Laparoscopic redo pyeloplasty with a buccal mucosal graft.

Introduction: Redo pyeloplasty can be difficult due to scar tissue or fibrosis. Ureteral reconstruction with a buccal mucosal graft is performed safely and successfully, but most reports of ureteral reconstruction using a buccal mucosal graft are of robot-assisted surgery, with few reports of laparoscopic-assisted surgery. A case of laparoscopic-assisted redo pyeloplasty using a buccal mucosal graft is presented. Case presentation: A 53-year-old woman was diagnosed with ureteropelvic junction obstruction, and a double-J stent was placed to relieve backache. She visited our hospital 6 months after double-J stent placement. Three months later, laparoscopic pyeloplasty was performed. At 2 months postoperatively, anatomic stenosis occurred. Holmium laser endoureterotomy and balloon dilation were performed; however, the anatomic stenosis recurred, and laparoscopic redo pyeloplasty with a buccal mucosal graft was performed. After redo pyeloplasty, obstruction was improved, and her symptoms disappeared. Conclusion: This is the first case of using a buccal mucosal graft for laparoscopic pyeloplasty in Japan.

[Adult Prepubertal-Type Teratoma Diagnosed Using Fish Analysis : A Case Report].

A 34-year-old man visited our hospital complaining of a small painless left scrotal mass. His serum alpha-fetoprotein and human chorionic gonadotropin-beta levels were normal. Ultrasonography revealed a solitary 14 mm mass. Magnetic resonance imaging revealed a mass with high intensity on T2-weighted imaging. Computed tomography revealed a heterogeneous tumor in the left scrotum. Left high orchiectomy was performed. The histopathological diagnosis was a teratoma without germ cell neoplasia in situ (GCNIS). Fluorescence in situ hybridization analysis showed no appearance of i(12p). The patient was clinically diagnosed as having a prepubertal-type testicular teratoma. Adult teratomas contain GCNIS and are aggressively treated as malignant germ cell tumors. However, a prepubertal-type teratoma is benign and does not relapse. It is essential to validate the appearance of i(12p) to differentiate prepubertal and postpubertal-type teratoma.

High Serum Alkaline Phosphatase Flare after First-Line Androgen Deprivation Therapy Predicts Poor Prognosis in Metastatic Prostate Cancer Patients Treated with Second-Generation Androgen Receptor Targeted Therapy.

OBJECTIVES: To determine whether an alkaline phosphatase (ALP) flare after androgen deprivation therapy (ADT) is associated with the treatment response in castration-resistant prostate cancer (CRPC) and predicts the prognosis of metastatic prostate cancer (PCa) patients. METHODS: One hundred and nineteen patients diagnosed with metastatic PCa between 2008 and 2017 were retrospectively studied. The ALP flare ratio was calculated as the ratio of ALP levels 1 month after beginning ADT to ALP levels at diagnosis. The association of the ALP flare ratio with the prostate-specific antigen (PSA) response to CRPC treatment (second-generation androgen receptor targeted therapy (ART) or docetaxel), time to CRPC, and overall survival (OS) were investigated. RESULTS: The time to CRPC and OS was significantly longer in patients with an ALP flare ratio less than 1.33 compared to a ratio more than 1.33. No difference in PSA response was seen regarding the ALP flare ratio in both ART and docetaxel treatment. Second-generation ART-treated patients with a low ALP flare ratio showed longer OS than those with a higher ALP flare ratio (p=0.0367). However, no difference was seen between a high and low ALP flare ratio (p=0.8054) in docetaxel-treated patients. The ALP flare ratio was the most significant prognostic factor for OS (p < 0.0001). CONCLUSIONS: A higher ALP flare ratio after first-line ADT was a significant prognostic factor in metastatic PCa, especially in patients treated with second-generation ART for CRPC. Chemotherapy for patients with a higher ALP flare ratio 1 month after induction of ADT may be a clinically relevant decision.

False-positive 123I-metaiodobenzylguanidine scan in a patient with renal cell carcinoma: A case of chromophobe renal cell carcinoma oncocytic variant with a complicated clinical course.

