Incidental finding of extramammary Paget's disease during active surveillance for early-stage prostate cancer in a prostate biopsy.

Introduction: Skin tissue contamination within transcutaneous visceral organ biopsies is seldom found. We encountered a rare case of extramammary Paget's disease incidentally diagnosed by prostate biopsy during active surveillance for prostate cancer. Case presentation: A 71-year-old Japanese patient was diagnosed with prostate cancer, and active surveillance was selected. After 1 year, prostate biopsy was performed by a transperitoneal approach, and 16 biopsy cores were taken. One biopsy core contained skin tissue showing extramammary Paget's disease. Careful skin examination confirmed the presence of an extramammary Paget's disease lesion in the left perineum, and curative surgical resection was performed. Recurrence and metastasis did not occur after 6 months of follow-up. Conclusion: Although the perianal region is a common site of extramammary Paget's disease, early-stage extramammary Paget's disease is often asymptomatic. Thus, during a transcutaneous biopsy, it is important to consider the appearance of the skin and the pathological features of migrating skin tissue.

A national questionnaire survey of Japanese urologists on active surveillance for low- and intermediate-risk prostate cancer.

OBJECTIVE: To conduct a national questionnaire survey of Japanese urologists on active surveillance (AS) for low- and intermediate-risk prostate cancer (PCa). METHODS: A questionnaire was sent to 922 Japanese Urological Association Teaching Base Hospitals. The items included were years of experience as a urologist, sex, workplace, treatment equipment owned, specialty area of daily practice, specialty area of urological cancer, and six hypothetical cases of AS. The cases were categorized by the following Gleason scores: 3 + 3 low risk of PCa, 3 + 4 intermediate risk, and 4 + 3 intermediate risk, with or without comorbidities for each case. Comorbidities were defined as cardiovascular diseases or illnesses warranting anticoagulant therapy. RESULTS: Altogether, 1962 questionnaires were analyzed. Responses were almost equally distributed among all age groups. Workplaces included general hospitals (49.4%), university hospitals (40.3%), and cancer centers (4.2%). Percentages of proposed AS for low risk/no comorbidity, low risk/with comorbidity, intermediate-risk 3 + 4/no comorbidity, intermediate risk 3 + 4/with comorbidity, intermediate risk 4 + 3/no comorbidity, and intermediate risk 4 + 3/with comorbidity were 90.5%, 90%, 39.5%, 48.7%, 15%, and 22%, respectively. Analysis of the correspondents' backgrounds showed that the more the urologists' years of experience, the less they were to advise AS of low-risk patients. In the presence of comorbidities, urologists across all age groups tended to propose AS, even in the same Gleason grade group. Cancer center urologists recommended AS more often than their counterparts at general and university hospitals. CONCLUSIONS: Approximately 40% of urologists proposed AS for intermediate-risk cases, confirming that AS for intermediate-risk patients is being considered in Japan.

Photodynamic diagnosis-assisted transurethral resection using oral 5-aminolevulinic acid decreases residual cancer and improves recurrence-free survival in patients with non-muscle-invasive bladder cancer.

BACKGROUND: 5-aminolevulinic acid is a protoporphyrin IX precursor used for photodynamic diagnosis. We aimed to clarify the therapeutic benefits of orally administered 5-aminolevulinic acid for photodynamic diagnosis in transurethral resection for non-muscle-invasive bladder cancer in a real-world setting. METHODS: From January 2009 to December 2020, patients with non-muscle-invasive bladder cancer who have undergone visually complete resection by initial transurethral surgery were included. Histopathologically confirmed residual and intravesical recurrent bladder cancer was retrospectively investigated and compared with transurethral resection using photodynamic diagnosis and conventional white light. RESULTS: One hundred and fifteen patients who underwent photodynamic diagnosis-transurethral resection were compared with 346 patients who underwent white light-transurethral resection. The second transurethral resection revealed that the proportion of residual T1 and Ta bladder cancer was lower in the photodynamic diagnosis group than in the white light group (10.3% vs. 33.8%, P = 0.001). Additionally, the proportion of intravesical recurrence was lower in the photodynamic diagnosis group than in the white light group (9.6% vs. 41.9%, P < 0.001). Using 5-aminolevulinic acid-photodynamic diagnosis during transurethral resection of bladder tumor improved the cumulative intravesical recurrence-free survival (log-rank test: P < 0.001). Furthermore, multivariate analyses indicated that not using 5-aminolevulinic acid-photodynamic diagnosis was an independent predictive factor for residual bladder cancer (odds ratio, 6.16; 95% confidence interval, 2.10-18.0; P < 0.001) and intravesical recurrence (hazard ratio, 2.01; 95% confidence interval, 1.05-3.83, P = 0.034). CONCLUSIONS: Introducing 5-aminolevulinic acid-photodynamic diagnosis into transurethral resection reduces residual bladder cancer and improves the cumulative intravesical recurrence-free survival in patients with non-muscle-invasive bladder cancer, indicating its possible therapeutic benefits.

