Successful treatment with enfortumab-vedotin of metastatic signet ring cell cancer expressing nectin-4 and originating from the bladder.

Introduction: As an aggressive adenocarcinoma phenotype, primary signet ring cell carcinoma of the urinary bladder is an extremely rare variant. The prognosis of metastatic signet ring cell carcinoma of the urinary bladder is extremely poor and the clinical course for its specific pathogenesis remains unelucidated. Case presentation: A 64-year-old Japanese male patient was diagnosed with invasive urothelial carcinoma with glandular differentiation of a signet ring cell-type with pT4aN0M0, and he was eventually diagnosed with metastatic signet ring cell carcinoma of the urinary bladder. He was initially responsive to systemic combination induction chemotherapy of S-1 and cisplatin followed by avelumab switch maintenance therapy; however, signet ring cell carcinoma of the urinary bladder relapse occurred in the pathological findings of a biopsy from the right thigh. Immunohistochemical analysis of this specimen identified strong positive staining for nectin-4 and, following enfortumab-vedotin treatment, the patient showed a good response. Conclusion: We thus describe a rare case of metastatic signet ring cell carcinoma of the urinary bladder with nectin-4 expression diagnosed by a biopsy of a metastatic site.

Surgical management of prepubertal testicular tumors: A 30-year study in our institution.

OBJECTIVES: The 2021 European Association of Urology-European Society for Paediatric Urology guidelines on Pediatric Urology recommended testis-sparing surgery (TSS) as the primary approach to treat prepubertal testicular tumors exhibiting favorable preoperative ultrasound diagnoses. However, prepubertal testicular tumors are rare and clinical data regarding them is limited. Here, we analyzed the surgical management of prepubertal testicular tumors based on cases observed over approximately 30 years. METHODS: Data were retrospectively reviewed from medical records of consecutive patients aged <14 years with testicular tumors who received treatment at our institution between 1987 and 2020. We compared patients by their clinical characteristics, namely, those who underwent TSS versus radical orchiectomy (RO) and those who received surgery in 2005 onward versus prior to 2005. RESULTS: We identified 17 patients, with a median age at surgery of 3.2 years (range 0.6-14.0) and a median tumor size of 15 mm (range 6-67). The tumor size was significantly smaller in patients who underwent TSS than in those who underwent RO (p = 0.007). Patients treated in 2005 onward were more likely to undergo TSS than those treated prior to 2005 (71% vs. 10%, respectively), without significant differences in tumor size or the rate of preoperative ultrasound. No TSS cases required conversion to RO. CONCLUSIONS: Recent improvements in ultrasound imaging technology allow for more accurate clinical diagnosis. Therefore, the indications of TSS for prepubertal testicular tumors can be judged based not only on the tumor size but also on the diagnosis of benign tumors by preoperative ultrasound.

A Multicenter, Prospective, Non-randomized Study Evaluating Surgical hand Preparation between Double-Gloving and Single-Gloving for Preventing Postoperative Infection in Robotic and Laparoscopic Minimally Invasive Surgeries.

PURPOSE: This study aimed to analyze a feasible and suitable surgical precautionary preparatory technique. The techniques of double-gloving with hygienic hand wash (DH) and single-gloving with surgical hand wash (SS) were compared for their ability to prevent postoperative infection in robotic and laparoscopic minimally invasive surgeries. MATERIALS AND METHODS: A prospective, non-randomized, multicenter study was conducted between January 2016 and June 2020. We divided the robotic and laparoscopic cases into two groups: DH and SS. Data on infectious outcomes were collected. Propensity score matching was performed to control for operative characteristics between the two groups. The primary endpoint was the presence of fever and surgical site infections (SSIs) indicating postoperative infection. RESULTS: Among four medical centers, seven surgeons were allocated to either the DH or the SS group. A total of 221 and 251 patients underwent DH and SS, respectively. Propensity score matching, which included 171 cases from each group, showed that the incidence of fever during hospitalization was significantly lower in the DH group than that in the SS group (11.7% vs. 23.4%, p=0.007). Multivariable analysis revealed that DH was associated with a reduced odds ratio for developing postoperative fever during hospitalization (risk ratio: 0.49, p=0.043). No differences were found in SSI before and after hospitalization between the two groups. CONCLUSION: DH resulted in less postoperative fever and had a comparable effect in preventing SSIs. This procedure could be an alternative to the SS protocol in some minimally invasive surgeries.

