Test clamp procedure in robot-assisted partial nephrectomy: is it a safe procedure?

We performed test clamp procedure in robot-assisted partial nephrectomy (RAPN) to prevent massive bleeding during tumor resection and to omit dissection of non-feeding arteries around the tumor. We subsequently analyzed the safety and usefulness of the procedure. The Test clamp procedure was performed for 1 to 3 min during renal artery test ischemia prior to the actual ischemia and tumor resection. We confirmed the disappearance of blood flow around the renal tumor using color Doppler ultrasonography. If arterial blood flow around the tumor remained, we surveyed the site for other arteries that needed to be clamped and repeated the test clamp procedure until renal blood flow around the tumor disappeared. We retrospectively analyzed consecutive RAPN cases performed from July 2016 to March 2020 at our institutions and reviewed medical records. The clinical data of the RAPN cases were statistically analyzed. Sixty-four RAPN cases underwent the test clamp procedure, which was categorized as the TEST group. Test clamping was performed safely without any clamping-related complications in all cases. Eleven cases (17%) underwent partial ischemia, which was a significantly higher number than that in the control group. Massive bleeding during tumor resection was more frequent in the control group. Postoperative deterioration of estimated glomerular filtration rate did not differ significantly between both groups. Although further investigation was still necessary, our findings indicate that the test clamp procedure may be a safe and secure procedure to perform in RAPN for both patients and surgeons.

Favorable Response of Pembrolizumab as Second-Line Therapy for Advanced Urothelial Carcinoma with Only Small Lesions to not be Considered Measurable by RECIST.

PURPOSE: Pembrolizumab is currently considered the standard second-line treatment for advanced urothelial carcinoma (UC). This study aimed to investigate the efficacy and safety of pembrolizumab in patients with advanced UC in real-world data, which is not well-reported. MATERIALS AND METHODS: The study included 97 patients with advanced UC whose lesions were classified according to the Response Evaluation Criteria in Solid Tumors (RECIST). The median age was 73 years. Nineteen patients (20%) with performance status (PS) 2-4 were included. The percentages of liver, lung, bone, and lymph node metastasis were 18%, 27%, 19%, and 76%, respectively. The efficacy, safety, and risk factors for prognosis were evaluated for patients with and without measurable lesions. RESULTS: The best response was complete response in nine patients (9%) and partial response in 16 patients (17%). The median progression-free survival and overall survival were 3.7 months (95% confidence interval [CI]: 2.8-4.7) and 11.8 months (95% CI: 6.7-17.0), respectively. Twenty-one (22%) patients had no measurable lesions per RECIST. In univariate and multivariate analysis, PS 2-4 and lesions by RECIST were identified as factors associated with short overall survival (OS). The median OS of 18.3 months in patients without lesions by RECIST was significantly longer than the median OS of 6.7 months in patients with lesions by RECIST (p = .012). CONCLUSION: We demonstrated that good PS 0-1 and no measurable lesions, especially small lesions, by RECIST were favorable prognostic factors in patients with advanced UC treated by pembrolizumab.

Blood Cell Count Biomarkers Predicting Efficacy of Pembrolizumab as Second-line Therapy for Advanced Urothelial Carcinoma.

BACKGROUND/AIM: To investigate the blood markers for predicting pembrolizumab efficacy in advanced urothelial carcinoma (UC). PATIENTS AND METHODS: This study included 91 advanced UC patients. The relationship between prognosis and markers from peripheral blood cell counts, including the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), and systemic inflammation response index (SIRI=monocytes × neutrophils/lymphocytes), was evaluated. RESULTS: Multivariate analysis indicated that pretreatment NLR and the 1-month-change NLR were both significantly associated with overall survival (OS) after pembrolizumab initiation. When the patients were divided into four groups according to calculated cutoffs using Cox proportional hazard model, the pretreatment NLR <2.9 and 1-month change NLR <+43% groups had a significantly better OS than the pretreatment NLR ≥2.9 and 1-month-change NLR ≥+43% groups. CONCLUSION: NLR, MLR, PLR and SIRI before pembrolizumab and 1-month-change NLR in advanced UC correlated with OS after pembrolizumab treatment.

