Fourth national Japanese antimicrobial susceptibility pattern surveillance program: Bacterial isolates from patients with complicated urinary tract infections.

INTRODUCTION: Antimicrobial susceptibility patterns of bacterial pathogens isolated from patients with complicated urinary tract infections were analyzed using the national surveillance data, comprising 793 bacterial strains from eight clinically relevant species. MATERIALS AND METHODS: Data were collected for the fourth national surveillance project from July 2020 to December 2021 by the Japanese Society of Chemotherapy, the Japanese Association for Infectious Disease, and the Japanese Society of Clinical Microbiology. Surveillance was supervised with the cooperation of 43 medical institutions throughout Japan. RESULTS: Fluoroquinolone required a minimum inhibitory concentration (MIC) of 2-64 mg/L to inhibit the 330 tested Escherichia coli strains. The proportion of levofloxacin-resistant E. coli strains increased from 28.6% in 2008 to 29.6% in 2011, 38.5% in 2015, and 44.5% in 2021. The proportion of levofloxacin-resistant strains of Pseudomonas aeruginosa also increased from previous survey results, showing a continuing downward trend. Conversely, the proportion of levofloxacin-resistant strains of Enterococcus faecalis decreased relative to previous reports. Neither multidrug-resistant P. aeruginosa nor carbapenem-resistant Enterobacteriaceae were detected. For methicillin-resistant Staphylococcus aureus (MRSA), the proportion of vancomycin-susceptible strains (MIC of 2 µg/mL) decreased from 14.7% to 7.7%. DISCUSSION: Bacterial strains that produced extended-spectrum ß-lactamase included E. coli (82/330 strains, 24.8%), Klebsiella pneumoniae (11/68 strains, 16.2%), and Proteus mirabilis (4/26 strains, 15.4%). As compared to previous surveillance reports, these strains showed an increase in proportion over the years.

Urinary bladder metastasis from breast cancer: A rare case report.

Breast cancer is a major contributor to cancer-related morbidity and mortality in women, which is primarily attributed to metastases. Common metastatic sites include the lungs, liver, and bone, whereas bladder metastasis is rare. We report a case of bladder metastasis from breast cancer in a 61-year-old woman, highlighting the challenges in diagnosis and treatment. The patient, previously diagnosed with invasive lobular carcinoma, presented with renal failure and underwent transurethral resection of bladder tumor. Pathological analysis confirmed metastasis from breast cancer. Bladder metastasis from breast cancer demands vigilance and prompt intervention because of its potential prognostic impact.

[Bladder Cancer Detected Incidentally by Cystoscopy before Radical Prostatectomy].

Radical prostatectomy is the treatment of choice for localized prostate cancer. In our institution, preoperative cystoscopy is performed routinely to clarify the prostate anatomy, including the median lobe and position of ureteral orifices. We conducted a retrospective analysis of 721 patients, from January 2008 to December 2022, our aim being to assess the clinical course of bladder cancer discovered incidentally through cystoscopy prior to radical prostatectomy. We found that bladder cancer was detected in eight of these patients (1.1%), seven of whom had low-grade, non-invasive, papillary urothelial carcinomas ; the remaining patient had a high-grade lesion. Notably, the pathological stage was Ta in all cases. The median duration of follow-up of patients with bladder cancer was initially set at 21 months (12-24 months). During the follow-up period, bladder cancer recurrence was identified in three patients. Patients who remained recurrence-free beyond the follow-up period underwent radical therapy. Importantly, no evidence of prostate cancer progression was detected throughout the follow-up period. Thus, incidental bladder cancer detected prior to radical prostatectomy is predominantly non-invasive, ensuring safe treatment of both the bladder and prostate cancers. Our findings suggest that cystoscopy could be omitted.

Real-world sequential treatment patterns and clinical outcomes among patients with advanced urothelial carcinoma in Japan.

