[Management of Internal Ureteral Stent (Double J-Stent) Occlusion].

Occlusion of internal ureteral stents commonly called double-J (DJ) stent leads to renal dysfunction, urinary tract infection, and difficulty in replacing the stent. We investigated the cause of stent occlusion and whether DJ stent occlusion persisted with change in the type of stent. The internal ureteral stent, Bird® Inlay™ Optima or Boston Scientific® Tria™, was inserted in 43 ureters of 33 patients who underwent replacement more than three times between September 2017 and June 2020. We defined stent occlusion as follows: a guide wire could not be passed through a stent during the replacement. In the first occlusion, the type of stent was changed. In the second occlusion, the stent placement interval was shortened from 12-13 weeks to 6-8 weeks. The presence of urinary stone and insertion of a urethral catheter had a high risk of DJ stent occlusion. Stent occlusion was observed in 20 of the 43 ureters. After the type of stent in 20 ureters with stent occlusion was changed, there were no DJ stent occlusions in 16 of the 20 ureters. Nevertheless, in 4 of the 20 ureters, even if we changed the type, DJ stent occlusion was still present; hence, the replacement interval was shortened. Therefore, changing the type of stent may be a recommended intervention for DJ stent occlusion.

[IMPACT OF THE SPREAD OF COVID-19 ON THE UROLOGY PRACTICE IN OUR HOSPITAL].

(Purpose) Our hospital plays the role of a prefectural core hospital for COVID-19 and mainly accepts moderate and severely ill patients. In addition, our hospital is also actively responsible for regional emergency medical care, and is designated as a cancer treatment cooperation base hospital. We started accepting patients with COVID-19 in April 2020, and 2 out of 10 wards of our hospital are in operation as exclusive wards for COVID-19 at the time of May 31, 2021. In this study, we compared the effects of the spread of COVID-19 on our urological practice with those before the spread. (Materials and methods) The number of urological operations, their types and average length of stay, the number of outpatients / inpatients, the unit cost of medical treatment income, the referral rate, and the reverse referral rate were calculated based on the in-hospital clinical statistics. (Results) The number of urological operations decreased to 847, 862, and 768 in fiscal year 2018, 2019, and 2020, respectively. There was no significant change in the number of surgeries for malignant tumors in fiscal year 2020, but the number of surgeries for benign diseases decreased. The number of emergency operations tended to increase in fiscal year 2020. The number of urological hospitalized patients in fiscal year 2018, 2019, and 2020 decreased to 653, 690, and 533, and the average length of stay was shortened to 8.4, 8.8, and 8.1 days, respectively. The outpatient and inpatient unit prices per patient when fiscal year 2018 was set to 100 were increasing to 119.5 and 104.9, 133.7 and 119.1 in fiscal year 2019 and 2020, respectively. (Conclusion) It is thought that the spread of COVID-19 has clarified the function and characteristics of our hospital in community medicine.

Periprostatic fat thickness quantified by preoperative magnetic resonance imaging is an independent risk factor for upstaging from cT1/2 to pT3 in robot-assisted radical prostatectomy.

OBJECTIVES: To analyze the correlation between periprostatic fat thickness on multiparametric magnetic resonance imaging and upstaging from cT1/2 to pT3 in robot-assisted radical prostatectomy. METHODS: We retrospectively evaluated data from men with cT1/2 prostate cancer treated with robot-assisted radical prostatectomy at Nara Prefecture General Medical Center, Nara, Japan, between March 2013 and December 2017. We calculated the periprostatic fat thickness and subcutaneous thickness from preoperative multiparametric magnetic resonance imaging. We divided the cohort into two groups for analysis. Group 1 included patients upstaged from clinical to pathological stage, whereas group 2 included those without upstaging. RESULTS: Data on 220 patients meeting the inclusion criteria were included in the analysis. A total of 36 patients were upstaged from clinical T1 or T2 to pathological T3, whereas 184 patients were not upstaged. The upstaging was associated with prostate volume, Gleason score, prostate-specific antigen density, periprostatic fat thickness, Prostate Imaging Reporting and Data System score based on univariate analysis. Multivariate analysis showed prostate volume (P = 0.03, odds ratio 0.958, 95% confidence interval 0.921-0.996), Gleason score (P = 0.022, odds ratio 2.676, 95% confidence interval 1.153-6.213) and periprostatic fat thickness (P = 0.004, odds ratio 1.26, 95% confidence interval 1.079-1.471) as independent risk factors of upstaging. CONCLUSIONS: Prostate volume, Gleason score and periprostatic fat thickness on multiparametric magnetic resonance imaging are significantly associated with and independent risk factors for upstaging from cT1/2 to pT3 in patients undergoing robot-assisted radical prostatectomy.

Simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site to the dorsal vein complex during anterior reconstruction led to a better postoperative urinary continence after robot-assisted laparoscopic prostatectomy.

OBJECTIVES: To elucidate whether a modified technique for anterior reconstruction could improve urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: Among 325 consecutive patients who underwent RALP at our hospital, 297 patients were included in this retrospective study, who had complete records including the status of postoperative urinary continence. Among these 297 patients, 194 underwent anterior reconstruction by suturing the lateral bladder wall to the arcus tendineus of the pectineal fascia without fixation of the vesicourethral anastomosis site to the dorsal vein complex (DVC) (lateral-suture group). In the remaining 103 patients, simple suturing of the bladder neck muscle layer at the vesicourethral anastomosis site with DVC to immobilize the vesicourethral anastomosis site (immobilized group) was performed. Those who did not required a pad was defined as continent. RESULTS: Operative and console times were significantly shorter in the immobilized group (242 vs. 268 min; p = 0.03, and 174 vs. 203 min; p = 0.009, respectively). Although there was no significant difference between the groups regarding the recovery of urinary continence within 3 months after RALP (21 vs. 22% at 1 month; p = 0.77, and 54 vs. 60% at 3 months; p = 0.33, respectively), more patients achieved urinary continence in the immobilized group than lateral-suture group after 6 months (71 vs. 83% at 6 months; p = 0.03 and 82 vs. 96% at 12 months; p = 0.001, respectively). CONCLUSIONS: Simple suture of the bladder neck muscle layer at the vesicourethral anastomosis site to DVC led to a better urinary continence status 6 months or later after RALP.

Preoperative MRI Parameters Predict Urinary Continence after Robot-Assisted Laparoscopic Prostatectomy in Prostatic Cancer Patients.

We aimed to investigate whether preoperative MRI findings could predict the bladder neck location on postoperative cystography and recovery of urinary incontinence after robot-assisted laparoscopic radical prostatectomy (RALP). We retrospectively reviewed 270 consecutive patients who had complete preoperative data, including MRI, and underwent postoperative observation for more than three months. Preoperative MRI parameters consisted of the membranous urethral length (MUL) and pubic symphysis-prostate apex length (PAL) on sagittal images. The bladder neck location on a postoperative cystography was defined as the lowest extension of the tapering contrast medium in the bladder, and its relation to the pubic symphysis (above (higher group) and below (lower group) the middle of the pubic symphysis height) was evaluated. Those who required no pad or a safety pad were defined as being continent. PAL was significantly shorter in the higher group than that in the lower group (25.5 vs. 29.1 mm; p < 0.0001). The continent group at three months had a significantly longer MUL and shorter PAL than those in the incontinent group (8.1 vs. 6.7 mm; p < 0.05, and 26.0 vs. 28.1 mm; p < 0.05, respectively). Preoperative MRI parameters could predict the bladder neck location on postoperative cystograms and the recovery of urinary incontinence after RALP.

[Migration of Hem-o-Lok Clips into the Urinary Bladder Used during Robot-Assisted Laparoscopic Prostatectomy].

Recently, robot-assisted laparoscopic prostatectomy (RALP) has become a widely accepted surgical alternative for the treatment of prostate cancer. The intravesical migration of clips is a rare surgical complication of RALP. From March2013 to July 2018, 320 patients underwent RALP at our hospital. Migration of a Hem-o-Lok clip into the urinary bladder occurred in 4 of the 320 patients (1.3%). We analyzed these 4 patients in terms of subjective symptoms, intra- and post-operative findings, site of the migrated clip, and its treatment. The mean duration from RALP to the diagnosis was 13.8 months (2-26 months). The main symptoms due to migrated clips were : narrowed urinary stream, perineal pain, gross hematuria, and painful urination. In all cases, the size of the migrated clip was medium-large, and the events developed on the side contralateral to the first assistant. The clips were transurethrally removed using a Holmium-laser in 2 patients, and spontaneous excretion was observed in 1. The remaining patient has been asymptomatic and is being conservatively observed. In order to prevent the migration of clips used during RALP, the size of the clips and direction of the clip tail may be important. The first assistant should place the clips carefully, especially on the contralateral side.

