Prevalence and characteristics of patients with upper urinary tract urothelial carcinoma having potential Lynch syndrome identified by immunohistochemical universal screening and Amsterdam criteria II.

BACKGROUND: This study aimed to identify patients with upper urinary tract urothelial carcinoma (UTUC) having potential Lynch syndrome (pLS) by immunohistochemistry (IHC) of DNA mismatch repair gene-related proteins (MMRPs) and Amsterdam criteria II and explore their clinical characteristics. METHODS: We retrospectively collected the clinical data of 150 consecutive patients with UTUC who underwent surgical resection at our institution between February 2012 and December 2020, and immunohistochemistry (IHC) of four MMRPs (MLH1, MSH2, MSH6, and PMS2) on all UTUC specimens was performed. Patients who tested positive for Amsterdam criteria (AMS) II and/or IHC screening were classified as having pLS and others as non-pLS, and their characteristics were explored. RESULTS: In this study, 5 (3%) and 6 (4%) patients were positive for AMS II and IHC screening, respectively. Two patient were positive for both AMS II and IHC screening, resulting in 9 (6%) patients with pLS. The pLS group was predominantly female (67% vs. 36%; p = 0.0093) and had more right-sided tumors (100% vs. 43%; p = 0.0009) than the non-pLS group. Of the 6 patients who were positive for IHC screening, 4 showed a combined loss of MSH2/MSH6 (n = 3) and MLH1/PMS2 (n = 1). Other two patients showed single loss of MSH6 and PSM2. CONCLUSIONS: AMS II and IHC screening identified pLS in 6% of patients with UTUC. The IHC screening-positive group tends to have relatively high rate of combined loss, but some patients have single loss. AMS II may overlook patients with LS, and a universal screening may be required for patients with UTUC as well as those with colorectal and endometrial cancer.

Saccadic oscillations as a biomarker of clinical symptoms in amyotrophic lateral sclerosis.

BACKGROUND: Among eye movements in amyotrophic lateral sclerosis (ALS), we identified the characteristics of square-wave jerks (SWJs) seen during times without visual fixation (VF) and analyzed their relationships with clinical parameters. MATERIALS AND METHODS: Clinical symptoms were evaluated and eye movements were tested using electronystagmography in 15 patients with ALS (10 men, 5 women; mean age, 66.9 ± 10.5 years). SWJs with and without VF were recorded, and their characteristics were identified. Relationships between each SWJ parameter and clinical symptoms were evaluated. Results were compared with eye movement data from 18 healthy individuals. RESULTS: The frequency of SWJs without VF was significantly higher in the ALS group than in the healthy group (P < 0.001). When the condition was changed from VF to no-VF in the ALS group, the frequency of SWJs was significantly higher in healthy subjects (P = 0.004). A positive correlation was seen between frequency of SWJs and percentage predicted forced vital capacity (%FVC) (R = 0.546, P = 0.035). CONCLUSION: The frequency of SWJs was higher with VF in healthy people, and was suppressed without VF. In contrast, the frequency of SWJs was not suppressed without VF in ALS patients. This suggests that SWJs without VF have some clinical significance in ALS patients. Moreover, a relationship was noted between the parameters of SWJs without VF in ALS patients and results of pulmonary function tests, suggesting that SWJs during times without VF may offer a clinical parameter of ALS.

