Artery Pseudoaneurysm after Robotic-Assisted Partial Nephrectomy].

Partial nephrectomy (PN) for small renal tumors has become increasingly common. Complications of PN include renal artery pseudoaneurysm (PA), a potentially life-threatening condition. However, the true incidence and natural history of PA after PN remain unclear. Therefore, we conducted a retrospective study of the radiographic characteristics of robotic-assisted partial nephrectomy (RAPN) observed during the postoperative period. We selected 36 consecutive patients with renal carcinoma who underwent RAPN at our institution between December 2016 and May 2019. Patients with contraindications for the use of contrast medium were excluded. A total of 31 eligible patients underwent computed tomography angiography (CTA) during the early postoperative period after RAPN and the incidence of PA was evaluated. Among the patients with PASs, asymptomatic PAs were followed without intervention and their clinical course was assessed using CTA at 1 to 3 months postoperatively. PA was identified in 5 out of 31 (16.1%) patients after RAPN. Median duration between PN and the first CTA was 6 days (range, 1-8). Median PA size was 13 mm (range, 8-17). All (100%) PAs were asymptomatic and resolved spontaneously, as verified by CTA during the late postoperative period. Median duration between identification of PA on early postoperative CTA and subsequent resolution was 92 days (range, 35-106). Our findings indicated that asymptomatic PA after PN can be followed without intervention.

Urethral Tuberculosis: A Forgotten Cause of Urethral Stricture.

We describe the clinical features of a 75-year-old man who presented to our hospital with frequent urination for 3 months. Retrograde urethrography showed extended and continuous narrowing of the stricture in the anterior urethra. Cystourethroscopy showed extended narrowing of the urethral lumen without normal membrane. Urine acid-fast bacillus culture and polymerase chain reaction assays indicated a diagnosis of urethral tuberculosis. Anti-tuberculosis therapy was initiated. Urethral tuberculosis is a very rare cause of urethral stricture in developed countries that can be diagnosed by cystourethroscopy. Urethral tuberculosis should be considered in the differential diagnosis of urethral stricture.

[A Consideration for the Surgical Approach in Laparoscopic Total Pelvic Exenteration after Radiotherapy : A Case Report].

A 66-year-old woman underwent concurrent chemoradiotherapy (CCRT) for stage IIA cervical cancer. However, two recurrent masses were detected at the vaginal stump 6 years after CCRT, and we performed laparoscopic total pelvic exenteration to obtain a complete cure. Because the terminal ileum appeared white secondary to the effects of radiotherapy, we constructed an ileal conduit using the ileum, approximately 40 cm toward the mouth from the ileocecum. We performed transperineal resection of the vagina and urethra and intersphincteric resection as anal-preservation surgery along with transverse colostomy. We used a right short gracilis myocutaneous flap to reconstruct the pelvic floor and perineum. The operation time was 816 min, and the estimated blood loss was 1,168 ml. On histopathological examination of the resected specimen, the parauterine tissue showed a positive surgical margin. Patients with recurrent cervical cancer after CCRT show poor prognosis. Complete resection with a negative margin is associated with more favorable prognosis in patients with recurrent pelvic masses. Compared with an open procedure, laparoscopic pelvic exenteration is safe and feasible in these patients. Selection of an optimal surgical approach, urinary diversion, and pelvic floor reconstruction is important for complete resection and prevention of perioperative complications.

Complete atrioventricular dissociation and sinus arrest after pheochromocytoma resection.

INTRODUCTION: Although preoperative bradycardia has been reported in several pheochromocytoma cases, postoperative bradycardia has not. This is the first case report of complete atrioventricular dissociation and sinus arrest occurring after pheochromocytoma resection. CASE PRESENTATION: A 38-year-old woman was referred for a left adrenal incidentaloma. Twenty-four hour urinary collection showed elevated noradrenaline. Iodine-123-meta-iodobenzylguanidine scintigraphy showed high tracer uptake in the left adrenal region. Open left adrenalectomy was performed, and histopathological examination confirmed the diagnosis of pheochromocytoma. Thirty minutes following surgery, complete atrioventricular dissociation and sinus arrest developed. Vagal reflex attenuation due to decreased noradrenaline after tumor removal and perioperative pain and fear were believed to be the causes. A temporary pacemaker was implanted to prevent sudden death due to vagal overstimulation. CONCLUSION: Vagal reflex attenuation after pheochromocytoma resection can result in complete atrioventricular dissociation and sinus arrest. Adequate preoperative preparation and close monitoring during and after surgery are imperative.

Two Applications for Laparoscopic Combined Ventral and Dorsal Side Approach in the Lateral Decubitus Position: (1) Right-Modified Retroperitoneal Lymph Node Dissection, (2) Nephrectomy for Horseshoe Kidney.