OBJECTIVES: Immune checkpoint inhibitors and enfortumab vedotin have opened new avenues for sequential treatment strategies for locally advanced/metastatic urothelial carcinoma (la/mUC). In the pre-enfortumab vedotin era, many patients could not receive third-line treatment owing to rapid disease progression and poor general status. This study aimed to analyze real-world sequential treatment practices for la/mUC in Japan, with a focus on patients who do not receive third-line treatment. METHODS: We analyzed data for 1023 la/mUC patients diagnosed between January 2020 and December 2021 at 54 institutions from a Japanese nationwide cohort. RESULTS: At the median follow-up of 28.5 months, the median overall survival from first-line initiation for 905 patients who received systemic anticancer treatment was 19.1 months. Among them, 81% and 32% received second- and third-line treatment. Notably, 52% had their treatment terminated before the opportunity for third-line treatment. Multivariate logistic regression analysis revealed that low performance status (≥1), elevated neutrophil-to-lymphocyte ratio (≥3), and low body mass index (<21 kg/m2) at the start of first-line treatment were independent risk factors for not proceeding to third-line treatment (p = 0.0024, 0.0069, and 0.0058, respectively). In this cohort, 33% had one of these factors, 36% had two, and 15% had all three. CONCLUSIONS: This study highlights the high frequency of factors associated with poor tolerance to anticancer treatment in la/mUC patients. The findings suggest the need to establish optimal sequential treatment strategies, maximizing efficacy within time and tolerance constraints, while concurrently providing strong supportive care, considering immunological and nutritional aspects.

Bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy.

Renal cell carcinoma often metastasizes to the adrenals; however, bilateral adrenal metastases are rare. We here report a patient with bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy and review relevant published reports. A 64-year-old man underwent robot-assisted partial nephrectomy for a left renal tumor. During follow-up, he was diagnosed with bilateral adrenal metastases. He underwent left adrenalectomy followed by right partial adrenalectomy to preserve adrenal function. The renal tumor later metastasized to other parts of the body. He continues to receive systemic treatment and remains in partial remission. Patients with pT1aN0M0 renal cell carcinoma generally have a favorable prognosis. However, occasional such patients develop multiple metastases. To the best of our knowledge, this is the first reported case of bilateral adrenal metastases after partial nephrectomy. Clinicians should keep this rare scenario in mind.

[A Case of Aldosterone-Producing Adrenocortical Carcinoma].

A 59-year-old man presented with high blood pressure, hypokalemia and muscle weakness. His aldosterone/renin ratio was high and plasma renin activity was low. Computed tomography (CT) showed a heterogeneous left adrenal mass. Primary aldosteronism was diagnosed and laparoscopic left adrenalectomy was performed. The pathological diagnosis was adrenocortical carcinoma with positive surgical margins. He underwent radiotherapy and mitotane as adjuvant therapies. Subsequently, CT revealed multiple metastases, in the liver and retroperitoneum. After six courses of EDP (a combination of etoposide, doxorubicin and cisplatin), CT showed widespread metastases in the retroperitoneum and he chose to receive the best supportive care. Aldosterone-producing adrenocortical carcinoma is exceedingly rare. To the best of our knowledge, only67 cases have been reported. Complete resection is needed to improve prognosis and this was not achieved in our case. We therefore recommend careful selection of the operative procedure.

Myopericytoma in the corpus cavernosum of the penis: A case report of a rare disease.

Introduction: Myopericytomas usually occur in the extremities of older individuals; however, they also rarely occur in the penis. We report a case of myopericytoma in the corpus cavernosum of the penis and review the relevant literature. Case presentation: A 76-year-old man presented with a slow-growing painless nodule on the left side of the penis. On physical examination, a non-tender, 7-mm mass was palpable. This tumor showed inhomogeneous low signal intensity on T2-weighted magnetic resonance imaging. The mass was excised and a myopericytoma diagnosed by pathological examination of the operative specimen. Conclusion: We here report a rare case of myopericytoma in the corpus cavernosum of the penis. To the best of our knowledge, this is the second reported case of a myopericytoma in the penis and the first in the corpus cavernosum of the penis. Clinicians should keep this rare possibility in mind when investigating a mass in the penis.

[A Case of Multiple Penile Schwannoma].

