High frequency of concomitant squamous metaplasia in bulbar urethral stricture and its association with reconstructive delay and urethral rest.

PURPOSE: To determine the prevalence of concomitant squamous metaplasia (SM), the initial histological change from normal urethra to urethral stricture, in bulbar urethral strictures and to investigate the associated clinical factors. METHODS: A retrospective review was conducted on 165 male patients with bulbar urethral strictures who underwent excision and primary anastomosis (EPA) between 2010 and 2020, for whom complete clinical data and excised urethral specimens were available. An experienced pathologist histologically evaluated concomitant SM in paraffin sections of the proximal end of the excised urethra blinded to the clinical data. Disease duration was calculated as the period from the initial diagnosis of urethral stricture to the date of EPA. The association between concomitant SM and clinical background was investigated. RESULTS: SM was identified in 86 (52.1%) patients. The median disease duration in patients with SM (38 months) was significantly longer than that in patients without SM (9 months, p < 0.0001). In multivariate analysis, the longer disease duration, non-traumatic stricture etiology, and failure to maintain urethral rest with urinary diversion via a suprapubic tube for more than 90 days were independent factors predicting concomitant SM. No significant difference was observed in success rates of EPA between patients with SM (93.2%) and those without SM (97.5%, p = 0.18). CONCLUSIONS: Reconstructive urologists need to be aware that concomitant SM is frequent in patients with bulbar urethral stricture, especially in those with long disease duration and those who were voiding volitionally during the period of urethral rest.

A case of traumatic urethral stricture complicated by periurethral abscess while awaiting delayed urethroplasty.

Introduction: We report a case of bulbar urethral injury complicated by periurethral abscess due to inappropriate suprapubic catheter management. Case presentation: A 58-year-old man with bulbar urethral injury due to perineal trauma was referred to our hospital, and a suprapubic catheter was inserted for initial management. Although he was instructed to connect the catheter to the urine collection bag, he connected a plug to the catheter. As a result, he developed periurethral abscesses due to extravasated urine from the injured urethra, requiring percutaneous drainage and prolonging the time to definitive urethroplasty for the urethral stricture. Conclusion: It is essential that the suprapubic catheter be connected to a urine collection bag rather than a plug to keep the bladder as empty as possible and to minimize extravasation of the urine from the injured urethra.

Efficacy of urethral reconstruction for urethral stricture associated with hypospadias surgery in adults.

OBJECTIVES: We report our experience with urethral reconstruction for hypospadias surgery-related urethral stricture in terms of surgical and patient-reported outcomes. METHODS: Twenty-nine adult males who underwent urethral reconstruction for hypospadias surgery-related urethral stricture between August 2008 and January 2022 were retrospectively reviewed. Uroflowmetry and patient-reported outcomes were evaluated at 3, 6, and 12 months, and annually thereafter. Surgical success was defined as the absence of additional procedures. Patients were asked to rate their satisfaction with urethral reconstruction as "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". RESULTS: The median patient age at referral was 43 years. The median number of previously performed hypospadias surgeries was three, and 18 patients (62.8%) had been treated with repeated transurethral procedures. The median stricture length was 54 mm (interquartile range 36-81). Performed urethral reconstruction included staged urethroplasty in 22 (75.9%), one-stage onlay augmentation in 3 (10.2%), and perineal urethrostomy in 4 (13.8%) cases. Urethral reconstruction was successful in 26 patients (89.7%) over a median postoperative period of 31 months. Patient-reported outcomes were assessed in 25 (86.2%) patients. The mean maximum flow rate, international prostate symptom score total score, international prostate symptom score quality of life score, and EuroQol-5 dimensions index significantly improved postoperatively. Twenty-three patients (92%) were "very satisfied" or "satisfied" with the outcome of their urethral reconstruction. CONCLUSIONS: Urethral reconstruction is a highly successful and patient-satisfying treatment for hypospadias surgery-related urethral stricture in adult patients. Perineal urethrostomy is a reasonable alternative for elderly patients and for patients with complicated hypospadias surgery-related urethral strictures.

