Increasing rectum-prostate distance using a hydrogel spacer to reduce radiation exposure during proton beam therapy for prostate cancer.

SpaceOAR, a polyethylene-glycol hydrogel, reduces rectal radiation exposure during radiation therapy for prostate cancer. Previously, our group reported the modified technique of hydrogel insertion, which achieves greater separated distance at prostate-apex. This study aimed to investigate the impact of separated distance at prostate-apex and our modifier technique, on radiation exposure reduction during proton beam therapy (PBT). We included 330 patients undergoing PBT with the relative biological effectiveness (RBE) of 63 Gray (Gy) for localized prostate cancer, and categorized them into groups 0 (no spacer, n = 141), 1 (separated distance of spacer at the prostate-apex level < 7.5 mm, n = 81), and 2 (distance ≥ 7.5 mm, n = 108). The rectal volumes to receive 30-60 Gy (RBE), was estimated and described as Rectal V30-60 (ml) in 10 Gy increments. The Rectal V30-60 (ml) was significantly lower in group 2 than in group 1, and in group 1 than in group 0. After propensity score matching, the multivariate logistic regression analysis revealed that the most significant factor to reduce radiation exposure was our modified technique of hydrogel insertion. Therefore, using a hydrogel spacer to expand the prostate-rectum distance not only at prostate-mid to prostate-base level but also at the prostate-apex level can reduce the radiation exposure in PBT for prostate cancer.

Factors affecting testicular volume after orchiopexy for undescended testes.

PURPOSE: Children with undescended testes (UDTs) undergoing orchiopexy at a later age reportedly experience more negative effects on post-orchiopexy testicular volume (TV). This study aimed to investigate the effect of orchiopexy according to the age at operation. METHODS: We included 93 patients (127 testes) who underwent orchiopexy between 2008 and 2020. According to their age at orchiopexy, they were divided into Group 1 (< 24 months; n = 36, median follow-up: 17 [14-39] months) and Group 2 (≥ 24 months; n = 57, median follow-up: 16 [13-34] months). TV was measured with ultrasonography preoperatively and postoperatively. In unilateral UDTs, the testicular volume rates (TVR) were calculated as diseased-side TV/intact-side TV × 100%. A TVR < 50% indicated preoperative testicular atrophy (pre-op TA), whereas volume loss ≥ 50% from baseline indicated postoperative testicular atrophy (post-op TA). RESULTS: Only seven patients experienced pre-op TA. The TV of these 14 atrophic testes improved after orchiopexy (TVR: 100% (7/7) in Group 1 and 85% (6/7) in Group 2). Furthermore, the median TVR significantly improved after orchiectomy, from 27 to 58% (p < 0.01) and from 32 to 61% in Groups 1 and 2 (p < 0.05), respectively. Post-op TA was found in four testes (8%) in Group 1 and three testes (4%) in Group 2. Multivariate analysis showed that only preoperative testicular location predicted post-op TA. CONCLUSION: Post-orchiopexy TA may occur regardless of the patient's age at orchiopexy, and orchiopexy is recommended irrespective of age at diagnosis.

Effectiveness of a voiding evaluation technique using a diaper equipped with a urination-activated alarm system to assess bladder function and voiding patterns in infants.

PURPOSE: Four-hour voiding observation is a conventional method for evaluating bladder function in infants. However, it requires a diaper check every 5 min during the observation period, which creates an unusual environment for the infant, making the evaluation of natural urination difficult. This study aimed to investigate the parameters of urination before mature bladder function using a diaper equipped with a urination-activated alarm system. METHODS: The study participants were 51 infants aged 0-4 years without bladder dysfunction. A urination-activated sensor was used to notify the inspector wirelessly when urination was detected, enabling the immediate assessment of ultrasonically measured residual urine. Bladder capacity was calculated as the sum of both residual urine volume and micturition volume, and the residual urine rate as the residual urine volume divided by bladder capacity. RESULTS: A total of 36 boys and 15 girls were enrolled. The median (interquartile range) residual urine volume, bladder capacity, and residual urine rate were 3.0 mL (1.1-6.6), 53.0 mL (33.9-75.3), and 7.0% (2.1-15.0), respectively. Infants aged 0-1 and 2-4 years were then classified into Group A (N = 27) and Group B (N = 24), respectively. The residual urine rate was significantly higher in Group A (11.0% [5.4-21.2]) than in Group B (4.8% [0.6-8.9]; p < 0.01). CONCLUSIONS: Voiding observation using a urination-activated alarm system allowed less invasive analysis in infants and revealed that the residual urine rate decreased with mature bladder function from about 2 years of age.

