Re-salvage focal low-dose rate brachytherapy for local recurrence of prostate cancer after salvage focal low-dose rate brachytherapy.

Introduction: Salvage brachytherapy represents an effective treatment for local recurrence of prostate cancer after prior external beam radiotherapy. However, the optimal therapeutic strategies for local recurrence after salvage brachytherapy have not yet been determined. Case presentation: We describe the case of a 77-year-old man who underwent re-salvage focal low-dose rate brachytherapy for local recurrence after carbon ion radiotherapy and salvage focal low-dose rate brachytherapy. We performed re-salvage focal low-dose rate brachytherapy for the recurrence with a different type of seed, which resulted in a significant reduction in the prostate-specific antigen level. During the 35-month follow-up after re-salvage focal low-dose rate brachytherapy, no recurrence of prostate cancer and no severe radiation-related toxicities were observed. Conclusion: Our patient was successfully treated with re-salvage focal low-dose rate brachytherapy for local recurrence after salvage focal low-dose rate brachytherapy. This treatment strategy might be effective for such patients and is not associated with sexual dysfunction or severe adverse events.

Development and Validation of a Preoperative Nomogram for Endoscopic Management Decision Making in Upper Urinary Tract Urothelial Carcinoma.

OBJECTIVE: We aimed to develop and validate a preoperative nomogram that predicts low-grade, non-muscle invasive upper urinary tract urothelial carcinoma (LG-NMI UTUC), thereby aiding in the accurate selection of endoscopic management (EM) candidates. METHODS: This was a retrospective study that included 454 patients who underwent radical surgery (Cohort 1 and Cohort 2), and 26 patients who received EM (Cohort 3). Utilizing a multivariate logistic regression model, a nomogram predicting LG-NMI UTUC was developed based on data from Cohort 1. The nomogram's accuracy was compared with conventional European Association of Urology (EAU) and National Comprehensive Cancer Network (NCCN) models. External validation was performed using Cohort 2 data, and the nomogram's prognostic value was evaluated via disease progression metrics in Cohort 3. RESULTS: In Cohort 1, multivariate analyses highlighted the absence of invasive disease on imaging (odds ratio [OR] 7.04; p = 0.011), absence of hydronephrosis (OR 2.06; p = 0.027), papillary architecture (OR 24.9; p < 0.001), and lack of high-grade urine cytology (OR 0.22; p < 0.001) as independent predictive factors for LG-NMI disease. The nomogram outperformed the two conventional models in predictive accuracy (0.869 vs. 0.759-0.821) and exhibited a higher net benefit in decision curve analysis. The model's clinical efficacy was corroborated in Cohort 2. Moreover, the nomogram stratified disease progression-free survival rates in Cohort 3. CONCLUSION: Our nomogram ( https://kmur.shinyapps.io/UTUC_URS/ ) accurately predicts LG-NMI UTUC, thereby identifying suitable candidates for EM. Additionally, the model serves as a useful tool for prognostic stratification in patients undergoing EM.

Evaluation of sexual function after dutasteride treatment in patients with once-negative prostate biopsy and benign prostate hyperplasia.

INTRODUCTION: Patients with benign prostatic hyperplasia are usually treated with 5α-reduced inhibitors (5ARIs) such as finasteride and dutasteride. However, studies on the influence of 5ARIs on sexual function have been controversial. In this study, we evaluated the impact of dutasteride treatment for erectile function in patients with once-negative prostate biopsy and benign prostate hyperplasia. PATIENTS AND METHODS: 81 patients with benign prostate hyperplasia were enrolled in a one-armed prospective study. They were administrated 0.5 mg/day of dutasteride for 12 months. Patient characteristics and changes of International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF)-15 scores at baseline and 12 months after dutasteride administration were examined. RESULTS: The mean ± standard deviation (SD) age of the patients was 69.4 ± 4.9 years and the prostate volume was 56.6 ± 21.3 mL, respectively. The mean ± SD prostate volume and PSA levels were decreased 25.0 and 50.9%, respectively, after 12 months of dutasteride administration. IPSS total, voiding subscore, storage subscore, and quality of life score significantly improved after 12 months of dutasteride administration. No statistically significant change in IIEF-total score from 16.3 ± 13.5 to 18.8 ± 16.0 (p = 0.14), IIEF-EF score from 5.1 ± 6.9 to 6.4 ± 8.3 (p = 0.13) were observed. There was no decrease in erectile function severity. CONCLUSION: Twelve months administration of dutasteride for patients with BPH improved urinary function and did not increase the risk of sexual dysfunction.

