Usefulness of hand-assisted retroperitoneal laparoscopic radical nephrectomy for extreme obese patients -a case report.

We report a case of retroperitoneal laparoscopic radical nephrectomy (LRN) in which the addition of a hand port was necessary and effective. A 52-year-old man with obesity (BMI 40.6 kg/m2) was diagnosed with a 52-mm left renal cell carcinoma (cT1bN0M0). To avoid thick subcutaneous and visceral fat in the abdomen, we selected LRN using a retroperitoneal approach with four ports in the kidney position. During surgery, a large amount of flank pad and perirenal fat prevented us from securing a sufficient surgical field through traction of the kidney with a retractor. A pure laparoscopic procedure was not feasible;therefore, we added a hand port. Subsequently, we removed the flank pad from the hand port and secured the surgical field by tracing the kidney manually. Finally, hand-assisted LRN was completed without an open conversion. In retroperitoneal LRN, we rarely encounter patients for whom a pure laparoscopic procedure is not feasible because of the large amount of flank pad or perirenal fat. It is important to preoperatively confirm not only the BMI but also the amount of flank pad and perirenal fat on imaging. Hand-assisted LRN via the retroperitoneal approach can be safely performed even in extremely obese patients. J. Med. Invest. 71 : 187-190, February, 2024.

Preoperative rapid growth of inferior vena cava tumor thrombus in renal cell carcinoma.

Introduction: We present the case of a rapidly growing inferior vena cava tumor thrombus in renal cell carcinoma. Case presentation: We present a case of a 66-year-old woman with right renal cell carcinoma with a tumor thrombus extending 2 cm into the inferior vena cava on an initial Imaging. Radical surgery was performed 6 weeks after the first visit. Intraoperatively, the tumor thrombus was confirmed to have grown near the diaphragm. The tumor was resected using an inferior vena cava clamping just below the diaphragm. The tumor thrombus and renal cell carcinoma were completely removed. There was no recurrence 6 months postoperatively. Conclusion: Inferior vena cava tumor thrombus in renal cell carcinoma can grow in a short period, suggesting that preoperative imaging evaluation at the appropriate time is important. Once inferior vena cava tumor thrombus of renal cell carcinoma occurs, surgery should not be delayed unless there is an urgent reason.

Obstructive azoospermia caused by epididymis injury with testicle rupture on the other side.

Background: Epididymal injuries without ipsilateral injuries of the testicles are rare. We report a case of a solitary right epididymal injury complicated by left testicular rupture. Case Presentation: A 21-year-old man experienced scrotal trauma caused by a motorcycle accident. Bilateral swelling and tenderness of the scrotum were observed. Ultrasonography and computed tomography revealed a ruptured left testicle; therefore, surgery was performed. During surgery, the left testicle was excised because it was completely ruptured, and the right testicle and epididymis were evaluated to identify the cause of swelling of the right scrotum. The right testis was not injured; however, the right epididymis was lacerated. Subsequently, the lacerated right epididymis was repaired using sutures. A semen analysis performed at 1, 4, and 7 months after surgery revealed the absence of sperm in the semen. Conclusion: Epididymal injuries should be considered as differential diagnoses for scrotal trauma.

A case of marked rectal stenosis due to Douglas' pouch metastasis of renal pelvic carcinoma successfully treated with salvage enfortumab vedotin: correlation between serum KL-6 levels and tumor response.

Introduction: We report a rare case of marked rectal stenosis due to Douglas' pouch metastasis of renal pelvic urothelial carcinoma successfully treated with enfortumab vedotin. Case presentation: A 77-year-old female presented with difficulty in defecation and abdominal distension. She had received two courses of cisplatin plus gemcitabine followed by four courses of maintenance avelumab for postoperative lymph node metastasis of renal pelvic urothelial carcinoma. KL-6 levels were elevated, and a computed tomography scan revealed an irregularly shaped large mass occupying Douglas' pouch, with marked rectal stenosis. Metastatic urothelial carcinoma was pathologically diagnosed, and enfortumab vedotin was initiated after colostomy. After 12 courses of enfortumab vedotin, metastatic lesions showed marked shrinkage and KL-6 levels decreased. Conclusion: Enfortumab vedotin elicited a remarkable response in treating rectal stenosis due to metastasis of renal pelvic urothelial carcinoma in Douglas' pouch. Furthermore, serum KL-6 levels were correlated with the severity of metastatic urothelial carcinoma.

Differential diagnosis and prognosis of small renal masses: association with collateral vessels detected using contrast-enhanced computed tomography.

BACKGROUND: Active surveillance (AS) is one of the treatment methods for patients with small renal masses (SRMs; < 4 cm), including renal cell carcinomas (RCCs). However, some small RCCs may exhibit aggressive neoplastic behaviors and metastasize. Little is known about imaging biomarkers capable of identifying potentially aggressive small RCCs. Contrast-enhanced computed tomography (CECT) often detects collateral vessels arising from neoplastic angiogenesis in RCCs. Therefore, this study aimed to evaluate the association between SRM differential diagnoses and prognoses, and the detection of collateral vessels using CECT. METHODS: A total of 130 consecutive patients with pathologically confirmed non-metastatic SRMs (fat-poor angiomyolipomas [fpAMLs; n = 7] and RCCs [n = 123]) were retrospectively enrolled. Between 2011 and 2019, SRM diagnoses in these patients were confirmed after biopsy or surgical resection. All RCCs were surgically resected. Regardless of diameter, a collateral vessel (CV) was defined as any blood vessel connecting the tumor from around the kidney using CECT. First, we analyzed the role of CV-detection in differentiating between fpAML and RCC. Then, we evaluated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of RCC diagnosis based on CV-detection using CECT. We also assessed the prognostic value of CV-detection using the Fisher exact test, and Kaplan-Meier method and the log-rank test. RESULTS: The sensitivity, specificity, PPV, NPV, and accuracy of CV-detection for the diagnosis of small RCCs was 48.5, 45.5, 100, 100, and 9.5% respectively. Five of 123 (4.1%) patients with RCC experienced recurrence. CV-detection using CECT was the only significant factor associated with recurrence (p = 0.0177). Recurrence-free survival (RFS) was significantly lower in patients with CV compared with in those without CV (5-year RFS 92.4% versus 100%, respectively; p = 0.005). In addition, critical review of the CT images revealed the CVs to be continuous with the venous vessels around the kidney. CONCLUSIONS: The detection of CVs using CECT is useful for differentiating between small fpAMLs and RCCs. CV-detection may also be applied as a predictive parameter for small RCCs prone to recurrence after surgical resection. Moreover, AS could be suitable for small RCCs without CVs.