Role of Brachytherapy Boost in Clinically Localized Intermediate and High-Risk Prostate Cancer: Lack of Benefit in Patients with Very High-Risk Factors T3b-4 and/or Gleason 9-10.

This study examined the role of brachytherapy boost (BT-boost) and external beam radiotherapy (EBRT) in intermediate- to high-risk prostate cancer, especially in patients with very high-risk factors (VHR: T3b-4 or Gleason score 9-10) as patients with double very high-risk factors (VHR-2: T3b-4 and Gleason score 9-10) previously showed worst prognosis in localized prostate cancer. We retrospectively reviewed multi-institutional data of 1961 patients that were administered radiotherapy (1091 BT-boost and 872 EBRT: 593 conventional-dose RT (Conv RT: equivalent to doses of 2 Gy per fraction = EQD2 ≤ 72 Gy) and 216 dose-escalating RT (DeRT = EQD2 ≥ 74 Gy). We found that BT-boost improved PSA control and provided an equivalent overall survival rate in the intermediate- and high-risk groups, except for patients within the VHR factor group. In the VHR-1 group (single VHR), BT-boost showed a superior biochemical control rate to the Conv RT group but not to the DeRT group. In the VHR-2 group, BT-boost did not improve outcomes of either Conv RT or DeRT groups. In conclusion, BT-boost showed no benefit to modern DeRT in the patients with VHR; therefore, they are not good candidates for BT-boost to improve outcome and may be amenable to clinical trials using multimodal intensified systemic treatments.

Usefulness of bicarbonate Ringer's solution as perfusate during transurethral resection of the prostate.

Transurethral resection of the prostate (TURP) is the most common standard surgical procedure used for benign prostatic hyperplasia. Transurethral resection in saline (TURis) is a bipolar electrosurgery system used to prevent TURP (or TUR) syndrome. The bicarbonate Ringer's solution is not generally used as perfusate for TURP. Hence, we compared the efficacy of the bicarbonate Ringer's solution with that of physiological saline as perfusate during TURP. This prospective, multicenter, cooperative study was conducted on 40 adult patients admitted to a medical college hospital. After obtaining informed consent from all the patients, they were divided into two groups (20 patients per group). For patients of one group, bicarbonate Ringer's solution, and for other group, physiological saline was used as perfusate. Compared to the physiological saline, the electrolyte composition of the bicarbonate Ringer's solution was closer to that of plasma. Hence, the group using bicarbonate Ringer's solution as perfusate was exhibited less variation in plasma electrolytes and blood gas data. The primary endpoints were adverse events of grade 1 or higher according to the JCOG postoperative complication criteria ver. 2.0, unintended diseases, or related signs in patients who underwent the protocol therapy. The secondary endpoints were changes in blood pH, bicarbonate ion level, anion gap (AG), base excess (BE), and chloride (C1), which occurred during and after the surgeries. Therefore, bicarbonate Ringer's solution has superior with that of physiological saline as perfusate during TURP which is directly administered into the blood vessels as an infusion solution.Bicarbonate Ringer's solution is directly administered into the blood vessels as an infusion solution.

Efficacy of testosterone replacement therapy plus alternate-day tadalafil for patients with late-onset hypogonadism: An open-label, randomized, crossover study.

OBJECTIVE: To examine the efficacy and safety of combination treatment with testosterone replacement therapy plus alternate-day tadalafil (10 mg) in patients with late-onset hypogonadism. METHODS: In this open-label, randomized, crossover study, 29 patients with late-onset hypogonadism were randomly assigned to receive testosterone replacement therapy for 12 weeks followed by combination treatment for 12 weeks (Group 1) or combination treatment for 12 weeks followed by testosterone replacement therapy (Group 2). Symptom questionnaires were administered and blood tests were performed prior to and following each treatment to assess safety and efficacy. At the end of the study, participants were asked about their treatment preferences. RESULTS: An adverse effect, a rheum symptom, occurred in only one participant, and 26 participants completed the study without any toxicity. Scores on the Aging Male Symptoms scale and the modified short version of the International Index of Erectile Function, and Overactive Bladder Symptom scores were significantly improved in the combination treatment phase of Group 2, whereas no significant difference between the phases were observed in Group 1. In total, 12 out of the 14 participants in Group 1 and 11 out of the 12 participants in Group 2 preferred combination treatment, which reached statistical significance (P = 0.008 and 0.004 for Groups 1 and 2, respectively). CONCLUSIONS: Testosterone replacement therapy with add-on alternate-day tadalafil is a safe and satisfactory treatment for patients with late-onset hypogonadism.