[Pubic Bone Osteomyelitis in Patient with Prostate Cancer after Robot-Assisted Laparoscopic Prostatectomy; A Case Report].

A 72-old man had undergone robot-assisted laparoscopic prostatectomy for localized prostate cancer (cT2aN0M0). He was referred to us with a complaint of lower abdominal pain, pain at the bilateral inner thigh, gait disturbance and persistent pyuria three months after surgery. A pelvic MRI revealed inflammation of the pubic area, and pubic bone osteomyelitis was suspected. He was admitted and administered doripenem hydrate (DRPM) intravenously for 3 weeks. The symnptoms of gait disturbance, pain at the bilateral inner thigh, and lower abdominal pain were improved gradually. Levofloxacin hydrate (LVFX）wa s administered orally for 8 weeks subsequently. He has been followed and has had no recurrence of these symptoms.

Clinical benefit of early treatment with bone-modifying agents for preventing skeletal-related events in patients with genitourinary cancer with bone metastasis: A multi-institutional retrospective study.

OBJECTIVES: To evaluate the clinical benefit of bone-modifying agents and identify the risk factors of skeletal-related events in patients with genitourinary cancer with newly diagnosed bone metastasis. METHODS: This was a multicenter retrospective study including a total of 650 patients with bone metastasis of the following cancer types: hormone-sensitive prostate cancer (n = 443), castration-resistant prostate cancer (n = 50), renal cell carcinoma (n = 80) and urothelial carcinoma (n = 77). Clinical factors at the time of diagnosis of bone metastasis were analyzed. Early treatment with bone-modifying agents was defined as follows: administration of bone-modifying agents before the development of skeletal-related events and within 6 months from the diagnosis of bone metastasis. RESULTS: During the follow-up period (median 19.0 months, interquartile range 6.0-43.8 months), skeletal-related events were reported in 88 (20%) patients with hormone-sensitive prostate cancer, 17 (34%) patients with castration-resistant prostate cancer, 58 (73%) patients with renal cell carcinoma and 34 (44%) patients with urothelial carcinoma. Early treatment with bone-modifying agents significantly prolonged the time to the first skeletal-related event in castration-resistant prostate cancer, renal cell carcinoma and urothelial carcinoma, but not in hormone-sensitive prostate cancer. Bone pain and elevated alkaline phosphatase levels were independent predictive risk factors of the first skeletal-related event. The subgroup analysis showed that early treatment with bone-modifying agents was associated with prolonged time to the first skeletal-related events in patients with bone pain or elevated alkaline phosphatase levels. CONCLUSIONS: Early treatment with bone-modifying agents should be considered, especially for patients with bone pain and elevated alkaline phosphatase levels, to prevent skeletal-related events in patients with genitourinary cancer with bone metastasis.

The diagnostic utility of retroperitoneoscopic tissue biopsy for unresectable retroperitoneal lesions excluding urogenital cancers.

BACKGROUND: Retroperitoneal tumors are an uncommon disease known to consist of a diverse group of benign and malignant neoplasms. Treatment of unresectable retroperitoneal lesions requires pathological diagnosis. Here, we report the utility and safety of retroperitoneoscopic biopsy for unresectable retroperitoneal lesions excluding urogenital cancers. METHODS: We analyzed 47 patients consisting of 23 (49%) and 24 (51%) cases that underwent retroperitoneoscopic tissue biopsy and open biopsy, respectively. The clinicopathological features, including postoperative complications, were compared between the two groups. RESULTS: Tumor pathology was diagnosed successfully with a single operation in all patients. Malignant pathology (68%) was more common than benign pathology (32%). The most common pathology was malignant lymphoma, which accounted for about 50% of all cases. There was no significant difference with respect to the age, sex, tumor size, presence of tumor-related symptom, histopathology, operative time, and complications. Three (13%) of 23 patients in the retroperitoneoscopic biopsy group received percutaneous needle biopsy before laparoscopic excisional biopsy because the evaluation of needle cores failed to confirm subclasses of diagnosed pathologies. One patient was converted to open surgery just after the initiation of operation due to severe adhesion of adjacent structures. We had two cases with iatrogenic urinoma due to ureteral injury after retroperitoneoscopic biopsy. CONCLUSIONS: We conclude that retroperitoneoscopic biopsy is a safe and useful tool for benign and malignant retroperitoneal lesions, in comparison to open biopsy. It is critical to carefully examine the preoperative imaging for the location of tumors, especially those close to the renal pelvis and ureter.