INTRODUCTION: 123I-metaiodobenzylguanidine scanning has high sensitivity and specificity for the diagnosis of tumors derived from sympathetic nerves or the adrenal medulla. We report the rare case of a 123I-metaiodobenzylguanidine false-positive renal cell carcinoma. CASE PRESENTATION: The patient was referred to our hospital with an incidental left renal mass during evaluation for hypertension. An ovarian tumor and prominent ascites were also observed. Serum and urine catecholamine levels were high to suspect a catecholamine-producing tumor of the kidney. 123I-metaiodobenzylguanidine scintigraphy showed increased 123I-metaiodobenzylguanidine intake in the tumor. Laparoscopic radical left nephrectomy was performed. The pathologic diagnosis was an oncocytic variant of chromophobe renal cell carcinoma. No pheochromocytoma features were found. CONCLUSION: We report the first case of a 123I-metaiodobenzylguanidine false-positive renal cell carcinoma. This case was diagnosed with primary aldosteronism and Meigs' syndrome, which made the clinical course more complicated.

PSA response following the 'steroid switch' in patients with castration-resistant prostate cancer treated with abiraterone: A case report.

A 69-year-old man presented initially with back pain and incomplete bilateral lower limb paralysis. The level of prostate-specific antigen (PSA) in the patient was elevated to 167.0 ng/ml, and multiple bone metastases were detected. Thoracic laminectomy was performed in an emergency due to spinal decompression. Subsequently, the patient was diagnosed with prostate cancer from an examination of resected bone specimens. Combined androgen blockade with degarelix and bicalutamide was initiated in October 2013. Consequently, the serum PSA level decreased to <1.0 ng/ml, but thereafter gradually increased. Subsequent bicalutamide withdrawal response was not observed, and switch of anti-androgen therapy to flutamide also resulted in a poor response. Then, abiraterone (1,000 mg daily) in combination with prednisolone (10 mg daily) was initiated when the level of PSA increased to 35.9 ng/ml in June 2015. The level of PSA decreased to the lowest point of 4 ng/ml; however, PSA level increased again to 21.7 ng/ml in April 2016. Consequently, a 'steroid switch' was attempted. Abiraterone therapy was continued, but concomitant corticosteroid was switched from prednisone to dexamethasone (1.0 mg per day). Fortunately, serum PSA level decreased promptly to the lowest point of 0.6 ng/ml. In the present case report, a review of recent literature was presented and potential explanations of the mechanism underlying the 'steroid switch' were described. Pharmacokinetic differences between dexamethasone and prednisolone may partially explain why the 'steroid switch' occurs. Other mechanisms may include the activation of the glucocorticoid receptor, mineralocorticoid receptor and/or mutant androgen receptor. Corticosteroids accelerate a number of transcription factors, cellular growth factors and cytokines, which may also be potential mechanisms. The 'steroid switch' at PSA progression might be a feasible option for therapy, which may delay the development of the disease. Although the underlying mechanisms require further study, clinicians should pay attention to this phenomenon.

Usefulness of R.E.N.A.L Nephrometry Scoring System and Centrality Index Score for Predicting Outcome of Laparoscopic Partial Nephrectomy.

OBJECTIVES: The aim of this study was to investigate the clinical usefulness for prediction of outcome of laparoscopic partial nephrectomy (LPN) using the R.E.N.A.L nephrometry scoring system (RNS) and centrality index score (C-index). MATERIALS AND METHODS: We retrospectively reviewed 64 patients who underwent LPN from 2010 to 2014 in our institution. The RNS and C-index scores were assigned according to the described protocols for their systems. The relationships between the patients' scores before surgery and the outcomes of LPN, warm ischemia time (WIT), operative time (ORT), estimated blood loss (EBL), and percent change in estimated glomerular filtration rate (eGFR) were analyzed retrospectively. RESULTS: Mean tumor size was 3.1 cm, mean WIT was 27.6 minutes, mean ORT was 189.0 minutes, and mean EBL was 187 mL. Although the RNS had statistically significant correlations with WIT, ORT, and percent change in eGFR, these correlations were not score-dependent. For WIT, a statistically significant difference was observed between the low-risk group and the middle-risk group. For percent change in eGFR, a statistically significant difference was observed between the low-risk group and the high-risk group only. For the C-index, statistically significant correlations between complexity categories and WIT, ORT, EBL, and percent change in eGFR were observed. Regarding the raw C-index scores, linear correlations were observed between the scores and each outcome of LPN. CONCLUSIONS: The RNS and C-index are useful for predicting the complexity of LPN. The C-index may be more suitable than the RNS for predicting postoperative renal function.