Urethral reconstruction for iatrogenic urethral stricture after transurethral prostate surgery: An analysis of surgical and patient-reported outcomes.

OBJECTIVES: We investigated the efficacy of urethral reconstruction in male patients with iatrogenic urethral stricture after transurethral prostate surgery. METHODS: We retrospectively reviewed the cases of 82 patients who underwent urethral reconstruction for iatrogenic urethral stricture caused by transurethral prostate surgery between August 2011 and July 2021. Patients were followed up postoperatively with uroflowmetry, postvoid residual urine measurement, and questionnaires using Peeling's picture score, International Prostate Symptom Score, International Consultation on Incontinence Questionnaire Short Form, Sexual Health Inventory for Men, EuroQol-5 dimensions, and EuroQol-5 dimensions visual analog scores. Successful urethral reconstruction was defined as the absence of a postoperative decrease in urinary force and any additional treatment. RESULTS: The median patient age was 72 years, and the stricture site was the urethral meatus in eight (9.8%) patients, penoscrotal junction in 42 (51.2%), and proximal bulbar urethra in 26 (31.7%). Six patients (7.3%) had synchronous urethral strictures. Urethral reconstruction was successful in 78 patients (95.1%), with a median follow-up of 43 months. The mean maximum flow rate (P < 0.0001), postvoid residual urine (P = 0.004), Peeling's picture score (P < 0.0001), the score for each question and total International Prostate Symptom Score and International Prostate Symptom Score-quality of life scores (P < 0.0001 for all comparisons), and EuroQol-5 dimensions and EuroQol-5 dimensions visual analog scores (P < 0.0001 for both) significantly improved postoperatively. However, the Sexual Health Inventory for Men and International Consultation on Incontinence Questionnaire Short Form scores remained unchanged (P = 0.09 and 0.70, respectively). CONCLUSIONS: Urethral reconstruction was effective for urethral stricture due to transurethral prostate surgery in both subjective and objective aspects.

Impact of urethroplasty on overactive bladder symptoms in patients with anterior urethral strictures.

OBJECTIVES: To investigate the incidence of overactive bladder in men with anterior urethral stricture and to evaluate the impact of urethroplasty on its improvement. METHODS: A total of 104 men with anterior urethral stricture who underwent urethroplasty between 2016 and 2020 completed a validated urethral stricture surgery patient-reported outcome measure comprising six lower urinary tract symptoms questions on voiding symptoms and overactive bladder symptom score before and 3, 6, and 12 months after urethroplasty. Patients with an urgency score of ≥2 for overactive bladder symptom score question 3, and a total overactive bladder symptom score of ≥3 were considered to have overactive bladder. An improvement in overactive bladder was defined as a decrease in the total overactive bladder symptom score by at least three points. RESULTS: Thirty-nine patients (37.5%) were considered to have overactive bladder, and improvement in overactive bladder after urethroplasty was found in 30 (76.9%). Maximum flow rate on uroflowmetry, postvoid residual urine volume, lower urinary tract symptoms total score, and total overactive bladder symptom score were all significantly improved after urethroplasty (P < 0.0001 for all variables). There was a positive correlation between changes in lower urinary tract symptoms total score and total overactive bladder symptom score (Spearman's correlation 0.48, P < 0.0001). Multivariate logistic regression analysis showed that greater change in lower urinary tract symptoms score was an independent predictor of improvement in overactive bladder (odds ratio 1.30, 95% confidence interval 1.06-1.59; P = 0.002). CONCLUSIONS: Overactive bladder is prevalent in patients with anterior urethral stricture, and can be effectively improved after urethroplasty. Improvement of voiding symptoms are key for improving overactive bladder symptoms.

Deep lateral transurethral incision for vesicourethral anastomotic stenosis after radical prostatectomy.

