[Resumption of Enfortumab Vedotin Supported by Diagnosis of a Late- Onset Immune-Related Adverse Event in Metastatic Urothelial Carcinoma : A Case Report].

A 71-year-old man presented with exertional dyspnea. Chest radiography revealed multiple pulmonary nodules, and contrast-enhanced computed tomography showed findings suspicious of right renal pelvic cancer. Percutaneous lung tumor biopsy revealed a histological diagnosis of urothelial carcinoma, and right renal pelvic cancer cT3N2M1 was diagnosed. Favorable response was shown during primary chemotherapy with gemcitabine and cisplatin but resulted in tumor progression after four cycles. The patient was switched to a second-line treatment, pembrolizumab, which resulted in rapid tumor growth. Hyper-progression was suspected, and the patient was promptly switched to a third-line treatment, enfortumab vedotin. The tumor shrank significantly. After three treatment cycles, an adverse event of enteritis was observed. A biopsy of the intestinal mucosa led to a histopathologic diagnosis of late-onset immune-related adverse event; therefore, enfortumab vedotin could be continued.

[Risk Factors for Recurrence in Patients with Pathological Lymph Node-Positive Prostate Cancer after Extended Lymph Node Dissection in Laparoscopic and Robotic-Assisted Radical Prostatectomy].

From April 2007 to April 2018, we performed lymph node dissection in 305 cases of laparoscopic radical prostatectomy and 202 cases of robot-assisted radical prostatectomy at our hospital, and there were 68 cases with positive lymph node metastasis (pN1). Of these 68 cases, we examined retrospectively 62 cases in which extended lymph node dissection (ELND) was performed. The median number of removed lymph nodes was 25 (interquartile range [IQR] ; 18-34) and the median number of metastatic lymph nodes was 1 (IQR ; 1-3). Postoperative prostate-specific antigen (PSA) recurrence was observed in 40 of the 62 patients. The median time to PSA recurrence was 24 months. After univariate analysis, PSA at initial diagnosis (iPSA) of 10 ng/ml or more, pathological Gleason score (pGS) of 8 or more, total number of lymph node metastases of 2 or more, and positive surgical margin (RM＋) were found to be riskfactors of PSA recurrence. In multivariate analysis, iPSA of 10 ng/ml or more, pGS of 8 or more and RM＋ were independent riskfactors of PSA recurrence (p＜0.05). In the cases without riskfactors such as iPSA≥10, pGS≥8, and RM＋, immediate postoperative adjuvant therapy may be avoided even with pN1.

Atypical oncologic failure after laparoscopic and robot-assisted radical cystectomy at a single institution.

BACKGROUND: The incidence of atypical oncologic failure in patients with bladder cancer, including peritoneal carcinomatosis, and recurrences at the port site and soft tissue after laparoscopic and robot-assisted radical cystectomy are not well characterized. METHODS: We retrospectively reviewed the records of 52, 51, and 12 patients who underwent open, laparoscopic, and robot-assisted radical cystectomy, respectively, for bladder cancer from 2007 to 2018 at our institution. We identified techniques associated with atypical oncologic failure. RESULTS: The median follow-up period was 29 months. Among the 115 patients, 29 (25%) experienced oncological recurrences, and 7 (6%), 12 (10%), and 23 (20%) had atypical, local, and distant recurrences, respectively. The laparoscopic and robot-assisted radical cystectomy groups had significantly higher incidences of total atypical oncologic failure than the open radical cystectomy group (p = 0.013), including six, one, and two patients with peritoneal carcinomatosis, port site carcinomatosis, and soft tissue involvement, respectively. All 7 patients with atypical oncologic failure died of cancer; the median time from surgery to death was 9.3 months. All these patients were cT â‰§ 3 and had grade 3 disease. In three patients (43%), the pathological tissue contained variants other than urothelial carcinoma. Five (71%) were among the initial twenty patients. Four patients (57%) had histories of intraoperative urine spillage or bladder perforation during transurethral resection. CONCLUSIONS: Patients with cT â‰§ 3 stage, with pathological variants other than urothelial carcinoma, and those undergoing procedures that lead to extravesical dissemination should avoid laparoscopic radical cystectomy when the procedures are first introduced.

[Simple Methods to Prevent Postoperative Inguinal Hernia after Extraperitoneal and Transperitoneal Robot-Assisted Radical Prostatectomy].

