Can bladder preservation therapy come to the center stage?

Decision-making in urological cancer care requires a multidisciplinary approach for refinement, but its impact on urothelial carcinoma of the bladder has not been fully addressed for the past three decades, except for the latest immunological checkpoint inhibitor approved by the U.S. Food and Drug Administration for metastatic muscle-invasive bladder cancer that is resistant to platinum-based chemotherapy. For the time being, radical cystectomy is the gold standard of curative therapy for muscle-invasive bladder cancer. Trimodal therapy that combines chemotherapy for the purpose of radiation sensitization, external beam radiotherapy and transurethral resection of bladder tumor has emerged as a potential alternative treatment option that preserves the bladder. In lack of randomized studies for bladder preservation therapy compared with surgery, the principles of management of urothelial carcinoma of the bladder have evolved in recent times, with an emphasis on bladder preservation. A number of bladder preservation techniques are available to the surgeon; however, appropriately selected patients with muscle-invasive bladder cancer should be offered the opportunity to discuss various treatment options, including organ-sparing trimodal therapy. The aim of the present study was to compare the primary outcomes of the available treatment methods and identify the sources of variance among studies. A review of various bladder preservation techniques in vogue for the management of urothelial carcinoma of the bladder is discussed.

Postoperative Outcomes of Hybrid Repair in the Treatment of Aortic Arch Aneurysms.

BACKGROUND: The advent of thoracic endovascular aneurysm repair (TEVAR) has bought about a tremendous revolution in the treatment strategy for aortic arch aneurysms. We reviewed our experience using TEVAR with the hybrid approach in the treatment of aortic arch aneurysms to evaluate its feasibility, safety, and effectiveness. METHODS: Between October 2008 and July 2014, 61 consecutive patients (51 men; mean age 75.8 ± 7.7 years; range, 43-85 years) underwent elective treatment for aortic arch aneurysms with the hybrid approach. The 61 patients were separated into 2 groups. Thirty-five patients underwent total debranching TEVAR for zone 0 (debranching TEVAR group), 26 patients underwent long elephant trunk (ET) followed by secondary retrograde TEVAR (ET group). Preoperative, perioperative, and follow-up data were collected retrospectively in the database. RESULTS: The technical success rate was 100%. The paraplegia rates in total debranching TEVAR and long ET TEVAR and were 2.9% and 3.8%, respectively. The stroke rates in total debranching TEVAR and long ET TEVAR were 11.4% and 7.7%, respectively. The overall 30-day mortality and in-hospital mortality rates for all 61 patients were 0% and 3.4% (n = 2; both were in the total debranching TEVAR group), respectively. There were no perioperative type 1 or 3 endoleaks that required secondary intervention. The mean hospital stay was 15.8 days. The median follow-up was 309 ± 303 days. No aneurysm-related deaths occurred during follow-up. CONCLUSIONS: The hybrid approach can be safely performed with good technical success and good midterm results. In future, new alternative devices for aortic arch pathologies, such as a branched stent graft that eliminates extra-anatomic bypass, should be developed.

Relationship between the distal migration and length of the distal landing zone after endovascular aneurysm repair (EVAR).

BACKGROUND AND PURPOSE: Endovascular aneurysm repair (EVAR) is the main treatment for patients with abdominal aortic aneurysms. This study examines the relationship between the migration of the distal landing zone and the length of the landing zone. MATERIALS AND METHODS: The subjects of this study were 36 patients who underwent contrast-enhanced computed tomography 1 year after EVAR. We constructed curved multi-planar reconstruction imaging and measured the length of migration, the angle of the common iliac artery, and the diameter of the distal landing zone. RESULTS: The mean length of migration was 1.2 ± 1.7 mm. Fifty-four legs had a distal landing zone of over 15 mm and 18 legs had a distal landing zone of less than 15 mm. Four (7.4 %) of the 54 legs with a landing zone of over 15 mm and 3 (16.7 %) of the 18 legs with a landing zone of less than 15 mm had migration of over 3 mm. This difference was significant (P = 0.05). CONCLUSION: The rate of migration on the distal landing zone 1 year after EVAR was reasonable when the length of the landing zone was about 15 mm. It is possible that significant migration can occur in patients with distal landing zones less than 10 mm in length.