Pazopanib after Nivolumab-Induced Tumor Lysis Syndrome in a Patient with Metastatic Clear-Cell Renal Cell Carcinoma.

Nivolumab, a programmed death-1 checkpoint inhibitor, is worldwide available for metastatic renal cell carcinoma (mRCC). Limited data exist on the response to vascular endothelial growth factor receptor-tyrosine kinase inhibitor (TKI) therapy after administration of nivolu-mab. In this case study, we report on a patient with tumor lysis syndrome (TLS), which was induced by pazopanib after the administration of nivolumab. A 69-year-old woman with a primary diagnosis of mRCC received pazopanib as a fourth-line therapy, after sunitinib, axitinib, and nivolumab as first-, second-, and third-line therapies, respectively. Two weeks after the administration of pazopanib, she presented to the emergency room of our institution, complaining of fatigue associated with nausea and diarrhea. Her laboratory results showed hyperphosphatemia, hyperuricemia, hypocalcemia, and possible acute kidney injury; the results were consistent with TLS. Our case report highlights TLS as a potential reaction to pazopanib following nivolumab; and we consider careful observation is necessary when administering TKI after immune checkpoint inhibitors.

Efficacy of combined treatment of intramuscular testosterone injection and testosterone ointment application for late-onset hypogonadism: an open-labeled, randomized, crossover study.

INTRODUCTION: The best method for administering testosterone replacement therapy (TRT) for late-onset hypogonadism (LOH) remains controversial. This study aimed to compare the efficacy and safety of a combined treatment (CT) involving intramuscular testosterone injection and testosterone ointment application [Glowmin® (GL)] with intramuscular injection monotherapy (IMIM). MATERIALS AND METHODS: Patients were randomly assigned as follows: Group 1 received IMIM for 12 weeks and CT for 12 weeks and Group 2 received CT for 12 weeks and IMIM for 12 weeks. Patients were then asked about their treatment preferences: (A) IMIM, (B) a combination of IMIM and ointment, or (C) either A or B. RESULTS: Patients (n = 43) completed the study without any adverse effects. No significant differences between each treatment period were found. In Group 1, most patients chose B (n = 13) while in Group 2, most chose A (n = 10). In each group, patients preferred the second treatment phase; however, statistical significance was not reached between A and B (Group 1, p = 0.11 and Group 2, p = 0.47, respectively). CONCLUSION: TRT by CT is compatible with TRT by IMIM. Patients who cannot continue TRT because of polycythemia from IMIM may be suited to CT.

Clinical features of immune-related thyroid dysfunction and its association with outcomes in patients with advanced malignancies treated by PD-1 blockade.

Programmed cell death protein-1 (PD-1) blockade therapy has improved outcomes in the treatment of advanced cancers. The therapy is well-tolerated, although it occasionally causes immune-related adverse events (irAEs). Thyroid dysfunction is one of the most common irAEs seen. Our aim was to clarify the clinical characteristics of thyroid dysfunction induced by PD-1 blockade and its association with the therapeutic effect of the treatment in advanced cancers. A total of 174 patients who received nivolumab or pembrolizumab for metastatic or unresectable advanced cancers were included in this retrospective study. The patients were divided into two groups: The thyroid dysfunction group and the euthyroid group. In the present study, the clinical characteristics, the association with anti-thyroid antibodies, as well as the progression-free survival (PFS) and overall survival (OS) were estimated. An adjusted Cox proportional hazard regression model was used to evaluate prognostic factors for OS and PFS. This study showed that 25 out of 150 patients (16.7%) developed immune-related thyroid dysfunction. Hypothyroidism occurred in the early stage of the clinical course (median: 12 weeks); subsequently, 9 of the 25 patients underwent a transient period of hyperthyroidism, all with mild symptoms. The presence of positive anti-thyroid antibodies at baseline was significantly higher in the thyroid dysfunction group (13/22) than in the euthyroid group (18/100, P=0.0002). Moreover, PFS (median: 66 vs. 27 weeks, hazard ratio (HR): 0.50, 95% CI: 0.26-0.89, P=0.02) and OS (median 156 vs. 59 weeks, HR: 0.34, 95% CI: 0.13-0.75, P=0.01) were significantly longer in the thyroid dysfunction group than in the euthyroid group. Multivariable analysis also revealed that thyroid dysfunction was an independent prognostic factor for OS (HR: 0.42, 95% CI: 0.16-0.97, P=0.04). These findings may enable the early recognition and appropriate management of thyroid dysfunction, and help in maximizing the therapeutic effect of PD-1 blockade.

