[Pelvic Reconstruction in Abdominal Trachelectomy and Bilateral Salpingo-Oophorectomy for Occult Uterine Endometrial Cancer Found in Specimens Removed in the Context of Laparoscopic Sacrocolpopexy].

In the patients undergoing pelvic organ prolapse (POP) repairs, the incidence of occult uterine endometrial cancer is low and there is no established management procedure for preoperative cancer screening. We report a case of pelvic reconstruction in abdominal trachelectomy and bilateral salpingo-oophorectomy for occult uterine endometrial cancer found in specimens removed in the context of laparoscopic sacrocolpopexy (LSC). A 70-year-old woman presented to our center with cystocele. She underwent LSC and laparoscopic supracervical hysterectomy. She had no atypical genital bleeding; and, transvaginal ultrasound, pelvic plane magnetic resonance imaging and cervical cytology showed no evidence of malignancy. However, the pathological examination showed uterine endometrial cancer. She underwent trachelectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection. A part of mesh was removed with a cervical stamp, but the remaining mesh was sewn together. At 5 months after the operation, no recurrence of uterine endometrial cancer and POP was seen.

Effects of a supplement combining Pycnogenol® and l-arginine aspartate on lower urinary dysfunction compared with saw palmetto extract.

OBJECTIVES: Lower urinary tract symptoms (LUTS) and sexual dysfunction (SDys) are common problems that affect quality of life (QOL) in elderly men. In addition to prescribed drugs, many over-the-counter medications including supplements are used to treat QOL diseases. Phosphodiesterase inhibitors are reported to be effective for both LUTS and SDys by increasing nitric oxide levels. French maritime pine bark extract Pycnogenol®, which is a potent nitric oxide donor, is reported to be effective for SDys. However, no reports have been published on whether it ameliorates LUTS. DESIGN: Open-labeled, randomized study. The effects of two supplements, Nokogiriyashi EX® containing 160 mg saw palmetto (SP) extract per tablet and Edicare® containing 10 mg of Pycnogenol®, 115 mg of l-arginine and 92 mg of aspartate (PAA) per tablet on International Prostate Symptom Score (IPSS), IPSS-QOL, Overactive Bladder Symptom Score (OABSS), International Index of Erectile Function 5 (IIEF5), Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), urinary 8-OHdG and uroflowmetry (UFM) of total 40 men with LUTS and SDys were examined. RESULTS: 19 subjects were instructed to take two tablets of SP, on the other 20 were on four tablets of PAA for 16 weeks. IPSS and IPSS-QOL showed statistically significant improvements in both groups. OABSS and IIEF5 were significantly improved in the PAA group. Conversely, ICIQ-SF, 8-OHdG and UFM did not change in either group. CONCLUSIONS: PAA might be an effective therapeutic alternative for elderly patients with LUTS and SDys.

A questionnaire survey on attitude toward sperm cryopreservation among hematologists in Japan.

Advances in multimodal treatment have led to dramatic improvement in cancer treatment outcomes. It is now necessary to consider cancer patients' holistic quality of life. Fertility preservation is the top concern for cancer survivors of reproductive age. Sperm cryopreservation before treatment is recommended for postpubescent men, but many patients lose fertility without having been informed about options for fertility preservation. To determine how sperm cryopreservation is perceived and practiced in Japan, we surveyed hematologists who often treat young males. A questionnaire about sperm cryopreservation was sent to 45 major hematology institutions. A total of 22 institutions responded before the deadline. All institutions but one responded that they felt sperm cryopreservation is necessary. Only 15 institutions responded that they inform patients about sperm cryopreservation, and 12 institutions responded that they perform sperm cryopreservation before chemotherapy. A total of 213 young males started their first course of chemotherapy during the survey period, of whom 61 (28.6%) had their sperm cryopreserved. Although almost all hematologists stated that sperm cryopreservation is necessary for fertility preservation, not all institutions informed patients about it. Our findings indicate that, to promote fertility preservation in Japan, it will be necessary to systematize sperm cryopreservation and build inter-hospital networks.

Clinical efficacy and tolerability of Gosha-jinki-gan, a Japanese traditional herbal medicine, for nocturia.

We evaluated the efficacy and tolerability of Gosha-jinki-gan (GJG; jì sheng shèn qì wán) in 30 cases of nocturia ( yè niào) unresponsive to α1-blockers or antimuscarinic drugs. All patients received GJG extract powder (2.5 g) three times a day for 12 weeks as an add-on therapy to α1-blockers or antimuscarinic drugs. Subjective outcomes assessed by the International Prostate Symptom Score-quality of life, and the benign prostatic hyperplasia impact index and objective outcomes assessed by urinary frequency and the urine production rate at night showed significant improvement after treatment. Moreover, other objective outcomes assessed by maximum flow rates, postvoid residual, serum human atrial natriuretic peptide levels, and urinary 8-hydroxy-2'-deoxyguanosine levels did not change. Adverse events were observed in 10% of cases; however, these events were mild. GJG appears to be a safe and effective potential therapeutic alternative for patients with nocturia unresponsive to α1-blockers or antimuscarinic drugs. Further clinical investigations are required to elucidate the precise pathophysiologic mechanisms of GJG in nocturia.