The Paris System for reporting urinary cytology improves the negative predictive value of high-grade urothelial carcinoma.

BACKGROUND: The Paris System (TPS) for reporting urinary cytology differs from conventional systems (CS) in that it focuses on the diagnosis of high-grade urothelial carcinoma (HGUC). This study investigated the impact of TPS implementation on the diagnostic accuracy of HGUC by comparing it with our institutional CS. METHODS: A total of 649 patients who underwent transurethral resection of bladder tumor (TURBT) between January 2009 and December 2020 were included in this study. Our institution adopted TPS to report urinary cytology in February 2020. The diagnostic accuracy of HGUC in preoperative urinary cytology was compared with the presence or absence of HGUC in resected specimens of TURBT before and after TPS implementation. RESULTS: After implementing TPS in urinary cytology, 89 patients were reviewed and compared with 560 patients whose urinary cytology was diagnosed by CS. TPS and CS for detecting HGUC had 56.0% and 58.2% sensitivity, 97.8% and 91.2% specificity, and 93.3% and 87.9% positive predictive values, respectively. There were no significant differences between TPS and CS in terms of sensitivity, specificity, and positive predictive value for HGUC (P = 0.83, 0.21, 1.00). On the other hand, the negative predictive value for HGUC using TPS was 80.0%, which was significantly higher than that of CS (66.4%, P = 0.04) The multivariate logistic regression analysis indicated that not using TPS was one of the independent predictive factors associated with false-negative results for HGUC (odds ratio, 2.26; 95% confidence interval, 1.08-4.77; P = 0.03). CONCLUSION: In instances where urinary cytology is reported as negative for HGUC by TPS, there is a low probability of HGUC, indicating that TPS has a potential diagnostic benefit.

Impact of the severity of urethrovesical anastomotic leakage on urinary continence following robot-assisted laparoscopic prostatectomy.

We assessed whether the severity of anastomotic urinary leakage detected during routine cystourethrography after robot-assisted laparoscopic prostatectomy (RALP) affects urinary continence recovery. Around 302 patients who underwent RALP between August 2013 and May 2019 were included retrospectively. According to routine cystourethrographic findings obtained on the sixth or eighth postoperative day, which indicated leakage severity, patients were divided into three groups: no-leakage, grade 1 (linear shaped leakage, but not spreading), and grade 2 (spreading strip-shaped leakage). The preoperative factors and intraoperative factors were compared between no-leakage and leakage group (grade 1 and grade 2). Continence recovery was compared between the three groups. Continence recovery was defined as no pad used or one security pad used in a day. Cystourethrography revealed anastomotic urinary leakage in 44 patients (14.5%), of which 20 patients (6.6%) had grade 1 leakage and 24 patients (7.9%) had grade 2 leakage. On multivariate logistic regression analysis, the only significant predictor for urethrovesical anastomotic urinary leakage on cystourethrography following RALP was intraoperative anastomotic leakage (OR 5.306; 95% CI 1.530-18.398, p = 0.009). Continence recovery rates for no-leakage, grade 1 leakage, and grade 2 leakage groups were 11%, 20%, and 25% after 1 month (P = 0.131); 25%, 25%, and 45.8% after 3 months (P = 0.474); 44.6%, 55%, and 60.8% after 6 months (P = 0.184); and 63.1%, 87.5%, and 78.2% after 12 months (P = 0.095), respectively. In conclusion, urinary leakage in urethrovesical anastomosis, even at its severity, had no negative effects on continence recovery after RALP.

