Effectiveness of Steroid Pulse Therapy for Systemic Side Effects after Bacillus Calmette-Guérin Intravesical Instillation Therapy: A Series of Five Cases.

INTRODUCTION: Bacillus Calmette-Guérin (BCG) instillation is an established therapy for the treatment of carcinoma in situ (CIS) of the bladder and prevention of recurrence after transurethral resection of bladder tumor noninvasive bladder cancer. However, serious systemic side effects may occur in less than 5% of patients with BCG intravesical instillation. Systemic side effects can sometimes be fatal and require early and accurate treatment. We describe five cases wherein steroid pulse therapy was effective for treating the systemic side effects after BCG intravesical instillation. Case Presentations. BCG intravesical instillation was used to prevent the recurrence of nonmuscle invasive bladder cancer and treat CIS of the bladder; the dose used was 40-80 mg each time, and the Tokyo strain was used. The patients developed fever, impaired consciousness, arthralgia, conjunctival hyperemia, and symptoms of cystitis. The median time from installation to side effect manifestation was 6 days (0-8). One to two courses of steroid pulse therapy were administered (1 course in 3 days), and the dose of methylprednisolone was 500-1000 mg/day. BCG sepsis was observed in one case; however, in the other four cases, one course of steroid pulse therapy showed a rapid improvement in symptoms. In the case of BCG sepsis, hemodialysis and mechanical ventilation were required because of septic shock and acute renal failure. Antituberculosis drugs (isoniazid, rifampicin, and ethambutol) were started promptly; however, no improvement was noticed. Two courses of steroid pulse therapy improved the patient's general condition, and hemodialysis and mechanical ventilation were no longer required. All patients survived without relapse of symptoms. CONCLUSION: Our cases suggest that early steroid pulse therapy may be effective for rapid symptom improvement of the systemic side effects of BCG instillation therapy.

Guidelines for the medical management of pediatric vesicoureteral reflux.

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow-up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long-term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

Effect of neoadjuvant chemotherapy in patients undergoing radical cystectomy for muscle-invasive bladder cancer: a retrospective, multi-institutional study.

OBJECTIVE: We evaluated the effect of neoadjuvant chemotherapy in patients undergoing radical cystectomy for urothelial bladder cancer. METHODS: We retrospectively examined 140 consecutive patients with muscle-invasive bladder cancer (clinical stage T2 to T4 and N0) who underwent radical cystectomy with or without neoadjuvant chemotherapy at four academic institutions between January 2006 and December 2016. Patients were categorized into the neoadjuvant chemotherapy group (those who underwent treatment with any neoadjuvant chemotherapy regimen; n = 69) and the non-neoadjuvant chemotherapy group (those who did not receive any neoadjuvant chemotherapy regimen; n = 71). The primary outcome measure was overall survival. RESULTS: The 5-year overall survival rates were 58.0% and 61.8% in the neoadjuvant chemotherapy and non-neoadjuvant chemotherapy groups, respectively (P = 0.320). The 5-year overall survival rates for the neoadjuvant chemotherapy and non-neoadjuvant chemotherapy groups were 64.8% and 68.4%, respectively, among cT2N0 patients (P = 0.688) and 38.6% and 21.6%, respectively, among cT3-4aN0 patients (P = 0.290). When patients with cT3-4aN0 disease in the neoadjuvant chemotherapy group were divided into responders (

[A Case of Non-Treated Prostate Cancer with Disseminated Intravascular Coagulopathy].

An 87-year-old man was referred to our hospital with a high suspicion of prostate cancer, because of high prostate-specific antigen (PSA) levels (1,500 ng/ml). The laboratory results showed a PSA level of 1, 411 ng/ml, platelet count of 7.5×104/µl, and fibrinogen level of 68 mg/dl. D-dimer and fibronogen degradation product (FDP) levels were >240 and >480 µg/m respectively. Based on the above results, the patient was diagnosed as having prostate cancer with disseminated intravascular coagulopathy (DIC score=8 points). The patient was immediately hospitalized and heparin was administered to treat the DIC. On the 5th day, a prostate biopsy was performed and treatment was started with combined androgen blockade (CAB) therapy. The pathology report confirmed the diagnosis of prostate cancer with a Gleason Score of 4+3. Multiple bone and lymph node metastases were found on magnetic resonance imaging, computed tomography and, bone scans. Based on the results, the prostate cancer was stage cT3 N1 M1b. The medication was changed from heparin to nafamostat mesylate on the 12th day, due to the presence of DIC with the malignancy. After successful treatment with CAB, denosumab, and thrombomodulin alpha, the DIC levels improved (DIC score=3 points), and the PSA levels decreased to 51.5 ng/ml on the 47th day. DIC has been known to occur during treatment for prostate cancer ; however, cases of DIC with prostate cancer without any treatment are rare.