A 48-year-old man presented with a painless nodule on the right ventral aspect of the penile shaft root. The patient visited the hospital and complained that the mass was growing. On physical examinations, a 5 cm mass without tenderness was palpated. An isoechoic mass about 4 cm in size was observed on ultrasonography. Inhomogeneous high signal intensity was observed on T2-weighted magnetic resonance imaging. A needle biopsy revealed schwannoma. During surgery for excision of the tumor, another small tumor was detected both tumors were resected. Both tumors were diagnosed as schwannoma by pathological examination. Out of 40 cases of penile schwannoma reported, eight were of multiple tumors. In our case, it was difficult to detect the other small tumor by preoperative diagnosis. Therefore, we recommend careful observation during surgery.

[A Case of Bladder Plasmacytoma Diagnosed during Treatment of Multiple Myeloma].

A 78-year-old man was treated with Bortezomib, Lenalidomide, and Dexamethasone, for multiple myeloma. Two years after the start of treatment, the patient came to our department with a complaint of gross hematuria. Cystoscopy revealed a tumor on the left wall of the bladder. Urine cytology was negative. Magnetic resonance imaging (MRI) of the lower abdomen showed a slightly high signal on the T2-weighted image, indicating an intravesical mass lesion invading outside the bladder. Contrast-enhanced computed tomography (CT) also showed an intravesical mass and enlarged left external iliac lymph node swelling. Transurethral resection of bladder tumor was performed. The resection specimen showed tumor cells. The pathological examination revealed CD138 (+) and light-chain restriction. The patient was diagnosed with plasmacytoma. The patient was treated with radiation therapy for plasmacytoma of the bladder and surrounding lymph nodes, and then with daratumumab and dexamethasone for multiple myeloma for one year; however, the patient died because of worsening of multiple myeloma.

Clinical practice pattern in patients with advanced urothelial cancer who had progressed on pembrolizumab in the pre-enfortumab vedotin era.

OBJECTIVES: Pembrolizumab, an anti-PD-1 monoclonal antibody, revolutionized the treatment for advanced urothelial carcinoma. However, the standard treatment for patients after disease progression with pembrolizumab had not been established until the recent approval of enfortumab vedotin. We analyzed the treatment of these patients in the real world, and the patient background and outcomes. METHODS: We extracted data from 543 patients who experienced progressive disease after pembrolizumab initiation from a Japanese nation-wide cohort of platinum-refractory, metastatic urothelial carcinoma. RESULTS: The median overall survival of the 543 patients was 3.5 months (95% confidence interval 3.0-4.1). Of these, only 20.6% (n = 112) received chemotherapy as a subsequent systemic treatment after progressive disease. The regimen of chemotherapy was very diverse. The median overall survival was 11.9 months (95% confidence interval 9.2-14.7) for patients who received chemotherapy, compared to 2.4 months for those who did not receive chemotherapy (95% confidence interval 2.1-2.9; P < 0.0001). Patients who received subsequent chemotherapy were more likely to have better performance status, neutrophil-to-lymphocyte ratio <3, hemoglobin >11 mg/dL, and history of a single chemotherapeutic regimen at pembrolizumab initiation. CONCLUSIONS: This report highlights the real-world practice of the management after pembrolizumab treatment failure in the pre-enfortumab vedotin era, characterized by infrequent use of subsequent anticancer therapy comprising various regimens, reflecting the lack of a standard treatment. Clinical introduction of enfortumab vedotin is expected to improve treatment outcomes in this setting. The present study will provide important baseline data for evaluating the influence of enfortumab vedotin on clinical practices and outcomes.

[A Case of Primary Renal Angiosarcoma with a Rapidly Worsening Course].

A 69-year-old man presented with left flank pain and underwent a computed tomographic scan, which revealed a large left renal mass of 16×9×5 cm. A left nephrectomy was performed. Pathological analysis revealed that the tumor was consistent with angiosarcoma of the left kidney with a negative surgical margin. He received combination therapy with radiation therapy and four courses of chemotherapy with doxorubicin and ifosfamide. However, he died 10 months after surgery because of pleural dissemination and peritoneal dissemination. Primary renal angiosarcoma is an extremely rare and highly aggressive tumor with a dismal survival rate, and a satisfactory surgical margin is necessary for its successful treatment. If primary renal angiosarcoma is suspected, biopsy may be considered before surgery. Primary renal angiosarcoma treatment with combination therapy of surgery, radiotherapy, and chemotherapy by a specialist multidisciplinary team with experience and expertise in sarcoma is preferable. Development of therapy for angiosarcoma is awaited.

