Comparisons of in-hospital fee and surgical outcomes between robot-assisted, laparoscopic, and open radical cystectomy: a Japanese nationwide study.

OBJECTIVE: To evaluate in-hospital fees and surgical outcomes of robot-assisted radical cystectomy (RARC), laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC) using a Japanese nationwide database. METHODS: All data were obtained from the Diagnosis Procedure Combination database between April 2020 and March 2022. Basic characteristics and perioperative indicators, including in-hospital fees, were compared among the RARC, LRC and ORC groups. Propensity score-matched comparisons were performed to assess the differences between RARC and ORC. RESULTS: During the study period, 2931, 1311 and 2435 cases of RARC, LRC and ORC were identified, respectively. The RARC group had the lowest in-hospital fee (median: 2.38 million yen), the shortest hospital stay (26 days) and the lowest blood transfusion rate (29.5%), as well as the lowest complication rate (20.9%), despite having the longest anesthesia time (569 min) among the three groups (all P < 0.01). The outcomes of LRC were comparable with those of RARC, and the differences in these indicators between the RARC and ORC groups were greater than those between the RARC and LRC groups. In propensity score-matched comparisons between the RARC and ORC groups, the differences in the indicators remained significant (all P < 0.01), with an ~50 000 yen difference in in-hospital fees. CONCLUSIONS: RARC and LRC were considered to be more cost-effective surgeries than ORC due to their superior surgical outcomes and comparable surgical fees in Japan. The widespread adoption of RARC and LRC is expected to bring economic benefits to Japanese society.

Gradual resolution over time of recurrent dystrophic calcification after bipolar transurethral resection of the prostate: A case report.

Dystrophic calcification (DC) after transurethral resection of prostate (TURP) is rare. In our patient, bipolar TURP was performed by an experienced urologist, without complications. Seven months later, he developed a tingling urethral sensation, difficulty in urination, urgency, and perineal discomfort. Computed tomography (CT) showed a high-density area occupying the prostatic resection cavity. Re-surgery involved laser ablation of the DC. Two months later, the DC recurred. At the second re-surgery, the DC was removed without using electricity. Repeat CT at 13 months showed near complete disappearance of the DC. Wound healing might interrupt the vicious cycle of DC recurrence.

Differential treatment responses to immune checkpoint inhibitor (ICI) therapy in a case of multiple primary malignancies: the programmed death ligand-1 (PD-L1) negative ureteral and lung metastasis from a clear cell renal cell carcinoma appearing after robotic-assisted partial nephrectomy progressed after ICI therapy, while synchronous PD-L1-positive primary lung squamous cell carcinoma responded very well to ICI therapy: a case report.

BACKGROUND: Renal cell carcinoma (RCC) and non-small cell lung cancer (NSCLC) are representative malignancies that respond well to immune checkpoint inhibitors (ICIs). Research has been conducted to identify biomarkers, such as programmed death ligand-1 (PD-L1), that would allow the response to ICI therapy to be predicted; however, the complex tumor immune system consisting of both host and tumor factors may also exert an influence. CASE PRESENTATION: Computed tomographic imaging (CT) incidentally revealed a left renal mass, and a left pulmonary nodule with multiple lymph node metastases (LNMs). Firstly, video-assisted thoracic surgery revealed a lung tumor invading the chest wall. Histologically, the findings of the tumor were consistent with squamous cell carcinoma (SCC), and immunohistochemistry (IHC) showed positive PD-L1 expression. The renal tumor was excised by robotic-assisted partial nephrectomy (RAPN). Histologically, the renal tumor showed the features of clear cell carcinoma (CCC). Four months after the RAPN, CT revealed left hydronephrosis caused by an enhancing ureteral tumor. Then, multiple right lung metastases appeared, and the left lung tumor increased. Following treatment including atezolizumab, the primary lung SCC and the multiple LNMs almost disappeared completely, while the ureteral and right lung metastases showed progression. The ureteral metastasis was resected by left open nephroureterectomy. Histology of the ureteral tumor revealed features consistent with CCC. Histological examination of the multiple right lung metastases that were resected by partial lobectomy via a small thoracic incision also revealed features consistent with CCC. Two months after nephroureterectomy, a solitary left lung metastasis was treated by nivolumab and ipilimumab. Six months after nephroureterectomy, the patient died of RCC. Further studies of specimens revealed that the tumor cells in the primary RCC and the ureteral and lung metastases showed negative results of IHC for PD-L1. CONCLUSIONS: The responses to ICI therapy of concomitant RCC and NSCLC were quite different. The PD-L1 expression status in individual tumors in cases of multiple primary malignancies (MPMs) may directly predict the response of each malignancy to ICI therapy, because the host immune system, which may affect the response to ICI therapy, could be the same in MPMs.

