[A Case of Primary Adenocarcinoma Mucinous Subtype of the Bladder].

A 48-year-old man who presented with asymptomatic gross hematuria in July 202X had been followed up without treatment. In January 202X, he was referred to our department due to the exacerbation of his hematuria. Contrast-enhanced magnetic resonance imaging revealed bladder cancer suggested bilateral seminal vesicle and prostate invasion, and enlarged right internal and external iliac lymph nodes. The pathological diagnosis was mucinous bladder adenocarcinoma. Prostate biopsy results were negative. Upper and lower gastrointestinal examinations were unremarkable. We suspected bladder cancer cT4aN2M0. In March 202X＋1, the patient underwent robotic-assisted laparoscopic total bladder resection, pelvic lymph node dissection, and intracorporeal urinary tract modification (ileal conduit creation). The final diagnosis was primary mucinous adenocarcinoma pT4aN2M0 of the bladder. Given the heightened risk of recurrence, the patient was administered a three-month course of oxaliplatin and capecitabine (XELOX) as adjuvant postoperative chemotherapy. The patient remains free of progression at 8 months postoperatively. Adenocarcinoma of the bladder is an exceedingly rare entity, with no established chemotherapeutic protocols. Primary mucinous adenocarcinoma of the bladder is even more exceptional. Presently, only regimens similar to those for colorectal cancer or adenocarcinoma of unknown primary, including 5-fluorouracil, are considered. In our particular case, we elected to pursue XELOX therapy, aligning with the principles governing the management of colorectal cancer.

The expression of human testis-specific actin capping protein predicts in vitro fertilization outcomes: A novel biomarker of sperm function for assisted reproductive technology.

PURPOSE: Sperm function tests do not adequately assess fertilization potential, and new indices are required. We have previously reported that human testis-specific actin capping proteins may be involved in both sperm morphology and function. This study aimed to determine whether testis-specific actin capping proteins can be a predictive marker of IVF success. METHODS: Ninety-seven infertile couples who underwent IVF at an infertility clinic were included. Sperm were immunohistochemically stained to evaluate capping protein expression, and the percentage of sperms with normal staining was calculated. The relationship between actin capping protein expression and IVF outcomes was examined. RESULTS: The couples were divided into four groups according to the percentage of normally expressing actin capping protein as follows: ≥90% Group Ⅰ, 80%-90% Group Ⅱ, 70%-80% Group Ⅲ, and <70% Group Ⅳ. Multiple regression analysis showed a significant trend in fertilization rates across the 4 groups (p for trend =0.008).There was no significant trend in pregnancy rates (p for trend =0.276). CONCLUSION: The human testis-specific actin capping protein may be a marker of male contributing factors that predict IVF outcomes.

[Pediatric Multiple Endocrine Neoplasia Type 2B with Pheochromocytoma Diagnosed after Perforation of a Colonic Diverticulum : A Case Report].

A 12-year-old girl was found to have decending colon diverticulum perforation and retroperitoneal abscess on computed tomography (CT) carried out to determine the cause of fever and stomachache. CT-guided drainage tube placement was performed. She was suspected of having MEN2B from her specific facial appearance, Marfan-like body shape and lingual mucosa neuroma. Cervical ultrasonography and serum tumor marker revealed medullary thyroid carcinoma and metastasis to cervical lymph node. Genetic examination revealed a mutation of RET gene codon 918. Therefore, she was diagnosed as having MEN2B. Laboratory data showed elevated urinary catecholamines. Metaiodobenzylguanidine (MIBG) adrenal scintigraphy showed bilateral adrenal uptake and a definitive diagnosis of bilateral adrenal pheochromocytomas was made. Discharge from the drainage tube persisted and it was difficult to continue conservative treatment. Therefore, laparoscopic bilateral adrenalectomy and transverse colon colostomy were performed. Subsequently, total thyroidectomy and cervical lymph node dissection were performed. At five years of follow up, bilateral lung metastases were observed, but the serum calcitonin level was normal and the patient is under observation.

Decreased renal function increases the nighttime urine volume rate by carryover of salt excretion to the nighttime.