Incidental Bladder Cancer Found on Cystoscopy during Prostate Biopsy: Prevalence, Pathological Findings, and Oncological Outcome.

INTRODUCTION: We examined the prevalence, pathological findings, and oncological outcomes of incidental bladder cancer found on cystoscopy among patients eligible for prostate biopsy (PB). METHODS: We retrospectively reviewed 803 patients who underwent cystoscopy prior to PB between January 2010 and September 2020. In cases of bladder tumor-like findings on cystoscopy, biopsy or transurethral resection of the bladder tumor was performed. The primary and secondary outcomes were the prevalence of incidental bladder cancer and pathological and oncological outcomes of incidental bladder cancer, respectively. RESULTS: Incidental findings were observed in 31/803 patients (3.9%). Bladder tumor-like findings were found in 24/803 patients (3%), while 9/803 patients (1.1%) were pathologically diagnosed with urothelial carcinoma. The stage and grade of incidental bladder cancer were pTa in 8/9 patients and pT1 in 1/9 and low grade in 8/9 and high in 1/9, respectively. The median tumor size of the papillary pedunculated type was 0.5 cm. At 26-month median follow-up, no recurrence was observed. CONCLUSION: Cystoscopy during PB may yield incidental bladder cancer findings, although the prevalence is very low. Incidental bladder cancer was of low stage and grade, which seemed unrelated to survival. Moreover, performing routine cystoscopy in conjunction with PB is not recommended as it may lead to overdiagnosis of low-risk bladder cancer.

A case of pyelocalyceal diverticulum urothelial carcinoma that was difficult to distinguish from cystic renal cell carcinoma preoperatively.

INTRODUCTION: Pyelocalyceal diverticulum is a rare disease sometimes difficult to distinguish from cysts. We report a case of urothelial carcinoma originating from a pyelocalyceal diverticulum, difficult to distinguish from cystic renal cell carcinoma preoperatively. CASE PRESENTATION: A 51-year-old Japanese man complained of gross hematuria. Computed tomography revealed a solid mass in one of the many cystic lesions in the left kidney. He was diagnosed with left cystic renal cell carcinoma and underwent retroperitoneal laparoscopic nephrectomy. Pathological examination revealed high-grade invasive urothelial carcinoma arising within the renal pyelocalyceal diverticulum. The definitive diagnosis was high-grade invasive urothelial carcinoma (pT3). In retrospect, the retrograde pyelography findings indicated the cyst and urinary tract connection. Residual ureterectomy and adjuvant chemotherapy were later performed. The patient has since been recurrence-free. CONCLUSION: Whether cystic renal cell carcinoma is suspected on imaging, pyelocalyceal diverticulum should be considered a differential diagnosis, though unlikely to be encountered in daily practice.

Myocarditis as an immune-related adverse event following treatment with ipilimumab and nivolumab combination therapy for metastatic renal cell carcinoma: a case report.

BACKGROUND: Immune checkpoint inhibitors are new immunotherapy drugs globally used for many malignancies, including renal cell carcinoma. Myocarditis as an immune-related adverse event is rare but highly fatal, suggesting that its frequency may be higher than reported. This paper describes a case of myocarditis that developed asymptomatically following ipilimumab and nivolumab combination therapy for renal cell carcinoma. CASE PRESENTATION: A 71-year-old Asian man who presented to hospital with fever, fatigue, and weight loss of approximately 10 kg within 2 months was diagnosed with Xp.11.2 translocation renal cell carcinoma. Computed tomography revealed multiple lung masses, mediastinal lymph node enlargement, and a level II tumor thrombus reaching the inferior vena cava (cT3bN0M1; International Metastatic Renal Cell Carcinoma Database Consortium, poor risk). Ipilimumab/nivolumab combination therapy was started as induction therapy. The patient experienced acute interstitial nephritis as an immune-related adverse event after treatment initiation; however, a good response to steroid therapy was observed. The antitumor effect of the immunotherapy was notable. Although he experienced pulmonary embolism, it seemed asymptomatic and harmless; thus, a second infusion was introduced. From the eighth day, he demonstrated rapidly worsening cardiogenic shock with asymptomatic electrocardiographic changes and drastic drop in cardiac biomarkers, and a diagnosis of myocarditis as an immune-related adverse event was made. Although immediate methylprednisolone mini-pulse therapy followed by tapered prednisolone prevented mortality, extensive myocardial fibrosis with marked ejection fraction decline persisted as a sequela. Consequently, follow-up without treatment was instituted; however, much of the tumor response initially observed was maintained over several months. CONCLUSION: Physicians treating patients with immune checkpoint inhibitors should be aware of their potentially life-threatening cardiotoxic effects. This study emphasized the importance of a high index of suspicion, prompt diagnosis, and early intervention in patients who present with cardiac abnormalities and possible myocarditis after receiving immunotherapy.