Transvesicoscopic ureteral reimplantation and ureteroscopy for management of primary obstructed non-refluxing megaureter with ureteral calculus.

Introduction: Primary obstructed non-refluxing megaureter, a type of congenitally dilated ureter, often resolves spontaneously. Surgery may be indicated in symptomatic cases; however, there are no reports of transvesicoscopic ureteral implantation and ureteroscopy for ureteral stones. Therefore, we describe the treatment of primary obstructed non-refluxing megaureter and ureteral calculi using this technique. Case presentation: A 6-year-old Japanese girl was referred for abdominal pain and gross hematuria due to right megaureter with multiple stones in the renal lower-pole calyces and ureter. She was diagnosed with primary obstructed non-refluxing megaureter and ureterovesical junction obstruction. The stones were removed using mini-percutaneous nephrolithotomy and transvesicoureteroscopic surgery, respectively. A narrow segment of the right ureter was cut, and transvesicoscopic ureteral plication and reimplantation were performed. The procedures were successful without postoperative complications. Conclusion: Transvesicoscopic ureteral reimplantation with ureteroscopy may be a safe, effective and minimally invasive surgical option for ureterovesical junction obstruction with ureteral stones.

Pelviureteric junction obstruction of the ipsilateral kidney caused by hydronephrosis secondary to crossed fused renal ectopia.

Introduction: Crossed fused renal ectopia is rare and usually asymptomatic. However, it is associated with urological anomalies. Case presentation: A 15-year-old Japanese boy was transported to our hospital with right abdominal pain and hematuria after a soccer ball hit his right abdomen. Computed tomography revealed right hydronephrosis beyond the center of the body and no left kidney. Percutaneous nephrostomy was performed immediately, and a pyeloplasty was scheduled for 5 months later. Right hydronephrosis was noted to have been caused by left pelvic expansion due to a crossed fused ectopic kidney (secondary to a left pelviureteric junction obstruction). Subsequently, a left dismembered pyeloplasty was performed. Twenty-four months later, pain and hematuria were absent, and the creatinine level was 1.1 mg/dL. Ultrasonography revealed a shrunken right kidney. Conclusion: We encountered a unique urological anomaly with crossed fused renal ectopia. Comprehensive anatomical evaluation before surgery is important for maintaining long-term renal function.

Status epilepticus in a patient with intractable epilepsy caused by renal colic due to a ureter stone.

INTRODUCTION: Epilepsy has a variety of seizure-inducing factors. Epileptic seizures caused by renal colic are extremely rare. CASE PRESENTATION: A 22-year-old woman with intractable epilepsy was brought to our hospital as an emergency case, because of vomiting and status epilepticus. She had implanted a vagus nerve stimulator in the left anterior chest at the age of 20 years. Computed tomography showed a ureter stone in the right distal ureter. On the second day of hospitalization, ureteroscopic lithotripsy was performed under general anesthesia. The patient's seizures were controlled to a frequency of once a month or less in the four months after discharge. CONCLUSION: We encountered a rare case of the frequency of status epilepticus increased by renal colic due to a ureter stone. Ureteroscopic lithotripsy was effective in controlling the frequency of status epilepticus increased by renal colic.

A novel method of transvesicoscopic ureteral reimplantation of an ectopic ureter with a mate ureter in a duplex kidney.