Postoperative cystogram findings predict recovery of urinary continence after robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: To assess the association between postoperative cystogram findings and subsequent outcomes on urinary continence after robot-assisted laparoscopic radical prostatectomy (RALP). METHODS: A retrospective review of 250 consecutive patients who were observed for at least 12 months after RALP. The postoperative cystogram findings examined were: the location of the bladder neck, degree of bladder abnormalities, and presence of outflow of contrast medium into the urethra during the filling phase of cystography. The continence status based on pad usage was recorded. Those who required no pad or only a safety pad were defined as continent. RESULTS: Patients with a bladder neck location above the middle of the pubic symphysis height exhibited significantly higher continence levels than those with a lower bladder neck location at both postoperative 3 and 12 months (P < 0.0001 and P = 0.0002, respectively). The higher a bladder neck was located, the earlier the urinary continence was achieved after RALP (P < 0.0001). Patients without contrast outflow into the urethra during cystogram demonstrated a significantly more favorable continence status at the 3-month follow-up (P = 0.004). Patients without bladder abnormalities on postoperative cystogram demonstrated a significantly more favorable continence status at the 12-month follow-up than those with bladder abnormalities (P = 0.01). CONCLUSIONS: Postoperative cystogram findings may predict recovery of urinary continence after RALP.

Rapidly progressing programmed cell death 1 inhibitor-related pneumonitis in a hemodialytic patient with metastatic renal cell carcinoma.

INTRODUCTION: The efficacy and safety of nivolumab for patients receiving hemodialysis remain uncertain. Herein, we report a patient receiving a maintenance hemodialysis with life-threatening interstitial pneumonitis caused by nivolumab for metastatic renal cell carcinoma. CASE PRESENTATION: A 61-year-old man with chronic kidney disease after nephrectomy for renal cell carcinoma was started on hemodialysis. Six months later, he developed multiple bone metastases and received pazopanib. Pazopanib, however, was not effective. We then switched to nivolumab as second-line treatment. Five days after the first administration of nivolumab, he complained of respiratory discomfort and malaise with oxygen desaturation. Chest computed tomography demonstrated diffuse areas of ground glass opacity in both lung fields, suggesting programmed cell death 1 inhibitor-related pneumonitis. Prompt corticosteroid therapy led to improvement of the symptoms. CONCLUSION: Caution should be exercised on the administration of nivolumab to hemodialysis patients due to the risk of interstitial pneumonitis.

[Iatrogenic Injuries of Urinary Tract : Outcomes of Surgical Repairs].

Iatrogenic urinary tract injuries are known complications of digestive and pelvic surgeries. We retrospectively reviewed 13 patients with bladder injuries and 16 patients with ureteral injuries requiring surgical repair or stent placement in our hospital between 2013 and 2016. Obstetric-gynecologic surgery accounted for 10 bladder injuries and 11 ureteral injuries on hysterectomy and Cesarean section. Digestive surgery led to 1 bladder injury and 5 ureteral injuries on colon resection, and urologic surgery resulted in 1 injury on biopsy of a retroperitoneal tumor. Regarding bladder injuries, 10 patients underwent cystorrhaphy, and 3 patients received indwelling of a transurethral Foley catheter alone. Concerning ureteral injuries, 7 patients underwent repair of the injured ureter (ureteroneocystostomy in 5, and ureteroureterostomy in 2), and 9 patients received ureteral stent placement after postoperative retrograde urography. Repair failure was defined when urine leakage, urinary fistula, or urinary stricture requiring ureteral stent placement still existed at 90 days after the repair treatment. The bladder injuries in all 13 cases were successfully repaired. The ureteral injury treatments in 7 out of 16 patients (43.8%) were judged as being unsuccessful because of the condition requiring a ureteral stent at 90 days. There was a correlation between the delayed diagnosis of ureteral injury and unsuccessful repair. The present study showed that the prompt identification of urinary tract injuries, especially ureteral injuries, can result in decreased morbidity andsubsequently improved outcomes.

Overactive bladder induces transient hypertension.

