[Pelvic Reconstruction in Abdominal Trachelectomy and Bilateral Salpingo-Oophorectomy for Occult Uterine Endometrial Cancer Found in Specimens Removed in the Context of Laparoscopic Sacrocolpopexy].

In the patients undergoing pelvic organ prolapse (POP) repairs, the incidence of occult uterine endometrial cancer is low and there is no established management procedure for preoperative cancer screening. We report a case of pelvic reconstruction in abdominal trachelectomy and bilateral salpingo-oophorectomy for occult uterine endometrial cancer found in specimens removed in the context of laparoscopic sacrocolpopexy (LSC). A 70-year-old woman presented to our center with cystocele. She underwent LSC and laparoscopic supracervical hysterectomy. She had no atypical genital bleeding; and, transvaginal ultrasound, pelvic plane magnetic resonance imaging and cervical cytology showed no evidence of malignancy. However, the pathological examination showed uterine endometrial cancer. She underwent trachelectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. A part of mesh was removed with a cervical stamp, but the remaining mesh was sewn together. At 5 months after the operation, no recurrence of uterine endometrial cancer and POP was seen.

Medium term anatomical and functional outcomes following modified laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: We evaluated the anatomical and functional outcomes following modified laparoscopic sacrocolpopexy (LSC) utilizing deep dissection of the vaginal walls and distal mesh fixation at the anterior and posterior compartments. We hypothesized that anatomical and functional outcomes improve after this modified LSC technique. METHODS: This was a retrospective study of all women (n = 240) who underwent LSC for pelvic organ prolapse (POP) from January to December 2017 in a tertiary center. POP-Q staging, validated questionnaires (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Pelvic Floor Distress Inventory Questionnaire-Short Form), and uroflowmetry were used to evaluate the anatomical and functional outcomes. Statistical analyses were performed using McNemar test and repeated measures analysis of variance with Fisher's least significant difference post hoc (p < 0.05). RESULTS: The anatomical success rate is 96%, with a prolapse recurrence rate of 3.8% at 3-year follow-up. Bulge symptoms and anatomical compartments were significantly improved after LSC. Clinically, there were significant improvements after LSC in voiding dysfunction and bowel symptoms. Also, there was a significant increase in stress urinary incontinence and non-significant decrease in mixed urinary incontinence and urge urinary incontinence. ICIQ-SF and Colorectal-Anal Distress Inventory 8 scores were significantly lower after LSC, signifying improvement in incontinence and bowel symptoms. CONCLUSION: Our modified LSC technique is safe and effective in restoring level 1 and level 2 supports, without adverse effects on urinary and bowel function. Bladder and bowel symptoms have also been found to keep improving over time.

Clinical outcomes after laparoscopic sacrocolpopexy for pelvic organ prolapse: A 3-year follow-up study.

OBJECTIVES: To evaluate the mid-range subjective and objective success rate of laparoscopic sacrocolpopexy. METHODS: Of the 317 women with pelvic organ prolapse who underwent laparoscopic sacrocolpopexy surgery at the same center between January 2013 and March 2015, we assessed 233 patients who were followed up for >3 years. We carried out urogynecological examinations and used questionnaires for the postoperative assessment of the patients. Scoring 0 points on question 3 of the Pelvic Floor Distress Inventory-20 was considered to show subjective success. Objective success was defined as stage 0 or 1 on the Pelvic Organ Prolapse Quantification. RESULTS: The subjective and objective success rates in the third year after surgery were 89.7% (209/233) and 90.6% (211/233), respectively, and those in the first year were 90.6% (211/233) and 91.0% (212/233), respectively. Perioperative complications included bladder injury (0.4%) in one case and vaginal wall injury (0.4%) in one case. Postoperative complications included the incidence of chronic pain (mesh retraction) in one case, which was the only case requiring re-operation due to complications (0.4%); vaginal suture exposure (0.4%) in one case; port-site hernia (0.4%) in one case; and subileus (0.4%) in one case. The complications associated with voiding function included de novo stress urinary incontinence (20.6%) in 48 cases, out of which there were 12 cases of de novo overactive bladder (5.2%) and eight cases required midurethral sling procedures. CONCLUSIONS: Laparoscopic sacrocolpopexy provides a good outcome with a low rate of subjective and objective recurrence and surgical complications.