INTRODUCTION: The reimplantation of an ectopic ureter is still performed as an open surgery, although laparoscopic or robot-assisted laparoscopic surgery has gained popularity as a minimally invasive treatment for pediatric urological disorders. CASE PRESENTATION: A 15-day-old Japanese boy was referred to our hospital with right hydronephrosis. A detailed examination revealed complete ureteral duplication on the right side and a dilated ectopic upper pole ureter, opening into the prostatic urethra. Since the patient had recurrent febrile urinary tract infections, we performed plication and ureteral reimplantation of the dilated ectopic ureter using a transvesicoscopic surgical method at the age of 2 years and 5 months. CONCLUSION: We safely performed transvesicoscopic ureteral reimplantation for an ectopic upper pole ureter with a mate ureter in a duplex kidney, following the detection of an ectopic ureter within the bladder, due to the prior understanding of the wrapping of both ureters in a common sheath.

A Novel Transvesicoscopic Ureteral Reimplantation Technique to Treat an Infantile Ectopic Ureter in a Single System.

An ectopic ureter is a significant urinary tract malformation often treated during early childhood and is surgically managed based on its condition. Generally, only extravesical ureteral reimplantation is available as a treatment option for an ectopic ureter with well-preserved renal function. This report describes a case of a 28-months-old girl with an ectopic ureter in a single system who experienced repeated febrile urinary tract infections, successfully treated using a transvesicoscopic ureteral reimplantation as a minimally invasive treatment. To the best of our knowledge, this is the first report of transvesicoscopic ureteral reimplantation for an ectopic ureter in a single system.

A case of posterior urethral valve identified in an older child by straining to void.

Posterior urethral valves (PUVs) are the most common cause of congenital urethral obstruction. However, the diagnosis of a PUV is sometimes difficult. A 13-year-old Japanese boy and his mother visited our hospital, and his mother complained that he frequently strained to void although he had no complaint. Uroflowmetry revealed a plateau-shaped curve and a voiding cystourethrography (VCUG) revealed a PUV. Thus, we performed a transurethral incision of the PUV, and his voiding status improved. Because some patients with mild PUV may not notice their dysuria, we believe that VCUG should be performed without hesitation when a urethral lesion is suspected.

Low Serum Inhibin B/Follicle-Stimulating Hormones and Anti-Müllerian Hormone/Follicle-Stimulating Hormones Ratios as Markers of Decreased Germ Cells in Infants with Bilateral Cryptorchidism.

PURPOSE: In cryptorchidism, germ cell development failure presents from infancy and may be reflected by altered hormonal levels produced by Sertoli cells. Our object was to assess for associations between serum hormone levels and testicular histopathology in cryptorchidism with an infertility risk according to the pretreatment undescended testicular positions. MATERIALS AND METHODS: Prepubertal cryptorchid boys aged 7-91 (median 20) months who underwent orchidopexy between 2014 and 2019 were included (122 unilateral [median 19 months {range 7-91}], 23 bilateral [24 months {11-81}]). We evaluated the pretreatment testicular position and size; serum hormone levels; and the mean number of germ cells per tubule transverse section (G/T). We also performed a subgroup analysis of boys aged ≤24 months at orchidopexy. RESULTS: Serum inhibin B levels and G/T were significantly lower in bilateral than in unilateral cryptorchid boys (median 96 [range 46-197] pg/ml vs 125 [21-354] pg/ml, p=0.026; 0.20 [0-2.59] vs 0.65 [0-4.55], p <0.001, respectively). Inhibin B/follicle-stimulating hormones (FSH) and anti-Müllerian hormone (AMH)/FSH ratios were positively correlated with G/T in bilateral cryptorchid boys aged ≤24 months (12, p=0.008 and p=0.019, respectively). Low inhibin B/FSH and AMH/FSH ratios and high FSH were predictors of impaired G/T as per receiver operating characteristic curves (p=0.019, p=0.004 and p=0.004, respectively), whereas in unilateral cryptorchid boys aged ≤24 months, serum hormone levels and G/T did not differ with the pretreatment testicular positions. CONCLUSIONS: In bilateral cryptorchid boys aged ≤24 months at orchidopexy, low inhibin B/FSH and AMH/FSH ratios may reflect impaired G/T and future infertility risk.

Antireflux endoscopic injection therapy in post-pubertal patients via techniques adopted for the dilated ureteral orifice: a retrospective single-center study.