Robot-assisted laparoscopic partial nephrectomy for horseshoe kidney: A case report.

INTRODUCTION: Horseshoe kidney has unique anatomical features, such as a complex blood supply. We report a patient with renal cell carcinoma in a horseshoe kidney, who underwent tumor resection by robot-assisted laparoscopic partial nephrectomy based on preoperative three-dimensional computed tomography. CASE PRESENTATION: A 66-year-old man was referred to our hospital with a 2-cm enhancing mid-pole mass in the left moiety of a horseshoe kidney. The clinical diagnosis was renal cell carcinoma cT1aN0M0 (R.E.N.A.L. nephrometry score: 1 + 2 + 3 + 3 = 9p). Robot-assisted laparoscopic partial nephrectomy was performed with selective clamping based on reconstructed three-dimensional images. The warm ischemia time was 13 min. Pathologic examination confirmed a diagnosis of pT1a clear cell renal cell carcinoma with negative surgical margins. At 6 months postoperatively, computed tomography showed no local recurrence or metastasis and renal function was intact. CONCLUSION: Robot-assisted laparoscopic partial nephrectomy with preoperative three-dimensional computed tomography may have advantages for resection of tumors in patients with horseshoe kidney.

Tumour multifocality and grade predict intravesical recurrence after nephroureterectomy in patients with upper urinary tract urothelial carcinoma without a history of bladder cancer.

OBJECTIVE: Patients with upper urinary tract urothelial carcinoma (UUT-UC) without a history of bladder cancer have a different natural history of intravesical recurrence after nephroureterectomy compared with those with a history of bladder cancer. The aim of this study was to identify predictive factors for post-operative intravesical recurrence in patients with non-metastatic upper urinary tract-localized urothelial carcinoma without a history of bladder cancer and who were not taking medication during the perioperative period. METHODS: This retrospective study included 133 patients who were treated between 1995 and 2012. Univariate and multivariate analyses were used to evaluate the clinical and pathological factors associated with the cumulative incidence of bladder cancer. RESULTS: Of the 133 patients, 51 (38.3%) developed intravesical recurrence during a median follow-up of 71 months (range, 0.8-210.8). In the multivariate analysis, multifocality (P = 0.03) and high tumour grade (P = 0.007) were significantly associated with the cumulative incidence of bladder cancer. We constructed a prediction classification model on the basis of the total number of risk factors. The 2-year cumulative incidence rates were 5.6, 34.8 and 50.0% in individuals with no, one and two risk factors, respectively. There was a significant difference between patients with no risk factors and those with two risk factors (P = 0.01). CONCLUSIONS: Although this retrospective study had several limitations, tumour multifocality and tumour grade were found to be potential risk factors for intravesical recurrence in our cases.

[A pediatric wilms' tumor presenting with a right renal injury].

We report a case of a pediatric Wilms' tumor presenting after a right renal injury. A 6-year-old girl presented to a nearby hospital with right back pain after a fall. An abdominal computed tomography (CT) scan revealed a right renal injury with active hemorrhaging. She was then referred to our hospital. There another CT scan and a magnetic resonance imaging (MRI) scan revealed the disappearance of the active hemorrhaging but also the presence of a large renal tumor. We performed a right nephrectomy. The renal tumor was diagnosed as a nephroblastoma. Considering dissemination by trauma, chemotherapy and radiation therapy were performed.