Significance of postoperative membranous urethral length and position of vesicourethral anastomosis for short-term continence recovery following robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: We assess whether short-term recovery of urinary incontinence following robot-assisted laparoscopic radical prostatectomy (RARP) is associated with postoperative membranous urethral length (MUL) and position of vesico-urethral anastomosis (PVUA). METHODS: Clinical variables including PVUA and pre-and postoperative MUL were evaluated in 251 patients who underwent RARP from August 2019 to February 2021. Continence recovery was defined as no pad or one security liner per day assessed by patient interview at least 6 months follow-up. Univariate and multivariate logistic regression analyses were used to assess variables associated with continence recovery at 3 months after the operation. RESULTS: Continence recovery rates at 3 and 6 months were 75% and 84%, respectively. Lower BMI (< 25 kg/m2) (p = 0.040), longer preoperative MUL (≥ 9.5 mm) (p = 0.013), longer postoperative MUL (≥ 9 mm) (p < 0.001), higher PVUA (< 14.5 mm) (p = 0.019) and shorter operating time (< 170 min) (p = 0.013) were significantly associated with continence recovery at 3 months in univariate analysis. Multivariate analysis revealed that postoperative MUL (OR 3.75, 95% CI 1.90-7.40, p < 0.001) and higher PVUA (OR 2.02, 95% CI 1.07-3.82, p = 0.032) were independent factors for continence recovery. Patients were divided into 3 groups based on the multivariate analysis, with urinary continence recovery rates found to have increased in turn with rates of 43.7% versus 68.2% versus 85.0% (p < 0.001) at 3 months. CONCLUSIONS: PVUA and postoperative MUL were significant factors for short-term continence recovery. Preservation of urethral length might contribute to continence recovery after RARP.

Utility of radiomics features of diffusion-weighted magnetic resonance imaging for differentiation of fat-poor angiomyolipoma from clear cell renal cell carcinoma: model development and external validation.

PURPOSE: To investigate the utility of radiomics features of diffusion-weighted magnetic resonance imaging (DW-MRI) to differentiate fat-poor angiomyolipoma (fpAML) from clear cell renal cell carcinoma (ccRCC). MATERIALS AND METHODS: This multi-institutional study included two cohorts with pathologically confirmed renal tumors: 65 patients with ccRCC and 18 with fpAML in the model development cohort, and 17 with ccRCC and 13 with fpAML in the external validation cohort. All patients underwent magnetic resonance imaging (MRI) including DW-MRI. Radiomics analysis was used to extract 39 imaging features from the apparent diffusion coefficient (ADC) map. The radiomics features were analyzed with unsupervised hierarchical cluster analysis. A random forest (RF) model was used to identify radiomics features important for differentiating fpAML from ccRCC in the development cohort. The diagnostic performance of the RF model was evaluated in the development and validation cohorts. RESULTS: The cases in the developmental cohort were classified into three groups with different frequencies of fpAML by cluster analysis of radiomics features. RF analysis of the development cohort showed that the mean ADC value was important for differentiating fpAML from ccRCC, as well as higher-texture features including gray-level run length matrix (GLRLM)_long-run low gray-level enhancement (LRLGE), and GLRLM_low gray-level run emphasis (LGRE). The area under the curve values of the development [0.90, 95% confidence interval (CI) 0.80-1.00] and validation cohorts (0.87, 95% CI 0.74-1.00) were similar (P = 0.91). CONCLUSION: The radiomics features of ADC maps are useful for differentiating fpAML from ccRCC.

Mini-Cog to Predict Postoperative Delirium in Patients Who Underwent Transurethral Resection of Bladder Tumor While Awake.

OBJECTIVE: In the postoperative management of transurethral resection of bladder tumor, attention should be paid to the appearance of delirium. Recently, the mini-cognitive assessment instrument (Mini-Cog) has been validated as a screening tool for cognitive impairment. We assessed whether positive preoperative cognitive impairment screening by Mini-Cog is associated with the occurrence of postoperative delirium. MATERIAL AND METHODS: In this study, consecutive patients who underwent transurethral resection of bladder tumor while awake and were cognitively screened preoperatively using the Mini-Cog test at our institution were retrospectively analyzed. The relationship between the Mini-Cog test and clinical variables was examined. Univariate and multivariate analyses were carried out to determine the risk factors for the occurrence of postoperative delirium. RESULTS: Of the 193 included patients, 37 (19%) patients had probable cognitive impairment (Mini-Cog scores < 3). There were significant differences in patients' age (P < .001), Eastern Cooperative Oncology Group-physical status (P=.01), decline in instrumental activities of daily living from baseline (P=.03), preoperative diagnosis of dementia (P < .001), and use of benzodiazepine (P=.03) between the Mini-Cog score ≥ 3 group and the Mini-Cog score < 3 group. Multivariate analysis demonstrated that a Mini-Cog score < 3 (odds ratio=6.8, P < .001) and instrumental activities of daily living decline (odds ratio=3.0, P=.02) were independent risk factors for the occurrence of postoperative delirium. CONCLUSION: Screening of patients for cognitive function using the Mini-Cog test before transurethral resection of bladder tumor may allow for better identification of patients at risk of postoperative delirium.

