[A case of colonic adenocarcinoma incidentally occurring in an Indiana pouch].

We present a rare case of colonic adenocarcinoma occurring in an Indiana pouch. A 68-year-old man underwent radical cystectomy with Indiana pouch urinary diversion for the treatment of bladder cancer 16 years ago. He was referred to our hospital for the treatment of a right staghorn stone, left renal stone, and pouch stones. Cystoscopic findings showed a 10×10 mm tumor distal to ureter anastomosis. Under the diagnosis of colonic adenocarcinoma in an Indiana pouch, tumor and stones were successfully removed. Adenocarcinoma occurrence after ureterosigmoidostomy is well-known. However, diagnosis of adenocarcinoma in an Indiana pouch is extremely rare.

[A case of inverted urothelial carcinoma of bladder].

We present a case of inverted urothelial carcinoma of the bladder. A 60-year-old male was referred to our hospital for bilateral ureteral stones. When transurethral ureterolithotripsy was performed to treat these stones, a tumor at the trigone of bladder was incidentally diagnosed. This tumor was pedunculated and its surface was not uniformly round. After the operation, this tumor was diagnosed as inverted urothelial carcinoma through the histopathologic examination. The patient was subsequently followed up for 6 months and there was no evidence of recurrence. Although this is a rare case, it is worth considering there is an urothelial carcinoma with inverted proliferation.

[A case of mesothelial cyst at the inguinal region].

A 54-year-old man presented with the left inguinal swelling. The operation was performed with diagnosis of the hydrocele of spermatic cord. A tumor was 3.0 cm x 2.5 cm in size, cystic with yellowish serous fluid. After the operation, this tumor is diagnosed as mesothelial cyst through the histopathologic examination. This is a rare case, however it is worth to consider that there is a possibility to be a mesothelial cyst when the tumor has been found at the inguinal region.

[Successful gemcitabine-nedaplatin therapy in a hemodialysis patient with ureteral carcinoma after bilateral nephroureterectomy].

A 79-year-old male, who received hemodialysis due to bilateral nephroureterectomy and cysto-prostateurethrectomy. Five months later, an enlarged lymph node was found in the left of inguinal area. Abdominal computed tomography revealed a low density mass from the para-aortic lymph node to the left of inguinal area, suggesting lymph node metastasis of ureteral carcinoma. After 3 cycles of gemcitabinenedaplatin therapy, the size of lymph node metastasis decreased. This is a report of successful treatment of ureteral carcinoma with hemodialysis.

Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens.

PURPOSE: The prognostic significance of positive surgical margins (PSM) in radical prostatectomy (RP) specimens remains unclear. While most studies have concluded that a PSM is an independent adverse prognostic factor, others report that surgical margin status has no effect on prognosis. One reason for these discordant conclusions is the variable number of patients with a PSM who receive adjuvant therapy and the differing statistical methods used to account for the effects of the time course of adjuvant treatment on recurrence. We evaluated the prognostic significance of PSMs using multiple methods of analysis accounting for patients who received adjuvant therapy. MATERIALS AND METHODS: We analyzed 1,389 consecutive patients with clinical stage T1-3 prostate cancer treated with RP by 2 surgeons from 1983 to 2000. Of 179 patients with a PSM, 37 received adjuvant therapy (AT), 29 radiation therapy and 8 received hormonal therapy. Because the method used to account for men receiving AT can affect the outcome of the analysis, data were analyzed by the Cox proportional hazards technique accounting for patients receiving AT using 5 methods: 1) exclusion, 2) inclusion (AT ignored), 3) censoring at time of AT, 4) failing at time of AT and 5) considering AT as a time dependent covariate. RESULTS: Overall 179 patients (12.9%) had a PSM, including 6.8% of 847 patients with pT2 and 23% of 522 patients with pT3 disease. A PSM was a significant predictor of cancer recurrence when analyzed using methods 1, 3, 4 and 5 (p=0.005, p=0.014, p=0.0005, p=0.002, respectively). However, it was not a predictor of recurrence using method 2 in which AT was ignored (p=0.283). Using method 5 multivariate analysis demonstrated that a PSM (p=0.002) was an independent predictor of 10-year progression-free probability (PFP) along with Gleason score (p=0.0005), extracapsular extension (p=0.0005), seminal vesicle invasion (p <0.0005), positive lymph nodes (p <0.0005) and preoperative serum prostate specific antigen (p <0.0001). Using method 5 the 10-year PFP was 58% +/- 12% and 81% +/- 3% for patients with and without a PSM, respectively (p <0.00005). The relative risk of recurrence in men with a PSM using method 5 was 1.52 (95% confidence interval 1.06-2.16). CONCLUSIONS: We confirm that a PSM has a significant adverse impact on PFP after RP in multivariate analysis using multiple statistical methods to account for patients who received AT. While prostate cancer screening strategies have resulted in a majority of men having organ confined disease at RP, surgeons should continue to strive to reduce the rate of positive surgical margins to improve cancer control outcomes.