Robot-assisted partial nephrectomy via retroperitoneal approach in a patient with horseshoe kidney.

INTRODUCTION: Horseshoe kidney is a renal fusion anomaly often associated with ectopia, malformation, and vascular changes. Robot-assisted partial nephrectomy is selected for patients with T1a renal cell carcinoma; however, there are few reports of renal cell carcinoma in horseshoe kidney. We present a case of robot-assisted partial nephrectomy via a retroperitoneal approach in a patient with horseshoe kidney with a brief literature review. CASE PRESENTATION: An 84-year-old woman presented with a 2-cm mass in horseshoe kidney. She underwent robot-assisted laparoscopic partial nephrectomy via a retroperitoneal approach. CONCLUSION: The use of robot-assisted laparoscopic partial nephrectomy in patients with horseshoe kidney is very rare, and only four cases have been reported. Because of the unique anatomical structure, surgeons need to consider surgical strategy more carefully, considering tumor location, vascular anatomy, and past history of abdominal surgery.

[A Case of Ureteral Metastasis from Prostate Cancer].

Ureteral metastasis from prostate cancer is rare. The present case report describes an 83-year-old patient with distant metastasis of prostate cancer to the right ureter that caused hydronephrosis. Upon initial examination at our hospital, he presented with a high prostate-specific antigen (PSA) level of 10.0 ng/ml. He was diagnosed with prostate adenocarcinoma, with Gleason score of 10 (5＋5) and clinical staging of cT2aN0M0. Intensity-modulated radiation therapy (IMRT) was performed after 1 year and 7 months of androgen depriation therapy. At 1 year and 4 months after IMRT, PSA increased to 3.068 ng/ml. Computed tomography scan revealed right hydronephrosis and thickening of the right ureter. We could not identify obvious malignant cells on ureteroscopic biopsy, and right nephroureterectomy was performed. Pathological examination revealed ureteral metastasis of prostate cancer. Six months after nephroureterectomy, PSA increased to 3.037 ng/ml. He was diagnosed with castration-resistant prostate cancer and has been treated with enzalutamide.

Rapid recurrence of squamous cell carcinoma at a lymphocele after nephroureterectomy: A rare case report.

INTRODUCTION: Lymphoceles are sometimes formed after pelvic lymph node dissection. However, recurrence at lymphoceles has not been reported previously. Here, we report a case of rapid prognosis of the recurrence at a lymphocele after nephroureterectomy. CASE PRESENTATION: A 78-year-old man underwent retroperitoneoscopic radical nephroureterectomy with pelvic lymphadenectomy for left ureteral urothelial carcinoma. The histopathological diagnosis was high-grade invasive urothelial carcinoma with squamous differentiation. Follow-up computed tomography at 3 months postoperatively showed a lymphocele with a small solid component, in the left pelvic region. At 7 months postoperatively, he presented with severe fatigue, and computed tomography showed a solid tumor had replaced the lymphocele. Computed tomography-guided biopsy was performed and histopathological diagnosis was squamous cell carcinoma. CONCLUSION: This report provides support for possible recurrence at the lymphocele after nephroureterectomy. If lymphocele occurs after surgery for malignant disease, it is recommended to follow up with the possibility of recurrence in the lymphatic cysts in mind.

[Clinical Course and Treatment of Acute Urinary Retention after Robot- Assisted Laparoscopic Radical Prostatectomy : A Single Institution Experience of 11 Cases].

Robot-assisted laparoscopic radical prostatectomy (RARP) is becoming the standard treatment procedure for localized prostate cancer. The main complications associated with RARP include urinary incontinence and sexual dysfunction. In addition, acute urinary retention (AUR) after urethral catheter removal is sometimes seen. Early catheter removal is a risk factor for AUR, and administration of alphablockers before catheter removal reduces the occurrence of AUR. However, the ideal management of AUR after RARP is not known. Here we report the clinical course and treatment after AUR. We performed 279 RARPs at our institution, and AUR developed in 11 cases. In all cases, urination status was improved after placement of a urinary catheter or intermittent catheterization. Later, urethral stricture was seen in 2 out of 11 cases. Ourstudy suggests that when AUR is observed afterRARP, catheterur ination should be initially performed. If urinary retention recurs, a urinary catheter should be placed with administration of alpha-blockers. The catheter is removed after about 3 days, and administration of analgesics is effective for reducing the pain on urination. If urination status is not improved, evaluation of the urethral stricture should be considered.