The Mini-Cog: A simple screening tool for cognitive impairment useful in predicting the risk of delirium after major urological cancer surgery.

AIM: The purpose of this study was to evaluate the impact of the mini-cognitive assessment instrument (Mini-Cog) on postoperative delirium after major urological cancer surgery. METHODS: In this single-center retrospective observational study, medical records were collected for patients who underwent major urologic cancer surgery at our department between 2020 and 2021, and underwent preoperative cognitive screening based on the Mini-Cog test (n = 331). The probable cognitive impairment is defined as a Mini-Cog score of <3. Univariate and multivariate logistic regression analysis were used to identify the risk factors for postoperative delirium. RESULTS: Patients with probable cognitive impairment were 60 (18%). Postoperative delirium occurred in 26 patients (8%). Using multivariate analysis, the Mini-Cog score of <3 (odds ratio [OR] = 12.7; P < 0.001), decline of instrumental activities of daily living (OR = 3.0; P = 0.04) and preoperative benzodiazepine use (OR = 8.3; P < 0.001) were independent risk factors for postoperative delirium. For predicting postoperative delirium, Mini-Cog score with a cutoff value of <3 granting sensitivity of 69.2%, specificity of 86.2%, positive predictive value of 30.0% and negative predictive value of 97.1%. CONCLUSIONS: The Mini-Cog test is a simple screening tool with only two components (a delayed, three-word recall task and a clock drawing test): it is useful in identifying potential cases of cognitive decline and patients at risk for postoperative delirium along with other information routinely collected preoperatively. Effective screening using the Mini-Cog test opens the possibility to provide optimal urologic care for older patients Geriatr Gerontol Int 2022; 22: 319-324.

Utility of a multidisciplinary team approach with transanal total mesorectal excision for resection of a large pelvic solitary fibrous tumor.

INTRODUCTION: Solitary fibrous tumors require complete surgical resection to avoid recurrence. Large solitary fibrous pelvic tumors are difficult to resect completely with conventional surgical methods. We herein report a case in which a joint surgical approach was required for resection due to the location and size of tumor. CASE PRESENTATION: A 45-year-old man had a large solitary fibrous tumor in the pelvis, which extended into the left obturator foramen. The patient underwent tumor resection with vesico-prostatectomy, transanal total mesorectal excision, and opening of the foramen obturatum. The tumor was grossly resected completely. No recurrence was noted nine months after surgery. CONCLUSION: A multidisciplinary team approach with transanal total mesorectal excision may provide complete resect of large pelvic solitary fibrous tumors.

Strangulated ileus from barbed suture following robot-assisted radical cystectomy: A case report.

The barbed suture e.g. V-Loc™, are occasionally used in urological surgery due to the practical advantage of omitting the need for surgical knots and reducing surgical time. In this report, an 83-year-old man diagnosed as having invasive bladder cancer underwent robot-assisted radical cystectomy: on the thirteenth postoperative day, he was diagnosed as having strangulated ileus of the small bowel. The small bowel was strangulated by bands formed between the stump of V-Loc™ and the fatty appendices of the sigmoid colon. This is the first report of a small bowel ileus associated with the barbed suture in the field of urology.

Prognostic significance of the postoperative/preoperative serum CEA level ratio in patients with solitary adrenal metastasis from lung cancer.