Photodynamic Diagnosis-guided Dual Laser Ablation for Upper Urinary Tract Carcinoma: Preoperative Preparation, Surgical Technique, and Clinical Outcomes.

BACKGROUND: Although ureteroscopic surgery (URS) is beneficial for low-risk upper urinary tract carcinoma (UTUC), there is no standardized URS technique or navigation system for challenging cases. OBJECTIVE: To present a URS technique for UTUC using thulium (Tm):YAG and holmium (Ho):YAG lasers under photodynamic diagnosis (PDD) guidance, named PDD-guided dual laser ablation (PDD-DLA) and compare its efficacy with that of conventional Ho:YAG laser ablation (HLA; historical control). DESIGN SETTING AND PARTICIPANTS: The study included ten consecutive UTUC patients who underwent PDD-DLA between 2017 and 2019. The control group comprised 16 consecutive patients who underwent HLA between 2006 and 2016. SURGICAL PROCEDURE: After oral administration of 5-aminolevulinic acid (20 mg/kg), UTUC tumors were endoscopically resected via PDD-DLA. MEASUREMENTS: Clinical data were prospectively collected for our institutional UTUC data set. Disease progression, UTUC recurrence, and clinical outcomes were assessed. RESULTS AND LIMITATIONS: PDD-DLA was successfully performed in all patients. The median tumor size was 23.5 mm (interquartile range [IQR] 12.8-30.0) and there were four cases (40.0%) of high-grade tumor. The median operative time was 120 min (IQR 98.5-142.5). No Clavien-Dindo grade ≥3 complications were observed. There were no differences in most clinical characteristics between the PDD-DLA and HLA groups. The 2-yr progression-free survival rate was 100% in the PDD-DLA group and 58.7% in the HLA group (p = 0.0197), and the 2-yr recurrence-free survival rate was 57.1% and 41.3%, respectively (p = 0.072). The PDD-DLA group had a lower incidence rate of salvage RNU compared with the HLA group (0.0% vs 50%; p = 0.009). The small sample size might affect the reproducibility of these results. CONCLUSIONS: PDD-DLA seems to be an effective and feasible endoscopic technique for UTUC treatment with favorable oncological outcomes. PATIENT SUMMARY: We investigated a new laser technique for treating cancer of the upper urinary tract called photodynamic diagnosis-guided dual laser ablation. Our strategy was effective in removing tumors and stopping bleeding. Further studies in larger groups of patients are needed to confirm whether this technique improves cancer outcomes.

Prostate-specific antigen density during dutasteride treatment for 1 year predicts the presence of prostate cancer in benign prostatic hyperplasia after the first negative biopsy (PREDICT study).

OBJECTIVES: To prospectively evaluate the detection rate of prostate cancer, and to identify the risk factors of prostate cancer detection after a 1-year administration of dutasteride and first negative prostate biopsy. METHODS: Patients with benign prostatic hyperplasia who presented high prostate-specific antigen levels after the first negative prostate biopsy were administered 0.5 mg dutasteride daily for 1 year. They underwent a repeat prostate biopsy after 1 year. The primary end-point was the detection rate of prostate cancer. The secondary end-point was the ability of prostate-specific antigen kinetics to predict prostate cancer detection. Prostate-specific antigen was measured before the initial prostate biopsy and at 6, 9 and 12 months after starting dutasteride. Patients were classified into a prostate cancer and a non-prostate cancer group. RESULTS: Prostate cancer was detected in 15 of 149 participants (10.1%). The total prostate-specific antigen change between the prostate cancer and non-prostate cancer group at 1 year was significantly different (P = 0.002). Although prostate-specific antigen levels at baseline did not significantly differ between study groups (P = 0.102), prostate-specific antigen levels at 6, 9 and 12 months were significantly different (P = 0.002, P = 0.001 and P < 0.001, respectively). The mean reduction rate of prostate-specific antigen density between the prostate cancer and non-prostate cancer group at 1 year was significantly different (-4.25 ± 76.5% vs -38.0 ± 28.7%, P = 0.001). Using a multivariate analysis, a >10% increase of prostate-specific antigen density at 1 year post-dutasteride treatment was the only predictive risk factor for prostate cancer after the first negative prostate biopsy (odds ratio 11.238, 95% confidence interval 3.112-40.577, P < 0.001). CONCLUSION: In the present study cohort, >10% increase in prostate-specific antigen density represented the only significant predictive risk factor for prostate cancer diagnosis in patients with elevated prostate-specific antigen after the first negative prostate biopsy.