Successful hemostasis by embolization in a case of uncontrollable arterial bleeding following posterior tension-free vaginal mesh procedure puncture.

An 82-year-old woman presented to our hospital in April 2009 complaining of sensations of a descending bladder and residual urine, and frequent urination. She had given birth to two children. She had undergone simple total hysterectomy for uterine myoma at another hospital in 1974 and anterior colporrhaphy for anterior vaginal wall prolapse, also at another hospital, in 2008. On presentation, examination with the pelvic organ prolapse quantitative system revealed a stage-III cuff scar prolapse and cystocele. A cystogram revealed a cystocele. We report here a tension-free vaginal mesh (TVM) procedure and the development of arterial bleeding following the third puncture for posterior TVM, which could not be controlled through the operative field but was successfully stopped by embolization.

Short-term effects of crossover treatment with silodosin and tamsulosin hydrochloride for lower urinary tract symptoms associated with benign prostatic hyperplasia.

OBJECTIVES: To compare the efficacy and safety of silodosin and tamsulosin in patients with lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH) by a randomized crossover method. METHODS: BPH patients with the complaint of LUTS were included in this study, and were randomly divided into two groups: a silodosin-preceding group (4 weeks of twice-daily administration of silodosin at 4 mg, followed by 4 weeks of once-daily administration of tamsulosin at 0.2 mg) or a tamsulosin-preceding group (4 weeks' administration of tamsulosin, followed by 4 weeks' administration of silodosin). No drug withdrawal period was provided when switching the drug. RESULTS: In the first treatment period, both drugs significantly improved the International Prostate Symptom Score total score, but the improvement by silodosin was significantly superior to that by tamsulosin. After crossover treatment, significant improvement was observed only with silodosin treatment. Moreover, intergroup comparison of changes revealed that silodosin showed significant improvement of straining and nocturia with first and crossover treatments, respectively, compared with tamsulosin. Silodosin also significantly improved quality of life (QOL) score in both treatment periods, while tamsulosin significantly improved QOL score only in the first treatment period. The most frequent adverse drug reaction was ejaculatory disorder with silodosin; however, the incidence of dizziness with silodosin was similar to that with tamsulosin. CONCLUSIONS: In BPH/LUTS patients, silodosin exhibits excellent efficacy in improving subjective symptoms in both initial and crossover treatment, and it appears to improve the QOL of patients.

Non-caseous granulation lymphadenitis in the neck as an initial manifestation of prostate carcinoma.

We encountered a 54-year-old Japanese man who presented with painless swellings on his bilateral neck. Although ultrasonographic findings suggested metastatic lymphadenopathy, histological examination of the mass revealed non-caseous granulation lymphadenitis. He was subsequently diagnosed as having prostate carcinoma with metastasis to the multiple bones. The present case suggested that prostate carcinoma could cause cervical lymphadenopathy due to non-caseous granulation as an initial manifestation, and could be a sign for an impending clinical expression of metastasis to an area draining to the lymph nodes.

Evaluation of renal function after laparoscopic partial nephrectomy with renal scintigraphy using 99mtechnetium-mercaptoacetyltriglycine.