Importance of Continuing Education for Medical Staff to Improve the Confirmation Rate of Intent for Organ Donation.

BACKGROUND: Among Organisation for Economic Co-operation and Development countries, the number of cadaveric donors per population is the lowest in Japan. The present study investigated whether a continuing educational intervention for medical staff, such as Donor Action Program (DAP) that is aimed at increasing the number of cadaveric donors, improved the confirmation rate of organ donation in potential donors. MATERIAL AND METHODS: We studied 2 hospitals with emergency centers in Toyama, Japan. DAP was conducted 2 to 3 times each year. We extracted mortality cases recorded in the emergency care departments of each hospital for over 10 years between 2007, prior to DAP's implementation, and 2017 to examine the confirmation rate of the intent of the families of potential donors for organ donation and the timing and methods for confirming intent to donate in cases that resulted in organ donation. RESULTS: The confirmation rate increased after the introduction of DAP and remained high (over 80%) in both hospitals after 2012. Regarding actual organ donation, some patients were asked by staff about their intent when they became potential donors in addition to the hospitalization intake form; it was offered by family members of some of the patients. CONCLUSION: Regular educational training on organ donation improved the confirmation rate of potential organ donors' donation intention. For organ donation, medical practitioners must take the appropriate steps to confirm the patient's intent to donate when he/she is determined as a potential donor.

Effectiveness of Synthetic Polymer-coated Peripherally Inserted Central Catheter in Patients With Advanced Cancer.

BACKGROUND/AIM: A peripherally inserted central catheter (PICC) is recommended for the safe administration of anticancer agents. The effectiveness of synthetic polymer-coated and non-coated PICCs was compared. PATIENTS AND METHODS: Patients with advanced cancers who had indwelling PICCs were reviewed using their medical records. Three types of PICCs were compared in terms of complications and catheter failure. RESULTS: A total of 90 patients were retrospectively analyzed, including 31 with Groshong PICCs, 30 with Argyle PICC kit, and 29 with Argyle PICC kit II. The incidence of catheter failure for Groshong PICC, Argyle PICC kit, and Argyle PICC kit II per 1,000 PICC days was 4.4614, 5.6617, and 0.8658, respectively. Catheter failure-free survival in the Argyle PICC kit II group was significantly better than that in the Argyle PICC kit group (p=0.0339). CONCLUSION: Argyle PICC kit II, a synthetic polymer-coated PICC, may render longer patency and prevention of catheter failure than non-coated PICCs.

Evaluation of Factors Affecting Metastasis for Renal Cell Carcinoma Based on Current Guidelines in Japan.

BACKGROUND/AIM: To analyze the suitability for metastasis evaluation of each pathologic item on the Fourth Edition of the General Rule for Clinical and Pathologic Studies on Renal Cell Carcinoma in Japan. PATIENTS AND METHODS: We retrospectively examined 457 cases of renal operation after 2011 using the current edition of the guidelines. RESULTS: The mean postoperative follow-up period was 25.3 months. Radical nephrectomy was performed in 264 cases, whereas partial nephrectomy was performed in 193 cases. Including the 33 cases discovered after operation, the overall number of metastatic cases was 68 (14.9%). Using the current edition of the guidelines, the items of histologic grade, morphology of tumor invasion, tumor pseudocapsule, and intrarenal metastasis were all correlated with distant metastasis. CONCLUSION: This is the first report showing that each item on the current Japanese guidelines for renal cell cancer was useful for predicting metastasis.

Massive Ascites in a Renal Transplant Patient after Laparoscopic Fenestration of a Lymphocele.

Retroperitoneal lymphocele is a common complication of renal transplantation. Here, we report the case of a 67-year-old woman with massive ascites after fenestration surgery for a lymphocele that developed following renal transplantation. She had been on continuous ambulatory peritoneal dialysis for 9 years. Living donor renal transplantation was performed and an intrapelvic lymphocele subsequently developed. The lymphocele did not resolve after aspiration therapy; therefore, laparoscopic fenestration was performed. Although the lymphocele disappeared, massive ascites appeared in its stead. Half a year later, the ascites was surgically punctured, which then gradually resolved and disappeared 6 weeks later. Aspiration therapy should be considered in patients on long-term peritoneal dialysis, although laparoscopic fenestration is safe and effective.