Transurethral ureterolithotripsy and extracorporeal shock wave lithotripsy in patients with idiopathic thrombocytopenic purpura.

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease defined by a low platelet count secondary to accelerated platelet destruction by anti-platelet antibodies. The resulting bleeding diathesis can present a therapeutic dilemma. We have treated two cases of ITP in which ureteral stones were successfully extracted by transurethral ureterolithotripsy (TUL) and extracorporeal shock wave lithotripsy (ESWL) after high-dose gamma-globulin therapy. The first case was in a 52-year-old woman and the second case was in a 65-year-old woman. Intravenous pyelography revealed a left ureteral stone in the first case and bilateral ureteral stones in the second case. High-dose gamma-globulin therapy and platelet transfusion elevated their platelet counts to safe levels; TUL and ESWL were then performed successfully with no bleeding complications. This is the first case report of ITP being treated by ESWL after high-dose gamma-globulin therapy. High-dose gamma-globulin therapy effectively provides adequate platelet counts for surgical treatment in patients with ITP.

Prognostic significance of location of positive margins in radical prostatectomy specimens.

OBJECTIVES: Cancer at the resection margin is associated with an increased risk of biochemical recurrence after radical prostatectomy (RP) even after adjusting for other known clinical and pathologic risk factors. In this study, we assessed the prognostic significance of sites of positive surgical margins (+SMs) in RP specimens. METHODS: We reviewed the data from 2442 patients with clinical Stage T1-T3 prostate cancer treated with RP from 1983 to 2004 who had had tumor maps generated from whole mount sections. The site of +SMs was assigned to six different areas (apex, bladder neck, seminal vesicle, anterior, posterolateral, and posterior). RESULTS: Of the 2442 patients, 201 (8.2%) had a +SM at a single site and 74 (3.0%) had a +SM at multiple sites in the RP specimen. The posterolateral and apex sections were the most commonly involved sites for a +SM. Those with a +SM had a greater risk of biochemical recurrence than those with negative surgical margins (hazard ratio 1.39, 95% confidence interval 1.004 to 1.92; P = 0.047). We found that a +SM at the posterolateral site was significantly associated with an increased risk of biochemical recurrence (hazard ratio 2.80 for +SMs versus negative SMs at the posterolateral region; 95% confidence interval 1.76 to 4.44). CONCLUSIONS: The effect on biochemical recurrence was influenced by the site of the +SM, with a posterolateral location having the most significant effect on prognosis. This heterogeneity of margin status has implications for predictive modeling, as well as the recommendation for adjuvant radiotherapy.

[Uncertain analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopy for men].

