Development and validation of novel nomogram to identify the candidates for extended pelvic lymph node dissection for prostate cancer patients in the robotic era.

OBJECTIVES: To determine candidates for extended pelvic lymph node dissection using a novel nomogram to assess the risk of lymph node invasion in Japanese prostate cancer patients in the robotic era. METHODS: A total of 538 patients who underwent robot-assisted radical prostatectomy with extended pelvic lymph node dissection in three hospitals were retrospectively analyzed. Medical records were reviewed uniformly and the following data collected: prostate-specific antigen, age, clinical T stage, primary and secondary Gleason score at prostate biopsy, and percentage of positive core numbers. Finally, data from 434 patients were used for developing the nomogram and data from 104 patients were used for external validation. RESULTS: Lymph node invasion was detected in 47 (11%) and 16 (15%) patients in the development and validation set, respectively. Based on multivariate analysis, prostate-specific antigen, clinical T stage ≥3, primary Gleason score, grade group 5, and percentage of positive cores were selected as variables to incorporate into the nomogram. The area under the curve values were 0.781 for the internal and 0.908 for the external validation, respectively. CONCLUSIONS: The present nomogram can help urologists identify candidates for extended pelvic lymph node dissection concomitant with robot-assisted radical prostatectomy among patients with prostate cancer.

Intravesical irrigation might prevent bladder recurrence in patients undergoing radical nephroureterectomy for upper urinary tract urothelial carcinoma.

OBJECTIVES: To examine the effectiveness of intravesical irrigation with physiological saline solution or distilled water for the prevention of bladder recurrence in patients undergoing laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma. METHODS: This retrospective study involved 109 upper urinary tract urothelial carcinoma patients who underwent laparoscopic nephroureterectomy, and were evaluated at Chiba University Hospital and Yokohama Rosai Hospital between 2001 and 2018. We investigated the outcomes and analyzed various clinical factors including with or without intravesical irrigation related to bladder carcinoma recurrence after surgery. Physiological saline solution or distilled water was used for irrigation, which was carried out only during surgery. RESULTS: The median follow-up period after surgery was 26.1 months. Bladder recurrence was confirmed within 2 years for 45 of the 109 patients in the present study. Irrigation was carried out for 48 cases (distilled water, 26 patients; physiological saline solution, 22 patients). Tumor grade (G1-2 vs G3; P = 0.05) and intravesical irrigation (yes vs no; P = 0.0058) were related to bladder recurrence on univariate analyses. On multivariate analyses, intravesical irrigation was the independent factor involved in the prevention of bladder recurrence (P = 0.0051). Comparison between the irrigation and non-irrigation groups showed that bladder recurrence rates were significantly lower in the irrigation group (irrigation group vs non-irrigation group: 25.0% vs 52.5%, P = 0.0066). There was no significant difference in the recurrence rate between the two solutions used for irrigation. CONCLUSIONS: Intravesical irrigation during surgery of upper urinary tract urothelial carcinoma might decrease postoperative bladder recurrence rates.

[THE RISK AND MANAGEMENT OF RADIATION INDUCED CYSTITIS AFTER RADIOTHERAPY FOR PROSTATE CANCER].

(Objectives) Radiation induced cystitis (RC) is one of the toxicities we must often treat after radiation therapy for prostate cancer.Some patients require urinary diversion with or without cystectomy.We evaluated the clinical risks and management of RC. (Patients and methods) The clinical records of 303 patients who underwent radiation therapy for prostate cancer (199 only radiation therapy; 104 adjuvant or salvage radiation therapy after radical prostatectomy) between 2005 and 2015 in our institute, were reviewed.We defined RC based on the presence of macrohematuria, not caused by reccurence of prostate cancer or occurrence of bladder cancer. (Results) The median follow up time was 37 months (range 1-132).Thirty patients (9.9%) developed RC.Compared to radiation therapy alone, adjuvant/salvage radiation therapy was found to be a risk for RC (4.5% vs. 20.1%, p< 0.01).Ten out of 30 RC patients needed hospitalization and 6 patients underwent urinary diversion with or without cystectomy.Two patients who underwent urinary diversion without cystectomy were hospitalized for a longer period compared with 4 patients with cystectomy. (Conclusion) Adjuvant/salvage therapy is a risk factor of RC after radiation therapy for prostate cancer.About 2% of the patients needed urinary diversion and cystectomy improved their prognosis.