Bladder metastasis with additional metastases in multiple other organs 4 years after radical nephrectomy for clear cell renal cell carcinoma: a case report and review of the literature.

BACKGROUND: Renal cell carcinoma rarely metastasizes to the bladder, and its biological behavior is not yet fully understood. CASE PRESENTATION: In our case (54-year-old Japanese woman), computed tomography evaluation suggested the presence of a bladder metastasis, associated with additional metastases in the lungs, mediastinal lymph nodes, ribs, and renal bed, 4 years after radical nephrectomy for renal cell carcinoma. The histological findings of the metastatic bladder tumor were consistent with those of clear cell carcinoma. The mediastinal lymph node, rib, and renal bed metastases responded to treatment with an immune checkpoint inhibitor administered for 12 months after surgery for the bladder and lung metastases. In patients with bladder metastasis, absence of metastases in other organs and an interval of more than 1 year after nephrectomy are known to be favorable prognostic factors. Interestingly, in our case, the bladder metastasis was detected more than 1 year after nephrectomy, which was a favorable factor, but there were also metastases in other organs, which was an unfavorable factor. Therefore, we reviewed the literature, including that pertaining to targeted therapy and immune checkpoint inhibitor therapy published in the last two decades, to analyze the clinical significance of the presence of additional metastasis in other organs in renal cell carcinoma (clear cell type, which is the predominant subtype) patients with bladder metastasis. CONCLUSIONS: Patients with bladder metastasis after nephrectomy for renal cell carcinoma also having metastases in other organs may respond to targeted therapy and immune checkpoint inhibitor therapy. This may suggest that the interval to relapse in the bladder after nephrectomy may be a more important prognostic factor than the presence of synchronous metastases in other organs.

Disseminated kidney tuberculosis complicating autosomal dominant polycystic kidney disease: a case report.

Mycobacterium tuberculosis infection in patients with autosomal dominant polycystic kidney disease (ADPKD) is rare, and its diagnosis and treatment are difficult because numerous cysts are exposed to infection and antibiotics do not easily penetrate infected cysts. Here, we report the case of a 43-year-old Japanese man with disseminated urogenital tuberculosis (TB) and ADPKD without human immunodeficiency virus (HIV) infection. Delayed diagnosis and ineffective anti-TB chemotherapy worsened his condition. Finally, he underwent bilateral nephrectomy but experienced postoperative complications. In conclusion, kidney TB should be recognized as a cause of renal infection in ADPKD, and surgical treatment should be instituted without delay. The importance of early diagnosis and treatment cannot be overemphasized to prevent kidney TB deterioration.

Effects of steroidal and non-steroidal antiandrogens on wild-type and mutant androgen receptors.

BACKGROUND: Molecular basis for secondary antiandrogen therapy in prostate cancer with mutant androgen receptors (ARs) is not fully elucidated. MATERIALS AND METHODS: Effects of steroidal and non-steroidal antiandrogens on transcriptional activities of wild-type and mutant (W741C, T877A, and W741C+T877A) ARs were measured. Crystal structure analysis and docking studies were performed using Molecular Operating Environment (MOE) package. RESULTS: DHT-induced transcriptional activity of the T877A mutant and the W741C mutant was suppressed by bicalutamide and hydroxyflutamide, respectively. Nilutamide suppressed the W741C mutant and the double mutant. Cyproterone acetate modestly inhibited the W741C mutant and the double mutant. The structural studies suggested that nilutamide and cyproterone acetate retain their antiandrogenic properties against both the W741C mutant and the double mutant due to fact that mutation W741C does not permit formation of key hydrophobic interaction between ligand and AR ligand binding domain, which is necessary for their conversion into agonists. CONCLUSIONS: Switching antiandrogens may be reasonable in prostate cancer with mutant ARs.