[Early and Mid-term Outcomes of Surgical Treatment with Conservative Approach Using Adventitial Inversion Technique for an Acute Type A Aortic Dissection].

OBJECTIVE: This study was performed to assess the early and mid-term outcomes of surgical treatment with adventitial inversion technique for an acute type A aortic dissection. METHODS: From June 2008 to June 2015, 48 patients underwent emergent surgery for acute type A aortic dissection. Ascending aorta/hemiarch replacement was performed in 44/48(91.7%)patients, and total arch replacement in 4/48(8.3%)patients. The adventitial inversion technique was used for both proximal and distal stump constructions of the dissected aortic wall without the reinforcement of Teflon felt. Aortic regurgitation was treated with resuspention of aortic commissures. RESULTS: The operative mortality was 8.3%(4/48). There was no re-exploration in all patients. Postoperative computed tomography showed the obliteration of false lumen in aortic root in all of patients, and aortic arch and/or descending thoracic aorta in 80.9%(38/47)of patients. The actuarial survival rates at 5 years were 74.7%.The freedom from aortic or aortic valve event rate and reoperation rate at 5 year were 90.9% and 95.2%, respectively. CONCLUSION: The adventitial inversion technique provides excellent early and mid-term outcomes for the repair of acute type A aortic dissection.

Validation of Patient Selection for Endovascular Aneurysm Repair or Open Repair of Abdominal Aortic Aneurysm ­ Single-Center Study.

BACKGROUND: To validate the criteria for endovascular aneurysm repair (EVAR) or open repair of abdominal aortic aneurysm (AAA) at Nagoya University Hospital, the results of both treatments were retrospectively compared. METHODS AND RESULTS: Patient selection for EVAR was primarily based on suitable anatomy, minimum age 75 years, and significant comorbidity. From June 2007 to April 2014, 426 patients were treated via EVAR (EVAR group) and 346 patients were treated with open surgery (OS group). The mortality rates of the EVAR and OS groups were not significantly different (0.2% vs. 1.1%; P=0.33). Patient age, operation time, amount of bleeding, and duration of hospital stay were significantly lower in the EVAR group compared with the OS group. The incidence of comorbidity was higher in the EVAR group compared with the OS group. The incidence of early postoperative complications was significantly higher in the OS group, whereas the incidence of late complications for both groups was similar. The cumulative aneurysm-related survival rates were similar (98.9% vs. 98.5%; P=0.767). The cumulative survival rates and reintervention-free rates at 5 years were lower for the EVAR group (76% vs. 89%, P=0.019; 81% vs. 89%, P=0.046). CONCLUSIONS: Patient selection practices and criteria for EVAR and open repair at Nagoya University Hospital are generally acceptable.

Magnetic resonance imaging findings in atypical polypoid adenomyoma.

OBJECTIVES: This article describes magnetic resonance imaging (MRI) findings in 3 cases of atypical polypoid adenomyoma (APAM). METHODS: Clinical and MRI manifestations of 3 patients with APAM were evaluated. High b value diffusion-weighted and dynamic contrast-enhanced images were performed. The size, shape, site of origin, and signal intensity (SI) of MRI findings were evaluated. RESULTS: All patients (age range, 37-47 years; mean age, 40 years) had a chief complaint of atypical genital bleeding with no history of pregnancy. In 2 cases, cytology of the endometrium was positive, and pathological analysis of curettage specimens indicated endometrioid adenocarcinoma. The MRI revealed an endometrial polypoid mass arising from the upper corpus (50%) or lower uterine segment (50%). Except for 1 tumor that seemed to invade the myometrium of the uterine wall due to its irregular margin, all tumors were well circumscribed. On T2-weighted MRI scans, the SI of the tumor was homogenous and marginally hyperintense, and contained markedly hyperintense cystic foci. On T1-weighted images, all the tumors were isointense relative to the myometrium, and in 1 case, a number of cystic foci showed high SIs. In a dynamic contrast-enhanced study, solid portions other than the cystic foci showed contrast enhancement in the arterial phase and demonstrated a washout pattern or plateau pattern in the late phase. All tumors demonstrated high SIs on diffusion-weighted images. CONCLUSIONS: Differentiating APAM from other malignant polypoid uterine endometrial tumors may still pose difficulties, especially when the tumor seems to invade the myometrium on MRI. Comprehensive clinical information about the patient including age, pathological assessment of the endometrium, and MRI findings should be essential to provide indication for a diagnosis of APAM.