BACKGROUND: To investigate the efficacy and safety of endoscopic injection therapy for vesicoureteral reflux in post-pubertal patients with dilated ureteral orifice via modified hydrodistension implantation techniques. METHODS: We retrospectively reviewed medical records including operational procedure and clinical course of all consecutive patients over 12 years old with a history of injection therapy. Endoscopic injection of dextranomer/hyaluronic acid copolymer was performed under hydrodistension implantation technique with some modifications in order to inject through dilated ureteral orifice align with the intramural ureter. Technical selections were done according to hydrodistension grade of the ureteral orifice. Voiding cystourethrography was evaluated at 3 months postoperatively. Hydronephrosis was evaluated using ultrasonography preoperatively until 6 months postoperatively. RESULTS: From 2016 to 2019, 12 patients (all female, 16 ureteral units; median age 32 [range 15-61] years) underwent endoscopic injection therapy at one of our institutions. We have identified grade II vesicoureteral reflux in 5 ureters, grade III in 8, and grade IV in 3 ureters. Grade 3 ureteral-orifice dilation were presented in 12 ureters (75%), grade 2 in 3 and grade 1 in 1 ureter in the present cases. Postoperatively, vesicoureteral reflux was diminished to grade 0 in 12 ureteral units (75%), decreased to grade I in 3 (9%), and remained grade III in 1 (6%). Three patients reported dull flank pain for several days postoperatively and there was 1 case of acute pyelonephritis. Temporary hydronephrosis was confirmed in 3 ureteral units (19%) at 1 month postoperatively. Median follow-up duration was 23 (range 13-63) months long. Although, 3 patients were experienced f-UTI 1-2 times, repeated VCUG showed no VUR recurrence. CONCLUSIONS: According to hydrodistension grade of the ureteral orifice, endoscopic injection therapy via modified hydrodistension implantation technique is an effective and safe treatment for vesicoureteral reflux in post-pubertal female patients with dilated ureteral orifice. While ureteral deformities or a history of anti-reflux surgery may increase the risks, these can be managed with appropriate methods that ensure sufficient mound appearance and height.

Genetic and histopathological analysis of transverse testicular ectopia without persistent Müllerian duct syndrome: two case reports.

BACKGROUND: Transverse testicular ectopia (TTE) is a rare anomaly in which both testes descend through a single inguinal canal into the same hemiscrotum. Although almost 20-50% of patients with TTE exhibit persistent Müllerian duct syndrome (PMDS) and many genetic analyses have been performed, no reports have described the genes contributing to TTE without PMDS. Here, we report two cases of TTE without PMDS using immunohistochemical staining and genetic analysis. CASE PRESENTATION: Two Asian patients with TTE without PMDS were subjected to orchiopexy. We performed testicular biopsies during operation and obtained blood samples before the operation. Testicular tissues were stained for c-kit, placental alkaline phosphatase (PLAP), and undifferentiated embryonic cell transcription factor 1 (UTF1) to evaluate the presence of intratubular malignant germ cells. Additionally, we performed polymerase chain reaction-based direct sequencing to identify single nucleotide polymorphisms in genes associated with regression of the Müllerian duct and testicular descent (that is, anti-Müllerian hormone [AMH], AMH receptor 2 [AMHR2], insulin-like 3 [INSL3], and relaxin family peptide receptor 2 [RXFP2]). The three-dimensional structures of proteins were predicted using SWISS-MODEL. In immunohistochemical analysis, c-kit and UTF1 were positive, whereas PLAP was negative in three testicular tissue samples from the two patients. These features were also detected on the unaffected side. In variant analysis, common missense variants in the AMH gene (g.365G>T; c.165G>T; p.Ser49Ile [rs10407022]) were observed. All variants in INSL3 and RXFP2 genes were intronic or silent. CONCLUSIONS: Because UTF1, a specific marker of spermatogonial stem cell activity, was expressed in both the affected and unaffected sides in the testicular tissues of two patients, the risk of malignancy may be high in these patients. Although the etiology of TTE without PMDS remains unclear, our variant analysis results were consistent with previous reports, and variants in the AMH gene (rs10407022) may contribute to the specific phenotype of TTE without PMDS.