BACKGROUND: Laparoscopic retroperitoneal lymph node dissection (RPLND) in metastatic testicular cancer is a technically challenging procedure. In right-modified RPLND, retrocaval lymph nodes are often not visible and cannot be adequately dissected using only the transperitoneal approach. In laparoscopic nephrectomy (LN) for horseshoe kidney, the kidney cannot be sufficiently moved due to its connection to the contralateral kidney, and the isthmus and lower poles have separate blood supplies arising from the aorta or iliac artery. Detection of these vessels is difficult using the transperitoneal approach, and identifying and incising the isthmus is difficult using the retroperitoneal approach. OBJECTIVE: To present a new surgical transperitoneal approach combining the ventral and dorsal sides in the lateral decubitus position. MATERIAL: In laparoscopic RPLND, we recently performed paracaval and retrocaval lymph nodes dissection (LND) from the dorsal side even in the transperitoneal approach. Following inter-aortocaval LND, the surgeon and scopist moved from the ventral to dorsal side of the patient and changed the roles of surgical ports. In this approach, the view on the monitor is similar to that in the retroperitoneal approach. We applied this technique to LN for horseshoe kidney. RESULTS: In RPLND combining ventral and dorsal side approaches, all lymph nodes were visible from various angles and complete dissection became easier without complications. In LN for horseshoe kidney, vessels to the isthmus could not be detected using the ventral side approach only; however, on combining the dorsal side approach all vessels were easily observed. After vessel resection, the median of the isthmus could be incised using the ventral side approach. CONCLUSION: A combined ventral and dorsal side approach is a feasible, safe, and effective technique for laparoscopic right-modified RPLND or nephrectomy for horseshoe kidney.

The third national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from complicated urinary tract infection patients.

The antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using national surveillance data. The data consisted of 881 bacterial strains from eight clinically relevant species. The data were collected for the third national surveillance project from January 2015 to March 2016 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was undertaken with the cooperation of 41 medical institutions throughout Japan. Fluoroquinolone required a MIC90 of 2-64 mg/L to inhibit the 325 Escherichia coli strains tested and the proportion of levofloxacin resistant E. coli strains increased to 38.5% from 29.6% in 2011 and 28.6% in 2008. The proportion of levofloxacin resistant strains of Pseudomonas aeruginosa and Enterococcus faecalis decreased from previous reports and the proportion of multidrug-resistant P. aeruginosa and carbapenem-resistant Enterobacteriaceae remained low. Among methicillin-resistant Staphylococcus aureus (MRSA) strains, strains with reduced susceptibility to vancomycin (minimum inhibitory concentration, 2 µg/mL) increased to 14.7% from 5.5%. Bacterial strains that produced extended-spectrum ß-lactamase included E. coli (79 of 325 strains, 24.3%), Klebsiella pneumoniae (9 of 177 strains, 7.7%), and Proteus mirabilis (6 of 55 strains, 10.9%). The proportion of extended-spectrum ß-lactamase producing E. coli and K. pneumoniae strains increased from previous surveillance reports.

Feasibility of laparoscopic adrenalectomy for metastatic adrenal tumors in selected patients: a retrospective multicenter study of Japanese populations.

BACKGROUND: Because of the small numbers of cases in single centers, the indications for and survival benefits of adrenalectomy for adrenal metastasis remain unclear. We evaluated the outcomes of laparoscopic adrenalectomy for patients with adrenal metastasis. METHODS: We retrospectively analyzed the records of 67 patients who underwent laparoscopic adrenalectomy for metastatic disease from 2003 to 2017 at 11 hospitals. Associations of clinical, surgical, and pathologic features with overall survival (OS) and positive surgical margins were evaluated using univariate and multivariate Cox regression analyses and univariate logistic regression analysis. RESULTS: Lung cancer (30%) and renal cell carcinoma (30%) were the most common primary tumor types. Intraoperative complications were observed in seven patients (10%) and postoperative complications in seven (10%). The surgical margin was positive in 10 patients (15%). The median OS was 3.8 years. Univariate analysis showed that the tumor size, episodes of extra-adrenal metastasis before adrenalectomy, extra-adrenal metastasis at the time of adrenalectomy, and positive surgical margins were significantly associated with shorter OS (p = 0.022, p = 0.005, p < 0.001, and p = 0.022, respectively). Multivariate analysis showed that extra-adrenal metastasis at the time of adrenalectomy and positive surgical margins remained statistically significant (p = 0.022 and p = 0.049, respectively). In the univariate analysis, the tumor size was significantly associated with positive surgical margins (p = 0.039). CONCLUSIONS: Laparoscopic adrenalectomy for adrenal metastasis can be safely performed in selected patients, and patients with isolated adrenal metastasis and negative surgical margins seem to have more favorable outcomes.

[Use of Vacuum-Assisted Closure Therapy in the Treatment of Postoperative Inguinal Lymphocele after Lymphadenectomy for a Vulvar Apocrine Adenocarcinoma : A Case Report].