OBJECTIVES: Several studies have shown the relationship between lower urinary tract symptoms and autonomic imbalance. We investigated the relationship between detrusor overactivity (DO) or urgency, and transient increase in blood pressure as a type of hypertension related to sympathetic hyperactivity. Study 1: we enrolled 14 male patients with DO and 10 without DO. We measured the overactive bladder symptom score (OABSS) and blood pressure during cystometry. Study 2: we enrolled 14 men patients with overactive bladder (OAB) and 8 without OAB. We measured OABSS and blood pressure using a 24-h ambulatory device. RESULTS: Study 1: the mean systolic pressure was significantly higher at urgency or SDV than at the other measurement points in the DO group (161.3 ± 23.2 vs. 134.5 ± 16.3, 137.8 ± 15.3, or 139.5 ± 14.8 mmHg). Study 2: the mean systolic pressure was significantly higher at the measurement points before micturition than at the points unrelated to micturition in the OAB group (159.7 ± 24.9 vs. 124.9 ± 13.8 mmHg). In conclusion, DO or urgency induces a transient increase of blood pressure, suggesting that OAB induces a type of hypertension before micturition.

[Ureteral Cancer Developing in Retrocaval Ureter : A Case Report].

Ureteral cancer in the retrocaval ureter is rare. We herein report a patient with this condition laparoscopically treated. A 69-year-old man was referred to us because of right ureteral cancer diagnosed during ureteroscopic surgery for a ureteral calculus. Histological diagnosis of the ureteroscopically biopsied material was non-invasive papillary urothelial carcinoma, low grade (G2). Computed tomography (CT) demonstrated a retrocaval ureter : a double J stent placed during ureteroscopy assisted the diagnosis. The patient underwent retroperitoneoscopic complete nephroureterectomy on the right side. Sufficient separation of the right ureter and the inferior vena cava under retroperitoneoscopic procedures facilitated en bloc extirpation of the kidney and ureter with a minimal lower abdominal incision. The surgical procedures for ureteral cancer in the retrocaval ureter, should be preoperatively considered with care.

[Bladder Rupture during Intravesical BCG Therapy : A Case Report].

A 69-year-old man received transurethral resection (TUR) ofbladder tumor. The histopathological diagnosis was urothelial carcinoma, high grade, pT1＋pTis. The surgical specimens obtained by second TUR showed no residual malignancy histopathologically. Intravesical Bacillus Calmette-Guerin (BCG) instillation therapy was initiated 2 months after the second TUR. He complained of lower abdominal pain and painful urination on the day following the second instillation of BCG. Computed tomography and cystography demonstrated rupture ofthe urinary bladder. During 2 weeks ofconservative treatment, the symptoms persisted. Then, open repair ofthe bladder was performed. Intravesical BCG therapy has been a widely accepted treatment for bladder cancer with high grade Ta and T1, and carcinoma in situ. In the present case, thinning ofthe bladder wall, delayed wound healing caused by 2 TURs, and abdominal pressure may have been the factors leading to the bladder rupture in addition to inflammation of the bladder due to BCG instillation. Although bladder rupture caused by intravesical BCG therapy has not been reported, we must be aware ofthe possibility ofthis rare condition, especially after 2 consecutive TURs.

[Acute Urinary Retention Caused by Acute Disseminated Encephalomyelitis : A Case Report].

An 11-year-old boy was referred to our department with the chief complaint of acute urinary retention. He had had a history of viral enteritis a few days before the onset of dysuria. He presented with a slight fever, mild headache and weakness of the extremities. A cerebrospinal fluid examination showed the elevation of cell number (cell number : 158/3, polynuclear cells : 29/3, and mononuclear cells : 129/3). Although spinal magnetic resonance imaging (MRI) did not show abnormal findings, fluid attenuated inversion recovery (FLAIR) image of the brain MRI showed a high signal area on the cerebral cortex. Acute disseminated encephalomyelitis (ADEM) was suspected from the clinical course, the cerebrospinal fluid examination, and brain MRI findings. A urethral catheter was indwelled for urinary retention, and steroid pulse therapy was promptly started. After removal of the urethral catheter seven days after the therapy initiation, normal urination without residual urine was observed. Findings of a cerebrospinal fluid test and brain MRI also showed improvement.

[Robot-Assisted Laparoscopic Prostatectomy for Patient with Hereditary Hemorrhagic Telangiectasia: A Case Report].

A 69-year-old man who had a history of several nasal hemorrhages and transfusions presented with hereditary hemorrhagic telangiectasia. He was referred to the previous hospital due to the elevation of prostate specific antigen (PSA) to 17.2 ng/ml, and was diagnosed with prostate cancer (cT3aN0M0, Gleason 4 + 5). He was referred to our hospital for the treatment of prostate cancer. Contrast lung computed tomography and brain magnetic resonance imaging did not show arteriovenous fistula in either the lung or brain. Upper gastrointestinal endoscopy showed capillary dilatations in the gastric mucosa. Robot-assisted laparoscopic prostatectomy with Trendelenburg position under general anesthesia was performed. Tracheal intubation was made using bronchofiberscopy. A gastric tube was not inserted. Intra- and postoperative course was uneventful, and there has been no elevation of PSA during the eight months followed.