Fate of ischemic limbs in patients with Buerger's disease based on our 30-year experience: does smoking have a definitive impact on the late loss of limbs?

PURPOSE: We herein review the long-term results of our series of critical ischemic limbs caused by Buerger's disease. METHODS: A retrospective review of 103 patients with critical limb ischemia who were diagnosed with Buerger's disease by Shionoya's criteria between 1980 and 2010. RESULTS: The age of onset was 38.0 ± 9.7 years (mean ± SD). The median follow-up was 97 months. Thirty-three patients had pain at rest, and 65 patients presented with ischemic ulcers in their toes and/or fingers. Gangrene was present in five patients. Sixteen patients achieved remission with medical therapy and smoking cessation. Sixty-six patients underwent sympathectomy. Bypass to the crural arteries was performed in 23 limbs, with assisted primary patency rates of 67.0 and 45.6 % at five and 10 years. Graft failure caused major amputation in two out of 10 smokers, but no limbs were lost among the 12 ex-smokers. Therapeutic angiogenesis using cell transplantation led to improvement in three ex-smokers; however, amputation was unavoidable in the one smoker who was treated. The limb salvage rate at 20 years was 90 % in ex-smokers and 69 % in smokers, which was not significantly different. CONCLUSIONS: This study demonstrated no significant difference in the limb salvage rate between ex-smokers and smokers. Our results do not support any advantageous effect of smoking cessation on the long-term remission in patients with Buerger's disease.

Possible involvement of Notch signaling in the pathogenesis of Buerger's disease.

PURPOSE: Under pathological conditions, the Notch signal pathway is involved in the inflammatory process in arteriosclerosis, atherosclerosis and angiogenesis under ischemic conditions. The purpose of this study was to observe whether or not Buerger's disease is associated with Notch signal activation. METHODS: All the patients were diagnosed between 1980 and 2009 at Nagoya University Hospital. Twenty-two specimens from 12 patients with Buerger's disease (TAO) and 13 specimens from nine patients with arteriosclerosis obliterans (ASO) were analyzed by immunohistochemistry for Notch1, Jagged-1 (a Notch ligand) and Hes-1 (a Notch 1 target transcription factor). RESULTS: Notch1 and Jagged-1 were highly expressed in the endothelium in the new vasa vasorum and in the smooth muscle cells in the media of specimens from both groups. These Notch-related proteins were also remarkably expressed in inflammatory cells in the intima of specimens from TAO patients. Fewer inflammatory cells expressed Notch-related proteins in atheromatous plaques (Notch1 (%): 8.4 ± 0.76 versus 1.3 ± 0.43, P < 0.001; Jagged-1(%): 9.3 ± 1.1 versus 5.2 ± 1.1, P = 0.03). Indeed, Hes-1, which is a transcription factor downstream of Notch1, was remarkably expressed in the endothelium of new capillary vessels and inflammatory cells in TAO patients. Notch1-positive mononuclear cells were also seen in the thrombus in samples from the TAO group. CONCLUSIONS: Our findings are the first demonstration that Notch signal activation in inflammatory cells may be involved in the pathophysiological mechanism underlying Buerger's disease.

A case of eosinophilic cholecystitis: Radiologic-pathologic correlation.