A 79-year-old man with vulvar apocrine adenocarcinoma and right inguinal lymph node metastasis underwent wide excision and free skin graft reconstruction of the primary lesion and right inguinal lymphadenectomy. However, left inguinal lymph node metastasis was noted after 11 months, and left inguinal lymphadenectomy was performed. Twelve days postoperatively, the patient developed left inguinal lymphocele. The lymphocele was drained percutaneously and compressed, but lymph secretion persisted and lymphocele skin necrosis was observed. Therefore, debridement and vacuum-assisted closure (VAC) therapy were performed in cooperation with the department of plastic surgery. Subsequently, lymph secretion declined and eventually stopped. The lymphocele scar was reconstructed with a free skin graft, and after further observation for 8 months, right lymph node swelling was noted. Nevertheless, on the left inguinal site, neither lymphocele recurrence nor inguinal lymph node metastasis was observed. In conclusion, VAC therapy might be beneficial in the treatment of postoperative inguinal lymphocele after lymphadenectomy.

Impact of tumor size on patient survival after radical nephrectomy for pathological T3a renal cell carcinoma.

PURPOSE: We recently reported the results from a multi-institutional retrospective outcome study involving 814 patients with renal cell carcinomas (RCCs) who had undergone radical surgery and whose diagnoses were confirmed via a central pathological review. This study aimed to clarify the impact of tumor size on survival outcomes in patients with pT3aN0M0 RCC after radical nephrectomy using this cohort. METHODS: Using the Kaplan-Meier method, overall survival (OS), cancer-specific survival (CSS) and relapse-free survival (RFS) were estimated for 103 pT3aN0M0 patients. The differences in the OS, CSS and RFS according to tumor size were evaluated using the log-rank test. To identify independent prognostic factors that affected each survival outcome, clinicopathological factors were examined using univariate and multivariate analyses, and the Cox proportional hazards model. RESULTS: The OS, CSS and RFS rates for 26 patients with pT3a RCCs ≤4 cm were significantly better than those for 77 patients with pT3a RCCs that were 4-7 cm or >7 cm (P = 0.0064, 0.0169 and 0.0001, respectively). Tumor size and venous invasion were independent prognosticators for OS, CSS and RFS. The OS and CSS for patients with pT3a tumors ≤4 cm were comparable with those for patients with pT1 RCCs, and the RFS for patients with pT3a RCCs ≤4 cm was similar to that for patients with pT1b RCCs. CONCLUSIONS: Tumor size significantly influenced the prognosis for patients with pT3aN0M0 RCC. This study's results suggest that the postoperative management of pT3a RCCs could be individualized according to tumor size.

Asymmetric oxidation of 1,3-propanediols to chiral hydroxyalkanoic acids by Rhodococcus sp. 2N.

Rhodococcus sp. 2N was found as a 1,3-propanediols-oxidizing strain from soil samples through enrichment culture using 2,2-diethyl-1,3-propanediol (DEPD) as the sole carbon source. The culture condition of the strain 2N was optimized, and the highest activity was observed when 0.3% (w/v) DEPD was added in the culture medium as an inducer. Chiral HPLC analysis of the hydroxyalkanoic acid converted from 2-ethyl-2-methyl-1,3-propanediol (EMPD) revealed that the strain 2N catalyzed the (R)-selective oxidation of EMPD. The reaction products and intermediates from DEPD and EMPD were identified by nuclear magnetic resonance analyses, and the results suggested that only one hydroxymethyl group of the propanediols was converted to carboxy group via two oxidation steps. Under optimized conditions and after a 72-h reaction time, the strain 2N produced 28 mM (4.1 g/L) of 2-(hydroxymethyl)-2-methylbutanoic acid from EMPD with a molar conversion yield of 47% and 65% ee (R).

[The Safety of Laparoscopic Radical Cystectomy during Initial Phases in a Japanese Multicenter Cohort].

We evaluated the safety of laparoscopic radical cystectomy (LRC) during initial phases and its learning curve in a Japanese multicenter cohort by studying 436 patients who underwent LRC with no robot assistance at 10 institutions in Japan. We divided the patients into three groups according to cumulative surgical volume at each institution (first 10 cases, 11-30 cases, after 31 cases in each institution), and compared perioperative and pathologic variables among the three groups. The first, second, and third groups included 100, 166, 170 patients, respectively. The preoperative variables were similar in the three groups except for the rate of neoadjuvant chemotherapy. The methods of LRC procedure, such as urinary diversion, the extent of lymph node dissection, and concomitant urethrectomy or nephroureterectomy, were similar in the three groups. Mean operative time was 629, 562 and 531 minutes, respectively, and mean blood loss was 755, 650 and 435 ml, respectively. Both values decreased over time with the institution's experience. There was no significant difference among the three groups in the rate of positive surgical margin, the number of retrieved lymph nodes, and the rate of intra- and postoperative complications. LRC was safely performed during initial phases with an acceptable complication rate and without compromising oncological results, although operative time was longer and blood loss increased.