3D printed kidney model could be an important educational tool for residents.

INTRODUCTION: This study aimed to evaluate whether it is useful for junior physicians to use a three-dimensional (3D) kidney model when evaluating the R.E.N.A.L. nephrometry score. MATERIALS AND METHODS: An expert and four urology residents retrospectively evaluated the R.E.N.A.L. nephrometry scores of 64 renal tumors (62 patients) that underwent robot-assisted partial nephrectomy at our hospital. The expert evaluated 64 R.E.N.A.L. nephrometry scores with computed tomography (CT), whereas four residents evaluated 32 cases using CT alone and the other 32 cases using CT and a 3D kidney model. The consistency between the expert and residents was assessed by Cohen's kappa score. Patient-specific 3D kidney models were created in a gird style using a 3D printer based on CT or magnetic resonance imaging of the patient. RESULTS: For all four residents, the accuracy of the overall R.E.N.A.L. nephrometry score was significantly higher with the 3D model and CT than with CT alone (P < .001). Regarding the individual components of the R.E.N.A.L. nephrometry score, the accuracy rates of "E," "N," "A," and "L" scores were higher with the 3D model and CT than with the CT alone (P = .020-.089). CONCLUSION: Patient-specific 3D-printed kidney models could improve the resident's understanding of the renal tumor complexity and could be an important educational tool for residents.

Mechanism of hypertensive crisis during energy device ablation of the adrenal gland: An experimental animal study.

OBJECTIVE: To elucidate the mechanism of hypertensive crisis during energy device ablation of the adrenal gland. METHODS: Electrocoagulation on the adrenal glands of six pigs was carried out with the same energy device (VIO300D) using four methods: (i) monopolar coagulation; (ii) monopolar soft coagulation using IO-advanced ball-type electrodes; (iii) bipolar soft coagulation by pinching; and (iv) bipolar soft coagulation by non-pinching (surface contact) using Bipolar forceps Premium. After electrocoagulation for 5 s, blood pressure and pulse changes were monitored, and adrenal hormones were measured from a central vein. The adrenal glands were removed, and the degree of tissue damage was scored histologically. RESULTS: Hypertensive crisis occurred with electrocoagulation of the adrenal gland by the monopolar coagulation, monopolar soft coagulation and bipolar soft coagulation pinching methods. Blood pressure did not change with the bipolar soft coagulation non-pinching method. Pathologically, tissue damage to the adrenal medulla was associated with elevated blood pressure and adrenaline and noradrenaline release. CONCLUSIONS: Hypertensive crisis caused by energy device ablation to the adrenal gland is caused by the release of catecholamines due to heat damage to the adrenal medulla rather than the type of energy device. Proper use of an energy device that does not cause thermal degeneration of the medulla is required to prevent hypertensive crisis.

The efficacy of axitinib as a first-line treatment for metastatic renal cell carcinoma.

AIM: To evaluate predictive factors which associated with oncological outcomes to first-line axitinib for metastatic renal cell carcinoma (mRCC). METHODS: A retrospective chart review was conducted patients who had been treated with axitinib as first-line therapy for the treatment of mRCC from September 2013 to February 2018. Axitinib was given by single daily oral administration at a dose of 10 mg, which was reduced according to adverse events (AEs). We investigated progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and AEs. RESULTS: Thirty-eight mRCC patients were enrolled. The median follow-up duration of axitinib treatment was 11.3 months (range = 1.0-56.9). ORR was 28.9%. Median PFS and OS was 12.8, and 17.9 months, respectively. In univariate analysis, baseline lactate dehydrogenase (LDH), neutrophil, corrected calcium (Ca), platelets (Plt) and time from diagnosis were selected as potential predictive factors. Multivariate Cox's proportional hazards model analysis showed that the number of risk factors were associated with PFS (P = 0.03) and OS (P = 0.02). CONCLUSION: Baseline LDH, neutrophil, Ca, Plt and time from diagnosis are predictive factors for both PFS and OS in first-line treatment with axitinib for metastatic renal cell carcinoma.

Utilization of a three-dimensional printed kidney model for favorable TRIFECTA achievement in early experience of robot-assisted partial nephrectomy.

BACKGROUND: This retrospective study aimed to investigate whether a three-dimensional (3D) model would improve the achievement of TRIFECTA, which was defined as the absence of perioperative complications and positive surgical margins and a warm ischemia time of <25 minutes, during robot-assisted partial nephrectomy (RAPN). METHODS: Prior to RAPN, a 3D-square type kidney model was prepared and used for all RAPN procedures in patients with T1a renal cell carcinoma (RCC) treated at a single center between March 2016 and April 2019. All RAPN procedures were performed by a single surgeon. RESULTS: The study included 50 patients, of whom 22, 24, and 4 had low-, intermediate-, and high-risk R.E.N.A.L Nephrometry scores, respectively. The TRIFECTA achievement rate was 86.0%, and transfusion or conversion to radical nephrectomy was not required in any of the patients. Only one Clavien-Dindo grade 3 complication was reported-a pseudoaneurysm that required embolism. The TRIFECTA achievement rate was independent of the R.E.N.A.L Nephrometry scores and the surgeon's experience level (25 cases each of early and advanced experience). CONCLUSIONS: The 3D model contributed to the achievement of TRIFECTA during RAPN performed by a less-experienced surgeon. These findings should be further evaluated in studies involving a larger number of cases and surgeons.

Postoperative Hemorrhagic Shock 7 Days After Robot-Assisted Radical Prostatectomy.