Nocturia and sleep quality after transurethral resection of the prostate.

OBJECTIVES: To evaluate the clinical efficacy of transurethral resection of the prostate on nocturia and sleep disorders in patients with lower urinary tract symptoms suggestive of benign prostatic obstruction. METHODS: A prospective multicenter study including lower urinary tract symptoms suggestive of benign prostatic obstruction patients with nocturia (twice or more) undergoing transurethral resection of the prostate was carried out. All patients were assessed using the International Prostate Symptom Score and the Pittsburgh Sleep Quality Index at baseline, and 6 months after transurethral resection of the prostate. RESULTS: Overall, 49 patients were included in the study. A total of 20 of them (41%) had a sleep disorder defined as a score of 5.5 or more on the Pittsburgh Sleep Quality Index global score. The nocturia score significantly correlated with component 4 of the Pittsburgh Sleep Quality Index (habitual sleep efficiency). Nocturia significantly decreased after transurethral resection of the prostate from 3.0 ± 1.2 to 1.9 ± 0.8, whereas the global Pittsburgh Sleep Quality Index score did not. In 20 patients with a sleep disorder before transurethral resection of the prostate, subjective sleep quality (component 1) and habitual sleep efficiency (component 4) significantly decreased after transurethral resection of the prostate, but this was not the case for the global Pittsburgh Sleep Quality Index score. In 16 patients with a persistent sleep disorder after transurethral resection of the prostate, International Prostate Symptom Score, voiding and storage symptoms score were higher than those of patients without a sleep disorder, although the nocturia score improved equivalently in both groups. CONCLUSIONS: Transurethral resection of the prostate diminishes nocturnal urinary frequency and partly improves sleep quality in patients with nocturia and lower urinary tract symptoms suggestive of benign prostatic obstruction. A persistent sleep disorder after transurethral resection of the prostate is associated with persistent voiding and storage symptoms.

Effect of imidafenacin on nocturia and sleep disorder in patients with overactive bladder.

OBJECTIVE: To evaluate the efficacy of imidafenacin on nocturia and sleep disorder in patients with overactive bladder (OAB). PATIENTS AND METHODS: A prospective multicenter study of imidafenacin 0.1 mg twice daily for patients with OAB and nocturia was conducted. At baseline and at week 4 and 8, patients were assessed using the overactive bladder symptom score (OABSS), frequency volume charts (FVC) and the Pittsburgh Sleep Quality Index (PSQI). RESULTS: Treatment with imidafenacin significantly improved OAB symptoms. Imidafenacin also improved PSQI, especially subjective sleep quality, sleep latency and daytime dysfunction. In FVC, the number of daytime voids and nighttime voids significantly decreased and average voided volume significantly increased after imidafenacin. Subanalysis of FVC based on the patients' age revealed that nocturnal polyuria was more often found in patients aged 75 years or over than in those aged under 75 years (79 vs. 55%, p < 0.05). Treatment with imidafenacin significantly reduced the nocturnal polyuria index only in patients aged 75 years or over. CONCLUSIONS: Imidafenacin can improve nocturia and sleep disorder in patients with OAB. The efficacy of imidafenacin on nocturia is attributable to an increase in bladder capacity and a decrease in nocturnal urine volume. We conclude that imidafenacin is an effective and safe drug for nocturia in patients with OAB.

[Optimum initial dose of silodosin for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia].