Positive Culture Prior to Transperineal Prostate Biopsy Was Not Associated with Post-Biopsy Febrile Urinary Tract Infection Development.

PURPOSE: To investigate the association between urine culture before transperineal prostate biopsy and post-biopsy febrile urinary tract infection (fUTI). PATIENTS AND METHODS: We retrospectively reviewed 307 patients who underwent urine culture before transperineal prostate biopsy between April 2017 and September 2020. Patients with indwelling urinary catheters (n=7) were excluded. Urine culture was performed 1-3 days before the biopsy, and all patients received prophylactic cefazolin regardless of culture results. A urine culture was defined as positive if cell density was more than 1×105 colony-forming units per mL. Baseline characteristics and the incidence of post-biopsy fUTI were compared between patients showing positive pre-biopsy culture results and those showing negative findings. RESULTS: Out of 300, seven patients (2.3%) had positive urine culture results before the biopsy. Age (p=0.077); prostate-specific antigen at diagnosis (p=0.267); prostate volume (p=0.78); number of biopsy cores (p=0.277); percentage of patients testing positive for cancer on biopsy (p=0.71); and percentages of patients with a history of biopsy (p>0.999), diabetes mellitus (p=0.604), and immunosuppressive medication use (p>0.999) were similar between the two groups. No patient in the positive urine culture group had post-biopsy fUTI. However, 1.7% (five patients) of the negative urine culture group had the disease (p>0.999) (four patients with prostatitis and one with pyelonephritis). Among them, two patients were diagnosed by urine culture at the time of post-biopsy fUTI. CONCLUSION: In asymptomatic patients, positive pre-biopsy cultures were not associated with the development of post-biopsy fUTI.

Apalutamide-associated skin rash in patients with prostate cancer: Histological evaluation by skin biopsy.

INTRODUCTION: Apalutamide-associated skin rash is a more common adverse event in the Japanese population than in the global population. However, its mechanism remains elusive, and limited histopathological information hampers further understanding. CASE PRESENTATION: Case 1: a 71-year-old man with metastatic castration-sensitive prostate cancer developed a skin rash after 70 days of apalutamide treatment. Case 2: a 71-year-old man with non-metastatic castration-resistant prostate cancer developed a skin rash after 71 days of apalutamide treatment. In both cases, the skin rash presented as a slightly exudative erythema. The histology showed spongiosis of the epidermis and perivascular and interstitial infiltration of lymphocytes and eosinophils in the upper dermis without necrotic keratinocytes. CONCLUSION: Apalutamide-induced skin rashes can involve an eczematous reaction clinically and histologically.

Effects of inflammatory prostatitis on the development and progression of benign prostatic hyperplasia: A literature review.

Benign prostatic hyperplasia is a major disease that affects the quality of life of middle-aged and older men. Although >70% of men aged >70 years have pathological benign prostatic hyperplasia, its pathogenesis and progression remain unclear. In this article, we reviewed the scientific literature on this condition and examined the development of lower urinary tract symptoms. Clinically, the weight of the prostate is not always proportional to the severity of the symptoms, and many factors can influence the progression of benign prostatic hyperplasia. Other than androgens, chronic inflammation can play an essential role in its development and the induction of symptoms, especially in symptomatic hyperplasia, because inflammatory cell infiltration is frequently observed in the prostate. Inflammation-induced changes in the prostate environment lead to changes in gene expression and subsequent chronicity of inflammation. It has been suggested that chronic asymptomatic prostatitis might be associated with changes in prostate structure and subsequent symptoms. In animal studies, the administration of anti-inflammatory drugs in rats with chronic prostatitis prevented the infiltration of inflammatory cells and increased the gland-to-stroma ratio. It is hoped that future research on the molecular biology of asymptomatic prostatitis might help to develop new therapeutic strategies for lower urinary tract symptoms associated with symptomatic prostatitis. Our conclusions provide a comprehensive insight into the prevalence and development of benign prostate hyperplasia and the treatment methods that can be used to treat it.