PURPOSE: The analgetic efficacy of intraurethral instillation of anesthetic jelly in rigid cystoscopic examination for men is not clearly confirmed. This study evaluated the usefulness of intraurethral instillation of anesthetic jelly by questionnaires regarding the pain and uncomfortable feelings during and after the cystoscopic examination. MATERIALS AND METHODS: A total of 62 men were enrolled in the study. Sixteen patients had not received cystoscopy previously (first cases), and 46 had prior experiences of cystoscopy more than twice (repeat cases). These patients were sequentially divided into two groups; one group (jelly-group) received intraurethral instillation of oxybuprocaine hydrochroride jelly (Benoxil jelly) prior to cystoscopic examination, and the other group (no-jelly-group) did not receive the jelly instillation. Pain during the jelly instillation to examination, and uncomfortable feelings at micturition after the examination was evaluated by questionnaires. RESULTS: Instillation of the jelly itself caused considerable pain, which almost similar to that of scope insertion. There was no significant difference in pain score between jelly-group and no-jelly-group during the insertion of the scope to examination. The miction pain after examination was significantly severer in the jelly-group than in the no-jelly-group in repeat cases. In addition, 75% of repeat cases felt better comfortableness when jelly was not instilled, and 96% of repeat cases did not want jelly instillation for their future examination. CONCLUSIONS: Intraurethral instillation of anesthetic jelly had no efficacy for reducing the pain during cystoscopy. Instillation of the jelly itself caused considerable pain, and it made pain and uncomfortable feelings after the examination worse. These results suggested that the instillation of anesthetic jelly before rigid cystoscopy in men might not be useful enough for reducing the uncomfortable feeling during the examination.

Do margins matter? The prognostic significance of positive surgical margins in radical prostatectomy specimens.

PURPOSE: The prognostic significance of positive surgical margins (PSM) in radical prostatectomy (RP) specimens remains unclear. While most studies have concluded that a PSM is an independent adverse prognostic factor, others report that surgical margin status has no effect on prognosis. One reason for these discordant conclusions is the variable number of patients with a PSM who receive adjuvant therapy and the differing statistical methods used to account for the effects of the time course of adjuvant treatment on recurrence. We evaluated the prognostic significance of PSMs using multiple methods of analysis accounting for patients who received adjuvant therapy. MATERIALS AND METHODS: We analyzed 1,389 consecutive patients with clinical stage T1-3 prostate cancer treated with RP by 2 surgeons from 1983 to 2000. Of 179 patients with a PSM, 37 received adjuvant therapy (AT), 29 radiation therapy and 8 received hormonal therapy. Because the method used to account for men receiving AT can affect the outcome of the analysis, data were analyzed by the Cox proportional hazards technique accounting for patients receiving AT using 5 methods: 1) exclusion, 2) inclusion (AT ignored), 3) censoring at time of AT, 4) failing at time of AT and 5) considering AT as a time dependent covariate. RESULTS: Overall 179 patients (12.9%) had a PSM, including 6.8% of 847 patients with pT2 and 23% of 522 patients with pT3 disease. A PSM was a significant predictor of cancer recurrence when analyzed using methods 1, 3, 4 and 5 (p=0.005, p=0.014, p=0.0005, p=0.002, respectively). However, it was not a predictor of recurrence using method 2 in which AT was ignored (p=0.283). Using method 5 multivariate analysis demonstrated that a PSM (p=0.002) was an independent predictor of 10-year progression-free probability (PFP) along with Gleason score (p=0.0005), extracapsular extension (p=0.0005), seminal vesicle invasion (p <0.0005), positive lymph nodes (p <0.0005) and preoperative serum prostate specific antigen (p <0.0001). Using method 5 the 10-year PFP was 58% +/- 12% and 81% +/- 3% for patients with and without a PSM, respectively (p <0.00005). The relative risk of recurrence in men with a PSM using method 5 was 1.52 (95% confidence interval 1.06-2.16). CONCLUSIONS: We confirm that a PSM has a significant adverse impact on PFP after RP in multivariate analysis using multiple statistical methods to account for patients who received AT. While prostate cancer screening strategies have resulted in a majority of men having organ confined disease at RP, surgeons should continue to strive to reduce the rate of positive surgical margins to improve cancer control outcomes.

Predicting the presence and side of extracapsular extension: a nomogram for staging prostate cancer.