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR LARGE RENAL CELL CARCINOMA: RETROSPECTIVE ANALYSIS OF SAFETY AND ONCOLOGICAL OUTCOME.

(Objectives) To evaluate the safety and oncologic efficacy of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) >7 cm, we retrospectively reviewed the clinical outcome and long-term cancer control of patients who underwent LRN in comparison to open radical nephrectomy (ORN). (Patients and methods) The clinical records of 79 patients with RCC >7 cm, who underwent radical nephrectomy (37 LRN; 42 ORN) between 1993 and 2014, were reviewed. (Results) The 2 groups (LRN and ORN) were comparable regarding age, body mass index and mean tumor size (86.5 mm vs. 94.6 mm).The operative time was significantly longer in the LRN group than ORN group (204 min vs. 168 min; p<0.05) and blood loss was significantly lower in the LRN group than in the ORN group (144 ml vs. 930 ml; p<0.05).No statistically significant difference was found in complication rate (10.8% vs. 23.8%) and the 2-year recurrence-free survival rate (85.6% vs. 83.8%). (Conclusion) Despite the longer operative time, LRN for large RCC was associated with lower blood loss. This study provides evidence of the safety and efficacy of LRN for large RCC.

[REITER'S SYNDROME FOLLOWING INTRAVASICAL BCG THERAPY FOR UROTHELIAL CARCINOMA. SUMMARY OF CASE REPORTS OVER THE PAST 13 YEARS IN JAPAN, INCLUDING OUR CURRENT 6 CASES].

Reiter's syndrome is one of the rare complications following intravesical bovis Bacillus Calmette-Guerin (BCG) treatment. In this study we have reviewed and discussed 101 cases including our own 6 cases over the past 13 years in Japan (2000-2013). The patients comprised 70 males and 25 females (6 cases were unknown), mean age of 63.1 (range 42 - 91). Arthritis occured 4-5 days after conjunctivitis. Thirty five (55%) of 68 patients needed corticosteroid treatment to control their arthritis. HLA-B27 is known as a risk factor of Reiter's syndrome, however, positive rate was only 2.4% (n = 41).

Novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation and long-term outcomes for a single surgeon.

Although novel techniques for avoiding incontinence during robot-assisted radical prostatectomy have been developed, long-term oncological outcomes are unknown. The objective of this study was to determine the long-term oncological outcomes and functional outcomes of novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation for a single surgeon. Data from 100 patients who underwent structure-preserving prostatectomies performed by a single surgeon were retrospectively analyzed. The median console time was 123 min. Bilateral nerve-sparing was performed in 43% of patients underwent, and 57% underwent unilateral nerve-sparing surgery. Most patients (96%) reached complete pad-zero urinary continence by one year after surgery. Satisfactory erectile function was achieved in 97% of patients who underwent bilateral nerve-sparing surgery, and 80% of patients who underwent unilateral nerve-sparing surgery. The surgical margin was positive for 25% of patients, and the biochemical recurrence-free rate at 5 years was 77%. The cancer-specific survival rate was 100% during the median follow-up period of 4.5 years. Clavien-Dindo grade III complications occurred in 1% of cases. The outcomes for novel nerve-sparing robot-assisted radical prostatectomy with endopelvic fascia preservation were similar to previously reported oncological outcomes, with satisfactory functional outcomes. This operative method may be useful for patients who are eligible for nerve-sparing surgery.

Feasibility of single-port laparoscopic partial adrenalectomy with selective adrenal venous sampling and high-resolution ultrasound for unilateral aldosterone-producing adenomas.