OBJECTIVES: To investigate the outcomes of deep lateral incision for vesicourethral anastomotic stenosis after radical prostatectomy and its impact on postoperative urinary incontinence. METHODS: We retrospectively investigated 43 men who underwent deep lateral incision for non-obliterated vesicourethral anastomotic stenosis after radical prostatectomy between 2011 and 2020. The bladder neck was deeply incised through its circular fibers into the surrounding perivesical fat at 3 and 9 o'clock through electrocautery incision using needle-type electrodes. Successful deep lateral incision was defined as the absence of additional treatment, including self-dilatation. The postoperative urinary incontinence status was evaluated based on the number of pads used daily. RESULTS: Deep lateral incision was successful in 35 (81.4%) patients, with a median follow-up period of 43 months (interquartile range 15-80 months). There was no significant association of age (P = 0.66), body mass index (P = 0.49) and history of diabetes mellitus (P = 0.39), radiation therapy (P = 0.89) or previous vesicourethral anastomotic stenosis treatment (P = 0.71) with the incision outcomes; however, there were significantly more unsuccessful cases in those with preoperative urinary retention (P = 0.04) or indwelling urinary catheters for >5 days post-incision (P = 0.01). A second incision was carried out in eight patients and a third incision in two patients, resulting in 42 (97.7%) successful incisions. A total of 37 (88.1%) patients had urinary incontinence and used at least one pad daily; seven (16.7%) underwent artificial urinary sphincter implantation after the last incision. CONCLUSIONS: Deep lateral incision is highly effective for treating vesicourethral anastomotic stenosis after radical prostatectomy. Appropriate treatment is required for urinary incontinence, which occurs frequently after incision.

Evaluation of the efficacy of perineal urethrostomy for patients with anterior urethral stricture: insights from surgical and patient-reported outcomes.

PURPOSE: To examine the efficacy of perineal urethrostomy (PU) in patients with anterior urethral stricture. METHODS: Patients who underwent PU for anterior urethral stricture between 2013 and 2020 were retrospectively reviewed (n = 56). Surgical success was defined as no need for additional intervention. Uroflowmetry and measurement of residual urine volume (PVR) were examined postoperatively, and the patients were asked to fill out sexual health inventory for men (SHIM) and the validated Urethral Stricture Surgery Patient-reported Outcome Measure questionnaires before and after PU. The overall patient satisfaction was also assessed. RESULTS: PU was successful in 92.9% of patients (n = 52), with a median follow-up of 34 months. Two of four were salvaged by re-do PU, and one was salvaged by forming a composite stoma using a penile skin graft. Thirty-nine patients (69.6%) filled out the questionnaires 6 months after surgery. The mean maximum flow rate, PVR, lower urinary tract symptoms (LUTS)-total score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 3.8 mL/s, 77.6 mL, 12.9, 2.6, and 53.6 at baseline to 17.6 mL/s, 21.3 mL, 4.1, 0.9, and 74.9 postoperatively (p = 0.003, p = 0.004, p = 0.005, p < 0.0001, p < 0.0001, respectively). The SHIM score did not change significantly (from 2.6 at baseline to 2.3 postoperatively; p = 0.59). As for patient satisfaction, 84.6% of patients (33/39) were "satisfied" (46.1%) or "very satisfied" (38.5%) with the outcome. CONCLUSIONS: PU had a high surgical success rate, and significantly improved patients' subjective symptoms and achieved a high level of satisfaction.

Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes.

PURPOSE: To report our experience with excision and primary anastomosis (EPA) for bulbar urethral stricture. METHODS: Patients who underwent EPA for bulbar stricture between 2012 and 2019 were retrospectively analyzed (n = 308). Successful urethroplasty was defined as the absence of the need for additional treatment. For follow-up, uroflowmetry was performed and the patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 6 months after EPA. Overall patient satisfaction after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 97.1% of patients (n = 299) with a median follow-up of 37 months. A total of 215 patients (69.8%) completed the questionnaires at 6 months postoperatively. The mean maximum flow rate, lower urinary tract symptom (LUTS)-total score, Peeling's picture score, LUTS-specific quality of life, and EuroQol-visual analog scale scores improved significantly from 7.7 ml/s, 11.6, 3.3, 2.4, and 58.0 at baseline to 24.1 ml/s, 2.7, 1.9, 0.4, and 82.1 postoperatively (p < 0.0001 for all comparisons). However, five-point or greater deterioration in the SHIM score was found in 41 patients (19.1%). Regarding patient satisfaction, 98.6% of patients (212/215) were "satisfied" (32.6%) or "very satisfied" (66.0%) with the outcome. A low postoperative LUTS-total score and Peeling's picture score were independent predictors of a "very satisfied" patient (p = 0.001 and p = 0.01, respectively). CONCLUSIONS: EPA had a high success rate and was associated with significant benefits in both subjective and objective outcomes. Contrarily, a high incidence of postoperative erectile dysfunction was observed.