PURPOSE: We developed a model to predict the side specific probability of extracapsular extension (ECE) in radical prostatectomy (RP) specimens based on the clinical features of the cancer. MATERIALS AND METHODS: We studied 763 patients with clinical stage T1c-T3 prostate cancer who were diagnosed by systematic needle biopsy and subsequently treated with RP. Candidate predictor variables associated with ECE were clinical T stage, the highest Gleason sum in any core, percent positive cores, percent cancer in the cores from each side and serum prostate specific antigen (PSA). Receiver operating characteristic (ROC) analyses were performed to assess the predictive value of each variable alone and in combination. We constructed and internally validated nomograms to predict the side specific probability of ECE based on logistic regression analysis. RESULTS: Overall 30% of the patients and 17% of 1,526 prostate lobes (left or right) had ECE. The areas under the ROC curves (AUC) of the standard features in predicting side specific probability of ECE were 0.627 for PSA, 0.695 for clinical T stage on each side and 0.727 for Gleason sum on each side. When these features were combined predictive accuracy increased to 0.788. The highest value (0.806) was achieved by adding the percent positive cores and the percent cancer in the biopsy specimen to the standard features. The resulting nomograms were internally validated and had excellent calibration and discrimination accuracy. CONCLUSIONS: Standard clinical features of prostate cancer in each lobe-PSA, palpable induration and biopsy Gleason sum-can be used to predict the side specific probability of ECE in RP specimens. The predictive accuracy is increased by adding information from systematic biopsy results. The predictive nomograms are sufficiently accurate for use in clinical practice in decisions such as wide versus close dissection of the cavernous nerves from the prostate.

Counseling men with prostate cancer: a nomogram for predicting the presence of small, moderately differentiated, confined tumors.

PURPOSE: Men diagnosed with clinically localized prostate cancer have a number of treatment options available, including watchful waiting, radical prostatectomy and radiation therapy. With the widespread use of serum prostate specific antigen (PSA) testing, prostate cancers are being diagnosed earlier in their natural history, with many tumors being small and of little health risk to the patient, at least in the short term. To better counsel men diagnosed with prostate cancer, we developed a statistical model that accurately predicts the presence of small moderately differentiated, confined cancer based on clinical variables (serum PSA, clinical stage, prostate biopsy Gleason grade and ultrasound volume) and variables derived from the analysis of systematic biopsies. MATERIALS AND METHODS: The analysis included 409 patients diagnosed by systematic needle biopsy with clinical stages T1c or T2a N0 or NX and M0 or MX prostate cancer who were treated solely with radical prostatectomy at 1 of 2 institutions. Additional biopsy features included number and percentage of biopsy cores involved with cancer and high grade cancer, in addition to total length of biopsy cores involved. Indolent cancer was defined as pathologically organ confined cancer 0.5 cc or less in volume and without poorly differentiated elements. Logistic regression was used to construct several prediction models and the resulting nomograms. RESULTS: Overall 80 (20%) of the patients had indolent cancer. The nomogram predicted the presence of an indolent cancer with discrimination (area under the receiver operating characteristics curves) for various models ranging from 0.64 to 0.79. Calibration of the models appeared good. CONCLUSIONS: Nomograms incorporating pretreatment variables (clinical stage, Gleason grade, PSA and the amount of cancer in a systematic biopsy specimen) can predict the probability that a man with prostate cancer has an indolent tumor. These nomograms have good discriminatory ability and calibration, and may benefit the patient and clinician when the various treatment options for prostate cancer are being considered.

A nomogram to predict seminal vesicle invasion by the extent and location of cancer in systematic biopsy results.

PURPOSE: We determined whether systematic biopsy results increases the accuracy of standard clinical information in predicting seminal vesicle invasion (SVI). MATERIALS AND METHODS: We analyzed a retrospective cohort of 763 patients with clinical stages T1c-T3 prostate cancer who were diagnosed by systematic biopsy and treated with radical prostatectomy. We recorded the location of each biopsy core and measured the length of cancer and total length of each core. Using logistic regression analysis we constructed and internally validated a nomogram to predict SVI. RESULTS: A total of 60 patients (7.9%) had SVI. Cancer was present in a biopsy core from the base in 437 patients, of whom 12.8% had SVI compared with only 1.2% of the 326 without cancer at the base. None of the 275 patients with prostate specific antigen (PSA) 10 ng/ml or less and no cancer at the base had SVI. On multivariate analysis serum PSA (p <0.0005), primary Gleason grade (p = 0.028) and percent cancer at the base (p <0.005) were the only significant predictors of SVI. The predictive accuracy of a standard model that included only stage, grade and PSA was maximally enhanced by including the percent cancer at the base (p = 0.0013). A nomogram that incorporated this variable produced probabilities of SVI that differed from the standard model by +/- 10% in 68% of the cases. CONCLUSIONS: The presence and amount of cancer in systematic needle biopsy cores from the base of the prostate strongly predicts the presence of SVI. Systematic biopsy results enhance the accuracy of nomograms to predict SVI.