Transvaginal surgery using self-cut mesh for pelvic organ prolapse: 3-year clinical outcomes.

OBJECTIVES: To evaluate subjective and objective outcomes, complication, recurrence, and reoperation rates after transvaginal mesh surgery for the management of pelvic organ prolapse. METHODS: This was a retrospective analysis of transvaginal mesh surgery carried out using self-cut mesh measuring subjective outcomes using validated questionnaires, and objective outcomes using Pelvic Organ Prolapse Quantification. Patients diagnosed with stage ≥2 pelvic organ prolapse were counseled about all possible surgical options. After thorough explanation about the benefits and risks during transvaginal mesh surgery, patients who gave signed consent were scheduled for surgery and evaluated at 1 and 3 years postoperatively. RESULTS: We included 101 patients who completed a minimum of 3-year follow up. One year and 3-year follow up showed significant improvement both on subjective and objective outcomes. Recurrences were observed in three patients (3%), with one (1%) patient undergoing reoperation. One case (1%) of intraoperative complication (bladder injury) and four cases (4%) of postoperative complications (two mesh exposure, one hematoma and one significant increase in post-voiding residual) were recorded. Overall patients' satisfaction was positive. CONCLUSIONS: Transvaginal mesh surgery using self-cut mesh is associated with significant improvement in both subjective and objective outcomes, offering low recurrence and complication rates, and high patient satisfaction rates. It can be a safe, effective and cost-efficient option not only for recurrence cases, but also as primary management of pelvic organ prolapse using a standardized technique and proper patient selection.

Sulfoquinovosylacylpropanediol is a novel potent radiosensitizer in prostate cancer.

OBJECTIVES: To examine the effects of combined treatment with sulfoquinovosylacylpropanediol and X-ray irradiation on the remodeling of the prostate cancer microenvironment, including angiogenic and hypoxic characteristics. METHODS: Human prostate cancer cells (DU145 and PC3) were implanted subcutaneously into the right hind legs of athymic nude mice. After the tumor volume reached 100-300mm(3) , 2mg/kg/day sulfoquinovosylacylpropanediol was given intravenously from day0 to day4, and cells were exposed to 4Gy X-ray irradiation on days0 and 3 (for a total of 8Gy). Tumors were fixed and stained for pathological analyses and immunohistochemical evaluations. To analyze vascular normalization, 60mg/kg pimonidazole dissolved in saline was injected intraperitoneally. RESULTS: Combined treatment with sulfoquinovosylacylpropanediol plus X-ray irradiation enhanced growth inhibition in DU145 xenografts. The tumor vessel density in DU145 cells significantly decreased after the combined treatment. Staining for αsmooth muscle actin in vessels was significantly increased. Pimonidazole staining, showing hypoxic lesions, was negative from 72h, but positive at 6 and 24h after the first combined treatment. In contrast, no enhancement of the microenvironment in PC3 xenografts was observed with sulfoquinovosylacylpropanediol plus X-ray irradiation. CONCLUSION: Sulfoquinovosylacylpropanediol could be a novel potent radiosensitizing agent targeting angiogenesis in prostate cancer.

Formation of paired Ga sites in CHA-type zeolite frameworks via a transcription-induced method.

Paired Ga sites represented by the Ga-O-Si-O-Ga sequence were firstly formed intentionally in CHA-type zeolite frameworks via the transcription of pre-formed paired Ga species in a Ga-rich amorphous silica-gallia under seed-assisted hydrothermal conditions. Such paired Ga sites behaved as ion-exchange sites for capturing divalent cation, Co2+.

Predictive urodynamic factors for de novo stress urinary incontinence after laparoscopic sacrocolpopexy for pelvic organ prolapse.