Is pre-referral management of anterior urethral strictures prior to urethroplasty appropriate?

OBJECTIVES: To evaluate whether the management of anterior urethral strictures prior to definitive urethroplasty is appropriate. METHODS: Of a total of 419 men diagnosed with anterior urethral strictures at hospitals across Japan and thereafter referred to our institution for definitive urethroplasty between 2004 and 2019, the medical records of 371, for whom data on stricture characteristics at the initial diagnosis and pre-referral management were available, were retrospectively reviewed. A pre-referral single transurethral procedure, such as direct vision internal urethrotomy or urethral dilation, was considered appropriate only for favorable stricture, defined as a single nontraumatic untreated bulbar urethral stricture ≤2 cm in size, and repeat transurethral procedures were considered inappropriate in any circumstances. The association between the appropriateness of the pre-referral management strategy and patient and clinical characteristics was analyzed. RESULTS: A total of 242 patients (65.2%) had a pre-referral history of at least one transurethral procedure, and performing the procedure was considered inappropriate for 221 patients (59.6%). On multivariate logistic regression analysis, location of the patient's residence far from our institution (outside of the Kanto area; odds ratio 3.35, 95% confidence interval 1.86-6.04; P < 0.0001), voiding with intermittent dilation (odds ratio 2.38, 95% confidence interval 1.38-4.12; P = 0.002), iatrogenic stricture (odds ratio 11.18, 95% confidence interval 5.30-23.61; P < 0.0001), and stricture longer than 20 mm (odds ratio 3.05, 95% confidence interval 1.47-6.38; P = 0.003) were the independent predictors of inappropriate use of transurethral procedures. CONCLUSIONS: Transurethral procedures are often inappropriately used. There is a clear need to promote appropriate management strategies for urethral strictures among general urologists.

Surgical and patient-reported outcomes of urethroplasty for bulbar stricture due to a straddle injury.

PURPOSE: To report our experience with urethroplasty for bulbar stricture due to a straddle injury based on surgical and patient-reported outcomes. METHODS: Patients who underwent urethroplasty for bulbar stricture due to a straddle injury between 2010 and 2018 were retrospectively analyzed (N = 132). Successful urethroplasty was defined as the absence of the need for additional treatment. The patients completed the validated Urethral Stricture Surgery Patient-reported Outcome Measure and Sexual Health Inventory for Men (SHIM) questionnaires before (baseline) and 1 year after urethroplasty. RESULTS: The median (interquartile range) age was 50 (36-62) years; urethral stricture length estimated from urethrograms, 8.6 (5.1-12.5) mm; and postoperative follow-up, 41 (22-56) months. Urethroplasty was performed through excision with primary anastomosis in 95.5% (n = 126) and onlay augmentation with a buccal mucosa graft in 4.5% (n = 6). Urethroplasty was successful in 98.5% (n = 130). The 2 failures due to periurethral abscess were successfully salvaged with another urethroplasty. Eighty-four patients (63.6%) completed the questionnaires at 1 year postoperatively. The mean lower urinary tract (LUT)-specific quality of life, SHIM, and EuroQol-visual analog scale scores all improved significantly from 2.6, 8.5, and 57.5 at baseline to 0.3, 11.6, and 84.6 postoperatively (p < 0.0001, p = 0.004, p < 0.0001, respectively). All patients were either "satisfied" (19/84, 22.6%) or "very satisfied" (65/84, 77.3%). Lower postoperative LUT symptom score was an independent predictor of a "very satisfied" patient (odds ratio 0.81, 95% confidence interval 0.67-0.98, p = 0.002). CONCLUSIONS: Urethroplasty for bulbar stricture due to a straddle injury has a high success rate and is beneficial for both subjective and objective symptoms.