Efficacy and toxicity of intravesical Bacillus Calmette-Guérin therapy in elderly patients with non-muscle-invasive bladder cancer.

OBJECTIVES: This study aimed to compare the efficacy and toxicity of intravesical Bacillus Calmette-Guérin (BCG) therapy between elderly and younger patients with non-muscle-invasive bladder cancer (NMIBC). MATERIAL AND METHODS: This retrospective study included 87 NMIBC patients who received intravesical BCG between January 2011 and December 2018. We compared the treatment outcomes of patients ≥75 and <75 years old. Our primary endpoint was intravesical recurrence-free survival after treatment. The secondary endpoint was the toxicity caused by intravesical BCG. RESULTS: The elderly and younger patients included 38 and 49 patients with mean ages of 80.6 and 66.3 years (p < 0.01), respectively. Their baseline parameters were similar, aside from age. The elderly and younger patients' 5-year recurrence-free survival rates were 59.4% and 51.6%, respectively, and were not significantly different (log-rank test, p = 0.72). Moderate to severe pain on micturition requiring prescription medications was observed more frequently in the elderly patients than in the younger patients (p < 0.01). No elderly patients required hospitalization for any adverse events. However, 3 (6.1%) younger patients were treated for urinary tract infection in the hospital. CONCLUSIONS: The efficacy and toxicity of intravesical BCG therapy for NMIBC patients are not associated with age. Therefore, elderly patients with high-risk NMIBC should be treated in the same manner as younger patients in clinical practice.

Use of surgical checklist during transurethral resection increases detrusor muscle collection rate and improves recurrence-free survival in patients with non-muscle-invasive bladder cancer.

OBJECTIVE: To elucidate the therapeutic benefits of using a surgical checklist during transurethral resection for non-muscle-invasive bladder cancer. METHODS: A nine-item surgical checklist was established in January 2016 to assess disease risk and resection adequacy, and it was prospectively implemented into clinical practice. Patients diagnosed with non-muscle-invasive bladder cancer who underwent complete resection from January 2009 to August 2019 were included in this study. The presence of detrusor muscle in the transurethral resection specimen and the intravesical recurrence-free survival were compared between patients who underwent transurethral resection before and after surgical checklist implementation. RESULTS: A total of 125 patients who underwent transurethral resection after surgical checklist implementation were reviewed and compared with 125 patients who underwent transurethral resection before surgical checklist implementation. The use of the surgical checklist led to an increase in the proportion of transurethral resection specimens containing detrusor muscle (92% vs 69.6%, P < 0.01) and a decrease in the recurrence rate (19.2% vs 49.6%, P < 0.01). Multivariate analysis showed that transurethral resection without a surgical checklist was an independent predictive factor influencing the absence of detrusor muscle in the transurethral resection specimen (odds ratio 4.78, P < 0.01) and intravesical recurrence (hazard ratio 1.92, 95% confidence interval 1.14-3.23; P = 0.01). Kaplan-Meier plots showed that the recurrence-free survival rate was significantly lower when the surgical checklist was not used (log-rank test result P < 0.01). CONCLUSIONS: This study shows the therapeutic benefits of surgical checklist in improving the quality of resection during transurethral resection and reducing the recurrence rate in patients with non-muscle-invasive bladder cancer.

The predictive factor for pathological downgrading after prostatectomy in patients with biopsy Gleason score 4+3 or 4+4 prostate cancer.