The present study aimed to evaluate the prognostic significance of the postoperative to preoperative serum carcinoembryonic antigen (CEA) level ratio (CEA ratio) in patients with lung cancer with solitary metastasis of the adrenal gland after adrenalectomy. Furthermore, the optimal CEA ratio cutoff value for predicting disease-free survival (DFS) in patients with lung cancer after adrenalectomy was determined. The medical records of patients with lung cancer with isolated adrenal metastasis who underwent adrenalectomy at the National Cancer Center Hospital East (Kashiwa, Japan) between January 2013 and December 2020 were retrospectively reviewed. Receiver operating characteristic curve analysis was used to segregate patients into two groups (high and low CEA groups) and the clinical prognosis for the two groups was determined. In addition, the association between the CEA ratio and clinical factors was determined. A total of 14 patients with a median age of 68 years (range, 50-75 years) were analyzed, of which 9 (64%) were males. The optimal cutoff value for the CEA ratio to predict DFS was 0.60. The high CEA ratio group (≥0.60) displayed poorer DFS and cancer-specific survival (P=0.03 and 0.02, respectively). The CEA ratio was significantly associated with the preoperative CEA level (P=0.01) and the high CEA ratio (≥0.60) group had lower preoperative CEA levels. The study suggested that the perioperative CEA ratio may be an important emerging prognostic factor for patients with lung cancer with solitary adrenal gland metastasis. As the sample size was limited, a further study with a larger cohort is required to validate the present findings.

[A SUCCESSFUL CASE OF PARTIAL REPLACEMENT FOR MECHANICAL FAILURE OF ARTIFICIAL URINARY SPHINCTER].

Of the patients who have had artificial urinary sphincter (AUS) implantation, 30%-50% require reoperation because of recurrent stress urinary incontinence (SUI) or infection. The most common cause of recurrent postoperative SUI is the mechanical failure of the AUS. This case report describes AUS replacement without urethral manipulation after the mechanical failure of the AUS. A 63-year-old man underwent AUS implantation to treat severe SUI that developed after robot-assisted laparoscopic total prostatectomy. Intraoperatively during AUS implantation, the cuff was inflated under direct vision and the AUS was confirmed to work properly; however, SUI did not improve when the AUS was activated 7 weeks after surgery. Urethroscopy confirmed that the urethra was not contracted, and computed tomography indicated that the tube was not continuous with partially deflated pressure-regulating balloon (PRB). On reoperation, the tube was found to be disconnected at the intended point of connection. By refilling PRB and performing urethroscopy, we confirmed the PRB without leakage and good urethral cuff coaptation, respectively.The AUS replacement procedure was then completed with only the replacement of the control pump and reconnection of the tubing. After the surgery, AUS was immediately activated to confirm the improvement of SUI. After 3 months post-surgery, the patient have enjoyed urinary continence. If the defective part of the AUS system can be identified during replacement, the procedure can be completed with only partial replacement and without manipulation of the urethra, thus avoiding the risk of urethral injury.

A Pitfall of the Androgen Deprivation Therapy for Salivary Duct Carcinoma: Hormonal Therapy-Induced Castrate-Resistant Prostate Cancer.

Introduction: Salivary duct carcinoma (SDC) is a rare, high-grade salivary gland malignancy. Recently, targeting the androgen receptor (AR) is one of the most promising new therapeutic strategies for AR-positive SDC. Case Review: In this report, a 70-year-old man who was diagnosed with an AR-positive SDC underwent androgen deprivation therapy (ADT) as a treatment for recurrence after primary therapy. The ADT well contributed to control of SDC; however, the patient was referred to urologists for urinary hesitancy and slow flow and he was diagnosed as having castration-resistant prostate cancer. Literature Review: Since SDC is a rare disease, it has been difficult to establish the most effective therapy. Nevertheless, several papers have reported the clinical benefit of ADT for AR-positive SDC, and the latest version of the National Comprehensive Cancer Network guidelines also states the importance of assessing for the presence of AR in SDC.On the other hand, in the field of urology, it is also known that although ADT is initially effective in prostate cancer patients, prostate cancer often develops into castrate-resistant prostate cancer due to the adaptation of prostate cancer cells to ADT for survival and growth. Conclusion: We reported a case of castrate-resistant prostate cancer diagnosed during the ADT for metastatic SDC. The present case emphasizes the importance of screening for prostate cancer at the initiation of ADT treatment and during treatment.

