[A Case of Small Cell Carcinoma of the Urethra].

We report a case of small cell carcinoma of the urethra with inguinal lymph node metastases. A 50- year-old female patient presented with gross hematuria. Cystoscopy and computed tomography (CT) revealed a tumor surrounding the urethra and an inguinal lymphadenopathy. Biopsy of the urethral tumor demonstrated small cell carcinoma. Four courses of chemotherapy with etoposide and cisplatin, followed by 66 Gy of irradiation achieved complete remission. Unfortunately, 14 months later, positroemission-CT scan revealed recurrence of inguinal lymph node metastases. Although seven courses of chemotherapy with nogitecan were carried out, a new metastatic bone tumor developed. Amrubicin was administered as a third-line treatment, but was canceled after one course because of side effects. The patient died at 39 months after diagnosis. Small cell carcinoma of urethra with metastases has extremely poor prognosis, as is demonstrated by this case.

[A Case of Intra-Abdominal Testicular Cancer Occurring from an Overlooked Intra-Abdominal Testis in Undescended Testicular Surgery].

Here, we report an adult case of intra-abdominal testicular cancer after surgical treatment of an undescended testis in infancy. A 36-year-old male patient was accidentally diagnosed with a tumor in the pelvic cavity by ultrasonographic examination. He had hematuria and the human chorionic gonadotropin beta subunit level was slightly elevated. T2-weighedmagnetic resonance imaging revealed a well-defined and highly intense mass. Since these findings suggested intra-abdominal testicular cancer, laparoscopic surgery was performed to remove the mass. Laparoscopy revealed an intra-abdominal tumor accompanied by a looping vas deferens entering the left inguinal canal. The distal part of the looping vas had already been removed from the external inguinal ring. The pathological findings revealed a pT1 seminoma. The patient has been recurrence-free for 12 months. The present case implies the importance of careful investigation and treatment for intra-abdominal testicular cancer, since intra-abdominal testis might have been overlooked at the time of surgery for undescended testis.

Near-infrared ray catheter and indocyanine green via nephrostomy in delayed robotic reconstruction of injured ureter: A case report.

Delayed surgical reconstruction of iatrogenic ureteral injuries is often a challenging procedure because spreading scar tissue impedes accurate identification and dissection of the injured ureter. We report a novel real-time navigation system using a ureteral near-infrared ray catheter (NIRC) and indocyanine green (ICG) via nephrostomy in delayed robot-assisted ureteral reconstruction. A female patient presented with complete obstruction of the right upper ureter after gynecological surgery with extensive lymphadenectomy. A nephrostomy tube was urgently placed, and surgical repair was performed. A straight NIRC was placed in the right ureter up to the obstruction point. ICG was administered via nephrostomy. Near-infrared light could clearly visualize the ureter and renal pelvis encased in scar tissue. The ureter and renal pelvis were dissected and successfully anastomosed. We found that near-infrared navigation using ureteral NIRC and ICG via nephrostomy was valuable for delayed laparoscopic reconstruction of the injured ureter.

[A Case of Pelvic Unicentric Castleman Disease Treated by Preoperative Transcatheter Arterial Embolization and Tumor Complete Resection with Combined Lower Abdominal and Posterior Approach].

A 22-year-old woman was referred to our hospital for further examination of an incidentally discovered hypervascular pelvic tumor with a maximum diameter of 10 cm. Although Castleman disease was suspected based on the imaging findings and pathologic findings of the needle biopsy, a definitive diagnosis was not made. Preoperative transcatheter arterial embolization was performed to decrease intraoperative bleeding, and tumor resection was performed on the following day. As for posterior approach prior to anterior approach, the patient was placed in a prone position, and the dorsal aspect of tumor was approached through the dissection of gluteal muscles. Then, dilated branches of the internal iliac vein was found on the tumor capsule, which were safely ligated under direct vision with favorable visual field. Then, the patient was placed in a supine position, the tumor was completely resected by anterior approach without transfusion. Histopathological diagnosis was Castleman disease hyaline vascular type. The patient was discharged without complication and has been free from recurrence for 6 months after surgery.