To determine the pathophysiology of nocturnal polyuria associated with renal dysfunction, patients who underwent laparoscopic nephrectomy were prospectively studied. The diurnal variation in urine volume, osmolality, and salt excretion were measured on preoperative day 2 and postoperative day 7. The factors associated with an increase in the nighttime urine volume rate with decreased renal function were evaluated using multiple linear regression analysis. Forty-nine patients were included. The estimated glomerular filtration rate decreased from 73.3 ± 2.0 to 47.2 ± 1.6 mL/min/1.73 m2 (P < 0.01) and the nighttime urine volume rate increased from 40.6% ± 2.0% to 45.3% ± 1.5% (P = 0.04) with nephrectomy. The nighttime urine osmolality decreased from 273 ± 15 to 212 ± 10 mOsm/kg and the nighttime salt excretion rate increased from 38.7% ± 2.1% to 48.8% ± 1.7% (both P < 0.01) with nephrectomy. Multiple linear regression analysis showed that the increase in the nighttime urine volume rate was strongly affected by the increase in the nighttime salt excretion rate. A decrease in renal function causes an increase in the nighttime urine volume rate, mainly because of an increase in nighttime salt excretion.Trial registration number: UMIN000036760 (University Hospital Medical Information Network Clinical Trials Registry).Date of registration: From 1 June 2019 to 31 October 2020.

Novel hydrogen-producing Si-based agent reduces oxidative stress, and improves sperm motility and in vitro fertilization rate in varicocoele.

BACKGROUND: Varicocoele-induced male infertility potentially involves oxidative stress. Although varicocoelectomy is recommended for varicocoele patients presenting abnormal semen findings, no pharmacotherapeutic methods currently exist. We have recently developed a silicon-based agent that produces hydrogen by the reaction with water. OBJECTIVES: This study aimed to investigate the therapeutic effects of oral administration of a Si-based agent on varicocoele rat. MATERIALS AND METHODS: Twenty-one rats were divided into four groups: varicocoele + normal diet (n = 5), varicocoele + Si-based agent-supplemented diet (n = 6), sham + normal diet (n = 5), and sham + Si-based agent-supplemented diet (n = 5). All rats were euthanized four weeks after surgery. RESULTS: The mean left epididymal sperm motility was 74.4% in the sham group, 72.3% in the sham + Si group, 57.6% in the varicocoele group, and 66.9% in the varicocoele + Si group. Epididymal sperm motility was significantly lower in the varicocoele group, but was significantly higher upon Si-based agent ingestion (P < .01). The mean left testicular weight, Johnsen's score, and left epididymal sperm concentration did not differ significantly between groups. The 8-OHdG concentration and DNA fragmentation rate were significantly increased in the varicocoele group, but were significantly decreased in the Si-based agent intake group (P < .01). Additionally, the IVF rate was significantly lower in the varicocoele group (26.3%) compared with the sham group (73.4%; P < .01), and was significantly higher in the varicocoele + Si group (51.8%) compared with the varicocoele group (P < .05), indicating that the Si-based agent improves IVF rates. DISCUSSION AND CONCLUSION: Oral intake of the silicon-based agent improves epididymal sperm motility and in vitro fertilization rates through hydrogen production and subsequent reduction of oxidative stress. Considering the lack of effective noninvasive methods, this Si-based agent is potentially applicable for treating varicocoele-induced abnormal semen parameters.

Bladder urothelium converts bacterial lipopolysaccharide information into neural signaling via an ATP-mediated pathway to enhance the micturition reflex for rapid defense.

When bacteria enter the bladder lumen, a first-stage active defensive mechanism flushes them out. Although urinary frequency induced by bacterial cystitis is a well-known defensive response against bacteria, the underlying mechanism remains unclear. In this study, using a mouse model of acute bacterial cystitis, we demonstrate that the bladder urothelium senses luminal extracellular bacterial lipopolysaccharide (LPS) through Toll-like receptor 4 and releases the transmitter ATP. Moreover, analysis of purinergic P2X2 and P2X3 receptor-deficient mice indicated that ATP signaling plays a pivotal role in the LPS-induced activation of L6-S1 spinal neurons through the bladder afferent pathway, resulting in rapid onset of the enhanced micturition reflex. Thus, we revealed a novel defensive mechanism against bacterial infection via an epithelial-neural interaction that induces urinary frequency prior to bacterial clearance by neutrophils of the innate immune system. Our results indicate an important defense role for the bladder urothelium as a chemical-neural transducer, converting bacterial LPS information into neural signaling via an ATP-mediated pathway, with bladder urothelial cells acting as sensory receptor cells.

[Disturbance of Consciousness in a Patient with an Indwelling Lumbar-Peritoneal Shunt Following Retroperitoneal Laparoscopic Radical Right Nephrectomy : A Case Report].