We investigated the optimum initial dose and timing of administration of α1A-adrenoceptor antagonist silodosin for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH/LUTS). Ninety-eight patients were given a 4 mg dose after breakfast (group A), 4 mg after supper (group B), or 4 mg after breakfast and after supper (group C). At baseline, 4, 8 and 12 weeks after treatment, we assessed International Prostate Symptom Score (IPSS) and quality of life (QOL) index. Twenty-five percent or less improvement of total IPSS and no improvement of QOL index compared with baseline were defined as treatment failure at each evaluation point. Otherwise treatment was considered effective. In group A and group B, patients with treatment failure at 4 or 8 weeks after treatment, the dose of silodosin was increased to 8 mg daily. At the end of the study, 83 patients were evaluable. At 12 weeks after treatment, 20 of the 31 patients in group A and 22 of the 29 patients in group B remained on the 4 mg dose ; silodosin was effective in 65 and 76% of the patients, respectively. When patients with dose escalation were included, silodosin was effective in 81 and 90% of the patients, respectively. Silodosin was effective in 18 of the 23(78%) patients in group C, although improvement of total IPSS and voiding symptom score of IPSS at 12 weeks after treatment was better in group C than in group A or group B, the difference was not significant. In patients with IPSS less than 20, the degree of improvement of IPSS was similar among the 3 groups. In contrast, in patients with IPSS of 20 or greater the degree of improvement was better in group C than in group B or group C, but the difference was not significant. Storage symptom score of IPSS was significantly improved in all 3 groups without any significant difference among the 3 groups. Three patients (52, 59 and 76 years old) experienced abnormal ejaculation. In conclusion, 4 mg of silodosin daily showed effectiveness against BPH/LUTS, but 8 mg of silodosin daily might be better for patients with severe LUTS.

Case report of renal pelvic adenocarcinoma associated with a renal stone that produced carbohydrate antigen 125 and carbohydrate antigen 19-9.

A 68-year-old man underwent left side simple nephrectomy for symptomatic severe hydronephrosis with decreased function due to a renal stone. Because of severe adhesion around the kidney, the renal pelvic wall was torn during the operation. Pathological diagnosis was papillary adenocarcinoma of the renal pelvis with positive staining for carbohydrate antigen 125 (CA125) and carbohydrate antigen 19 9 (CA19-9). Retrospective analysis of preoperative blood sample showed a high level of CA125 and CA19-9. Four-cycle adjuvant chemotherapy with paclitaxel/carboplatin (TJ regimen) was performed. However, local recurrence developed 1 month after the termination of chemotherapy. Although papillary adenocarcinoma of the renal pelvis is extremely rare, the possibility of renal pelvic tumor should be kept in mind for patients who have a long-standing renal stone and hydronephrosis with irregularity at the renal pelvic wall. CA125 and CA19-9 can be useful markers for upper urinary tract tumor.

[A case of a ureteral inflammatory pseudotumor].

The patient was a 28-year-old woman. In February 2002, she visited another physician due to acute pyelonephritis. Based on CT findings, a lower ureteral stricture caused by a benign extraureteral tumor was diagnosed. The patient was being monitored by periodic exchange of ureteral stents. In February 2003, the patient visited our department seeking a second opinion. Retrograde pyelography showed an elliptical filling defect in the lower urinary tract. Ureteroscopy showed that the surface of the tumor was mostly smooth, regular and partially papillary. Biopsy was performed, and histological analysis revealed only nonspecific inflammation. In December 2003, based on a diagnosis of benign ureteral tumor, we performed partial resection of the right urinary tract and ureterocystoneostomy. As rapid intraoperative pathological analysis confirmed an inflammatory pseudotumor, total nephroureterectomy was avoided.

[Postoperative hypoglycemia after resection of pheochromocytoma: a case report].