[COST ANALYSIS OF ANDROGEN DEPRIVATION THERAPY AND DRUGS FOR CASTRATION-RESISTANT PROSTATE CANCER].

(Purpose) Recently, new effective drugs for the treatment of castration-resistant prostate cancer (CRPC) have been developed. Although they are expected to prolong the survival time of patients with advanced prostate cancer, they may result in an economic burden. In this study, we determined the treatment results and the cost of CRPC drugs. (Methods) From 2014 to 2017, patients who were unfit for curative therapy were enrolled in this study. First, they received androgen deprivation therapy (ADT) by surgical or chemical castration. Once castration-sensitive cancer progressed to castration-resistant cancer, CRPC drugs, such as docetaxel, cabazitaxel, abiraterone and enzalutamide, were administered sequentially. In elderly or fragile patients, drug doses were often reduced to minimize their toxicity. The total costs of drugs for castration-sensitive and castration-resistant cancers were calculated, and the results were evaluated. (Results) Prostate biopsies detected prostate cancer in 257 patients. Eighty-one patients were treated with ADT, and 56 of the cancers were metastatic or showed a high prostate specific antigen level (>100 ng/ml). Thirty patients out of the 56 with advanced cancers developed CRPC, and the median time to CRPC was 10 months (range, 3-39). Drugs targeting CRPC were administered in 25 patients for a median duration of 20 months (range, 3-50). During the median observation period of 48 months (range, 13-75), 15 patients died of prostate cancer. The median annual cost of drugs for castration-sensitive cancer was 234,000 Japanese yen (2,187 US dollars) [range, 50,000-315,000 yen (467-2,943 US dollars) ]. In contrast, the median annual cost of drugs for CRPC was 2,041,000 yen (19,075 US dollars) [range, 346,000-5,017,000 yen (3,230-46,886 US dollars) ]. (Conclusions) Advanced prostate cancer tended to rapidly progress to CRPC, which required a sequence of expensive drugs for treatment. Early diagnosis preventing the development of advanced prostate cancer is desirable to reduce the economic burden for the health insurance system.

Masked acute rejection of the graft kidney under the recovery of native kidneys in a patient who underwent simultaneous liver and kidney transplantation.

INTRODUCTION: Simultaneous liver and kidney transplantation is a life-saving procedure for patients with liver failure and irreversible renal dysfunction. However, some studies have reported the recovery of native renal function after simultaneous liver and kidney transplantation. CASE PRESENTATION: A 33-year-old woman initially underwent living-donor liver transplantation for liver failure. When graft liver failure developed, she also sustained acute renal failure and required continuous hemodiafiltration for 6 weeks. Simultaneous liver and kidney transplantation from a brain-dead donor recovered her liver and renal function. A 1-year protocol graft kidney biopsy revealed acute cellular rejection despite stable serum creatinine levels. Renal scintigraphy showed functional native kidneys masking acute rejection of the graft kidney. The rejection was improved by pulse steroid therapy. CONCLUSION: Acute rejection of the graft kidney may silently progress due to recovery of the native kidney function after simultaneous liver and kidney transplantation. Renal scintigraphy and graft kidney biopsy should be considered even if blood tests indicate stable total renal function.

[Clinical Effect of Nivolumab on Advanced Renal Cell Carcinoma with Peritoneal Metastasis].

Peritoneal dissemination or metastasis is a relatively rare presentation of renal cell carcinoma. We report four cases of advanced renal cell carcinoma with peritoneal metastases treated with nivolumab. Three cases showed an objective response in the metastatic lesions including peritoneal sites. After nivolumab administration, the computed tomography scan showed a transient enlargement of peritoneal lesions in two cases, which could be considered as pseudoprogression. Temporal changes of neutrophil-tolymphocyte ratio, C-reactive protein, and eosinophil ratio during the clinical course reflected the treatment effect of nivolumab in these patients, indicating that these could be potential biomarkers of the response. To our knowledge, this is the first case series showing therapeutic activity of nivolumab against peritoneal metastases in patients with renal cell carcinoma.