Eosinophilic cholecystitis (EC) is a rare condition that is characterized by eosinophilic infiltration in the gallbladder wall. We report the case of a 35-year-old woman who presented with unremitting right upper quadrant pain for 1 month. Computed tomography showed a strongly enhanced inner layer of the gallbladder wall. Magnetic resonance imaging of the same area showed low signal intensity on T2-weighted imaging. Cholecystectomy was performed, and histological examination of the surgical specimen revealed >100 eosinophils per high-power field in the inner subserosal layer. The area of these histological findings corresponded to the strongly enhanced inner layer of the gallbladder wall identified on computed tomography.

Double Microballoon-occluded Ethanol Embolization for Pelvic Arteriovenous Malformation: A Case Report.

A 40-year-old man was incidentally found to have right-sided pelvic arteriovenous malformation (AVM) with an aneurysmal dominant outflow vein (DOV). The AVM had two main feeding arteries forming a cluster of fine vessels shunt to the DOV. As transvenous approach was impossible due to anatomical difficulty, transarterial ethanol embolization was performed under simultaneous double microballoon occlusion of the two feeding arteries in combination with protective coil embolization of the prostatic branches. Ethanol (13 mL) was intermittently injected from both microballoon catheters until the AV shunt was completely occluded. At 1-year follow-up, contrast-enhanced CT revealed shrinkage of the thrombosed DOV without any symptom. Our case demonstrated the usefulness of simultaneous double microballoon-occluded ethanol embolization for treating a localized pelvic AVM with a few feeding arteries.

Three-dimensional workstation is useful for measuring the correct size of abdominal aortic aneurysm diameters.

BACKGROUND: Abdominal aortic aneurysm diameter is usually measured by the maximum minor-axis diameter on axial computed tomography (CT). However, this "traditional" diameter may underestimate the real size, as the aorta is not always straight and the aneurysm shape is sometimes in the form of an ellipse along the cross section. Therefore, we measured maximum major-axis diameters using a three-dimensional (3D) workstation and compared them with the traditional maximum minor-axis diameters measured using thin-slice axial CT. METHODS: CT data of 141 AAA patients (with fusiform aneurysms) were stored in a 3D workstation. These thin-slice CT images were reviewed on the 3D workstation to obtain curved multiplanar reconstruction images (CPR images). Using the CPR images, we measured the maximum major-axis and minor-axis diameters on CPR and the angle of the aneurysms to the body axis. RESULTS: The mean traditional maximum minor-axis diameter was 51.2 ± 8.2 mm, whereas the mean maximum major-axis diameter on CPR was 54.7 ± 10.1 mm. Sixty eight patients had a mean aneurysm size of <50 mm when measured by the traditional minor-axis diameter. Among these patients, five (7.4%) had a major-axis diameter >55 mm on CPR. CONCLUSION: The measurement of the traditional maximum minor-axis diameter of aneurysms is useful in the case of most patients. However, the traditional maximum minor-axis diameter may underestimate the real aneurysmal diameter, particularly in patients with an ellipse-shaped aneurysm. The maximum major-axis diameter as measured using CPR images is effective for representing the real aneurysmal size.

A case of renomedullary interstitial cell tumor: Radiologic-pathologic correlation.

Renomedullary interstitial cell tumor (RMICT), referred to as a medullary fibroma, is almost always asymptomatic and incidentally identified either at autopsy or upon resection of the kidney for other reasons. Although a few cases of RMICTs that are large in size and clinically symptomatic have been reported, there are few reports of RMICTs contrasting imaging findings with pathological findings. In this report, we describe a relatively large RMICT case of 3 cm in size, focusing on the radiologic-pathologic correlation.

Detection of the Vesical Arteries Using Three-dimensional Digital Subtraction Angiography Relevant to Intra-arterial Infusion Chemotherapy for Bladder Cancer Using Double-balloon Catheters.