OBJECTIVES: Laparoscopic sacrocolpopexy is often performed to treat pelvic organ prolapse. Preoperative stress urinary incontinence (SUI) can improve after laparoscopic sacrocolpopexy. In contrast, some patients without incontinence preoperatively develop SUI after pelvic organ prolapse repair (ie, de novo SUI). This study aimed to identify the preoperative predictive factors of de novo SUI after laparoscopic sacrocolpopexy. METHODS: A total of 858 patients underwent laparoscopic sacrocolpopexy between January 2013 and November 2017 at Kameda Medical Center. Urodynamic studies were performed pre- and postoperatively on 75 patients. This retrospective study included 43 of 75 patients who did not have SUI preoperatively. We assessed urethral function according to functional profile length and maximum urethral closure pressure. We evaluated voiding function in terms of maximum flow rate, detrusor pressure at maximum flow rate, and postvoid residual volume. Furthermore, each factor was compared between de novo SUI-positive and SUI-negative groups. RESULTS: After laparoscopic sacrocolpopexy, 30 (69.8%) patients presented with SUI. The preoperative maximum urethral closure pressure was significantly lower in the de novo SUI-positive group (36.0 cmH2 O) than in the de novo SUI-negative group (50.5 cmH2 O, P = .020). More patients with maximum urethral closure pressure <40 cmH2 O had de novo SUI than patients with maximum urethral closure pressure ≥40 cmH2 O (P = .004). There were no significant differences between preoperative maximum urethral closure pressure and postoperative maximum urethral closure pressure in either group. CONCLUSIONS: Low preoperative maximum urethral closure pressure, particularly maximum urethral closure pressure <40 cmH2 O, is a predictor of de novo SUI after laparoscopic sacrocolpopexy.

Laparoscopic repair of vesicovaginal fistula caused by radiation therapy: Use of a perirectal fat interposition graft.

INTRODUCTION: We present a case of laparoscopic repair of vesicovaginal fistula caused by radiation therapy using a perirectal fatty tissue interposition graft. CASE PRESENTATION: A 72-year-old woman was diagnosed with vesicovaginal fistula induced by radiation therapy. Repair of the vesicovaginal fistula was achieved via laparoscopic approach. The fistula was exposed, followed by excision of fistula tract, fine dissection to achieve a traction-free approximation of bladder mucosa, then water-tight closure. An interposition graft derived from the perirectal fat was inserted to reduce the risk of repair failure. The patient did not have the incontinence problem at 1-year follow-up. CONCLUSION: The laparoscopic approach for vesicovaginal fistula repair is minimally invasiveness. Preparation of the interposition graft derived from the perirectal fatty tissue was easy and its mobility to achieve closure of the fistula was acceptable. Thus, this procedure is feasible for the repair of poorly vascularized tissues such as radiation-induced fistulas.

[Case report of rhabdoid tumor of the kidney occurring in own kidney following kidney transplantation from the living relative].

The patient was a 30-year-old man who had undergone living-donor kidney transplantation for renal failure caused by IgA nephropathy at age 29. On post-transplantation day 83, he visited our department with a chief complaint of asymptomatic hematuria. CT performed on post-transplantation day 95 revealed a tumor (size, 4 cm) in the right native kidney that had not been observed at the time of transplantation. CT performed on post-transplantation day 153 showed that the tumor had enlarged to 6 cm, while retrograde pyelogram performed on post-transplantation day 171 was negative for renal pelvic tumor. On post-transplantation day 193, radical right nephrectomy was performed. The tumor had directly invaded the diaphragm and the lower surface of the liver, and was histopathologically diagnosed as rhabdoid tumor of the kidney. As the pathological tissue was extremely malignant, hepatic posterior segmentectomy, right adrenalectomy, and lymph node dissection were further performed for metastases on post-transplantation day 200. On the 23rd day after radical right nephrectomy (post-transplantation day 216), the patient developed dyspnea. Chest CT showed pleural effusion, hemothorax in right lung and metastases in both lungs. The patient's general status gradually worsened thereafter, and he died on the 53rd day after radical right nephrectomy (post-transplantation day 246). Rhabdoid tumor of the kidney is a rare renal tumor that affects children, and only four adult cases have been reported to date. We report our experience with this rare case.

Laparoscopic lateral suspension for pelvic organ prolapse in a case with difficulty in performing laparoscopic sacrocolpopexy.