Is Primary Realignment Appropriate for the Initial Management of Straddle Injuries to the Bulbar Urethra?

OBJECTIVE: To compare the clinical courses of patients with straddle injuries to the bulbar urethra based on the initial management strategy for urinary drainage, mainly suprapubic tube placement (SPT) and primary realignment (PR), and to examine whether PR has a beneficial effect on subsequent urethroplasty with regards to surgical and patient-reported outcomes. METHODS: We reviewed the clinical courses of 126 patients with bulbar urethral stricture following straddle injuries who underwent delayed urethroplasty between August 2010 and April 2019. Patients were categorized as being initially treated with SPT (82 patients) or PR (44 patients). Stricture was considered complicated if preoperative urethrography or cystoscopy revealed iatrogenic scarring or a stricture away from the injury site. RESULTS: The percentage of patients who experienced delayed transurethral treatment at least once before referral was significantly higher in patients treated with PR than in those treated with SPT (25/44, 56.8% vs 16/82, 19.8%, P < .0001). Although there was no difference in stricture length in both cohorts, the fraction of patients with complicated stricture was significantly higher in patients treated with PR than in those treated with SPT (15/44, 34.1% vs 14/82, 17.1%, P = .003). There was no significant difference in the selected type of urethroplasty, operative time, blood loss, success rate, postoperative maximum urinary flow rate, voiding symptoms, or erectile function between the 2 groups. CONCLUSION: PR does not facilitate delayed urethroplasty and had no beneficial effect on urethroplasty outcome. PR might lead to delayed transurethral procedures, resulting in increased risk of complicated strictures.

Single-surgeon series of delayed anastomotic urethroplasty for pelvic fracture urethral injury: an analysis of surgical and patient-reported outcomes of a 10-year experience in a Japanese referral center.

PURPOSE: To report our experience with delayed anastomotic urethroplasty for pelvic fracture urethral injury (PFUI) during the last 10 years and evaluate both surgical and patient-reported outcomes. METHODS: Retrospective analysis of 115 patients undergoing delayed anastomotic urethroplasty for PFUI between 2008 and 2017 by a single surgeon (AH) was performed. Success was defined as a urethral lumen large enough for passage of a 17-Fr flexible cystoscope. We asked patients to complete questionnaires before (baseline) and 1 year after urethroplasty and compared by paired t and Wilcoxon signed-rank tests the answers to a question about LUTS-specific QOL and the health-related QOL indicated by EQ-5D index and visual analogue scores (EQVAS). Overall patient satisfaction 1 year after urethroplasty was also evaluated. RESULTS: Urethroplasty was successful in 108 patients (93.9%), and failed urethroplasty was significantly associated with greater intraoperative blood loss (p = 0.009) and smaller surgical experience (p = 0.018). Sixty-six patients (57.4%) completed questionnaires 1 year after urethroplasty, and 65 of those 66 (98.5%) were "satisfied" (36.4%) or "very satisfied" (62.1%) with the outcome of their urethroplasty. The LUTS-specific QOL scores (p < 0.0001), EQ-5D index scores (p < 0.0001), and EQVAS scores (p < 0.0001) all improved significantly after urethroplasty. CONCLUSIONS: Delayed anastomotic urethroplasty has a high success rate and significant beneficial effects on both LUTS-specific and health-related QOL, resulting in high patient satisfaction. Careful manipulation in a bloodless operative field by experienced surgeons could be the key to successful urethroplasty.

Evaluation of the effect of urethroplasty for anterior urethral strictures by a validated disease-specific patient-reported outcome measure.