AIM: We evaluated the functions of an affected kidney after laparoscopic partial nephrectomy (LPN) using renal scintigraphy with (99m)technetium-mercaptoacetyltriglycine ((99m)Tc-MAG3). METHODS: Split renal function of 10 patients who underwent LPN for renal tumors was assessed using renal scintigraphy with (99m)Tc-MAG3 before surgery, and 1 week and 3 months post-surgery. RESULTS: Median operating time was 196.5 min, median tumor diameter was 2.3 cm, mean blood loss was 64 mL and mean ischemic time was 38.5 min. Median change in serum creatinine level pre- to post-surgery was 0.15 mg/dL. Median contribution of the affected kidney to total renal function (calculated using (99m)Tc-MAG3) was 50.0%, 41.7% and 36.1% before surgery, 1 week and 3 months after LPN, respectively. In one patient, the tumor was resected after cooling of the affected kidney with ice slush for 15 min, and the split renal function ratio remained as high as 50% at 3 months post-operatively despite a total ischemic time of 61 min. CONCLUSIONS: This paper evaluated renal function on the affected side before and after surgery by measuring split renal function with renal scintigraphy using (99m)Tc-MAG3. Risk factors for renal dysfunction in the affected kidney after LPN include age over 70 years with more than 30 min warm ischemic time, re-clamping of the renal artery procedure, and a warm ischemic time greater than 60 min. We believe that renal cooling with slush ice prevents renal dysfunction of the affected kidney after LPN with longer warm ischemic times. However, an easier renal cooling technique should be sought for regular use of cooling procedures in LPN.

Acute myocardial infarction during combined chemotherapy with bleomycin, etoposide and cisplatin for testicular cancer.

We report a case of acute myocardial infarction during combined chemotherapy with bleomycin, etoposide and cisplatin for testicular cancer. A 30-year-old smoker without any history of ischemic heart disease complained of sudden chest pain on the ninth day of his third course of chemotherapy. An electrocardiogram showed ST segment elevation in II, III and aVF. Emergency coronary angiography revealed total occlusion of the right coronary artery by a thrombus, which was removed by coronary atherectomy.

[Sepsis following transrectal prostate biopsy: a report of 2 cases and reviewed similar cases in Japan].

We report two cases of sepsis and disseminated intravascular coagulation (DIC), potentially fatal complications, following transrectal prostate biopsy. We also review similar cases reported in Japan. Case 1: A 63-year-old man received a cathartic and levofloxacin (LVFX) for prophylaxis. After transrectal prostate biopsy, he presented with fever and chills. Blood cultures grew Escherichia coli resistant to LVFX. Under a diagnosis of sepsis, he received intensive management that included endotoxin removal therapy. The patient was hospitalized for 27 days. Case 2: A 64-year-old man received a cathartic and cefazolin (CEZ) for prophylaxis. He presented with fever and chills after biopsy, and was admitted to hospital. Blood cultures grew E. coli resistant to CEZ. Under a diagnosis of sepsis, he received intravenous antibiotics, transfusion, and anti-DIC drugs. The patient was hospitalized for 11 days.

[Schwannoma of the kidney with severe calcification: a case report].

Schwannoma arising from the kidney is a rare benign tumor, with only 20 cases reported in the English literature. We encountered a histopathologically typical Schwannoma of the kidney in a 39-year-old woman, which was characterized by marked calcification. Radical nephrectomy was performed under the diagnosis of renal cell carcinoma. The 21 reported cases of schwannoma of the kidney, including the present case, are reviewed in detail.

Screening program of prostate cancer at Tokai University Hospital: characterization of prostate-specific antigen measurement.

A total of 67,214 men participated in screening for prostate cancer (PC) using serum prostate-specific antigen (PSA) from April 1996 to March 2003 at Tokai University Hospital. In 3.5% (2330 / 67,214) of the men, an elevated PSA level (> 4.0 ng/ml) was found and 68.1% (1586/2330) of these subjects were examined at our Urological Outpatient Clinic. Re-testing of PSA showed that 8.4% (133/1586) had a normal level. Needle biopsy of the prostate was performed in 45.2% (633/1453) of the remaining men. As a result, 142 PCs were found and the detection rate was 0.2% (142 / 67,214). The age of the patients with PC was over 50 years. During this period, 135 individuals with voiding dysfunction were also diagnosed as having PC. Comparison of the patients detected by screening with those found at the outpatient clinic revealed significant differences of the age (64.8 vs. 71.9 years, p < 0.0001), serum PSA level (14.6 vs. 154.9 ng/ml, p < 0.0001), and clinical stage (p < 0.0001). In conclusion, a health screening program that includes serum PSA testing is useful for detection of PC at an earlier stage and in younger individuals. We recommend that all men aged 50 years or older undergo testing for PSA to detect PC at an early stage.