Purpose: This study aims to assess and measure the origin of the superior vesical artery and its distance from the anterior trunk of the internal iliac artery, to which the anticancer drug is infused via double-balloon-occluded arterial infusion bladder-preserving therapy for locally invasive bladder cancer. Material and Methods: The 160 pelvic sides of 80 patients were analyzed. Double-balloon catheters were bilaterally introduced into the contralateral superior gluteal artery via the internal iliac arteries using a bilateral transfemoral approach. The proximal balloon is placed at the internal iliac artery, proximally from superior gluteal artery bifurcation, whereas the distal balloon at the origin of the superior gluteal artery to isolate the anterior trunk of the internal iliac artery discharging to the targeted vesical arteries between the balloons. The side hole between the distal and proximal balloons was adjusted at the origin of the anterior trunk of the internal iliac artery to allow clear visualization of the angiographic flow into the bladder. After the distal and proximal balloons were inflated, three-dimensional rotational digital subtraction angiography was performed by simultaneous contrast injection from one extension tube connected to bilateral catheters. The distance (X) between the origins of anterior trunk of the internal iliac artery and superior vesical artery was measured on three-dimensional digital subtraction angiography images, and the origin of the inferior vesical artery was investigated. Results: All superior vesical artery originated from anterior trunk of the internal iliac artery. The mean x was 7.2 mm (range 1.0-22.0 mm). All inferior vesical arterys branched from anterior trunk of the internal iliac artery or its branches. Conclusions: Superior vesical artery commonly originates from the proximal portion of anterior trunk of the internal iliac artery close to superior gluteal artery bifurcation.

Endovascular and Percutaneous Embolotherapy for the Body and Extremity Arteriovenous Malformations.

Arteriovenous malformations (AVMs) consist of abnormal communications between the arteries and veins. They can involve any part of the body and extremity and grow in proportion to age and in response to hormonal influence or trauma. When symptoms progress from Schöbinger clinical stage II to III, transcatheter and/or direct puncture embolization are less-invasive and repeatable options for symptom palliation. The goal of embolization is to obliterate the AV shunt, and the choice of lesion access and embolic agents is based on the individual anatomy and flow. Embolization can be technically challenging due to complex vascular anatomy and morbidity risks. Therefore, a multidisciplinary management is essential for the diagnosis and therapeutic intervention of AVMs.

Subclavian artery aneurysm in Marfan syndrome.

We present a case of a left subclavian artery aneurysm in a 48-year-old man with Marfan syndrome. Aneurysms of the subclavian artery are rare in patients with Marfan syndrome. Resection of the aneurysm and interposition with a synthetic graft were performed through a supra- and infraclavicular incision, without resecting the clavicle. Histological findings were compatible with Marfan syndrome. In patients with Marfan syndrome, regular follow-up is important because of the occurrence of peripheral aneurysms other than the aorta.

Late type III endoleak from fabric tears of a zenith stent graft: report of a case.

We report a case of late type III B endoleak from a fabric tear in the main body of a Zenith bifurcated stent-graft approximately 19 months after implantation. A follow-up computed tomography (CT) scan showed gradual growth in the size of the aneurysm, but no apparent endoleak was recognized. However, the CT scan had demonstrated a mosaic pattern in the aneurysm sac, which could indicate an endoleak from a fabric tear. The defect was repaired by implantation of body extensions, but the patient died 5 h after the procedure.

Cost disparity between open repair and endovascular aneurysm repair for abdominal aortic aneurysm: a single-institute experience in Japan.

PURPOSE: We conducted this study to compare the cost of open surgical repair (OR) with that of endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA). METHODS: Between January 2007 and November 2008, 70 patients underwent open repair and 57 patients underwent EVAR. We evaluated the total cost, including that of the Diagnosis Procedure Combination (DPC), that of the surgical procedure, that of materials such as grafts and guide wires, and that of the anesthesia. RESULTS: The mean costs for OR versus EVAR were as follows: DPC, ¥632,370 versus ¥490,050, respectively, which was significant; anesthesia, ¥123,540 versus ¥86,220, respectively (P < 0.05); and materials, ¥257,770 versus ¥2,113,280, respectively (P < 0.05). Thus, the mean total cost was ¥1,825,830 versus ¥3,159,270 for open repair and EVAR, respectively (P < 0.05). CONCLUSIONS: New technologies should not only be clinically effective, but also cost effective. EVAR is less invasive clinically, but the cost of endovascular prostheses and other materials remains high.