Herein we present simple methods to prevent postoperative inguinal hernia (IH) after extraperitoneal and transperitoneal robot-assisted radical prostatectomy (RARP). Among 275 patients who underwent RARP between January 2014 and December 2016 at our institution, we evaluated 143 and 115 patients who underwent extraperitoneal-RARP (e-RARP) and transperitoneal-RARP (t-RARP), respectively, after excluding those with intraoperative detection of IH (17 patients). In the e-RARP group, all 143 patients (286 groins) underwent an IH prevention procedure. In the t-RARP group, the first 22 patients (44 groins) did not undergo an IH prevention procedure, whereas 29 patients (37 groins) with patent processus vaginalis (PPV) among the last 93 patients underwent the procedure. The IH prevention procedure during e-RARP included release of the vas deferens from the peritoneum and spermatic cord, and peritoneal dissection of the spermatic cord at the internal inguinal ring. The IH prevention procedure during t-RARP included release of the vas deferens from the peritoneum and spermatic cord, complete circumferential dissection of the peritoneum around the PPV at the level of the internal inguinal ring, and ligation of the PPV with a Hem-o- Loc○R clip. In the e-RARP group, postoperative IH occurred in 3 of the 143 patients (1.9%) during the follow-up period of 22.0±9.2 months. In the first subgroup of t-RARP, postoperative IH developed in 4 of the 22 patients (18%) during the follow-up period of 33.1±12.1 months, whereas in the last t-RARP group, postoperative IH developed in 3 of the 93 patients (3.3%) during the follow-up period of 20.1±8.6 months. Different IH prevention procedures performed in patients undergoing e-RARP and t-RARP were simple and effective in preventing postoperative IH.

[Necessity of Pelvic Drain Placement after Robot-Assisted Radical Prostatectomy].

Sixty eight patients had robot-assisted radical prostatectomy (RARP) from January 2016 to April 2017 with estimated blood loss of less than 500 ml. We compared the postoperative complication rates and the length of hospital stay between 34 of these patients who had pelvic drain placement (PD group), and the remaining 34 patients who had no drain placement (ND group). The approach was intraperitoneal in 25 patients in each group. The PD and ND groups were comparable for age (69.5 vs 70 yrs, P=0.459), clinical Gleason Score (6/7/≧8) 2/17/15 vs 3/8/23 (P=0.077), clinical stage (1c/2/3) 3/25/6 vs 1/25/8 (p=0. 539), operative time (311 vs 309 min, P=0.868), and estimated blood loss (p=0.166). The PD group had significantly higher median PSA level than the ND group (8.01 vs 6.25 ng/ml, P=0.023). Incidence of 30- day overall complications in the PD group (35 events) was lower than that in the ND group (38 events). All complications were classified as Clavien Dindo grade I. The postoperative hospital stay was 8 days in the PD group and 7 days in the ND group, showing no prolongation in the ND group. Pelvic drainage may be omitted after RARP without increasing postoperative complications or prolonging the hospital stay.

En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single-institution experience.

OBJECTIVE: To report the outcomes of laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma at Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan. METHOD: A retrospective review of the clinical records of five patients who underwent laparoscopic radical nephrectomy with inferior vena cava thrombectomy for right renal cell carcinoma between 2013 and 2017 was carried out. The surgical procedure included ligation and cutting of the right renal artery, followed by kidney mobilization. The left renal vein, and the caudal and cephalad sides of the inferior vena cava thrombus were clamped using laparoscopic vascular clamps, and the inferior vena cava was incised. The free kidney and tumor thrombus were placed en bloc in a retrieval bag. Subsequently, the inferior vena cava was laparoscopically closed using a continuous suture. RESULTS: The median operative time, pneumoperitoneum time, blood loss and postoperative hospital stay were 316 min, 266 min, 400 mL and 7 days, respectively. The median clamp time was 28 min (range 13-105 min). One patient (20%) required a perioperative blood transfusion. The surgical margin was negative in all patients. Only one patient experienced a major complication (Clavien-Dindo grade ≥3), namely a postoperative hemorrhage requiring transarterial embolism. CONCLUSION: En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy is a challenging yet feasible procedure for experienced surgeons in carefully selected patients. Further studies of this surgical procedure are required for standardization and safe application.

Comparison of perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy: Comparative outcomes of cT1a versus cT1b renal tumors.