Complete intraureteral stent placement relieves daytime urinary frequency compared with conventional placement in patients with an indwelling ureteral stent: post-hoc analysis of a randomized, controlled trial.

A previous randomized, controlled trial had demonstrated that complete intraureteral stent placement (CIU-SP) was superior to conventional stent placement (C-SP) in terms of improvement of stent-related urinary symptoms. However, it is unclear as to which subdomain symptom and cohort could benefit the most from CIU-SP compared to C-SP in urinary symptoms while considering the baseline urinary status. To determine this, a post-hoc analysis was performed using data from a previous study (CIU-SP group, n = 39; C-SP group, n = 41). We assessed the mean changes in the International Prostate Symptom Score (I-PSS) and the Overactive Bladder Symptom Score (OABSS) from baseline to day 14. Statistical comparison between the two groups was performed using analysis of covariance with adjustment of baseline urinary status as a covariate. Among 80 patients, the total I-PSS was significantly lower in the CIU-SP group than in the C-SP group in the cohort with mild urinary symptoms (P = 0.005), but not in those with moderate/severe symptoms (P = 0.521). The CIU-SP group showed significantly improved I-PSS and OABSS daytime frequencies, with the highest t statistic (2.47 and 2.10, respectively) among subdomains of both symptom scores compared with the C-SP group (both P < 0.001). In multivariate regression analysis, the stent placement method (CIU-SP vs. C-SP) was independently associated with the I-PSS daytime frequency on day 14 (P = 0.017). This study suggests that CIU-SP significantly improved stent-related daytime frequency compared with C-SP, and it may benefit especially those patients who have mild urinary symptoms before the placement of ureteral stents.

Development and external validation of a preoperative nomogram for predicting pathological locally advanced disease of clinically localized upper urinary tract carcinoma.

OBJECTIVE: To develop and validate a preoperative nomogram to predict pathological locally advanced disease (pLAD) of clinically localized upper urinary tract urothelial carcinoma (UTUC) treated with extirpative surgery. METHODS: In total, 1101 patients with cN0M0 UTUC (development cohort, n = 604; validation cohort, n = 497) from 2 independent academic databases were retrospectively analyzed. pLAD was defined as pT3/4 and/or pN+. Multivariate logistic regression was used to develop a nomogram. The accuracy of the nomogram was evaluated with a receiver operating characteristic curve, calibration plot, and decision curve analysis. RESULTS: The development and validation cohorts comprised 204 (33.8%) and 178 (35.8%) patients with pLAD, respectively. The multivariate analyses showed that the neutrophil-to-lymphocyte ratio (hazard ratio [HR], 2.27; P < .001), chronic kidney disease (HR, 1.56; P = .032), tumor location (HR, 1.60; P = .029), hydronephrosis (HR, 2.71; P < .001), and local invasion on imaging (HR, 8.59; P < .001) were independent predictive factors. After bootstrapping, a well-calibrated nomogram achieved discriminative accuracy of 0.77 in the development cohort. The decision curve analysis demonstrated improved risk prediction against threshold probabilities (≥8%) of pLAD. These results were consistent in the validation cohort. CONCLUSION: Our novel nomogram allows for more highly accurate prediction of pLAD of UTUC. This nomogram integrates standard imaging and laboratory factors that help to identify patients who will benefit from preoperative chemotherapy, extended lymph node dissection, or both.

Preoperative Pyuria Predicts for Intravesical Recurrence in Patients With Urothelial Carcinoma of the Upper Urinary Tract After Radical Nephroureterectomy Without a History of Bladder Cancer.