Background: Delayed postoperative bleeding after robot-assisted radical prostatectomy (RARP) is a rare life-threatening condition. We present such a case wherein a patient developed hemorrhagic shock from a ruptured pseudoaneurysm arising from the epigastric artery and discuss its management. Case Presentation: A 71-year-old man with prostate cancer underwent RARP. The urethral catheter was removed on postoperative day 7; 80 minutes later, the patient suddenly lost consciousness and went into shock. Enhanced CT revealed intra-abdominal bleeding; however, the cause was unknown. Intraoperatively, bleeding was observed from the anterior abdominal wall, which likely corresponded to the epigastric artery. However, this was controlled with monopolar electrocautery. Because of unstable hemodynamics, hemostasis was immediately performed by laparotomy, and bleeding was noted from the previously coagulated right inferior epigastric artery. Therefore, the cause was considered to be the rupture of a pseudoaneurysm. Conclusion : Our experience suggests that monopolar electrocautery may be inadequate for controlling bleeding that may be encountered during RARP, possibly leading to pseudoaneurysm formation, which may cause a delayed life-threatening hemorrhage. Meticulous and precise hemostasis is key to avoiding this complication.

Sunitinib versus sorafenib for patients with advanced renal cell carcinoma with renal impairment before the immune-oncology therapy era.

OBJECTIVES: The efficacy and safety of sunitinib versus sorafenib in patients with advanced renal cell carcinoma with renal impairment remains poorly documented. PATIENTS AND METHODS: We assessed the efficacy and safety of sunitinib and sorafenib in patients with advanced renal cell carcinoma with an estimated glomerular filtration rate of 15-60 mL/min/1.73 m2 by reviewing the medical records of patients treated at Jichi Medical University Hospital, Japan, between May 2008 and August 2016. RESULTS: Twenty-seven patients were treated with sunitinib and 14 with sorafenib. Median progression-free survival in sunitinib- and sorafenib-treated patients was comparable, at 6.6 vs 5.8 months, respectively (HR, 1.618; 95% CI, 0.689-3.798; P = 0.2691). Median overall survival was also comparable, at 65.9 vs 58.0 months (HR, 0.985; 95% CI, 0.389-2.479; P = 0.9748). Grade 3 or higher adverse events were significantly more frequent in the sunitinib-treated than sorafenib-treated patients (P = 0.0357). Compared to pre-treatment values, estimated glomerular filtration rate at the discontinuation of treatment was not decreased in either group. In contrast, estimated glomerular filtration rate was decreased on long-term treatment, particularly in previously nephrectomized patients. CONCLUSIONS: Sunitinib and sorafenib had similar efficacy in patients with advanced renal cell carcinoma and severe renal impairment. Although renal function was not markedly impaired in either group, close attention to decreased renal function may be necessary in previously nephrectomized patients on long-term treatment.

Stimulation of cellular senescent processes, including secretory phenotypes and anti-oxidant responses, after androgen deprivation therapy in human prostate cancer.

Endocrine resistance is a major problem in prostate cancer. Recent studies suggest that cellular plasticity plays a key role in therapy resistance. Yet little is known about the cellular changes of human prostate cancer after androgen deprivation therapy (ADT). In this study, we investigated cellular senescence, senescence-associated secretory phenotypes (SASPs), and anti-oxidant responses. Hormone ablation upregulated senescence-associated (SA)-ß-Gal activity in prostate glands, as well as the expressions of p27KIP1 and p53, in a mouse castration model. In line with this, the expressions of p21CIP1 and p27KIP1 were significantly more upregulated in human non-pathological prostatic glands after ADT than in untreated specimens. In a study of SASP markers, the expressions of IL6 and IL8 were also more upregulated in human non-pathological prostatic glands after ADT than in untreated specimens. IL6, IL8, and MMP2 were expressed more strongly in human prostate cancer specimens resected after ADT than in untreated tumors. Of note, treatment with the anti-oxidant reagent NAC significantly suppressed SA-ß-Gal activity in androgen-sensitive human prostate cancer LNCaP cells. In immunohistochemical analyses on anti-oxidant response genes, NRF2 and NQO1 were more upregulated after hormone ablation in human prostate gland and carcinoma specimens after ADT than in untreated specimens or in murine prostate glands after castration. Taken together, these findings suggest that ADT induces cellular senescence processes accompanied by secretory phenotypes and anti-oxidant responses in prostate. These cellular changes may be attractive targets for preventing endocrine resistance in prostate cancer.

Tumor Thrombus of Renal Cell Carcinoma Extending Into the Inferior Vena Cava, Ovarian Vein, and Ureter Treated With Neoadjuvant Axitinib.

Ureter tumor thrombus (TT) of renal cell carcinoma (RCC) is quite rare, although RCC-TT in the inferior vena cava (IVC) is not uncommon. We report the first case of RCC-TT extending into the IVC and ovarian vein as well as the ureter. Neoadjuvant axitinib shrank both the primary tumor and TT, making radical nephrectomy less invasive, particularly by downleveling the IVC-TT. Pathological examination of the primary tumor, IVC-TT, and ureter TT showed clear cell carcinoma with extensive necrosis. Although the role of neoadjuvant axitinib in RCC remains unclear, the present case suggests that neoadjuvant axitinib is clinically beneficial for RCC-TT.

Panoramic laparoscopic view of transverse testicular ectopia.

Transverse testicular ectopia (TTE) is a rare congenital anomaly in which both testes migrate toward the same hemiscrotum. We present a case of TTE in a 33-year-old man. Laparoscopy showed the left spermatic vessels, accompanied by parietal peritoneum, which formed a septum that divided the pelvic space into two, were extending transversely from the left lateral side of the descending colon toward the right internal inguinal ring over the sigmoid colon. A panoramic laparoscopic view of the spermatic vessels in TTE can clearly demonstrate the descending pathway and partly contribute to our understanding of the etiologic mechanisms of TTE.