Association of neuroendocrine differentiation with neoadjuvant hormone therapy effects in prostatic cancer.

Histological therapeutic effects of neoadjuvant hormone therapy (NHT) in prostatic cancer were examined, focusing on the association with neuroendocrine differentiation (NED), using 69 radical prostatectomy cases. The effects of NHT were classified into 3 grades based on the extent of tumor degeneration as observed with hematoxylin and eosin staining. NED cells in the cancer were semi-quantified into 4 grades (negative, 1+, 2+, and 3+) by immunohistochemical staining of chromogranin A (CgA). According to the therapeutic effects, the cases are divided as follows: good response in 26 patients, intermediate in 20, poor in 23. The histological therapeutic effects were significantly weaker in the CgA-positive group than the CgA-negative group (p=0.02). A close relationship between the extent of CgA expression and the histological response was also demonstrated (p=0.007). In the biopsy specimens before NHT, CgA was positive in 46% (32/69) and there was no significant difference in histological therapeutic effects between the positive and negative groups. However, the therapeutic effects were significantly weaker in 22 CgA-positive cases for both biopsy and prostatectomy specimens than in 18 CgA-negative cases for both specimens (p=0.001). In conclusion, although it seems difficult to predict the therapeutic effects of NHT using the biopsy specimens of prostatic cancer, we believe that NED is negatively associated with histological response of prostatic cancer to NHT.

[Metastatic small intestinal tumor associated with transitional cell carcinoma: a report of 2 cases and review of cases in Japan].

Transitional cell carcinoma (TCC) frequently metastasizes to lymph nodes, liver, lungs and bone. However, metastasis to the gastrointestinal tract is rare. We report two cases of bladder tumor which metastasized to the ileum. According to the literature, these are the 7th and 8th cases in Japan. Case 1: A 87-year-old man had a history of bladder tumor (TCC, grade 3, pT2bN0M0) and has transurethral resection of bladder tumor (TUR-BT) three times. Two months after the last TUR-BT, he was admitted with ileus. As computed tomography (CT) showed abdominal free air, our diagnosis was perforation of gastrointestinal tract. The patient received an operation which resected partial ileum. We found the elastic hard tumor in the ileum on the perforated lesion, which showed metastatic TCC in the ileum pathologicaly. Case 2 : A 53-year-old man visited our hospital with gross hematuria. Cystoscopy showed a non-papillary broad based tumor in the right wall of the bladder. CT showed a bladder tumor invaded into the prostate (pT4aN1M0), we performed total cyctectomy and ileal conduit after neo-adjuvant chemotherapy. During the operation, we found the tumor (2 cm in diameter) in the small intestine which was metastasized of bladder tumor.

[Hormonal therapy for prostatic cancer--state of the art].

Following the studies of Huggins and colleagues in 1941, the hormonal treatment of prostatic cancer has been aimed at neutralizing the influence of testicular androgens through surgical castration or the administration of high dose estrogen. Labrie et al introduced combined use of a LHRH agonist and an androgen antagonist for prostatic cancer. Various reports demonstrated a beneficial effect for combined androgen blockade using nonsteroidal antiandrogens for advanced prostatic cancer through meta-analysis of published randomized control trials. In Japanese status, a combined androgen blockade is popular for advanced prostatic cancer as well as local cancer by J-Cap survey. There is a lot of controversy about adjuvant hormonal therapy for prostatic cancer including intermittent hormonal therapy, but the results are not gotten yet.

[Neoadjuvant hormonal therapy for prostate cancer].

Preoperative neoadjuvant hormonal therapy is still controversial. This therapy's purpose is downstaging prostate cancer at radical prostatectomy and thereby improving the prognosis of prostate cancer. It has been repeatedly demonstrated that hormonal therapy causes significant alterations in the gross and microscopic appearance of the prostate. Most studies report a significant improvement in surgical margins and downstaging. However, it remains to be seen if the favorable findings lead to an improved outcome after radical prostatectomy. Our study showed 6-12 months neoadjuvant hormonal therapy with maximal androgen blockade did not lead to the improved result in long term follow-up. Because, PSA failure was observed 25% of the cases which received neoadjuvant hormonal therapy prior to radical prostatectomy.