Usefulness of selective renal artery embolization for urinary fistula following partial nephrectomy: Two case reports.

The present study reported two cases in which selective artery embolization were identified to assist in resolving urinary fistulae following partial nephrectomies. The first case involved a 51-year-old male who received a mini-incision partial nephrectomy with renorrhaphy. Following the operation, urine continued to discharge from the retroperitoneal drain. Selective renal artery embolization of the upper calyx at post-operation day 20 was highly effective and urine output from the drain stopped immediately. Case 2 involved a 66-year-old male, who also suffered from a urinary fistula following a partial nephrectomy. Selective renal artery embolization performed at post-operation day 21 was again effective. In each case, the upper calyx was separated from the renal pelvis. These cases demonstrated that suturing of the collecting system and renal parenchyma may result in the separation of the urine pathway, and that selective renal artery embolization appears to be a highly effective treatment in such cases.

Holmium Laser Enucleation of the Prostate With Percutaneous Nephrostomy Into the Transplanted Kidney in Patient With Severe Benign Prostatic Hyperplasia With Vesicoureteral Reflux - A Case Report.

A 66-year-old male, who had received renal transplantation 10 years before, was admitted to our hospital with urinary retention. The prostate volume was 169.2 ml. Furthermore, grade 5 vesicoureteral reflux (VUR) was shown in the cystography. Holmium laser enucleation of prostate (HoLEP) was performed, and percutaneous nephrostomy to the transplanted kidney was performed simultaneously to prevent from severe perioperative infection. After that, renal graft function improved and no urinary retention reoccurred, although surgical repair against VUR was necessary 10 months after HoLEP. We conclude that surgical treatment for BPH after kidney transplantation should be strongly considered with care for infections.

Prostatic Stromal Tumor of Uncertain Malignant Potential Which Was Difficult to Diagnose.

Here, we report a case of stromal tumor of uncertain malignant potential (STUMP) that was difficult to diagnose. A 53-year-old male was found to have a hard nodule on digital rectal examination; magnetic resonance imaging revealed a large nodule on the left side of the prostate, indicating prostate cancer. However, pathological diagnosis of the biopsy specimen was benign prostatic hyperplasia. Although a papillary tumor in the prostatic urethra was also seen on urethrocystoscopy, the tumor specimen obtained from transurethral resection was not malignant. The tumor in the prostatic urethra recurred only 3 months after transurethral resection, and pathological findings revealed benign hyperplasia not only in the stromal tissue but also in the epithelium; therefore, the prostate tumor was suspected to be STUMP. It took many prostate pathologists a long time to reach the final diagnosis of STUMP. STUMP is a rare benign tumor, difficult to diagnose, and sometimes transforms into stromal sarcoma. Thus, we should consider radical resection in such cases.

Preclinical Cushing's syndrome resulting from adrenal black adenoma diagnosed with diabetic ketoacidosis.

A right adrenal tumor was incidentally discovered on abdominal computed tomography performed on a 53-year-old Japanese man, who had been hospitalized with diabetic ketoacidosis. Normal values were obtained for adrenal hormones in the morning after an overnight fast and urinary cortisol excretion after treatment of diabetic ketoacidosis with insulin. However, overnight dexamethasone administration with 1 mg or 8 mg did not completely suppress serum cortisol levels. There were no remarkable physical findings related to Cushing's syndrome. The patient was diagnosed as having preclinical Cushing's syndrome (PCS). Histological examination of the adrenalectomy specimen demonstrated adrenal black adenoma. Blood glucose levels subsequently improved after adrenalectomy, and the patient never developed adrenal insufficiency after hydrocortisone withdrawal. The patient was treated with diet therapy alone, and maintained good glycemic control. However, the patient still showed a diabetic pattern in an oral glucose tolerance test. It seems that the existence of PCS in addition to the underlying type 2 diabetes mellitus contributed to aggravation of blood glucose levels. Although there are many aspects of the natural course of PCS that have not been thoroughly elucidated, it is necessary to remain aware that a PCS patient with abnormal glucose metabolism may develop diabetic ketoacidosis by environmental agents.