OBJECTIVES: To assess the perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy for cT1b renal tumors compared with cT1a. METHODS: From February 2015 to May 2018, 100 robot-assisted partial nephrectomy patients who underwent robot-assisted partial nephrectomy without renorrhaphy for renal tumors were included. We retrospectively reviewed the medical records, and compared the perioperative outcomes of 66 and 34 patients for cT1a and cT1b tumors, respectively. Inner suture was carried out in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft-coagulation system was used, and absorbable hemostats were placed on the resection bed. RESULTS: The median tumor size and RENAL nephrometry score were significantly different between the two groups (cT1a vs cT1b: 23.5 vs 45 mm, P < 0.001, 6 vs 8, P < 0.001). The median operating time and warm ischemic time were significantly longer in the cT1b group than in the cT1a group (154 vs 184 min, P < 0.001; 14 vs 21 min, P < 0.001). The median blood loss was not significantly different (2.5 vs 50 mL, P = 0.109). The positive surgical margin rate was 4.5% versus 11.7% (P = 0.22). Postoperative complications classified as Clavien-Dindo grade III or higher were port-site herniation (one patient), acute cholecystitis (one patient) and pseudoaneurysm (one patient) in the cT1b group. Urinary leakage was not observed in the two groups. CONCLUSIONS: Robot-assisted partial nephrectomy without renorrhaphy using the soft-coagulation system and absorbable hemostats appears to be feasible for renal or cT1b tumors. However, longer warm ischemic time and a high rate of complications can be expected compared with cT1a tumors.

[Traumatic Adrenal Injury : A Single-Institution Experience].

Traumatic adrenal injury is quite rare. From January 2008 to March 2018, out of 287 patients with genitourinary trauma, 23 patients (8%) were diagnosed with traumatic adrenal injury at Kobe City Medical Center General Hospital. We retrospectively reviewed the medical records and assessed the traumatic category, image findings and outcome. All 23 patients were bluntly injured. The causes of traumatic adrenal injury were motor vehicle accident (11 patients : 48%) and falls (9 patients : 39%). The majority of injuries occurred on the right side (18 patients : 78%). Associated injuries occurred in all 23 patients, most frequently in the liver (57%) and ribs (57%). Extravasation of contrast materials was identified on computed tomography (CT) in 4 patients (17%). Although 22 patients (96%) were conservatively managed, only 1 patient was treated by transcatherter arterial embolization because of hypotension. One patient died of intraabdominal bleeding. To our knowledge, the present study is the largest on traumatic adrenal injury in Japan.

[A Case of Renal Oncocytosis with Bilateral Multiple Renal Masses].

A 63-year-old man with microscopic hematuria underwent contrast-enhanced CT, which showed multiple bilateral renal masses. Percutaneous biopsy results indicated renal oncocytosis. The tumors remained unchanged for 3 years. Renal oncocytosis is a very rare tumor, but it is an established disease entity characterized by numerous oncocytic tumors and diffuse (sporadic) renal parenchymal epithelial oncocytic changes on an analysis histopathology. Although renal oncocytosis can be sporadic or part of Birt-Hogg-Dube syndrome (BHDS), our case did not associate with BHDS because of absence of lung cyst.

[A Case of Systemic Polyarteritis Nodosa Presenting with Scrotal Pain].

A 76-year-old man with a history of hypertension was admitted with high fever and left scrotal pain. Laboratory findings revealed high serum C-reactive protein levels. The left epididymis appeared to be swollen on computed tomography. The patient was diagnosed with bacterial epididymitis and treatment with antibiotics was initiated. Despite treatment, his left scrotal pain and fever did not improve. Additionally, he developed right scrotal and posterior neck pain. For histopathological diagnosis, a left high orchiectomy was performed and the findings revealed thickened arteriolar walls with infiltration of inflammatory cells around the testis, leading to a final diagnosis of systemic polyarteritis nodosa. Treatment with steroids led to complete resolution of the patient's systemic pain and inflammation.

[Off-Clamp, Non-Renorrhaphy Robot-Assisted Partial Nephrectomy : An Initial Experience in a Single Institution].