Appropriate timing of performing abdominal ultrasonography and termination of follow-up observation for antenatal grade 1 or 2 hydronephrosis.

BACKGROUND: Most cases of antenatal the Society of Fetal Urology (SFU) grade 1or 2 hydronephrosis (HN) improve or resolve spontaneously with conservative treatment. However, there is no consensus on the duration of follow-up for cases of grade 1or 2 HN. The aim of this study was to determine the need for continuous follow-up period and new management of children with antenatal grade 1or 2 HN. METHODS: Subjects underwent ultrasonographic assessment for HN according to the SFU classification. We retrospectively evaluated 112 patients with postnatal grade 1 HN and 69 with grade 2 HN using abdominal ultrasonography between January 2010 and December 2017. We examined the change in HN grade on repeat ultrasonography. Kaplan-Meier method was used to show the effect of HN grade on the rate of HN changes. RESULTS: The mean follow-up duration was 44.9 ± 36.4 months (range 12-274). Initial SFU grade 1 HN disappeared in 47.0% of cases at 12 months, 66.4% at 24 months and 73.2% at 48 months. Initial SFU grade 2 HN showed improvement in grade in 74.7% of cases at 12 months, 88.3% at 24 months and 89.5% at 48 months. However, 14.6% of SFU grade 1 and 2.8% of SFU grade 2 cases increased in grade and of the 17 cases, 16 cases worsened within the first 6 months. No cases with increased grade required pyeloplasty. Initial disappearance and later reappearance of HN occurred in 40.5% of SFU grade 1 and 2 cases. The mean duration of later reappearance of HN was 39.1 ± 36.2 months (range 12-137). No cases showed reappearance of HN after more than 1 year. CONCLUSIONS: Ultrasonography within the first 6 months was necessary for management of children with antenatal grade 1or 2 HN, because some patients showed worsening. After that, it is considered safe to spread the follow-up interval for stable cases. Most cases of grade 1or 2 HN resolved spontaneously, however a few cases reappeared within 1 year. Therefore, ultrasonography after 1 year was necessary in children with HN that spontaneously disappeared. The appropriate time to end the follow-up was considered to have been after 1 year or more has passed since the disappearance was confirmed.

Microscopic pulmonary tumor embolism from adenocarcinoma of the prostate.

INTRODUCTION: Microscopic pulmonary tumor embolisms from prostate cancer are extremely rare. In this case of prostate cancer, microscopic pulmonary tumor embolism developed during androgen deprivation therapy. CASE PRESENTATION: A 56-year-old man was diagnosed with prostate cancer and underwent androgen deprivation therapy. Three months after starting treatment, he noticed shortness of breath and developed acute progressive dyspnea. He was diagnosed with pulmonary hypertension; however, the cause was not found. His dyspnea was progressive and he died 40 days after the onset of symptoms. Autopsy proved that the cause of pulmonary hypertension was microscopic pulmonary tumor emboli from prostate cancer. Furthermore, histology revealed differences in the androgen receptors in the prostate and emboli, with significantly greater Ki-67 expression in the emboli than in the prostate. CONCLUSION: Prostate cancer proliferated in the pulmonary artery after hematogenous metastasis, caused vascular occlusion, and formed microscopic pulmonary tumor embolisms.

Comparison of Real-Time Virtual Sonography Navigation Versus BioJet Navigation on Magnetic Resonance Imaging-Guided Prostate Needle Biopsy: A Single Institutional Analysis.