PURPOSE: To better understand our urethroplasty outcome, we translated the English version of a urethral stricture surgery patient-reported outcome measure (USS-PROM) into Japanese and used it to evaluate the effect of urethroplasty for anterior urethral strictures. METHODS: The PROM quantifies lower urinary tract symptoms (LUTS) and health-related quality of life (EQ-5D), and it evaluates overall satisfaction by asking patients to choose "very satisfied", "satisfied", "unsatisfied", or "very unsatisfied". 93 Japanese-speaking male patients with anterior urethral stricture who underwent urethroplasty completed it before (baseline) and 6 months after urethroplasty. The psychometric criteria evaluated in the present study were the PROM's internal consistency, test-retest reliability, criterion validity, and responsiveness. RESULTS: Qmax was negatively correlated with the LUTS-total scores (r = - 0.61). Cronbach's alpha was 0.80 and the test-retest intraclass correlation coefficient for the LUTS-total score was 0.82. 83 patients (89.2%) achieved stricture-free, which was defined as no re-stricture on cystoscopy and no need for additional treatment. The mean total LUTS-score improved from 12.4 at baseline to 3.7 postoperatively (p < 0.0001). The mean EQ-5D visual analogue scores and EQ-5D index improved from 61.2 and 0.76, respectively, at baseline to 77.9 and 0.89 postoperatively (p < 0.0001, p < 0.0001). 55 patients (59.1%) were "very satisfied" with the outcome of their urethroplasty and 33 (35.5%) were "satisfied". CONCLUSIONS: The Japanese version of the USS-PROM has adequate psychometric properties. Urethroplasty improved not only objective data but also voiding symptoms and health-related QOL, and it resulted in a high rate of patient satisfaction.

[Clinical experience of treatment of liver metastasis of renal cell carcinoma treated with SMANCS/Lipiodol therapy].

The treatment for metastatic renal cell carcinoma (RCC) has changed dramatically after the beginning of molecular-targeted therapies. However,the treatment for liver metastasis is still difficult in patients with metastatic RCC. We treated liver metastases (8 target lesions) of RCC with stylene-maleic acid neocarzinostatin (SMANCS)/Lipiodol therapy. At the treatment procedure,a catheter was inserted at the femoral artery (Seldinger's method),a microcatheter was selectively inserted into the branch of hepatic artery which fed the liver metastasis,and then SMANCS/Lipodol was infused. We treated 1,2 and 1 patient 4,2, and 1 time,respectively. One lesion treated with SMANCS/Lipodol was further treated by radiofrequency ablation 13 days later. Of 6 metastatic lesions which could be followed up for more than 6 months after the treatment,one had partial response for 4 months and 4 had stable disease for more than 6 months. Four of the 6 lesions shrunk after SMANCS/Lipiodol treatment. Two of 4 patients survived more than 18 months after the first SMANCS/Lipiodol therapy. In all 9 SMANCS/Lipiodol treatments,grade 1 liver dysfunction (44.4%),ascites (11.1%) and fatigue (11.1%) occurred after the treatments. These adverse events were all improved by conservative treatments. SMANCS/Lipiodol therapy can be a treatment option as local treatment for liver metastasis of RCC.

[Urothelial carcinoma clear cell variant of the urinary bladder : a case report].

A 69-year-old woman who had been treated with hemodialysis for 16 months for chronic renal failure presented with a chief complaint of gross hematuria in March 2007. Cystoscopic examination revealed a non-papillary, pedunculated tumor located in the right wall of the urinary bladder. A transurethral resection of the bladder tumor (TURBT) was performed in September 2007. The pathological diagnosis was urothelial carcinoma clear cell variant. The patient is now apparently free of disease 20 months after TURBT. Urothelial carcinoma clear cell variant of the urinary bladder is a rare primary tumor, and this is the fourth case of urothelial carcinoma clear cell variant of the bladder to be reported.

[Clinical evaluation for adrenal metastasis of renal cell carcinoma in a single institute].