Hyperchloremic Metabolic Acidosis with Hyperglycemic Hyperosmolar Syndrome after Robot-Assisted Radical Cystoprostatectomy with Ileal Conduit Urinary Diversion: A Case Report.

Hyperchloremic metabolic acidosis can be a problem in urinary diversion using the ileum. A 73-year-old Japanese male was hospitalized in emergency due to anorexia and malaise 3 weeks after being discharged from the hospital after getting robot-assisted radical cystoprostatectomy and intracorporeal ileal conduit urinary diversion. The blood analysis revealed metabolic acidosis, elevated chloride ions, and marked hyperglycemia: he was diagnosed with hyperchloremic metabolic acidosis and hyperglycemic hyperosmolar syndrome. We started administering insulin and large amounts of fluid replacement; besides, we inserted a large-diameter open tip catheter into the ileal conduit in hopes of inhibiting urine reabsorption in the intestinal mucosa. His general condition gradually improved, and he was discharged 10 days after his hospitalization.

Rectal constriction due to metastasis of urothelial carcinoma of the bladder: A case report.

Urothelial carcinoma (UC) of the bladder rarely causes rectal constriction. We report a case of UC of the bladder that metastasized to the perirectal tissues and caused rectal constriction. The patient was diagnosed with metastasis of UC upon performing a biopsy of the perirectal tissues. No malignant findings were observed in the rectal mucosa. A relatively good prognosis of 26 months was obtained through multidisciplinary treatment combining surgery and chemotherapy. In cases of rectal constriction secondary to high-grade UC of the bladder, the possibility of metastasis of UC should be considered.

Diagnostic value of texture analysis of apparent diffusion coefficient maps for differentiating fat-poor angiomyolipoma from non-clear-cell renal cell carcinoma.

PURPOSE: To investigate the feasibility of texture analysis of apparent diffusion coefficient (ADC) maps for differentiating fat-poor angiomyolipomas (fpAMLs) from non-clear-cell renal cell carcinomas (non-ccRCCs). METHODS: In this bi-institutional study, we included two consecutive cohorts from different institutions with pathologically confirmed solid renal masses: 67 patients (fpAML = 46; non-ccRCC = 21) for model development and 39 (fpAML = 24; non-ccRCC = 15) for validation. Patients underwent preoperative magnetic resonance imaging (MRI), including diffusion-weighted imaging. We extracted 45 texture features using a software with volumes of interest on ADC maps. Receiver operating characteristic curve analysis was performed to compare the diagnostic performance between the random forest (RF) model (derived from extracted texture features) and conventional subjective evaluation using computed tomography and MRI by radiologists. RESULTS: RF analysis revealed that grey-level zone length matrix long-zone high grey-level emphasis was the dominant texture feature for diagnosing fpAML. The area under the curve (AUC) of the RF model to distinguish fpAMLs from non-ccRCCs was not significantly different between the validation and development cohorts (p = .19). In the validation cohort, the AUC of the RF model was similar to that of board-certified radiologists (p = .46) and significantly higher than that of radiology residents (p = .03). CONCLUSIONS: Texture analysis of ADC maps demonstrated similar diagnostic performance to that of board-certified radiologists for discriminating between fpAMLs and non-ccRCCs. Diagnostic performances in the development and validation cohorts were comparable despite using data from different imaging device manufacturers and institutions.

Improvement of urinary symptoms after bladder biopsy: A case of pathologically proven allergy-related cystitis during administration of nivolumab.