We report the surgical procedures and perioperative outcomes of off-clamp, non-renorrhaphy robotassisted partial nephrectomy (RAPN) in 7 out of 76 patients who underwent RAPN with off-clamp and nonrenorrhaphy between February 2015 and August 2017. The approach was chosen depending on the location of the tumor. Tumor enucleation was performed by using sharp incision and blunt dissection. For hemostasis, the soft-coagulation system was used and TachoSil○R was placed on the resection bed. As a rule, renorrhaphy was not performed. Median (range) patient age was 67 years (40-79), tumor size ; 14 mm (12-18), operative time ; 139 minutes (102-166), console time ; 51 minutes (41-75), estimate blood loss ; 10 ml (0-100). No patients required a perioperative blood transfusion. Median (range) tumor intraparenchymal depth was 10.4 mm (4.3-15.5) and distance from urinary collecting system was 9.3 mm (4.1-13.0). Pseudoaneurysm and urine leakage were not observed. No complications classified as Clavien-Dindo grade higher than grade 1 appeared. No cases had a positive surgical margin. Median (range) estimated glomerular filtration rate (eGFR) change rate at 3 months after surgery was 0% (-12.7-14.5). Off-clamp, non-renorrhaphy RAPN with the soft-coagulation system and TachoSil® is a feasible and safe procedure for patients carefully selected among those with superficial tumors.

[Evaluation of Lymphoceles by CT Scan Early after Robot-Assisted Radical Prostatectomy].

We report the incidence and characteristics of lymphoceles after robot-assisted radical prostatectomy (RARP). Computed tomography was performed on 79 patients one month after RARP or when symptoms appeared. The lymphocele was defined as a cystic lesion over 10 mm in diameter. Symptomatic and asymptomatic lymphoceles were identified in 25% (20/79) of all cases, and in 40.9% (18/44) of the cases with lymph node dissection (LND). Symptomatic lymphoceles were identified in 2.5% (2/79) of all cases. Lymphoceles were significantly associated with LND, pathological stage over T3, longer period of indwelling drain tube,and higher volume fluid of drain tube (p<0.05). In conclusion, lymphoceles are quiet common after RARP. However, they rarely become symptomatic.

[A Case of Chromophobe Renal Cell Carcinoma Associated with Birt-Hogg-Dubé Syndrome].

A 61-year-old man with a left renal mass, which was detected by ultrasound during a routine health examination, was referred to our department. The patient had a surgical history of two pneumothorax operations, and the patient's brother also had a history of pneumothorax surgery. A case of Birt-Hogg-Dubé (BHD) syndrome was suspected based on patient history. The pathological diagnosis of the resected tumor, which used robot-assisted laparoscopic partial nephrectomy, was determined to be chromophobe renal cell carcinoma (grade 2, pT1a). BHD syndrome was confirmed by genetic testing, where a nonsense mutation of exon 9 in the FOLLICULIN (FLCN) gene was detected. The patient is currently alive 10 months after surgery.

[Risk Factors for Mortalityin Patients with Urosepsis].

Urosepsis is not uncommon and sometimes causes a critical condition including death. We retrospectivelyanaly zed the risk factors for mortalityin urosepsis. We treated 80 patients as urosepsis from 2010 to 2014 in our hospital. Five patients (6%) died within 30 days of hospitalization. The median age of the patients who died of urosepsis was 92 years (range, 83-95 years). The main causes of urosepsis were complicated pyelonephritis in 4 patients and emphysematous pyelonephritis in one. In the subgroup analysis of elderly patients over 75 years old, bad performance status and lower serum albumin were significantlyrelated to mortality(p ＝0.033, 0.046). The elderlypatients, especiallywith bad performance status and lower serum albumin, are more likelyto die.

[Clinical Study of HoLEP for the Patients with Benign Prostatic Hyperplasia who are on Oral Antithrombotics].

Recently, holmium laserenucleation of the prostate (HoLEP) was associated with less bleeding compared with transurethral resection of prostate. Since 2012, we have performed HoLEP for benign prostatic hyperplasia (BPH) under continuous oral antithrombotics (OA). Between October 2004 and March 2015, 54 patients with BPH underwent HoLEP while on OA at our hospital. Eight patients underwent HoLEP without OA cessation and 46 patients with temporary OA cessation. No significant between-group difference was observed in age, prostate volume, transitional zone prostate volume, operation time, resection weight, resection weight per minute, urethral catheter duration, Hb decrease on day 1 post- HoLEP, hospital stay after HoLEP, bleeding intraoperative rate, bleeding rate after HoLEP and transfusion rate. None presented embolic complications. HoLEP was safe without OA cessation. However, highvolume BPH patients without OA cessation required intraoperative transfusion. Thus, high-volume BPH patients may benefit from OA cessation.

[Two Cases of Oncocytic Papillary Renal Cell Carcinoma].