Serum basic fibroblast growth factor as a marker of reflux nephropathy.

PURPOSE: The authors investigated whether serum basic fibroblast growth factor (b-FGF) can be used as a noninvasive marker of renal parenchymal damage (scarring) in cases of vesicoureteric reflux (VUR). METHODS: Serum levels of b-FGF were measured in 120 children with known grade III to grade V VUR and 21 controls using a standard enzyme-linked immunosorbent assay technique. RESULTS: Sixty-five children had grade III VUR, 39 had grade IV, and 16 had grade V. Renal scarring was seen in 43 children on radionuclide scanning. There were no significant differences between serum b-FGF levels for different grades of VUR without scarring and controls. However, serum b-FGF levels were significantly higher in VUR patients with renal scarring than in patients with VUR without renal scarring (P < .001). CONCLUSIONS: This report is the first to document serum b-FGF profiles in children with VUR and renal scarring. The authors recommend measuring it as a simple, noninvasive marker of renal scarring in cases of VUR.

[A case of squamous metaplasia of the ureter].

This paper reports a 73-year-old man who developed ureteral squamous metaplasia. Preoperative drip infusion pyelography showed a ureteral tumor with a major axis measuring 2.5 cm, which had a smooth surface and a broad base. Computed tomography findings suggested that the lesion might be a submucous mesodermal tumor or inverted papillary transitional cell carcinoma. Therefore, retroperitoneal laparoscopic left nephroureterectomy was performed.

Clinicopathological factors predicting recurrence of N0M0 renal cell carcinoma: a case series analysis of one facility.

BACKGROUND: Although many factors have been reported as predictors of the recurrence of renal cell carcinoma (RCC), none of the factors are consistent among different studies. In the study presented here, the potential clinicopathological predictors of the recurrence of N0M0 RCC were examined. METHODS: A total of 201 patients who underwent nephrectomy for N0M0 RCC were examined to determine the pathological tumor stage (pT stage), pathological tumor grade of malignancy (tumor grade), symptoms, and tumor size. RESULTS: RCC recurred in 29 patients (14.4%), 50% of whom developed new tumors within 24 months after nephrectomy. The disease-free 3- and 10-year survival rates declined as the pT stage and tumor grade increased: these rates were, respectively, 98.6% and 86.5% for pT1a; 93.7% and 87.9% for pT1b; 100% and 100% for pT2; 78.6% and 58.0% for pT3a; and 88.9% and 16.7% for pT3b. Significant differences in the recurrence rate were noted between pT3 and pT1 or pT2, as well as between grade 3 disease and grade 1 or grade 2 tumors. Multivariate analysis showed that a combination of the pT stage, grade, and presence of symptoms was useful for predicting the recurrence of RCC. CONCLUSION: The present study showed that patients undergoing nephrectomy for N0M0 RCC should be followed-up carefully for 2 years postoperatively with special attention to high pT stage, high grade, and the development of symptoms.

Significance of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for detection of renal cell carcinoma and immunohistochemical glucose transporter 1 (GLUT-1) expression in the cancer.

OBJECTIVE: Positron emission tomography (PET) is now primarily used in oncological indication owing to the successful application of fluorine-18 fluorodeoxyglucose (FDG) in an increasing number of clinical indications. Glucose transporter 1 (GLUT-1) is recognized as a major early marker of cellular malignant transformation. The aims of this study were to assess whether FDG-PET is a useful diagnostic tool for renal cell carcinoma and to compare the pathologic characteristics. METHODS: Nineteen consecutive patients who had renal cell carcinoma were examined using FDG-PET preoperatively. The results of PET were then compared to the histology obtained after radical surgery and the immunoreactivity of GLUT-1 was also studied. RESULTS: Pathologic examination confirmed that all 19 patients suffered from renal cell carcinoma. Increased FDG uptake was found in six of the 19 patients (31.5%). The immunohistochemical examination of GLUT-1 in renal cell carcinoma produced different results in each patient. There was no correlation with GLUT-1 immunoreactivity and FDG-PET positivity. CONCLUSION: These results suggest that FDG-PET may not be a useful diagnostic tool for renal cell carcinoma.