BACKGROUND: We assessed preoperative pyuria as a significant predictor of intravesical recurrence (IVR) in patients with upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). PATIENTS AND METHODS: We evaluated the data from 268 patients with UTUC without a history of bladder cancer who had undergone RNU from 2006 to 2016 at 4 academic institutions. The associations between the clinical variables and the presence of pyuria were evaluated by univariate analysis. IVR was assessed using the Kaplan-Meier method and Cox regression analysis. RESULTS: The median postoperative follow-up of patients with IVR-free survival was 29.1 months (interquartile range, 15.4-55.3 months). The rate of IVR was significantly greater in the patients with than in those without pyuria (P = .025). Multivariate analysis showed that preoperative pyuria (hazard ratio [HR], 1.70; P = .007), a ureteral tumor site (HR, 1.64; P = .012), and positive surgical margins (HR, 2.70; P = .013) were associated with a significantly increased risk of IVR. A postoperative risk stratification model using these factors showed significant differences among the 3 subgroups of patients with low, intermediate, and high risk. The 5-year IVR-free survival rates for the patients with low, intermediate, and high risk were 69.1%, 51.8%, and 18.8%, respectively (P = .004). CONCLUSION: Preoperative pyuria, a ureteral tumor site, and positive surgical margins were associated with a significantly increased risk of IVR. Although external validation is required, the presence of preoperative pyuria could be a significant predictor of IVR in patients with UTUC after RNU.

Efficacy and Safety of Complete Intraureteral Stent Placement versus Conventional Stent Placement in Relieving Ureteral Stent Related Symptoms: A Randomized, Prospective, Single Blind, Multicenter Clinical Trial.

PURPOSE: We compared the efficacy and safety of complete and conventional stent placement to relieve ureteral stent related symptoms. MATERIALS AND METHODS: We randomized 85 patients who required ureteral stent placement after lithotripsy into an intraureteral or a conventional stent placement group. The ureteral stent remained in place until postoperative day 14. We evaluated scores on the visual analog scale pain, the SF-36 (36-Item Short-Form Health Survey), the I-PSS (International Prostate Symptom Score) and the OABSS (Overactive Bladder Symptom Score) on postoperative days 3 and 14. We also assessed the total amount of analgesics administered and stent related complications. RESULTS: Overall the records of 80 patients were analyzed. Pain scores were significantly lower in the intraureteral vs the conventional stent placement group (postoperative days 3 and 14, 4.85 vs 9.78, p = 0.003, and 3.15 vs 6.20, p = 0.014, respectively). The total I-PSS score (postoperative days 3 and 14, 10.41 vs 14.90, p = 0.006, and 11.67 vs 16.10, p = 0.022, respectively) and total analgesic use (19.23 vs 88.54 mg, p <0.001) were significantly lower in the intraureteral group. However, differences in the SF-36 and the total OABSS scores did not significantly differ. On subgroup analysis the pain score in the groin and bladder areas, incomplete emptying and daytime frequency on the I-PSS, the quality of life index and daytime frequency on the OABSS were significantly better in the intraureteral stent placement group than the conventional stent placement group on postoperative days 3 and 14 (all p <0.05). There was no difference in the complication rate between the 2 groups. CONCLUSIONS: Intraureteral stent placement may be associated with less ureteral stent related discomfort than conventional stent placement. This novel placement method is feasible and safe, and it can be immediately used in daily clinical practice.

Testosterone Profiles After Brachytherapy for Localized Prostate Cancer.

OBJECTIVE: To evaluate patients' serum total testosterone levels (STLs) after brachytherapy (BT) for prostate cancer. METHODS: We enrolled 102 men who underwent permanent interstitial BT using I125 without androgen deprivation therapy for localized prostate cancer. Seed BT radiation dose was 145 Gy. Patients were followed for 24-60 months after BT. The primary outcome was STL kinetics after BT. Predictors of testosterone decrease were also analyzed. RESULTS: Median preimplantation STL was 4.18 ng/mL. STL decreased significantly to a median nadir of 89.4% of baseline (3.72 ng/mL) occurring at 6 months, and then recovered to baseline at 18 months after BT. The group of patients whose STLs fell below 3.00 ng/mL (biochemical hypogonadism) after BT started with lower baseline STLs (median: 3.54 ng/mL) than patients whose STLs did not fall below 3.00 ng/mL (median: 4.90 ng/mL). The group of patients whose STLs decreased by more than 1.00 ng/mL over the study period had significantly higher median baseline STLs (median: 5.05 ng/mL) than the group whose STLs decreased by less than 1.00 ng/mL (median: 3.64 ng/mL). CONCLUSION: Although STL decreased significantly after I125-based BT, STL decline after treatment for localized prostate cancer was not large and recovered over time.

