Dose compliance of estramustine phosphate in neoadjuvant chemohormonal therapy combined with degarelix acetate predicts the biochemical recurrence in patients with very high-risk prostate cancer who underwent robot-assisted radical prostatectomy.

OBJECTIVES: The objective of this study is to evaluate the safety and efficacy of neoadjuvant degarelix acetate and low-dose estramustine phosphate for high-/very high-risk prostate cancer. METHODS: Overall, 187 patients diagnosed with National Comprehensive Cancer Network high-/very high-risk cTanyN0M0 localized prostate cancer who consented to undergo robot-assisted radical prostatectomy after receiving neoadjuvant chemohormonal therapy for 6 months were prospectively enrolled between December 2017 and March 2023. Adverse events, perioperative and histopathological outcomes, and biochemical recurrence-free survival rates were examined. Survival analysis compared the estramustine phosphate completion and reduction groups. RESULTS: Thirty-six patients discontinued neoadjuvant therapy in <5 months owing to adverse events (n = 34) or other reasons (n = 2). Eleven were excluded for being in the postoperative castration range. Of the 140 patients who underwent surgery, 124 continued with two tablets of estramustine phosphate and 16 with one tablet. Overall, 82 patients were very high-risk. Histopathological outcomes were significantly worse in the very high-risk group than those in the high-risk group. Very high-risk status and estramustine phosphate reduction were significant factors in biochemical recurrence in multivariate analysis. The biochemical recurrence-free survival rate in very high-risk patients was significantly lower in the estramustine phosphate dose reduction group than in the completion group but not significant in high-risk patients. Major adverse events were anemia (n = 174), elevated transaminase levels (n = 68), and deep vein thrombosis (n = 24). Severe adverse events included acute coronary syndrome (n = 4) and pulmonary embolism (n = 3). CONCLUSIONS: Dose compliance with estramustine phosphate predicted biochemical recurrence in patients with very high-risk prostate cancer undergoing robot-assisted radical prostatectomy with neoadjuvant chemohormonal therapy.

Safety of urethral preservation using urethral frozen section analysis in radical cystectomy.

Background: The objective of this study is to assess whether urethral preservation can be performed safely using frozen section analysis (FSA) of the urethral stump on urethral recurrence after radical cystectomy. Methods: Between June 2012 and July 2022, we investigated consecutive male patients who underwent urethral FSA during radical cystectomy for urothelial carcinoma. For FSA-abnormal cases, urethrectomy was performed, and for FSA-normal cases, the urethra was preserved. The diagnostic accuracy of FSA was assessed in comparison with the pathological findings of the permanent sections of the same tissue. Postoperatively, computed tomography and urinary cytology were performed as routine surveillance of recurrence. Results: Of the 77 patients included in this study, three patients with abnormal FSA underwent concurrent urethrectomy. The negative predictive value of urethral FSA was 100%. With a median postoperative follow-up of 38 months (interquartile ranges 21-71), no urethral recurrence was observed. Conclusions: FSA may be useful in determining the indication for urethrectomy.

Totally retroperitoneal approach for robot-assisted nephroureterectomy with bladder cuff without repositioning.

INTRODUCTION: Robot-assisted nephroureterectomy (RANU) for upper urinary tract urothelial carcinoma is typically performed via the transperitoneal approach because of limited surgical space. However, a retroperitoneal approach may be preferable in patients with a history of abdominal surgery or in those in whom pelvic lymph node dissection is unnecessary. MATERIALS AND SURGICAL TECHNIQUES: RANU via the retroperitoneal approach was selected for two patients diagnosed with high-grade upper urothelial carcinoma with a history of abdominal surgery. Nephrectomy was performed in the 90° flank position, and the bed was tilted at 20°. The retroperitoneal space was extended, and the robot trocar was subsequently repositioned in the left lower quadrant. After redocking the robot, the distal ureter was dissected, and the bladder cuff was resected en bloc along with the kidney and the ureter. Neither patient had any complications within 3 months postoperatively. DISCUSSION: By devising a new technique for trocar placement, total retroperitoneal RANU without repositioning was possible, even in a small patient.

[A Case of Retroperitoneal Lymphangioleiomyomatosis].

Contrast-enhanced computed tomography (CT) revealed a multilocular cystic mass extending from the level of the renal artery origin to the internal and external iliac artery regions in a woman in her 40s who presented with vomiting and diarrhea. A percutaneous biopsy was performed, and histopathological examination revealed bundle-like proliferations of spindle-shaped cells with oval nuclei in acidophilic cytoplasm. Immunohistochemical staining was positive for HMB-45, alpha-smooth muscle actin, E-cadherin, and estrogen and progesterone receptors; the provisional diagnosis was perivascular epithelioid cell tumor. Considering the patient's age and sex, the final diagnosis was primary retroperitoneal lymphangioleiomyomatosis (LAM). She did not meet the diagnostic criteria for tuberous sclerosis complex and was considered to have sporadic LAM. As complete surgical resection was considered to be impossible and no lung lesions, which indicate poor prognosis, were observed, we decided to keep her under surveillance. The patient was asymptomatic, with no significant changes on imaging for 6 months.

Efficacy of cabozantinib therapy for brain metastases from renal cell carcinoma.

Introduction: We report two cases of renal cell carcinoma with brain metastases that showed remarkable responses to cabozantinib. Case presentation: (Case 1) A 70-year-old man with cT3aN0M0 clear cell renal cell carcinoma underwent radical nephrectomy and developed multiple brain metastases 2 months postoperatively. The brain lesions regressed after stereotactic radiotherapy followed by ipilimumab plus nivolumab therapy, but a new brain metastasis that caused hemiplegia developed after 6 months and showed no response to stereotactic radiotherapy. However, complete remission was achieved, and hemiplegia ceased within 2 weeks of cabozantinib therapy. (Case 2) A 63-year-old man with cT3aN0M1 clear cell renal cell carcinoma and brain metastases underwent upfront cytoreductive nephrectomy. The brain lesions progressed rapidly 1 month postoperatively. The lesions disappeared 2 weeks after cabozantinib plus nivolumab therapy. Conclusion: Cabozantinib, alone or in combination with immune checkpoint inhibitors, may be a viable option for clear cell renal cell carcinoma with brain metastases.

A case of penile self-mutilation during a suicidal attempt successfully treated using a multidisciplinary approach.

Introduction: Penile self-mutilation is predominantly associated with psychiatric disorders and rarely occurs during suicide attempts by men with depressive mood disorders. Herein, we have reported a case of penile self-mutilation by a patient with depression. Case presentation: A 63-year-old man with a 20-year treatment history of depression presented to our hospital an hour after cutting his penile shaft during a suicide attempt. Hemostasis was achieved by urologists, and his psychiatric condition was evaluated by psychiatrists. The patient and his family hoped for penile replantation. His mood disorders were controllable, and microscopic replantation was performed by plastic surgeons after multidisciplinary discussion. The patient recovered, urinated without any signs of urinary stricture, showed no progression of depression, and did not repeat the mutilation. Conclusion: Penile self-mutilation during suicide attempts is a rare urological emergency that requires multidisciplinary management involving urologists, psychiatrists, and plastic surgeons.