OBJECTIVE: Clinicopathogical features and prognosis of patients with renal cell carcinoma (RCC) concomitant with adrenal involvement (metastasis or invasion) were evaluated in a single institute. METHODS: In 380 patients with RCC who underwent radical nephrectomy 18 patients had adrenal involvement (13 ipsilateral adrenal involvement). Clinicopathological factors were compared between patients with ipsilateral adrnal involvement and control patients. Cause-spesific survival was calculated by Kaplan-Meier Method. RESULTS: Patients with ipsilateral adrenal involvement had significantly higher percentage of tumor>5.5 cm, upper pole tumor, pathological stage (pT) 3< or =, lymph node metastasis, distant metastasis outside ipsilateral adrenal gland, histological grade 3 and microvascular invasion than control patients (p<0.05). Therefore, large tumor (especially 5.5 cm<), upper pole tumor, clinical T3 (especially patients with tumor thrombus), lymph node metastasis and distant metastasis were candidates for risk factors of ipsilateral adrenal involvement. 76.9% of ipsilateral adrenal metastasis could be diagnosed by computed tomography (CT). Thus, preoperative adrenal finding by CT is very important to determine the indication of ipsilateral adrenalectomy. All 3 patients with small ipsilateral adrenal metastasis that could not be detected preoperative CT died within one and half year postoperatively. Patients with solitary adrenal metastasis appeared to have better prognosis compared to those with both adrenal and other metastases. In 4 patients who survived more than 2 years after the presentation of adrenal metastasis, 3 patients had solitary adrenal metastasis and underwent adrenalectomy. CONCLUSION: From the results in a single institute, radiological finding of adrenal grand, tumor size, tumor location, T stage, lymph node metastasis and distant metastasis outside ipsilateral adrenal gland are possible important factors to determine the indication of ipsilateral adrenalectomy preoperatively.

BIGH3 is overexpressed in clear cell renal cell carcinoma.

To identify new target marker genes in renal cell carcinoma (RCC), we compared the gene expression profiles of clear cell RCC (cc-RCC) and normal kidney tissue using serial analysis of gene expression. Our results revealed that the transforming growth factor beta induced 68 kDa protein (TGF-betaI: beta ig-h3 (BIGH3), plasminogen activator inhibitor-1 (PAI-1) and transforming growth factor beta1 (TGF-beta1) genes are up-regulated in cc-RCC. To further assess the role of BIGH3 in RCC, we investigated the mRNA expression levels of BIGH3, TGFbeta1, PAI-1 and also of TGF-beta1 related genes in 53 RCC and 30 normal kidney tissues by quantitative real-time RT-PCR (QRT-PCR). We further determined the BIGH3 protein levels in 52 cc-RCC paraffin-embedded tissue samples by immunohistochemistry. BIGH3 mRNA was found to be highly overexpressed in cc-RCC compared with normal tissues with an average ratio of 27. The mRNA levels of TGF-beta1 and PAI-1 were also detected at significantly elevated levels in these cancers. Immunohistochemical analysis of BIGH3 also revealed strong staining in the majority of the cc-RCC samples. In addition, the up-regulation of BIGH3 and PAI-1 was found to correlate with the clinicopathological parameters associated with a poorer patient outcome, whereas TGF-beta1 expression was determined to be unrelated to cancer progression. Strong BIGH3 staining thus tended to be associated with a poor prognosis. BIGH3 was also induced in some RCC cell lines by TGF-beta1 stimulation and this correlated well with PAI-1 up-regulation, suggesting that these enhancements are regulated by a similar mechanism in these tumors.

Decreased serum adiponectin levels in patients with metastatic renal cell carcinoma.

BACKGROUND: Low levels of serum adiponectin are associated with increased risk and aggressiveness of obesity-related cancer. The purpose of the study reported here was to investigate the association between serum adiponectin levels and clinicopathological parameters of renal cell carcinoma. METHODS: Preoperative serum total and high-molecular-weight (HMW) adiponectin levels were measured in 118 patients with renal cell carcinoma, and their association with clinicopathological parameters was analysed. RESULTS: There were no statistically significant associations between total adiponectin and HMW adiponectin and pathological stage, regional lymph node involvement, histological grade, histological type (clear cell carcinoma versus other types) or presence of venous invasion. Total and HMW adiponectin levels in patients with metastasis, however, were significantly lower than in patients without metastasis (P = 0.044 for total adiponectin and P = 0.041 for HMW adiponectin). Low total and HMW adiponectin levels were significantly associated with metastasis in patients with a normal BMI (<25 kg/m(2)) (P = 0.034 for total adiponectin and P = 0.028 for HMW adiponectin) but not in overweight and obese patients (P = 0.652 for total adiponectin and P = 0.489 for HMW adiponectin). Multivariate logistic regression analysis showed that total adiponectin level was an independent predictor of metastasis of renal cell carcinoma in all patients (P = 0.024, 95% CI = 1.031-1.560) and in patients with a normal BMI (P = 0.040, 95% CI = 1.043-6.534). CONCLUSIONS: Serum total and HMW adiponectin levels were decreased in patients with metastatic renal cell carcinoma. Adiponectin might be a molecular link between obesity and the progression of renal cell carcinoma.