We report a case of severe hypoglycemia following resection of pheochromocytoma. A 39-year-old male was admitted to our hospital with a chief complaint of palpitation. Blood pressure and fasting blood glucose were within the normal range. Computed tomography and magnetic resonance imaging revealed a right adrenal tumor (7.5 x 5 x 7 cm) and 131I-MIBG scintigraphy showed marked tumor uptake of isotope. As plasma and urinary catecholamine levels were very high, a clinical diagnosis of pheochromocytoma was established. Doxazosin and propranolol were administered for 43 days prior to adrenalectomy. During intensive care monitoring 2 hours postoperatively, the patient became drowsy and began to sweat. Although blood pressure remained stable, severe hypoglycemia (38 mg/dl) and hyperinsulinism (63.67 microU/ml) were confirmed. Infusion of 50% glucose improved these symptoms and plasma glucose level and insulin secretion normalized within 15 days of surgery. We also reviewed 25 cases of hypoglycemia after resection of pheochromocytoma. We recommend close monitoring of blood glucose for at least 6 hours after adrenalectomy for pheochromocytoma.

Changes in urinary parameters after oral administration of potassium-sodium citrate and magnesium oxide to prevent urolithiasis.

OBJECTIVES: To examine urinary parameters among normal individuals and patients with calcium oxalate (CaOx) stones after oral administration of potassium-sodium citrate (KNa-Cit) and magnesium oxide (MgO). Urinary citrate and magnesium have been known as the inhibitors of CaOx stone formation. Supplementation with potassium-magnesium citrate prevents the recurrence of CaOx stones. METHODS: Twenty-five male volunteers aged 21 to 42 years without a history of urinary stones were given either KNa-Cit or MgO, or both. Fourteen patients with recurrent CaOx stones were also given both supplements, and 24-hour urine samples were collected to determine the urinary parameters. RESULTS: The administration of both KNa-Cit and MgO to the normal individuals increased the excretion of citrate, magnesium, and potassium by 70.0%, 44.2%, and 50.0%, respectively. These parameters increased less when KNa-Cit or MgO was administered individually. After administration of both supplements to the patients with stones, the citrate, magnesium, and potassium levels increased by 62.1%, 63.3%, and 25.3%, respectively, and oxalate decreased by 66.5%. In both normal individuals and patients, the ion activity product index of CaOx decreased significantly more after administration of the combination than with either compound alone or before administration. CONCLUSION: The combination of KNa-Cit and MgO is more effective than either supplement alone in inhibiting the crystallization of CaOx stones. The combination may improve the urinary parameters of patients with stones accompanied by hypocitraturia and/or hypomagnesuria.

[Ammonium acid urate stone due to laxative abuse: a case report].

We report a case of ammonium acid urate stone due to laxative abuse. A 27-year-old female complained of left flank pain. Computed tomography revealed bilateral ureter stones (right 16.5 x 9.0 mm; left 4 mm), while left ureter stone was radiolucent on the plain X ray film. Bilateral hydronephrosis was seen, but no therapy was performed for the right stone, because 99mTc-MAG3 scintigraphy revealed that right kidney had no function. The left stone was successfully removed by transurethral approach. The stone was revealed to be an ammonium acid urate by infrared spectrophotometry. She had been taking many laxatives (bisacodyl, sennoside, aloe extract) for 12 years to control her body weight. Ammonium acid urate stones are rarely seen in developed countries. We have reviewed 9 cases in Japan, describing ammonium acid urate stones due to laxative abuse. Among these patients, 24-hour urine volume and excretion in urinary sodium were decreased, and serum aldosterone was increased. The involvement of laxative abuse should be considered when ammonium acid urate is formed in a woman with a low body mass index.

[Extracorporeal shock wave lithotripsy for ureteral stone in patient with implanted cardiac pacemaker: a case report].

We report a case of extracorporeal shock wave lithotripsy (SWL) for ureteral stone in patient with implanted cardiac pacemaker. A 68-year-old woman was admitted to our hospital for left back pain due to left single ureteral stone (13 x 7 mm) in 2002. A permanent cardiac pacemaker has been implanted for sick sinus syndrome in 1997. After evaluation for cardiac function and pacemaker function by a cardiologist and a pacemaker technician, SWL (MFL 5000, Dornier) was performed without changing pacemaker mode (DDD mode). Shock waves were incorrectly exposed a few time triggered by arterial pacing amplitude, but no cardiovascular event or malfunction of the pacemaker was occurred during or after SWL. The ureteral stone was successfully fragmented with 2,400 shock waves (24 kV) and the fragments were delivered immediately.