[Metallic stents as a new therapeutic procedure for urinary tract obstruction].

Tube stents are widely used to achieve internal urinary drainage in the urology field. Recently, in an attempt to improve upon metallic stents, these stents were introduced for use in the obstructed urethra and ureter. We review the current indications and devices for internal urinary drainage using metallic stents. In recent years, intraprostatic metallic stents have been established as a minimally invasive alternative treatment for benign prostatic hyperplasia (BPH). Appropriate patient selection and optimal stent positioning are required. However, intraprostatic metallic stents represent a useful option to BPH therapy for high operative-risk patients. Only limited data exist concerning patency rates and the efficacy of stent treatment of ureteral obstruction, and the indications for the implantation of metallic stents in these patients is controversial. The efficacy of metallic stents in this situation is not clear, but some investigators suggest that the implantation of metallic stents in obstructed ureters may be safely and effectively performed in patients with incurable malignancies.

[Experience with the memotherm stent in high-risk urinary retention patients].

PURPOSE: We report on our experience with the Memotherm stent implanted in high-risk patients who had an indwelling catheter. PATIENTS AND METHODS: Seventeen patients (mean age 80.6 years, range 55 to 93) who had an indwelling catheter were treated by placement of the Memotherm stent. The mean duration time of indwelling catheter were 12.7 months (range 1 to 60). The methods of implantation was used the special delivery system and treatment can be done with the patient under local anesthesia with non-steroidal anti-inflammatory drug. To assess the efficacy of the treatment we measured urinary peak flow rate (ml/sec), residual urine volume (ml) and residual urine rate (residual urine volume/total urine volume: %). Subjective symptoms were evaluated using the International Prostate Symptom Score (I-PSS). The mean follow-up time was 3.3 months (range 1 week to 8 months). RESULTS: There were no severe medical problems associated with stent placement. Sixteen patients were able to void immediately after insertion of the stent. The remaining 1 required an indwelling catheter to 2 months, however, eventually able to void. Only 7 of the 17 patients can be evaluation for urinary flow and residual urine, nevertheless the mean urinary peak flow rate showed 9.7 ml/sec, the mean residual urine volume was 77.4 ml, and the mean residual urine rate was 27.5%. Also, average I-PSS showed 13.4 in these patients. CONCLUSIONS: As a results of this study, the Memotherm stent is good conservative therapy for high-risk urinary retention patients.

[Two cases of ganglioneuroma].

Ganglioneuroma is relatively rare, and difficult to distinguish from other tumors due to lack of image findings specific for ganglioneuromas. In this report, two cases of ganglioneuroma preoperatively diagnosed as non-functioning adrenal tumor and retroperitoneal tumor are reported. A 25-year-old male and a 29-year-old male visited our institute with chief complaints of upper abdominal pain and asymptomatic microscopic hematuria, respectively. Computed tomographic scan and magnetic resonance imaging showed a 7 x 6 x 5 cm solid tumor above the upper pole of the right kidney in the former case, 8 cm poorly enhanced tumor grown surrounding the left renal artery in the latter case. Surgical resection was performed in both cases. In the latder case, since intraoperative histological examination showed no malignant finding, renal vessels penetrating in the tumor were preserved by transecting the tumor. Postoperative histological examination revealed an adrenal ganglioneuroma and a retroperitoneal ganglioneuroma in the former and latter cases, respectively. A ganglioneuroma can be surgically dissected with favorable prognosis, but preoperative differential diagnosis is sometimes difficult due to few specific radiological and laboratory findings.

[The clinicopathological characteristics in renal cell carcinoma with end-stage renal disease].