BACKGROUND: The surgical and endocrinological outcomes of single-port laparoscopic partial adrenalectomy for patients with aldosterone-producing adenomas are unknown. Precise diagnosis of intra-adrenal aldosterone activity and a precise surgical procedure may improve outcomes. In this study, we aimed to determine the surgical and endocrinological outcomes of single-port laparoscopic partial adrenalectomy with preoperative segmental selective adrenal venous sampling and intraoperative high-resolution laparoscopic ultrasound in patients with unilateral aldosterone-producing adenomas. We identified 53 patients with partial adrenalectomy and 29 patients with laparoscopic total adrenalectomy. Single-port surgery was performed for 37 and 19 patients, respectively. METHODS: A single-center, retrospective cohort study. All patients with unilateral aldosterone-producing adenomas diagnosed by selective adrenal venous sampling and treated surgically between January 2012 and February 2015 were included. Follow-up with biochemical and clinical assessments was set at 1 year after surgery for short-term outcomes and was performed every 3 months after surgery. RESULTS: We identified 53 patients with partial adrenalectomy and 29 patients with laparoscopic total adrenalectomy. Single-port surgery was performed for 37 and 19 patients, respectively. Single-port surgery was associated with shorter operative and laparoscopic times (odds ratio, 0.14; 95% confidence interval, 0.039-0.49; P = .002 and odds ratio, 0.13; 95% confidence interval, 0.032-0.57; P = .006, respectively). All single-port and multi-port partial adrenalectomy cases showed complete short-term (median 1 year) biochemical success, and 92.9% (26 of 28 patients) who underwent single-port partial adrenalectomy and 100% (13 of 13 patients) who underwent multi-port partial adrenalectomy showed complete long-term (median 5.5 years) biochemical success. No complications were observed with single-port adrenalectomy. CONCLUSION: Single-port partial adrenalectomy is feasible after selective adrenal venous sampling for unilateral aldosterone-producing adenomas, with shorter operative and laparoscopic times and a high rate of complete biochemical success.

Pathological complete response of plasmacytoid variant bladder cancer to pembrolizumab following genomic analysis.

Introduction: Plasmacytoid variant bladder cancer is a rare variant of urothelial carcinoma that accounts for 1% of bladder cancers. Plasmacytoid variant urothelial carcinoma is characterized by an aggressive phenotype and poor clinical outcomes. Case presentation: A 61-year-old woman presented with gross hematuria. Cystoscopy showed a 16-mm solid tumor. Transurethral resection of the bladder tumor was performed, and the pathological diagnosis was invasive plasmacytoid variant urothelial carcinoma. Although the pathological T stage was pT1, computed tomography showed right obturator lymph node swelling. Since previous reports indicate poor response to chemotherapy for this disease, clinical sequencing was performed. Based on the high tumor mutation burden revealed, pembrolizumab was administered for 4 cycles, and computed tomography showed a partial response. Robot-assisted radical cystectomy was performed, and a pathological complete response including the pelvic lymph node was observed. Conclusion: Pembrolizumab may be a treatment option for plasmacytoid variant urothelial carcinoma following genomic analysis.

[A case of solitary bone metastasis of testicular seminoma 6 years post orchiectomy].

A 40-year-old man visited our hospital in August, 2007 with the complaint of gait disturbance. Six years ago he had had right high orchiectomy for treatment of stage I seminoma at another hospital. The magnetic resonance imaging (MRI) examination showed a small tumor and compression fracture in the eighth thoracic vertebrae. Emergency spinal decompression with bone biopsy was done. The pathological diagnosis of the bone was metastasis of seminoma. He was treated with 3 courses of BEP (bleomycin, etoposide and cisplatin) therapy and external beam radiotherapy (36 Gy) was performed. His symptom of gait disturbance disappeared gradually, and was evaluated to be in complete remission. He has been alive with no evidence of recurrence for 3 years.

[Pros and cons of active surveillance for low-risk prostate cancer].

Because of the recent increase of prostate specific antigen (PSA)-screening, potential risks of overdiagnosis and overtreatment are more easily pointed out for low-risk prostate cancer. Active surveillance is one of the therapeutic options for the management of patients with low-risk prostate cancer. Concerning the indication of active surveillance, candidates for it have been selected based on several clinical factors including clinical stage(T), PSA level, Gleason score, and the number of positive cores on prostatic biopsy, but the selection criteria have not yet been uniformly established. As for the observation method, PSA doubling time and results from repeated biopsies have been utilized to select a high-risk case for whom intervention by curative therapy will be recommended. However, there are still controversies concerned with which is the most appropriate method of follow-up during active surveillance. In addition, the psychological impact of active surveillance on both the patient and the health care staff needs to be taken into account. Since the efficacy and safety of active surveillance were demonstrated by the results of several clinical studies, it is regarded as one of the superior and acceptable therapeutic options for patients with low-risk prostate cancer. It is expected that both the patient and health care staff would choose active surveillance as a reliable option when the appropriate selection criteria and the suitable follow-up method are determined and established.