An 83-year-old man with an indwelling lumbar-peritoneal (L-P) shunt (for idiopathic normal-pressure hydrocephalus) underwent retroperitoneal laparoscopic radical right nephrectomy for renal cell carcinoma (pT1aN0M0). Peritoneal perforation occurred intraoperatively, and he developed postoperative disturbance of consciousness. Computed tomography showed mild ventricular enlargement, which was attributed to L-P shunt failure secondary to increased pneumoperitoneum pressure. His level of consciousness was improved when we raised his head. Few reports have discussed complications observed during retroperitoneal laparoscopic surgery in patients with an indwelling L-P shunt. This case report discusses this topic along with a discussion of previously reported findings.

Intravesical ATP instillation induces urinary frequency because of activation of bladder afferent nerves without inflammatory changes in mice: A promising model for overactive bladder.

ATP in the suburothelial layer is released from the bladder urothelium by mechanical stimuli. ATP directly activates purinergic receptors that are expressed on primary bladder afferent neurons and induces the micturition reflex. Although ATP is also released to the bladder lumen from the bladder urothelium, the role of ATP in the bladder lumen is unknown. Recently, clinical studies have reported that urinary ATP levels are much higher in patients with an overactive bladder than healthy controls. These results suggest that ATP in the bladder lumen is also involved in the micturition reflex. In this study, we performed intravesical ATP instillation in the mouse bladder. We evaluated urinary function with novel reliable methods using improved cystometry and ultrasonography, which we previously established. We found that intravesical ATP instillation induced urinary frequency because of activation of bladder afferent nerves without inflammatory changes in the bladder or an increase in post-void residual urine. These results suggest that not only ATP in the suburothelial layer, but also ATP in the bladder lumen, are involved in enhancement of the micturition reflex.

[Urachal Actinomycosis : A Case Report].

The patient was a 66-year-old woman who was examined by a local physician for the chief complaint of a mass palpable in the left lower abdomen. Abdominal plain computed tomography (CT) indicated a subcutaneous mass extending continuously from the apex of the bladder to the retropubic space, and she was referred to our medical department. Tumor markers were normal, and cystoscopic examination indicated no clear findings. Abdominal contrast-enhanced CT and plain abdominal magnetic resonance imaging results led to suspicion of actinomycosis. An open biopsy was performed on the subcutaneous mass, and subsequent histopathological testing led to a definitive diagnosis of actinomycosis. After 2 weeks of antibiotic therapy, the mass had diminished on CT. There has been no relapse approximately 24 weeks after discontinuation of the antibiotic therapy.

[Development of Ectopic Adrenocorticotropic Hormone Syndrome in a Patient with Prostate Cancer during Combined Androgen Blockade Therapy].

A 74-year old man presented to us with difficulty urinating. The laboratory examinations revealed an elevated prostate-specific antigen (PSA) level. A prostate biopsy revealed prostate adenocarcinoma. The computed tomography scan showed metastasis to lymph nodes in the pelvic cavity and both adrenal glands. Combined androgen blockade therapy was started, and PSA levels began to decrease gradually. However, 2 months later, he was hospitalized for treatment of cellulitis and was found to have hypertension, hyperglycemia, and hypokalemia. Endocrinological studies showed elevated serum adrenocorticotropic hormone (ACTH) and serum and urinary cortisol levels. The plasma cortisol level was not reduced by either the 1 mg or 8 mg dexamethasone suppression test, and the plasma cortisol and ACTHlevels did not respond to the corticotropin-releasing hormone test. Computed tomography indicated increased metastasis, and endocrinological studies and other examinations suggested a diagnosis of ectopic ACTHsyndrome. Combined androgen blockade therapy was continued, and inhibitors of adrenocortical synthesis were also administered. However, 16 weeks later, he died of prostate cancer. On autopsy, the histological examination revealed small cell carcinoma in the prostate and adrenal glands and other sites of metastasis, while immunohistochemistry findings revealed that the tumors in the prostate and adrenal glands were strongly positive for ACTH.

[A Case of Epithelioid Angiomyolipoma of the Kidney with Tumor Thrombus Extending into the Renal Vein : Case Report].