HSP60 may predict good pathological response to neoadjuvant chemoradiotherapy in bladder cancer.

BACKGROUND: Heat shock proteins (HSPs) play crucial roles in cellular responses to stressful conditions. Expression of HSPs in invasive or high-risk superficial bladder cancer was investigated to identify whether HSPs predict pathological response to neoadjuvant chemoradiotherapy (CRT). METHODS: Immunohistochemistry was used to assess expression levels of HSP27, HSP60, HSP70, HSP90 and p53 in 54 patients with invasive or high-risk superficial bladder cancer, prior to low-dose neoadjuvant CRT, followed by radical or partial cystectomy. Patients were classified into two groups (good or poor responders) depending on pathological response to CRT, which was defined as the proportion of morphological therapeutic changes in surgical specimens. Good responders showed morphological therapeutic changes in two-thirds or more of tumor tissues. In contrast, poor responders showed changes in less than two-thirds of tumor tissues. RESULTS: Using a multivariate analysis, positive HSP60 expression prior to CRT was found to be marginally associated with good pathological response to CRT (P = 0.0564). None of clinicopathological factors was associated with HSP60 expression level. In the good pathological responders, the 5-year cause-specific survival was 88%, which was significantly better than survival in the poor responders (51%) (P = 0.0373). CONCLUSIONS: Positive HSP60 expression prior to CRT may predict good pathological response to low-dose neoadjuvant CRT in invasive or high-risk superficial bladder cancer.

Possible involvement of bone morphogenetic protein 2 in heterotopic ossification in metastatic lesion from urothelial carcinoma of bladder.

Heterotopic bone formation caused by urothelial carcinoma is rare. The precise mechanism of heterotopic ossification is still unknown. We report a case of urothelial carcinoma with heterotopic bone formation in a metastatic site and investigate the expression of bone morphogenetic protein 2 (BMP-2) and the BMP receptor (BMPR)-Ib using immunohistochemistry. Positive staining of BMP-2 was observed in the cytoplasm of tumor cells in both bladder and psoas lesions. In addition, positive staining of BMPR-Ib was seen in osteoblast-like cells adjacent to bone formation in the psoas metastasis. The heterotopic ossification may result from the metaplasia of pluripotent stem cells into osteoblast cells induced by BMP-2 in a paracrine fashion.

[A case of sarcomatoid carcinoma in the region of the female urethra].

A 78-year-old woman was presented with bleeding in the region of the genitalia. The tumor arose from the urinary meatus and biopsy was performed. The pathological examination revealed sarcomatoid carcinoma which was composed of squamous cell carcinoma and spindle cell sarcoma. She underwent urethrectomy and suprapubic cystostomy. She is alive at 26-month follow-up, after local radiation therapy of 50 Gy to the recurrence sites.

[Bladder stone formation caused by a Stamey cuff as the nidus indwelt 16 years ago].

Although foreign bodies left in the body may remain asymptomatic for long periods, they may also cause various complications. We present a case of a Stamey cuff placed in the retroperitoneal space, which remained asymptomatic for 16 years in a 62-year-old woman. When a vesical calculi formed, it caused voiding pain in the lower abdomen. She underwent transurethral cystolitholapaxy. The nidus of the stone was a Stamey cuff used in the Stamey procedure performed 16 years before. Open cystotomy was needed to remove it. Convalescence was uneventful and she had no complaints on urination. The possibility of calculous formation should be raised when there are symptoms on urination in a female with a history of pelvic surgery.

[Male infertility in an adult with unilateral Leydig cell tumor of the undescended testis].

We report a case of Leydig cell tumor of the postpubertal cryptorchid testis with the chief complaint of male infertility. A 36-year-old man had consulted another clinic and his semen analysis revealed oligospermia. A solid mass was palpated in the right inguinal undescended testis. He was referred to our hospital for treatment of the testicular tumor. Right inguinal orchiectomy was performed and pathological diagnosis was Leydig cell tumor with no malignant findings. After the surgery improvement was seen in his semen analysis. There was no evidence of recurrence 9 months after surgery.