Impact of ureteric stent removal by string on patient's quality of life and on complications at post-ureteroscopy for urolithiasis: a controlled trial.

OBJECTIVES: To evaluate the impact of ureteric stent removal by string vs ureteric stent removal by cystoscope with regard to pain at ureteric stent removal, complications and quality of life, as well as patients' self-rated symptoms, after ureteroscopy (URS) for urolithiasis. PATIENTS AND METHODS: Of 328 patients who underwent URS for upper urinary tract stones at our institution, 149 were randomly divided into a ureteric stent removal by string group (string group) and a ureteric stent removal by flexible cystoscope group (cystoscope group), using gender as a stratification factor. We focused on four sites, namely, the upper abdomen, bladder, flank and urethra, to evaluate the most painful site at stent removal. The primary endpoint was total pain scores for four sites at stent removal in the string group vs the cystoscope group. Secondary endpoints included comparison of the psychological well-being scores of patients using the five-item World Health Organization well-being index (WHO-5) preoperatively, pre-stent removal and 2 weeks after stent removal between the string group and cystoscope group. RESULTS: Of 149 patients analysed, 74 were in the string group and 75 were in the cystoscope group. In most patients, the ureteric stent was removed ~10 days after URS. The string group experienced significantly less pain than the cystoscope group (mean visual analogue scale [VAS] scores 2.73 vs 5.67; P < 0.001). Although VAS scores for women were not significantly different between the groups (P = 0.300), those for men were significantly lower in the string group (P < 0.001). In particular, men in the string group experienced significantly less urethral pain than those in the cystoscope group. The WHO-5 scores were not significantly different between the groups preoperatively, pre-stent removal or 2 weeks after stent removal. Stent string-related complications and self-rated symptoms were also not significantly different. CONCLUSION: Ureteric stent removal by string after URS led to significantly less pain than removal by cystoscope in men. Patients in the string group experienced no more complications in terms of urinary tract infections or accidental dislodgement than those in the cytoscope group.

Utility of F-18 FDG PET/CT for Detection of Bone Marrow Metastases in Prostate Cancer Patients Treated with Radium-223.

A 76-year-old man with symptomatic bone metastases from castration-resistant prostate cancer underwent Radium-223-dichloride (Ra-223) therapy. Before Ra-223 therapy, he had normal peripheral blood cell counts. Ra-223 therapy relieved his shoulder and low back pain. The elevation of the serum prostate-specific antigen (PSA), doubling every month during Ra-223 therapy, suggested a PSA flare or relapse. Some lesions showed decrease and some lesions showed increase on Tc-99m hydroxymethylene diphosphonate bone scintigraphy at two weeks after the third injection of Ra-223 therapy. Ra-223 therapy was discontinued due to thrombocytopenia that was getting worse rapidly. After treatment discontinuation, namely four weeks after the third injection of Ra-223, F-18 fluorodeoxyglucose (FDG) Positron Emission Tomography (PET)/CT and a biopsy were performed to evaluate for metastases, and bone marrow metastases were found. Ra-223 was effective for osteoblastic lesions, but not for bone marrow metastases. FDG PET/CT, but not a Tc-99m based bone scan, detected diffuse bone marrow involvement by cancer. This case report is the first to clarify the utility of FDG PET for the detection of bone marrow metastases confirmed by pathological examination in Ra-223 therapy for progressive castration-resistant prostate cancer.

Impact of loop-tail ureteral stents on ureteral stent-related symptoms immediately after ureteroscopic lithotripsy: Comparison with pigtail ureteral stents.