[Laparoscopic Non-Ischemic Partial Nephrectomy Using a Microwave Tissue Coagulator : A Single-Institutional Study].

We retrospectively investigated the surgical outcomes of renal cell carcinoma (RCC), perioperative complications, and residual renal function in patients receiving laparoscopic non-ischemic partial nephrectomy using a microwave tissue coagulator (MTC). Between January 2002 and December 2015, laparoscopic non-ischemic partial nephrectomy using MTC was performed in 49 patients. The histological diagnosis was RCC in 38 patients, angiomyolipoma in 4, oncocytoma in 2, and others in 5. A histologicallyproven positive surgical margin was observed in 1 (2.0%). Postoperative urine leakage occurred in 1, and it was treated conservatively. The mean follow-up period was 32.0 months. Although there was no patient who died of RCC, local recurrence occurred in 2 patients (4.1%) during the follow-up period. One of these 2 patients had a positive surgical margin. Deterioration of the residual renal function was not observed. Laparoscopic non-ischemic partial nephrectomy using MTC was safe and useful in terms of cancer control and preservation of renal function.

Reversible Posterior Leukoencephalopathy Syndrome Developing After Restart of Sunitinib Therapy for Metastatic Renal Cell Carcinoma.

A 64-year-old Japanese man had started molecular-targeted therapy with sunitinib for lymph node metastasis 5 years after nephrectomy for left renal cell carcinoma (clear cell carcinoma, G2, pT2N0M0). He was transported to our emergency department because of generalized tonic-clonic seizure, vision loss, and impaired consciousness with acute hypertension after 8 cycles of treatment (2 years after the initiation of sunitinib therapy, including a drug withdrawal period for one year). MRI of the brain (FLAIR images) showed multiple high-intensity lesions in the white matter of the occipital and cerebellar lobes, dorsal brain stem, and left thalamus. Reversible posterior leukoencephalopathy syndrome caused by sunitinib was suspected. In addition to the immediate discontinuation of sunitinib therapy, the administration of antihypertensive agents and anticonvulsants improved the clinical symptoms without neurological damage. Physicians should be aware that sunitinib causes reversible posterior leukoencephalopathy syndrome. The early recognition of reversible posterior leukoencephalopathy syndrome is critical to avoid irreversible neurological damage.

The best objective response of target lesions and the incidence of treatment-related hypertension are associated with the survival of patients with metastatic renal cell carcinoma treated with sunitinib: a Japanese retrospective study.

BACKGROUND: The aim of this study is to investigate the prognostic relevance of the best objective response of metastatic target lesions during sunitinib treatment in patients with metastatic renal cell carcinoma. METHODS: Radiographic analysis of the best objective response according to the Response Evaluation Criteria in Solid Tumors was assessed in 50 patients. Clinicopathological characteristics including the Heng risk classification and sunitinib-related adverse reactions were compared among four patient subgroups [complete response or partial response (CR/PR), stable disease (SD), progressive disease (PD), and those without treatment evaluation (NE)]. Kaplan-Meier and Cox proportional regression analyses of progression-free survival and overall survival were performed to identify prognostic variables. RESULTS: The best objective response was CR/PR in 12 (24 %) patients, SD in 22 (44 %), PD in 6 (12 %), and NE in 10 (20 %). The incidence of hypertension and hypothyroidism was associated with a better objective response. Progression-free survival was 15.0, 9.2, 6.8, and 2.2 months in the CR/PR, SD, PD, and NE groups, respectively (P = 0.0004, log-rank test), while the corresponding median overall survival was 59.7, 24.2, 17.1, and 18.1 months, respectively (P = 0.007). Multivariate analysis revealed that hazard ratios for risk of death of the SD, PD, and NE groups were 4.51 (P = 0.06), 7.93 (P = 0.02), and 4.88 (P = 0.04), respectively, as compared to the CR/PR group. CONCLUSIONS: Our findings suggested that the best objective response of target lesions was a prognostic marker for both progression-free survival and overall survival in sunitinib treatment. Furthermore, the incidence of sunitinib-induced hypertension was associated with a longer progression-free survival.