The proportion of Gleason pattern (GP) 4 prostate cancers at prostate biopsy has a clinically significant impact on risk stratification for patients with prostate cancer. In pathological diagnosis including GP 4, a biopsy Gleason score (GS) of 3+4 has a more favorable prognosis than a GS of 4+3 and 4+4. However, the discrepancy between biopsy and prostatectomy specimens is well known. The current study investigated the clinical parameters and biopsy specimens associated with pathological downgrading after prostatectomy in biopsies with a GS of 4+3 or 4+4 prostate cancer. A total of 302 patients with prostate cancer who underwent robot-assisted radical prostatectomy between August 2013 and May 2019 were retrospectively reviewed. A total of 103 patients had biopsies with GSs of 4+3 and GS 4+4 (unfavorable pathology). The proportion of patients who were downgraded from unfavorable disease to GS ≤3+4 (favorable pathology) in prostatectomy specimens was investigated. Logistic regression analysis was used to explore the association between clinical parameters and downgrading in prostatectomy specimens. A total of 43 patients (41.7%) were downgraded from biopsy GS to prostatectomy GS. The proportions of downgrade in biopsy GS 4+4 and 4+3 were 14.6 and 27.1%, respectively. The percentage of highest GS out of positive biopsy cores and the maximum percentage of cancer involvement within a positive core with the highest GS were lower in the downgrade group than in the no downgrade group (45 vs. 66.7%, P=0.025; 20 vs. 30%, P=0.048, respectively). When performing multivariate logistic regression analysis, the only significant predictor for downgrade was lower percentage of highest GS cores out of positive biopsy cores (odds ratio, 2.469; 95% confidence interval, 1.029-5.925 P=0.043). In conclusion, patients with biopsy GS 4+4 and 4+3 often exhibit a downgrade to GS 3+4 or less in prostatectomy specimens. The lower percentage of highest GS cores out of positive biopsy cores was associated with downgrade.

The Impact of Histopathological Features of Prostate Cancerous Lesions on Multiparametric Magnetic Resonance Imaging Findings using PI-RADS Version 2.

OBJECTIVES: To determine the square measure threshold of prostate cancer lesions in pathological specimens showing PI-RADS categories 3 to 5, and to identify the pathological characteristics of cancerous lesions over the threshold. METHODS: Cancer foci detected in horizontal sections of specimens were defined as pathological cancerous lesions, in which square measure, lesion location (peripheral or transition zone), Gleason pattern (GP), GP4-5 component percentages, and GP 4 subtypes were assessed. A receiver operating characteristic curve was used to determine the threshold of the square measure of pathological specimens that distinguishes between lesions of PI-RADS categories 1 and 2 and those of 3 to 5. Univariable and multivariable analyses were performed to determine the histopathological features associated with PI-RADS categories 3 to 5. RESULTS: A total of 100 consecutive patients underwent multiparametric magnetic resonance imaging before robotic-assisted laparoscopic prostatectomy. A total of 1366 pathological cancerous lesions were detected, 217 of which were classified as PI-RADS categories 3 to 5. A square measure of 40 mm2 on pathological specimens was the threshold for PI-RADS categories 3 to 5. Of the 415 lesions that were over 40 mm2, 211 lesions exhibited PI-RADS categories 1, 2 and 204 lesions exhibited PI-RADS categories 3 to 5. Multiple logistic regression analysis showed that square measure, fused glands, and cribriform glands were independently associated with PI-RADS categories 3 to 5. CONCLUSION: Cancerous lesions over 40 mm2 showing PI-RADS categories 3 to 5 are associated with square measure, fused glands, and cribriform glands.

Ureteroiliac artery fistula caused by full-length metallic ureteral stenting in a malignant ureteral obstruction: a case report.