Objective: To analyze the effectiveness and complication rate of MRI-guided prostate needle biopsies by using real-time virtual sonography (RVS) vs BioJet navigation. Methods: We retrospectively reviewed 171 patients who underwent an MRI-guided prostate needle biopsy at our institution. Patients whose prostate-specific antigen level was >4.0 ng/mL and who had suspicious prostate cancer (PCa) lesions by multiparametric MRI (mpMRI) underwent 2-core MRI-guided targeted biopsy (TB) and for MRI-guided TB: RVS and BioJet. RVS navigation synchronized mpMRI images with transrectal ultrasound (TRUS) images. BioJet navigation used a software program that merged images from mpMRI and TRUS to produce a composite image. We retrospectively compared the detection rate of PCa and the frequency of severe adverse events (AEs) between these two navigation systems, focusing on patients. In addition, we compared the detection rate of MRI-guided TB cores of two navigation systems regarding anatomical position (transitional zone [TZ] or peripheral zone [PZ]). Results: Data from RVS and BioJet biopsy groups were from 65 and 106 patients, respectively. Of these, RVS-TB included 141 cores (PZ: 49 cores, TZ: 92 cores), and BioJet-TB included 276 cores (PZ: 73 cores, TZ: 203 cores). In detecting PCa, by conducting both systematic biopsy and TB, and AEs in patients, a significant difference was not noted between RVS and BioJet navigation systems. In addition, there was no significant difference in the total detection rate for PCa in TB cores between the two methods. However, in the TZ, BioJet navigation showed a significantly higher detection rate of PCa than RVS navigation (35.0% vs 17.4%, p = 0.0023) by analyzing the cores of MRI-guided TB. Conclusion: When targeting TZ lesions, BioJet navigation had a greater detection rate for PCa compared with that of RVS navigation.

Disorganization of claudin-11 and dysfunction of the blood-testis barrier during puberty in a cryptorchid rat model.

BACKGROUND: Cryptorchidism is known to impair spermatogenesis. The blood-testis barrier (BTB) becomes defined in seminiferous tubules around puberty and provides a suitable environment for germ cells. Little is known about the BTB in undescended testes (UDT). OBJECTIVES: To determine the role of BTB during puberty in UDT using a non-surgical cryptorchid rat model. MATERIAL AND METHODS: Unilateral cryptorchid male rats were intraperitoneally injected with non-steroidal antiandrogen during intrauterine development; the testes were harvested at 4, 5, and 6 weeks after birth. Testicular histology, expression levels of the BTB proteins (claudin-11, occludin, zonula occludens-1), and apoptotic cells were evaluated by immunohistochemistry, Western blotting, and TUNEL assay. The functionality of the BTB was investigated by electron microscopy using the lanthanum tracer method. RESULTS: The testicular histology of undescended testes 6 weeks after birth showed maturation arrest at the spermatocyte level. The BTB protein distributions were altered in the UDT, with a noticeable difference in claudin-11(CLDN11) localization from 4 to 5 weeks after birth between control and UDT samples. BTB protein levels were similar. More apoptotic germ cells were detected in the adluminal compartment of tubules in the UDT than in the control testes. Electron microscopy showed that the lanthanum tracer was limited to the BTB of control testes, whereas it penetrated the BTB of UDT. DISCUSSION: Here, loss of normal BTB function and impaired spermatogenesis were observed in UDT during puberty. CLDN11 is a pivotal tight junction protein belonging to the BTB. Tight junctions are considered as essential for normal spermatogenesis, and abnormal CLDN11 organization may cause UDT-associated male infertility. CONCLUSION: CLDN11 disorganization within the BTB may cause spermatogenic impairment, possibly by limiting the BTB function.

Robot-Assisted Radical Cystectomy for Pediatric Bladder Rhabdomyosarcoma.