Purpose: To evaluate urination-related quality of life (QoL) in patients with an indwelling ureteral stent immediately after ureteroscopic lithotripsy (URSL) for upper urinary calculi. We compared the effects of loop-tail and pigtail ureteral stents on urination-related QoL. Materials and Methods: Of 135 patients who underwent URSL between May 2014 and March 2015 at our hospital, we retrospectively analyzed the records of 70 patients (42 men, 28 women; median age, 63 years) in whom the stent tail was positioned inside the bladder without crossing the midline and who completed the core lower urinary tract symptoms score (CLSS) questionnaire pre- and postoperatively. Results: There were significant differences in incomplete emptying (p=0.048) and bladder pain (p=0.041) between patients with loop-tail versus pigtail ureteral stents after URSL. In the multivariate analysis, stent type had a stronger association with incomplete emptying (p=0.022) and bladder pain (p=0.018) than age, sex, body mass index, stent side, operation time, diameter of ureteral access sheath, and stent type. Conclusions: Patients with loop-tail ureteral stents had better urination-related QoL in the immediate post-URSL stage than patients with pigtail stents.

Effect of Protective Lead Curtains on Scattered Radiation Exposure to the Operator During Ureteroscopy for Stone Disease: A Controlled Trial.

OBJECTIVE: To evaluate a reduction in the total radiation dose to the operator during ureteroscopy (URS) for stone disease by using protective lead curtains. MATERIALS AND METHODS: Two studies were planned to compare scattered radiation doses without (nonprotective lead curtain [n-LC] group) and with protective lead curtains (lead curtain [LC] group). In study 1, we measured the spatial distribution of the scattered radiation dose using a human phantom simulating URS for stone management for both groups. In study 2, we prospectively randomized patients undergoing treatment for stone disease with URS into n-LC (n = 62) and LC (n = 61) groups. Scattered radiation doses to the operator during URS were recorded. The primary end point was a reduction in the effective dose to the operator. RESULTS: In study 1, there was an 80% reduction in dose at the operator area between the n-LC and the LC groups. In study 2, the mean effective doses to the operator in the n-LC and the LC groups were 0.33 ± 0.85 and 0.08 ± 0.08 µSv (P = .003). The mean doses measured at the neck and waist outside of the lead apron and at the chest inside the lead apron in the n-LC and the LC groups were 2.22 ± 4.56 vs 0.84 ± 0.7 µSv (P = .008), 5.48 ± 12.4 vs 0.76 ± 0.89 µSv (P = .001), and 0.10 ± 0.47 vs 0.00 ± 0.00 µSv (P = .001), respectively. CONCLUSION: These curtains are useful for protecting the operator from scattered radiation, resulting in a reduction of the total radiation exposure for surgeons performing URS.

Evaluation of the Clinical Utility of Renin-Angiotensin System Inhibitors in Patients Undergoing Radical Surgery for Urothelial Carcinoma of the Upper Urinary Tract.

BACKGROUND: Renin-angiotensin system (RAS) inhibitors are effective for treating patients with cancer. The present study evaluated the impact of RAS inhibitors, including angiotensin-2 converting enzyme inhibitors and angiotensin 2 receptor blockers, after patients underwent radical surgery for upper urinary tract urothelial carcinoma (UTUC). METHODS: This retrospective study included 312 patients with nonmetastatic UTUC who underwent radical surgery. The oncological outcomes of patients treated or not treated with RAS inhibitors following surgery were evaluated. Recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were assessed using the Kaplan-Meier method and Cox regression analysis. RESULTS: The median follow-up duration after radical surgery was 44.7 months. The 5-year RFS, CSS, and OS rates of patients who did or did not receive RAS inhibitors were 82.3% versus 68.9% (P = .018), 88.9% versus 71.8% (P = .0044), and 68.7% versus 61.8% (P = .047), respectively. Multivariable analyses revealed that the use of RAS inhibitors was an independent prognostic factor for RFS, CSS, and OS (hazard ratio [HR] 0.48, P = .013; HR 0.31, P = .002; and HR 0.52, P = .01, respectively). Moreover, patients treated with RAS inhibitors versus untreated patients had better 5-year RFS compared with those in the pT2 and < pN1 subgroups (pT2: 100.0% vs. 62.2%, P = .014 and < pN1: 87.2% vs. 74.7%, P = .034). CONCLUSIONS: RAS inhibitors significantly improved RFS, CSS, and OS of patients with UTUC who underwent radical surgery. These agents may be particularly beneficial for patients with stage pT2 or < pN1 disease.