BACKGROUND: The metallic stent is a new device for relieving the urinary tract in patients with malignant ureteral obstruction with short life expectancy and has been used frequently worldwide for its efficacy and safety. A ureteroarterial fistula with indwelling ureteral stent is rare but highly fatal, and there are several reports of ureteroarterial fistula treated by conventional polymer stents, although there are no reports on metallic stents. To our knowledge, this paper describes the first case of a ureteroiliac artery fistula caused by a full-length metallic ureteral stent in malignant ureteral obstruction. CASE PRESENTATION: Our patient was a 57-year-old Asian woman with a history of locally advanced cervical cancer who underwent abdominal total hysterectomy and chemoradiotherapy. She was diagnosed with right hydronephrosis and hydroureter secondary to upper ureteral obstruction because of retroperitoneal lymph node metastasis. A urinary tract obstruction after placement of 12 months of polymer stent followed by 18 months of metallic stent was relieved, consequently resulting in intermittent gross hematuria with bladder tamponade and anemia. Contrast-enhanced computed tomography could not reveal a ureteroarterial fistula; however, retrograde pyelography emphasized the existence of a ureteroiliac artery fistula. The patient underwent successful endovascular heparin-bonded stent graft placement, and her gross hematuria disappeared thereafter. CONCLUSION: The metallic stent is a useful device for patients with malignant ureteral obstruction with a short life expectancy, although it may impose a higher pressure on the extraureteral tissue than conventional polymer stents due to its properties and may cause a ureteroarterial fistula. The narrowing of the external iliac artery diameter visualized by computed tomography may be helpful for predicting ureteroarterial fistulas.

Impact of second transurethral resection on recurrence in patients with high-grade Ta bladder cancer.

OBJECTIVES: To clarify the potential therapeutic benefit of a second transurethral resection for high-grade Ta bladder cancer. METHODS: From January 2009 to August 2019, 521 patients with bladder tumors underwent initial transurethral resection procedures at Kagawa University Hospital. Patients diagnosed with high-grade Ta bladder cancer considered to have been resected completely were included in this study. Recurrence and progression rates were compared between patients who received a second transurethral resection and those who did not. RESULTS: We identified 97 eligible patients, including 22 patients who received a second transurethral resection. In terms of clinical characteristics, the proportion of patients with bladder cancer and upper urinary tract tumor history was lower in the second transurethral resection group than in the no second transurethral resection group (P < 0.01 and P = 0.03, respectively). The histopathological findings of 22 transurethral resection procedures were no cancer in 13 (59.2%), Ta in six (27.2%) and carcinoma in situ in three patients (13.6%). After the second transurethral resection, one patient (4.6%) had recurrent high-grade T1 bladder cancer. The no second transurethral resection group showed a 44% recurrence rate (33 patients), including five patients (6.7%) with progression, and consequently, had a higher rate of recurrence than in the second transurethral resection group (P < 0.01). Multivariate analysis showed that no second transurethral resection was the independent predictive factor influencing recurrence (hazard ratio 8.662, P = 0.04). The Kaplan-Meier curve showed that a second transurethral resection significantly decreased the recurrence rate than that of patients without a second transurethral resection (P < 0.01). CONCLUSIONS: A second transurethral resection can reduce the recurrence rate in high-grade Ta bladder cancer, showing a possible therapeutic benefit of this procedure.

Retinal Nerve Fiber Layer Thickness Progression after Robotic-Assisted Laparoscopic Radical Prostatectomy in Glaucoma Patients.

PURPOSE: To investigate the effect of the steep Trendelenburg position surgical procedure on the retinal structure and function during robotic-assisted laparoscopic radical prostatectomy (RALP) in glaucoma patients. METHODS: At 1 month and 1 day before and at 1 and 2 months after the RALP operation, 10 glaucoma patients underwent standard automated perimetry and optical coherence tomography. After placing patients in a supine position, intraocular pressure (IOP) was measured at 5 min after intubation under general anesthesia (T1), at 5 discrete time points (5, 30, 60, 120, and 180 min; T2-6) and at 5 min after returning to a horizontal supine position (T7). The Guided Progression Analysis software program was used to assess serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression. RESULTS: Eight additional patients were newly diagnosed in addition to the two previous glaucoma patients. Average IOP (mmHg) at each time point was as follows: T1 = 11.2 ± 3.8, T2 = 19.0 ± 4.4, T3 = 23.3 ± 6.3, T4 = 25.1 ± 4.3, T5 = 25.5 ± 5.1, T6 = 28.3 ± 4.8, and T7 = 22.6 ± 5.4. IOP significantly increased during RALP. RNFL thickness progressed in two eyes of two patients after the surgery, even though there was no progression of the visual field. CONCLUSIONS: Two eyes of two patients exhibited significant RNFL thickness progression. Since an increased IOP during the surgery was the probable cause of the changes, ophthalmologic examinations should be performed before and after RALP, especially in glaucoma patients.