A case of bilateral testicular calcifications in a bicycle motocross rider accompanied by bulbar urethral injury.

A 21-year-old Japanese man who was a professional bicycle motocross rider injured his perineum during a competition. Chief complaints were gross hematuria, perineal pain, and subcutaneous ecchymosis of the scrotum. Urethrocystography revealed a torn bulbar urethra and extravasation in the same region. Scrotal ultrasonography revealed small calcifications in the bilateral testes. Here, we report a case of bilateral testicular calcifications caused by the continuous shock and vibration of the saddle in an off-road bicycle rider.

Durability of working channel in flexible ureteroscopes when inserting ureteroscopic devices.

PURPOSE: We studied the physical damage to the working channel of flexible ureteroscopes caused by insertion of various accessories. A procedure was developed to avoid channel damage. MATERIALS AND METHODS: An experimental model representing a flexible ureteroscope was prepared, and damage to its working channel was evaluated by inserting instruments through it. Deflection angles of the channel were changed from 0 degrees to 120 degrees, and each device was inserted and removed 100 times for each selected angle of the channel. Any induced pinholes were identified by an air-leak test. Also, the inside of the channel was inspected with an extremely fine fiberscope. RESULTS: Insertions of 3F biopsy forceps or a 2.4F Nitinol stone-retrieval device caused only slight damage to the model channel, even when the deflection angle was 120 degrees. However, the tips of 200- or 250-microm holmium laser fibers shaved the inner surface of the channel at 60 degrees of deflection, and at 120 degrees, the laser fiber either penetrated the channel or could not be advanced because of resistance by the channel wall. When the laser fiber was inserted within a protective tube, the channel was never damaged, even when the deflection angle was 120 degrees. CONCLUSIONS: When devices are inserted into the working channel of a flexible ureteroscope, damage to the wall depends on the kind of device and deflection angle. Harm could be avoided by inserting the devices, especially laser probes, within a protective tube.

Percutaneous pneumatic and laser lithotripsy as a possible therapeutic strategy for bilateral large calculi in a horseshoe kidney.

This report concerns a case of bilateral large calculi in a horseshoe kidney. Three sessions of percutaneous nephrolithotripsy for the calculi successfully disintegrated and removed the fragments without any complications. For complete stone removal we used pneumatic and laser lithotriptors which were passed, respectively, through a rigid nephroscope and a flexible pyeloscope. It is emphasized that the selection of the most suitable lithotriptor by taking their various features into account is important in endoscopic surgery for calculi which are likely to recur such as stones accompanied by infection or for anatomically anomalous kidneys such as horseshoe kidneys.

High-dose chemotherapy with peripheral blood stem cell transplantation for advanced testicular cancer.

BACKGROUND: The aim of this study was to investigate the efficacy and safety of high-dose chemotherapy (HDCT) for the treatment of patients with advanced testicular cancer. METHODS: Fourteen patients were treated with high-dose carboplatin, etoposide and cyclophosphamide (with or without THP-adriamycin) followed by peripheral blood stem cell transplantation. The treatment was used for two refractory cases, a second relapse, and for consolidation after the first relapse in one case each. It was also used for nine cases as part of the first-line treatment following primary conventional-dose chemotherapy, and for one case as the first salvage for a late recurrent tumor of teratoma with malignant transformation. RESULTS: The first two patients who received intensive pretreatment with cisplatin-based chemotherapy did not respond to HDCT. The two patients who were treated with HDCT as the first or second salvage therapy achieved successful outcomes. The results for the subsequent nine patients (consisting of two with stage IIIC, five with IIIB2, one with IIB, and one extragonadal seminoma) were two progressive disease, three no change and four partial remission. Only three are alive with NED following salvage surgery. Finally, a case of teratoma with malignant transformation did not respond well to two cycles of HDCT. There were no marked adverse reactions except one episode of severe neutropenic colitis. CONCLUSIONS: The results demonstrated the limited efficacy of HDCT even in cases with a good to intermediate risk rating according to classification by the International Germ Cell Cancer Collaborative Group. Because treatment for relapse after HDCT is extremely difficult, new HDCT regimens consisting of drugs that are not used in induction chemotherapy need to be established.