Comparison of reduced field-of-view DWI and full field-of view DWI for the differentiation between non-muscle invasive bladder cancer and muscle invasive bladder cancer using VI-RADS.

PURPOSE: To evaluate whether reduced field-of-view (rFOV) DWI sequence improves the differentiation between non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC) using VI-RADS. MATERIAL AND METHODS: Eighty-nine patients underwent bladder MRI with full field-of-view (fFOV) DWI and rFOV DWI sequence. Images were independently evaluated by 2 radiologists. The sensitivities, specificities, accuracies, and areas under the curve (AUCs) for the differentiation between NMIBC and MIBC with fFOV DWI and with rFOV DWI sequence were calculated using VI-RADS. Apparent diffusion coefficients (ADC) values were measured for each patient and averaged. RESULTS: The sensitivity, specificity, accuracy, and AUC by reader 1 were 92%, 78%, 82% and 0.905 with fFOV DWI, and 92%, 86%, 88% and 0.916 with rFOV DWI sequence, respectively. The sensitivity, specificity, accuracy and AUC by reader 2 were 96%, 76%, 82% and 0.900 with conventional DWI, and 96%, 81%, 85% and 0.907 with rFOV DWI sequence, respectively. The specificity and accuracy of reader 1 were significantly better with rFOV DWI sequence than with fFOV DWI, in contrast there was no significant difference for the others. The average of ADC values of fFOV DWI and rFOV DWI sequence were 1.004×10-6 mm2/s and 1.003×10-6 mm2/s, respectively. CONCLUSION: The diagnostic ability of rFOV DWI sequence may be better than that of fFOV DWI using VI-RADS for the differentiation between NMIBC and MIBC regardless of image-reading experience, it is controversial.

Molecular diagnosis of nonaneurysmal infectious aortitis.

We report a 79-year-old patient who presented with a fever and abdominal pain. The patient was initially thought to have a retroperitoneal fibrosis or inflammatory abdominal aortitis in a normal-sized caliber aorta. Broad-range polymerase chain reaction (PCR) and DNA sequencing revealed the presence of Enterobacter. We finally diagnosed nonaneurysmal infectious aortitis, and we performed a successful surgical resection. Establishing a diagnosis of aortic infection before formation of an aneurysm is difficult. The molecular diagnostic technique was particularly useful in specifying the microbial species and diagnosis.

Usefulness of POSSUM physiological score for the estimation of morbidity and mortality risk after elective abdominal aortic aneurysm repair in Japan.

BACKGROUND: The Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM), which consists of a physiological score (PS) and an operative severity score, is useful in determining the risk profile for patients with abdominal aortic aneurysms in Western countries, but no information is available on the use of this method in Japan. METHODS AND RESULTS: A retrospective cohort study involving 225 patients was performed, and the prognostic factors for morbidity and in-hospital mortality including POSSUM were investigated. The morbidity rate was 26%. On univariate analysis age, renal disease, hemoglobin, albumin, operation time, blood loss and PS were significantly different. On multivariate analysis PS was significantly different. Using receiver operating characteristic (ROC) analysis, PS had an area under the curve (AUC) of 0.712 and the best cut-off point was 18. The in-hospital mortality rate was 2.2%. On univariate analysis renal disease, albumin and PS were significantly different, and on multivariate analysis PS was significantly different. On ROC analysis PS had an AUC of 0.921 and the best cut-off point was 22. CONCLUSIONS: PS was the only independent risk factor for morbidity and in-hospital mortality. Further studies may be required to develop a risk-scoring system.