[A Case of Late Onset Nivolumab-Induced Interstitial Nephritis in a Patient with Metastatic Renal Cell Carcinoma].

A 43-year-old man underwent nephrectomy for right renal cell carcinoma (cT3aN0M1 (PUL), clear cell carcinoma). Thereafter, he was treated with sunitinib for lung metastases as the first-line therapy for three months. Because lung metastases progressed and new bone metastases appeared, nivolumab was started for the second-line treatment. Although the cancer progression was suppressed by multidisciplinary treatment combined with systemic immunotherapy and local radiation therapy, he developed severe acute kidney injury with cortical swelling after eighteen months of nivolumab treatment. A diagnosis of acute interstitial nephritis induced by nivolumab was made based on biopsy findings. Treatment with prednisolone (1.0 mg/kg daily) led to a rapid improvement in renal function. We must consider the possibility of immunerelated adverse events, especially nivolumab-induced acute kidney injury, even after long-term treatment.

[A Case of Pulmonary Tumor Thrombotic Microangiopathy in Castration-Resistant Prostate Cancer].

A man aged 83 years under treatment with enzalutamide for castration-resistant prostate cancer presented with general malaise and exertional dyspnea. The underlying cause could not be identified by further investigations. On the 5th hospital day, he died due to a sudden exacerbation of dyspnea. The results of an autopsy indicated tumor emboli and stenosis of small pulmonary arteries with the fibrocellular intimal thickening, and therefore our final diagnosis was pulmonary tumor thrombotic microangiopathy.

[The Study of Surgical Outcome for Robotic-Assisted Laparoscopic Radical Prostatectomy : Experience of a Single Surgeon with 70 Initial Cases].

We investigated the surgical outcome for robotic-assisted laparoscopic radical prostatectomy (RALP) withinitial 70 prostate cancer cases performed by a single surgeon between June 2014 and May 2016. The surgeon had a previous experience of more than 400 cases of laparoscopic radical prostatectomy (LRP). Comparative study of the surgical outcome was made between the first 35 patients (group 1) and the second 35 patients (group 2). The console time without lymph node dissection significantly decreased from group 1 to 2 (193 min vs 158 min, p=0.002). Among specific 3 parts of the console operation (part 1 : until the bladder neck transection, part 2 : until the prostate removal and part 3 : urethrovesical anastomosis), duration of parts 1 and 2 similarly decreased witha significant difference of 0. 001 and 0. 002, respectively. Continence recovery rates 1 month after RALP were significantly higher in group 2 than in group 1 (group1 : 48.5% vs group 2 : 74.2%, p=0.02). Between groups 1 and 2, the positive surgical margin rates of both pT2 and pT3 were similar (group 1 : 20. 8 and 50. 0%, group 2 : 17. 2 and 50. 0%, respectively). The perioperative 8 complications (11.4%) were classified into Clavien-Dindo grades 1 and 2. Our surgical outcome of initial 70 RALP cases was considered as comparable to that reported from the high volume centers.

[Urethral Hemangioma with Repeated Urinary Retention by Posterection Hematuria].

A 73-year-old man presented to our hospital due to postejaculation gross hematuria and dysuria. Three months after onset, urinary retention occurred repeatedly. Under general anesthesia, cystourethroscopy following drug-induced erection was performed. A solitary sessile lesion with varicosis was found between the verumontanum and external sphincter. The tumor was resected endoscopically and recurrence was not observed during the follow-up period. Histological examination revealed a cavernous hemangioma of the urethra. Urologists should keep in mind that urethral hemangioma can be a cause of hematuria after erection or ejaculation.