OBJECTIVES: The influence and the interdependence of pathological and clinical factors on prognostic differences between renal cell carcinoma (RCC) with end-stage renal disease (ESRD) and RCC without ESRD after nephrectomy has remained unclear. We compare the clinicopathological features between RCC with and without ESRD. MATERIALS AND METHODS: From June 1993 to May 2000, 150 RCC patients who underwent nephrectomy were pathologically defined to have pT1 to pT3NXM0. The patients were followed for 1 to 84 months (median 30 months) after the surgery. Total of 16 patients with ESRD and 134 patients without ESRD were studied, and the differences of clinicopathological features between two groups were statistically compared. RESULTS: We compare the clinicopathological features between RCC with and without ESRD. Patients' age, tumor size, rate of incidental cancer, pathological T stage, and grade were not significantly different between two groups. The 5-year recurrence-free probability rate was significantly higher in patients without ESRD than in patients with ESRD (log-rank test: p = 0.04). The status of ESRD, patients age and pathological T stage were significant predictors of recurrence when analyzed by Cox proportional hazards analysis (p = 0.01, p = 0.03 and p = 0.02, respectively). CONCLUSIONS: This study demonstrated that the ESRD is an independent prognostic factor in RCC patients after surgery. These results reflect that the patients with ESRD have higher risk of tumor progression. Therefore, early detection of tumors is particularly important in these patients by regular abdominal ultrasound or CT screening.

[The 1992 TNM classification of T2 prostate cancer predicts pathologic stage and prognosis better than the revised 1997 classification].

PURPOSE: In the 1997 the TNM staging system for prostate cancer was changed, reclassifying, T2 cancers from 3 groups (T2a, less than one half of one lobe; T2b, one lobe; and T2c, both lobes) to 2 groups (T2a, one lobe; and T2b, both lobes), combining the 1992 T2a and T2b into the 1997 T2a subclassification. We investigated the pathological stage and prognosis of cancers in the 1992 and 1997 subclassification to determine whether this change was warranted. MATERIAL AND METHODS: We studied a consecutive series of 555 patients with clinical stage T2 prostate cancer treated with radical prostatectomy (RP) between 1983 and 1998. We analyzed the clinical, pathological features and PSA non-progression rate after prostatectomy for patients classified according to the 1992 and the 1997 TNM system. Median follow-up was 51.3 months. RESULTS: In the 1992 TNM system T2a tumors were more likely to have a low PSA (5.8 versus 7.2 and 8.1 ng/ml, p = 0.034, p = 0.012), be confined to the prostate (67% versus 45% and 40%, p < 0.001 for both), be poorly differentiated (48% versus 63% and 66%, p = 0.002 for both) and have a low cancer volume (1.22 versus 2.27 and 2.63 cm3, p = 0.005 for both) than T2b and T2c tumors. But there were no significant differences between T2b and T2c. Reflecting these results, the patients with T2a cancer had a significantly better prognosis with 82 +/- 4% PSA non-progression rate at 5 years compared to 68 +/- 4% of patients with T2b and 73 +/- 4% of patients with T2c (p = 0.007, p = 0.048, respectively). In the 1997 TNM system T2a tumors were also different from T2b tumors in terms with the frequency of confined cancer (54% versus 40%, p = 0.006) and cancer volume (1.78 versus 2.63 cm3, p = 0.013). However, the those differences were smaller than those in 1992 system. There were no significant differences between 1997 T2a and T2b cancers in the serum PSA level and the frequency of a poorly differentiated cancer. In fact, the 5-years recurrence-free survival rate for patients with T2a (73 +/- 3%) was identical to that for T2b cancer. In a Cox proportional hazard regression analysis, however, neither the 1992 nor the 1997 TNM staging subclassifications of T2 cancers were independent predictor of PSA non-progression when the age of patient, serum PSA level and biopsy Gleason grade were included in the analysis. CONCLUSION: Since a palpable tumor less than half of one lobe (1992 T2a) has a distinctly different pathological and prognostic significance compared to T2b and T2c cancers, the T2a subclassification should be retained in future revisions of TNM staging system. However, because the digital rectal examination provides limited information, both PSA results and histological grade in a biopsy specimen should be incorporated into future revision of the TNM staging system.