Background: The standard treatments for muscle-invasive bladder cancer with no metastasis are total cystectomy and urinary diversion. Although robot-assisted radical cystectomy (RARC) was covered from April 2018 by the Japanese National Health Insurance system, and the number of RARC is increasing, there has been no pediatric case report on RARC in Japan. Case Presentation: We report the case of a 6-year-old Japanese girl who was referred to our hospital with the chief complaint of a vulvar tumor protrusion during defecation. We resected the tumor from her external urethral meatus, and transurethral resection for the residual partial bladder neck tumor was performed for both a definitive diagnosis and as a possible curative therapy. The pathologic diagnosis was an embryonic type of rhabdomyosarcoma. Although she was treated by chemotherapy combined with proton therapy, a residual tumor at the neck and a new lesion at the top of bladder were observed 2 years after initial treatment. Thus, RARC was performed. The surgical specimen was placed in an end-pouch and was then removed through the incised vaginal wall, with cosmetic consideration. A bilateral cutaneous ureterostomy was performed at the sites of the working ports for urinary diversion. In the future, we plan to perform abdominal wall catheterization. Postoperatively, she was treated with adjuvant chemotherapy. There was no recurrence for 19 months. Conclusion: Because she was a child, particularly a girl, the wounds should be small and inconspicuous considering the cosmetic aspect. Although the posterior aspect of the bladder seemed difficult to detach because of the adhesions, it was possible to safely perform RARC.

Rare case of Richter syndrome with testicular involvement successfully obtained good prognosis with rapid operation and immunochemotherapy.

INTRODUCTION: Richter syndrome refers to the transformation from chronic lymphocytic leukemia to assaultive lymphoma, often a diffuse large B-cell lymphoma, and has a greatly poor prognosis. Richter syndrome is characterized by rapidly growing lymphadenopathy but rarely presents with extra-nodal involvement, common sites being the digestive tract, lungs, kidneys, and central nervous system. However, Richter syndrome with testicular involvement is extremely rare. CASE PRESENTATION: Herein we report a very scare case of a male at the age of 72 with Richter syndrome and testicular involvement, diagnosed by the investigation of bilateral scrotal swellings. The patient had attained disease-free survival for over a year with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone, and the intrathecal administration of chemotherapeutic agents after diagnosis by immediate orchiectomy. CONCLUSION: An early pathological diagnosis by immediate orchiectomy and the early initiation of induction immunochemotherapy may be good prognostic factors in Richter syndrome involving the testes.

Can lichen sclerosus be diagnosed by preputial appearance or symptoms?

INTRODUCTION: Lichen sclerosus (LS), or balanitis xerotica obliterans, is a chronic, inflammatory disease accompanied by cicatrizing skin conditions resulting in pathologic phimosis. LS can be detected clinically by the whitish appearance of the glans or the foreskin, thickened, nonretractable foreskin, dysuria, and spraying. However, diagnosis is confirmed histopathologically. PURPOSE: The aim of this study was to investigate whether LS can be diagnosed on the basis of clinical manifestation and symptoms. PATIENTS AND METHODS: A retrospective analysis was performed, which included boys referred to our institutions for phimosis evaluation between May 2001 and December 2016. Pediatric urologists clinically diagnosed LS preoperatively. Boys with voiding problems, recurrent balanoposthitis, or who were unresponsive to topical steroid treatment underwent surgical treatment. Patients who underwent religious circumcisions were not included. RESULTS: Three-hundred twenty boys diagnosed with phimosis were identified, and 71 (22%) boys underwent surgery. Fifty-eight boys underwent complete or partial circumcision, and 13 boys underwent a dorsal slit or preputioplasty. Thirty foreskin samples were sent for histopathologic examination. Histopathologic evaluation showed evidence of LS in 13 of 30 (43%) circumcised boys, chronic inflammation in ten (33%), no abnormality in four (13%), dysplasia in two (7%), and acute inflammation in one (3%). In the 22 boys who were clinically diagnosed with LS, 13 patients had histopathologic evidence of LS (59%). Visually, eleven cases had whitish foreskins and 21 cases had thickened nonretractable foreskins, of which there were seven (64%) (P>0.05) and 12 (57%) (P<0.01) cases, respectively. These cases were histopathologically diagnosed with LS. Both whitish and thickened, nonretractable foreskin was observed in eight patients, of which seven (88%) (P<0.01) were also histologically diagnosed with LS. There was no correlation between histopathologic diagnosis and preoperative symptoms such as dysuria, ballooning, spraying, or penile pain (P>0.2). CONCLUSION: It is difficult to reliably distinguish whether a patient has histopathological LS by clinical findings alone.