INTRODUCTION: We present a case of cystitis, which was considered to be an immune-related adverse event associated with nivolumab administration. CASE PRESENTATION: A 47-year-old man suffered from sudden onset urinary symptoms after 18 cycles of nivolumab treatment for stage IV pulmonary adenocarcinoma. Urine culture and urine cytology were both negative. The symptoms were inferred to be related to nivolumab administration, and a bladder biopsy under spinal anesthesia was performed. The histopathological examination showed the evidence of allergic-related cystitis. We planned to administer corticosteroids, but the urinary symptoms disappeared after the bladder biopsy. Nivolumab treatment was continued without recurrent bladder symptoms. CONCLUSION: We reported a case of cystitis after treatment with nivolumab, which served as a reminder to consider the possibility of immune-related adverse events as a potential cause for any symptoms that develop during treatment with immuno-oncology drugs.

Urothelial carcinoma of the bladder with cutaneous metastases after robot-assisted radical cystectomy. Case report.

Bladder cancer is one of the common urologic malignant diseases. Cutaneous metastasis of bladder cancer is rare, with only a few case reports. The pattern of metastasis from bladder cancer is not well described. We report a patient with muscle-invasive bladder cancer who developed skin metastases after neoadjuvant chemotherapy and robot-assisted laparoscopic radical cystoprostatectomy. Skin metastases were confirmed histopathologically by skin biopsy. This case reminds us of the need to consider the possibility of skin metastasis in the differential diagnosis of skin symptoms in patients with malignant diseases.

A case of solid pseudopapillary neoplasm preoperatively diagnosed as left renal tumor.

Solid pseudopapillary neoplasm is a rare disease that accounts for approximately 2% of pancreatic neoplasms, and the treatment is complete resection of the tumor. We experienced a case preoperatively diagnosed as a left renal tumor with pancreatic invasion and histologically diagnosed with solid pseudopapillary neoplasm of the pancreas. The purpose of this case report is to illustrate the importance of differentiating solid pseudopapillary neoplasm in patients who present a left renal tumor with pancreatic invasion.

Rare small bowel obstruction: Parastomal hernia of cutaneous ureterostomy after robot-assisted radical cystectomy. Case report.

Robot-assisted radical cystectomy with or without intracorporeal urinary diversion has recently been explored as a viable surgical option for multiple, recurrent and muscle invasive bladder cancer. In this report, an 84-year-old female diagnosed as having invasive bladder cancer underwent robot-assisted radical cystectomy with intracorporeal cutaneous ureterostomy: in the third postoperative day, computed tomography of the abdomen was suggestive of incarcerated hernia through the abdominal wall defect created by the left ureterostomy. Subsequently, the parastomal hernia was repaired laparoscopically. To the best of our knowledge, this is the first report of a symptomatic parastomal hernia related to the cutaneous ureterostomy.

Simultaneous laparoscopic nephroureterectomy and robot-assisted radical cystectomy: Lessons learned from our initial experience.

BACKGROUND: In patients with high-risk bladder cancer and concomitant upper urinary tract malignancies, simultaneous cystectomy and nephroureterectomy is the principle oncological procedure of choice. Nevertheless, there are still not many reports of simultaneous robot-assisted radical cystectomy (RARC) and nephroureterectomy. Therefore, the aim of this study was to evaluate outcomes and complications of simultaneous RARC and laparoscopic nephroureterectomy in our institution. MATERIALS AND METHODS: This case series evaluated our initial clinical results of 3 patients who underwent simultaneous laparoscopic unilateral nephroureterectomy and RARC with the da Vinci Xi system between 2019 and 2020 at our hospital. Demographic data, preoperative parameters, and postoperative parameters were retrospectively analyzed. RESULTS: All 3 patients were men whose median age was 75 years (range 73-89 years). The median total operative time was 435 minutes (range 429-484 minutes), median estimated blood loss was 377 mL (range 125-410 mL), and median hospital stay was 26 days (range 21-36 days). In all 3 cases, each trocar was used in 7 ports. The postoperative complications were stratified according to the Clavien-Dindo Classification system, and a grade 3B complication developed in 1 patient: trocar site herniation of the small bowel. CONCLUSIONS: We reported our initial experience of simultaneous laparoscopic nephroureterectomy and RARC. A large-scale prospective, randomized, controlled trial will be required to prove the feasibility and safety of simultaneous laparoscopic nephroureterectomy and RARC.