INTRODUCTION: Mesh fixation at the promontory is the most important procedure in laparoscopic sacrocolpopexy. We present a case of pelvic organ prolapse wherein sacrocolpopexy was converted to lateral suspension intraoperatively due to tissue weakness of the promontory. CASE PRESENTATION: A 66-year-old woman with a sensation of bulge in the vagina presented to our clinic. She was diagnosed with uterine prolapse (grade III). Laparoscopic sacrocolpopexy was planned; exposure of the promontory and mesh fixation at the vesicovaginal and rectovaginal space could be smoothly performed. However, handling the needle at the promontory was impossible due to tissue weakness of the anterior longitudinal ligament of the sacrum. Consequently, mesh fixation was converted to lateral suspension. CONCLUSION: Difficult mesh fixation at the promontory is not rare in laparoscopic sacrocolpopexy. Lateral suspension may be useful as a trouble-shooting procedure for laparoscopic sacrocolpopexy, and surgeons performing laparoscopic sacrocolpopexy should know this procedure.

Influence of dialysis duration on the outcome of living kidney transplantation.

Previous studies have reported negative impacts of long-term dialysis on kidney transplantation (KTx) outcomes. However, advances in surgical techniques, immunosuppressive therapies, and post-transplant monitoring have led to an impressive increase in patient and allograft survival. Thus, the number of KTx among patients on long-term dialysis is increasing. We evaluated the influence of dialysis duration on the outcome of living donor KTx. Between January 2000 and October 2011, we performed 1098 first KTx from living donors in adults (>18 years). We divided the patients into six groups, A group: pre-emptive kidney transplantation, B group: <24 months duration of dialysis, C group: 25-60 months duration, D group: 61-120 months duration, E group: 121-240 months duration, and F group: ≥ 241 months duration. The 5-year patient survival rates were 95.7, 98.8, 99.0, 99.0, 97.3, and 100% in groups A-F, respectively. The 5-year graft survival rates were 91.3, 95.6, 94.2, 96.3, 90.7, and 100% in groups A-F, respectively. No significant differences were observed in patient or graft survival among the six groups. Longer dialysis duration was correlated with lower rates of preoperative hypertension and diabetes mellitus. Survivors of long-term dialysis tended to be in good compliance with self-management. If recipients of living KTx have few complications, good prognoses are expectable even if dialysis periods are very long.

Retroperitoneoscopic donor nephrectomy with multiple renal arteries does not affect graft survival and ureteral complications.

BACKGROUND: Outcomes of retroperitoneoscopic procurement of living kidneys with multiple renal arteries (MRA) in the recipients are largely unknown. Our aim is to access the effect of kidney allografts with MRA on donor and recipient outcomes after pure retroperitoneoscopic live donor nephrectomy (RPLDN). METHODS: From July 2001 to August 2010, 533 patients underwent live donor kidney transplants with allografts procured by RPLDN at our center. Of these 533 transplants, 406, 105, and 22 patients had one, two, and three renal arteries, respectively. We compared the retrospectively collected clinical data of each donor with MRA and the recipient using those with single renal artery as controls. RESULTS: Significant differences were found among the one-renal artery and three-renal artery groups regarding operative time, estimated blood loss, warm and cold ischemic time, and incidence of slow graft function (SGF). However, there was no significant difference regarding patient and graft survival among the three groups. Major complications, such as open conversion, bleeding, and blood transfusion, were not found in patients with MRA. Five ureteral complications occurred. Of these, there was one patient with MRA. In univariate analysis, MRA patients had a risk factor of developing SGF (P=0.005) but not ureteral complications following RPLDN. CONCLUSION: Kidneys with MRA after RPLDN increase the risk of SGF in recipients. However, they provide similar outcomes as to long-term graft survival and complications compared with those of single renal artery. Renal artery multiplicity should not be a contraindication for live kidney donation and may not increase the risk of ureteral complications.

Impact of right-sided nephrectomy on long-term outcomes in retroperitoneoscopic live donor nephrectomy at single center.