A 31-year-old man was referred to our hospital for macroscopic hematuria. An abdominal computed tomography (CT) scan showed a 36×30 mm enhancing left renal tumor with tumor thrombus extending into the left renal vein. Therefore,we diagnosed the tumor as a clinically classified cT3aN0M0 left renal cell carcinoma. Retroperitoneal laparoscopic radical left nephrectomy with renal vein thrombectomy was performed,with removal of the left kidney with the mass and tumor thrombus en bloc. The pathological diagnosis was epithelioid angiomyolipoma (EAML) of the left kidney. EAML is a rare tumor with malignant potential. In this case,although no signs of recurrence or metastasis have been observed for 9 months post-operation,we recommended a careful follow-up regimen.

[Recurrence of Well Differentiated Intrascrotal Liposarcoma in Retroperitoneum Five Years after Resection : A Case Report].

A 68-year-old man underwent an inguinal orchiectomy for a right testicular tumor and the pathological diagnosis was atypical lipomatous tumor. Nine years later, a resection procedure was performed for local recurrence. Five years after that second surgery, abdominal computed tomography (CT) findings revealed a low density mass 40 mm in size on the back side of the right kidney and enlarged fat in the retroperitoneal space. We performed a laparoscopic tumor resection under a diagnosis of lipoma or liposarcoma recurrence, and the pathological diagnosis was well differentiated liposarcoma. Treatment with pazopanib was started, as a CT examination showed that the tumor remained, after which we performed an open nephroureterectomy and resected the remaining tumor portion. Pazopanib treatment was continued and no obvious signs of recurrence were seen at 8 months after the most recent surgery. Although well differentiated liposarcoma usually recurs in the original tumor region, multicentric recurrence in other parts is possible.

[Solitary Fibrous Tumor in the Pelvic Space : A Case Report].

A 46-year-old man was found to have a mass in the pelvic cavity on computed tomography (CT) carried out for an examination for lower abdominal pain. Abdominal magnetic resonance imaging showed a mass which appeared to have hyposignals on both T1- and T2-weighted images. A positron emission tomography CT showed that the mass had a low maximum standardized uptake value (＝1.4). Biopsy of the mass showed tumoral cells demonstrating a 'patternless pattern' characterized by a haphazard, storiform arrangement of short spindle or ovoid cells. Immunohistochemistry disclosed CD34 positivity and desmin and alfa-smooth muscle actin (SMA) negativity which supported the diagnosis of solitary fibrous tumor. Tumorectomy was performed. Grossly, the tumor was a large encapsulated mass with well limited margins weighing 67.7 g. Histology revealed a mass with no necrotic or hemorrhagic degeneration. On immunohistochemistry, the tumor cells were strongly positive for CD34 and they were negative for desmin and alfa-SMA. At six months of follow up, the patient was well and he had no signs of recurrence.

[The efficacy of ethinylestradiol for castration-resistant prostate cancer].

OBJECTIVE: We analyzed the efficacy of ethinylestradiol as estrogen therapy on Castration-resistant Prostate Cancer (CRPC). PATIENTS AND METHODS: The study was conducted on 14 patients who were diagnosed as having CRPC and who were being prescribed ethinylestradiol (1.5-2.0 mg/day) with aspirin (100 mg/day) and an LH-RH agonist in our hospital from August 2011. RESULTS: All patients had already been treated with a combined androgen blockade (CAB), 8 patients had been treated with docetaxel, 9 patients with tegafur-uracil, 4 patients with estramustine phosphate sodium. Age and prostate-specific antigen (PSA) at prescription of ethinylestradiol was 55-85 (median 75.5) and 0.784-508.7 ng/ml (median 4.842 ng/ml). Thirteen patients (92.9%) achieved a decline in PSA, 8 patients (57.1%) achieved a decline in PSA > 50%. Time to progression was 0-18 months (median 7 months), and there were no severe adverse events including venous thromboembolic diseases. CONCLUSION: Oral ethinylestradiol administration may have efficacy for CRPC without severe adverse events. Ethinylestradiol may be one of the selective drugs for CRPC patients who do not wish to undergo intravenous chemotherapy or become resistant to docetaxel.

[Strangulation of the penis with a rubber band : a case report].

We report a case of strangulation of the penis with a rubber band. A 68-year-old man visited our hospital for treatment of a markedly swollen penis. Physical examination revealed one rubber band tightly coiled around the penis. The rubeer band was soon removed, gangrene of the penis continued. A high fever, chills and hypotension were recognized. Sepsis was presumed, and administration of antibiotics was started. Microbiologic cultures revealed streptococcus agalactiae in blood. Since his general condition did not improve, we performed partial penectomy. After the surgery, he showed complete recovery.