Black adrenal adenoma causing subclinical Cushing's syndrome complicated with pheochromocytoma.

INTRODUCTION: The development of adrenocortical adenoma and pheochromocytoma within the same adrenal gland is very rare. Furthermore, no reports have described coincident black adrenal adenoma and pheochromocytoma. We herein report a rare case of coincident black adrenal adenoma and pheochromocytoma in the same adrenal gland. CASE PRESENTATION: A 71-year-old Japanese woman was hospitalized because a right adrenal tumor had been incidentally found by computed tomography. She was diagnosed with subclinical Cushing's syndrome and underwent laparoscopic right adrenalectomy. The tumor contained two adrenal nodules. The cut surface of the larger nodule was brownish-black on macroscopic examination. Pathological studies revealed coincident black adrenal adenoma and pheochromocytoma. CONCLUSION: To the best of our knowledge, this is the first report of coincident black adrenal adenoma causing subclinical Cushing's syndrome and pheochromocytoma in the same adrenal gland. The mechanism of this rare scenario is unclear, and further study is necessary.

Port-site incisional hernia from an 8-mm robotic trocar following robot-assisted radical cystectomy: Report of a rare case.

INTRODUCTION: Port-site incisional hernia is a rare but well-known complication following a laparoscopic procedure and it may cause severe adverse outcomes, such as intestinal necrosis. Here, we report a rare case of hernia that occurred from an 8-mm trocar after robot-assisted radical cystectomy. CASE PRESENTATION: An 80-year-old woman was diagnosed with cT2bN1M0 bladder cancer. She underwent robot-assisted radical cystectomy. Nine days after surgery, she complained of severe abdominal pain. Computed tomography showed herniation of small intestine. Emergency explorative laparotomy revealed herniation of small intestine from an 8-mm trocar site. A section of the small bowel was necrotic and was resected. CONCLUSION: It is debatable whether we should routinely close the fascia of an 8-mm trocar site. The patient was an elderly woman with multiple major abdominal surgery histories and hernia risk factors. For these patients, fascial closure of the 8-mm trocar site may be indicated.

Prognosis of patients with muscle invasive bladder cancer who are intolerable to receive any anti-cancer treatment.

BACKGROUND: The aim of this retrospective study was to evaluate the prognosis of patients who had been diagnosed with muscle invasive bladder cancer (MIBC) and did not receive anti-cancer treatment because of their physical characteristics. METHODS: Between January 2012 and October 2019, 96 patients were diagnosed with MIBC (cT2-4N0M0) in our institution. Of those, 64 patients had undergone radical cystectomy (RC), 6 had received palliative radiation therapy, and 26 had not received any anti-cancer treatment. We further evaluated the 26 patients who had received no anti-cancer treatment. RESULTS: The no anti-cancer treatment group were significantly older (91 vs. 75 years, p<0.001), comprised fewer men (42% vs. 72%, p=0.015), and had poorer performance status (PS) (mean 2.69 vs. 0.32, p<0.001) than the RC group. The follow periods were 9.5 months and 28.5 months, respectively. Median overall survival (OS) was 12 months in the no anti-cancer treatment group, whereas the median OS was not reached during the study period in the RC group. In univariate analysis, OS was significantly associated with estimated GFR (eGFR) less than 30 mL/min/1.73m2 (median OS, 10 vs 16 months, p = 0.044). Multivariate analysis demonstrated that eGFR was significantly associated with OS (hazards ratio 0.267 [95% CI 0.0858-0.8357]; p = 0.0023). CONCLUSIONS: We evaluated the prognosis of patients with untreated MIBC. Their median OS was 12 months and eGFR was a significant prognostic factor. These findings may help in counseling patients about prognosis if no anti-cancer treatment is given.

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.