Objective. To assess the long-term graft survival of right-sided retroperitoneoscopic live donor nephrectomy (RPLDN), we compared the outcomes of right- and left-sided RPLDN. Methods. Five hundred and thirty-three patients underwent live donor renal transplantation with allografts procured by RPLDN from July 2001 to August 2010 at our institute. Of these, 24 (4.5%) cases were selected for right-sided RPLDN (R-RPLDN) according to our criteria for donor kidney selection. Study variables included peri- and postoperative clinical data. Results. No significant differences were found in the recipients' postoperative graft function and incidence of slow graft function. Despite significant increased warm ischemic time (WIT: mean 5.9 min versus 4.7 min, P < 0.001) in R-RPLDN compared to that in L-RPLDN, there was no significant difference between the two groups regarding long-term patient and graft survival. The complication rate in R-RPLDN was not significantly different compared to that in L-RPLDN (17% versus 6.5%, P = 0.132). No renal vein thrombosis was experienced in either groups. Conclusions. Although our study was retrospective and there was only a small number of R-RPLDN patients, R-RPLDN could be an option for laparoscopic live donor nephrectomy because of similar results, with the sole exception of WIT, in L-RPLDN, and its excellent long-term graft outcomes.

Successful Kidney Transplantation for End-Stage Renal Disease in Marfan's Syndrome.

Marfan's syndrome is a systemic disorder of the connective tissue caused by mutations in the extracellular matrix protein fibrillin-1, with aortic dissection and aneurysm being its most life-threatening manifestations. Kidney transplantation for end-stage renal disease (ESRD) in patients with Marfan's syndrome has not been reported in the literature, and the rate of the incidence of dissection or aneurysm in the iliac artery is unknown. Here, we present a patient with Marfan's syndrome with ESRD due to severe renal ischemia caused by massive bleeding from thoracoabdominal aortic dissection leading to transplant surgery of a living kidney procured from the patient's mother. After kidney transplantation, the renal function normalized without vascular complications, and stable graft function along with negative results for both microhematuria and proteinuria continued for two years. Also, vascular complication such as aneurysm or dissection of the iliac artery was not observed using ultrasonography during the follow-up period. ESRD patients with Marfan's syndrome might be suitable for kidney transplantation, but long-term and careful observations are needed.

Analysis of genetic and predisposing factors in Japanese patients with atypical hemolytic uremic syndrome.

Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. Approximately 10% of cases are classified as atypical due to the absence of Shiga toxin-producing bacteria as a trigger. Uncontrolled activation of the complement system plays a role in the pathogenesis of atypical HUS (aHUS). Although many genetic studies on aHUS have been published in recent years, only limited data has been gathered in Asian countries. We analyzed the genetic variants of 6 candidate genes and the gene deletion in complement factor H (CFH) and CFH-related genes, examined the prevalence of CFH autoantibodies and evaluated the genotype-phenotype relationship in 10 Japanese patients with aHUS. We identified 7 causative or potentially causative mutations in CFH (p.R1215Q), C3 (p.R425C, p.S562L, and p.I1157T), membrane cofactor protein (p.Y189D and p.A359V) and thrombomodulin (p.T500M) in 8 out of 10 patients. All 7 of the mutations were heterozygous and four of them were novel. Two patients carried CFH p.R1215Q and 3 other patients carried C3 p.I1157T. One patient had 2 causative mutations in different genes. One patient was a compound heterozygote of the 2 MCP mutations. The patients carrying mutations in CFH or C3 had a high frequency of relapse and a worse prognosis. One patient had CFH autoantibodies. The present study identified the cause of aHUS in 9 out of 10 Japanese patients. Since the phenotype-genotype correlation of aHUS has clinical significance in predicting renal recovery and transplant outcome, a comprehensively accurate assessment of molecular variation would be necessary for the proper management of aHUS patients in Japan.

A rare benign genitourinary tumor in a Japanese male: urinary retention owing to aggressive angiomyxoma of the prostate.

Close examination of a 67-year-old Japanese man, who complained of persistent nocturia, revealed that a semitransparent polypoid tumor had developed from the bladder neck to the prostatic urethra obstructing the internal urethral meatus, which resulted in excessive urinary retention and post-renal dysfunction. The tumor was resected by a transurethral procedure and a pathological examination of specimens revealed aggressive angiomyxoma (AAM) of the prostate. AAM usually develops in the intrapelvic and perineal organs of females. So far as we know, this is the second case of primary prostatic AAM reported in the English literature, and is the first case where the patient encountered urethral obstruction.