[Improvement in Hyperglysemia Following Unilateral Adrenalectomy for ACTH-Independent Macronodular Adrenal Hyperplasia (AIMAH) : A Case Report].

Adrenal corticotropin (ACTH) -independent macronodular adrenal hyperplasia (AIMAH) is a rare cause of Cushing's syndrome. Bilateral adrenalectomy is the treatment of choice, but lifetime steroid replacement is essential. Here we report a case of AIMAH whose hyperglycemia was improved following unilateral adrenalectomy. A 42-year-old woman with serious intellectual disability and intractable epilepsy presented with polydipsia. Casual blood glucose and hemoglobin A1c (HbA1c) were 322 mg/dl and 8.5%, respectively. The cortisol level was high and ACTH level was low. Abdominal computed tomography and magnetic resonance imaging revealed unsuspected macronodular enlargement of bilateral adrenal glands (left 8 cm, right 4 cm in maximal diameter) and she was diagnosed with AIMAH. Both adrenal glands showed intense 131 I-adosterol accumulation predominantly in the left side and left-unilateral laparoscopic adrenalectomy was performed. Both insulin and oral antidiabetic drugs could be cancelled postoperatively, and HbA1c decreased to 5.7%. Steroid was not replaced but she never experienced adrenal crisis. We conclude that unilateral adrenalectomy is a safe and effective treatment for certain cases of AIMAH.

Prognostic Impact of Renin-Angiotensin Inhibitors in Patients with Bladder Cancer Undergoing Radical Cystectomy.

BACKGROUND: Renin-angiotensin system blockade has been effective for the treatment of patients with several types of malignancy. This study evaluated the prognostic impact of renin-angiotensin system inhibitors, including angiotensin-2 converting enzyme inhibitors and angiotensin 2 receptor blockers, in patients with bladder cancer undergoing radical cystectomy. METHODS: This retrospective study included 269 patients who had undergone radical cystectomy. The oncologic outcomes of patients treated or not treated with renin-angiotensin system inhibitors after surgery were evaluated. Overall survival and cancer-specific survival were assessed by the Kaplan-Meier method and by Cox regression analysis. RESULTS: The median follow-up duration after radical cystectomy in survivors was 44.5 months. The 5-year, cancer-specific survival rates in patients who did and did not receive renin-angiotensin system inhibitors were 79.0 and 66.4 %, respectively (P = 0.011). Similarly, the 5-year overall survival rates were 76.1 and 61.4 %, respectively (P = 0.0097). Multivariable analyses showed that use of renin-angiotensin system inhibitors was an independent prognostic factor for cancer-specific survival (hazard ratio 0.47, P = 0.036) and for overall survival (hazard ratio 0.36, P = 0.022). CONCLUSIONS: Renin-angiotensin system inhibitors significantly reduced the risks of cancer-specific and overall mortality after radical cystectomy in patients with bladder cancer. Renin-angiotensin system inhibitors may improve oncologic outcomes in high-risk patients with bladder cancer.

[A Case of Traumatic Dislocation of the Penis].

We report a rare case of a traumatic dislocation of the penis. The patient was a 39-year-old man who was ambulanced to our hospital because of a motorbike accident. He was diagnosed to have a pelvic fracture. He was admitted to our department because of his urinary retention and lower abdominal pain. Only the penile skin was left as the genital organ, and neither the penis nor the glans penis was palpable. As the computed tomography scan of the abdomen revealed the dislocation of the penis under the skin in the foreside of the pubic bone, urinary retention due to the traumatic dislocation of the penis was diagnosed, and a percutaneous cystostomy was performed. After improvement of his general condition, the patient was transferred to our department for the evaluation of the perineal region, including the lower urinary tract, and for the treatment of the traumatic dislocation of the penis. First, as hematoma and abscess in the left spermatic cord were suspected by magnetic resonance imaging of the pelvic region, removal of the hematoma and abscess in the left spermatic cord as well as an anterograde cystoscopy were performed under lumbar anesthesia, and the absence of urethral injury was confirmed. After infection control, repositioning of the penis was jointly performed with the Department of Plastic Surgery of our hospital under general anesthesia. After the operation, spontaneous urination was observed and erectile function was observed to be normal.