Oncocytic papillary renal cell carcinoma isa variant of papillary renal cell carcinoma (PRCC). We herein report two cases treated with retroperitoneoscopic partial nephrectomy. Histologically, tumor cells of both cases exhibit round and regular nuclei with CK7 positive areas in the cytoplasm typical of TYPE1 PRCC and eosinophilic granular cytoplasm with E-cadherin positive areas in the cytoplasmic membrane, which indicates TYPE2 PRCC. Out of 46 cases reported in the literature, only one died of disease, which reveals its low malignant potential.

[Clinical Characteristics of Prostate Ductal Adenocarcinoma in Kyoto University Hospital].

Prostate ductal adenocarcinoma is a rare variant of prostate cancer and considered to be more aggressive than the common acinar type of adenocarcinoma. The appropriate treatment guideline for prostate ductal adenocarcinoma has not been established. The aim of the present study was to examine the clinical characteristics and the effectiveness of treatment for prostate ductal adenocarcinoma. From 2005 to 2012, 41 patients were diagnosed to have prostate ductal adenocarcinoma in Kyoto University Hospital. The mean±SD age was 68.6±7.0 years, and the median (range) initial serum PSA level was 9.3 (3.7-217) ng/ml. Among 17 patients who underwent radical prostatectomy, 10 (58.8%) had pT3 disease and 5 (29.4%) had biochemical recurrence during median follow-up of 22.9 months. Out of 19 patients treated with definitive EBRT with endocrine therapy, 2 patients (10.5%) experienced biochemical recurrence with median follow-up of 37.3 months. Five patients were treated with endocrine therapy alone, and 2 (40.0%) of them died of prostate ductal adenocarcinoma. In conclusion, patients with prostate ductal adenocarcinoma were more likely diagnosed as locally advanced diseases than those with prostate acinar adenocarcinoma. However, for patients without metastasis, either surgery or EBRT with endocrine therapy is effective with good prognosis.

Bladder afferent hyperexcitability in bladder pain syndrome/interstitial cystitis.

Bladder pain syndrome/interstitial cystitis is a disease with lower urinary tract symptoms, such as bladder pain and urinary frequency, which results in seriously impaired quality of life of patients. The extreme pain and urinary frequency are often difficult to treat. Although the etiology of bladder pain syndrome/interstitial cystitis is still not known, there is increasing evidence showing that afferent hyperexcitability as a result of neurogenic bladder inflammation and urothelial dysfunction is important to the pathophysiological basis of symptom development. Further investigation of the pathophysiology will lead to the effective treatment of patients with bladder pain syndrome/interstitial cystitis.

Novel constant-pressure irrigation technique for the treatment of renal pelvic tumors after ipsilateral ureterectomy.

We herein report a case of a renal pelvic tumor that developed in the residual left renal pelvis after right nephroureterectomy, left ureterectomy and total cystectomy in a patient with multiple urothelial tumors. The tumor was endoscopically ablated through a nephrostomy tract, and mitomycin C irrigation was carried out. We designed a novel constant-pressure irrigation system for effective and safe irrigation into the closed space of the renal pelvis. We created a hole in the urine bag tube, inserted a 5-Fr open-end ureteral catheter through the hole and kept the tip of the catheter at the end of the nephrostomy tube. The urine bag tube was placed 20 cm above the kidney level, and mitomycin C was continuously irrigated into the renal pelvis for 1 h. Six-weekly treatments were carried out, and tumor recurrence was not identified for 1 year.

[A case of late perirenal fat recurrence after partial nephrectomy for T1A renal cell carcinoma].

An 84-year-old man had undergone laparoscopic partial nephrectomy for right renal cell carcinoma (RCC), cT1aN0M0 in 2003. The histopathological diagnosis was clear cell carcinoma, grade 1, v (-), surgical margin negative, pT1a. Nine years and 10 months postoperatively, computed tomography scans demonstrated tumors on right renal fossa. As we could not detect other metastatic lesions, we diagnosed him with local recurrence of RCC and planned the surgery with curative intent. He underwent laparoscopic resection of retroperitoneal tumors. The histopathological diagnosis was clear cell carcinoma, grade 2 ＞ 3, v (-), surgical margin negative, and confirmed recurrence of RCC. In retrospective review of 176 cases of pT1a renal cell carcinoma with partial nephrectomy in our institute, 3 patients (1.7%) developed local recurrence and 2 patients (1.1%) developed late local recurrence.