Intratumoral lymphatics and lymphatic invasion are associated with tumor aggressiveness and poor prognosis in renal cell carcinoma.

OBJECTIVES: Because lymphangiogenesis and lymphatic invasion are key steps to nodal involvement in various types of cancer, we examined the clinicopathologic significance of lymphangiogenesis and lymphatic invasion in renal cell carcinoma. METHODS: Peritumoral lymphatics and intratumoral lymphatics (ITLs) from 106 patients with clear cell renal cell carcinoma specimens were immunostained with D2-40 antibody, which specifically recognizes the lymphatic-specific marker podoplanin. The clinicopathologic significance of the densities and presence of lymphatic vessels and lymphatic invasion (LVI) was evaluated, and the staining pattern of D2-40 was compared with that of CD34. RESULTS: Peritumoral lymphatics were present in 100 patients (94.3%), and ITLs were present in only 20 (18.9%). LVI was present in 6 patients (5.7%), of whom 5 had concomitant microvascular invasion. Some lymphatic vessels were positive not only for D2-40, but also for CD34. The presence of ITLs and LVI were significantly associated with pathologic T stage (P <0.0001 and P = 0.0136, respectively), regional lymph node involvement (P = 0.0312 and P = 0.0067, respectively), distant metastasis (P = 0.0046 and P = 0.0294, respectively), and microvascular invasion (P = 0.0105 and P = 0.0312, respectively). Univariate analysis showed that patients with ITLs had significantly shorter cancer-specific survival than those without ITLs (P = 0.0025) but multivariate analysis did not (P = 0.0527). CONCLUSIONS: The results of our study have shown that ITLs and LVI are associated with tumor aggressiveness, and patients with ITL have poor prognosis in renal cell carcinoma. One should be aware that some of the intratumoral microvessels are lymphatics and patients with microvascular invasion evident on the routine histologic examination often also have LVI.

Retroperitoneoscopic partial nephrectomy using radiofrequency coagulation for small renal tumors.

OBJECTIVES: Adoption of laparoscopic partial nephrectomy (LPN) has been limited by lack of reliable hemostatic techniques. We evaluated radiofrequency coagulation (RFC) in obtaining hemostasis during LPN for small renal masses. METHODS: Over 4 years LPN was performed by a retroperitoneal approach in 11 patients with solitary, predominantly exophytic renal tumors. A retroperitoneal approach was used in all patients. The renal hilum was not exposed. RF energy was delivered to coagulate the lesion and a margin of normal parenchyma. Tumors were excised together with at least a 0.5-cm margin of normal parenchyma, with the use of ultrasonic shears. RESULTS: Mean tumor size was 2.2 cm (range, 1.5 to 3.0). Mean operative time was 222 minutes (range, 130 to 305 minutes) and mean blood loss was 51 mL (range, 10 to 200 mL). During excision bleeding from the cut renal surface was minimal, and structure of the cortex and medulla still could be clearly distinguished after coagulation. No serious complications such as uncontrolled bleeding or urine leakage occurred. One patient had a thermal burn develop at the site of needle electrode insertion and hydronephrosis caused by pyeloureteral junction (PUJ) stricture. In follow-up, ranging from 8 to 53 months, no local recurrence or distant metastasis was detected by computed tomography. CONCLUSIONS: Hemostatic capability of RFC is excellent, improving visibility and ease of operation during LPN, and eliminating need for hilar clamping. Further experience and advancement of RF technology will be needed for the application of this method to larger, centrally located tumors.