Clinical efficacy and tolerability of two Japanese traditional herbal medicines, Hachimi-jio-gan and Gosha-jinki-gan, for lower urinary tract symptoms with cold sensitivity.

We evaluated the efficacy and tolerability of Hachimi-jio-gan (HJG; ba wèi dì huáng wán) and Gosha-jinki-gan (GJG; jì sheng shèn qì wán), two traditional Japanese medicines, in 60 patients with lower urinary tract symptoms (LUTS) having cold sensitivity unresponsive to α1-blockers or antimuscarinic drugs. All patients received a mixture of HJG or GJG for 12 weeks in addition to α1-blockers or antimuscarinic drugs as add-on therapy. International Prostate Symptom Score, International Prostate Symptom Score-Quality of Life, Benign Prostatic Hyperplasia Impact Index, and the number of nocturnal voids were statistically much improved. However, there was no change in maximal urinary flow rate and post-void residual urine. Urinary 8-hydroxy-2-deoxyguanosine was statistically greatly improved from baseline after treatment in the HJG group compared to the GJG group. Adverse reactions were observed in 8.3% of patients, but all reactions were mild. Both HJG and GJG mixtures can serve as safe and effective potential therapeutic alternatives in patients with LUTS and cold sensitivity unresponsive to α1-blockers or antimuscarinic drugs. Additionally, HJG mixture was found to have anti-oxidative activity, and therefore further long-term clinical investigations are needed to examine its anti-aging effects in addition to its effect on urinary symptoms.

Improvement of seminal quality and sexual function of men with oligoasthenoteratozoospermia syndrome following supplementation with L-arginine and Pycnogenol®.

We evaluated the effectiveness of antioxidant co-supplementation therapy using Larginine and Pycnogenol(®) in Japanese men with oligoasthenozoospermia and mild erectile dysfunction (ED). A total of forty-seven adult males with oligoasthenoteratozoospermia syndrome (OAT) were eligible for enrollment. The effectiveness of supplementation with a combination of L-arginine 690 mg and French maritime pine bark extract (Pycnogenol(®)) 60mg for OAT and ED was investigated. The sperm concentration was enhanced significantly after treatment 2 and 4 months (11.79 ± 9.86 to 21.22 ± 28.17 and 20.15 ± 23.99 × 106/ml). Significant improvements in the International Index of Erectile Function (IIEF) were observed in the total score of IIEF (57.69 ± 11.04 to 59.43 ± 12.57) and domain of Orgasmic Function (9.01 ± 1.92 to 9.34 ± 1.66) after 4 months of treatment. L-arginine acts to increase the production of nitric oxide and Pycnogenol(®) activates the endothelial nitric oxide synthase and it is a potent antioxidant and inhibitor of inducible nitric oxide synthase. This study suggests that the combination of Pycnogenol(®) and L-arginine (Edicare(®)) is helpful for infertile men to ameliorate simultaneously quality of sperms as well as erectile functions.

Induction of spermatogenesis by rhFSH for azoospermia due to spermatogenic dysfunction with maturation arrest: five case series.

When sperm cannot be retrieved from the testes of patients with azoospermia due to spermatogenic dysfunction (ASD), there is no rational way for the patient to become a biological father. We investigated the possibility of inducing spermatogenesis in such patients by hormonal therapy with recombinant human follicle-stimulating hormone (rhFSH) alone. Twenty-six ASD patients who could not obtain spermatozoa by microdissection testicular sperm extraction (micro-TESE) were confirmed to have arrested spermatogenesis at the late stage of maturation arrest. They were subsequently treated with 75-150 IU two times/week rhFSH alone for 12 months. The primary endpoint was the appearance of sperm in ejaculate, and we followed the patients to determine the outcome of inseminating their partners. After rhFSH treatment, mature spermatozoa were found in the ejaculate in five of 26 (19.2%) patients, all of whom showed histology of non-uniform type maturation arrest. Intracytoplasmic sperm injection of the mature spermatozoa resulted in two ongoing clinical pregnancies (insemination success rate, 40.0%). Recombinant human follicle-stimulating hormone treatment can be used as an advanced assisted reproductive technology to improve spermatogenesis in some azoospermic patients with maturation arrest of spermatogenesis and is a potential treatment option after unsuccessful micro-TESE.

Effects of preoperative dutasteride treatment in holmium laser enucleation of the prostate.

OBJECTIVES: To investigate factors influencing the degree of difficulty in finding and maintaining an appropriate plane on the surgical capsule of the prostate during holmium laser enucleation of the prostate. METHODS: A total of 116 men undergoing holmium laser enucleation of the prostate for benign prostate hyperplasia between January 2010 and September 2013 at our hospital were included in this analysis. The degree of difficulty in finding and maintaining the plane of the surgical capsule of the prostate was retrospectively evaluated and graded by using video-based analysis according to newly defined criteria (grade I, least difficult; grade IV, most difficult). Factors influencing the degree of difficulty were investigated. RESULTS: Video analysis was possible in 99 of 116 patients. Decapsulation difficulty in decapsulation was deemed as being grade I in 32 patients, grade II in 31 patients, grade III in 20 patients and grade IV in 16 patients. Preoperative dutasteride therapy was the only factor associated with an increasing level of difficulty in decapsulation during holmium laser enucleation of the prostate. CONCLUSIONS: Although preoperative dutasteride therapy effectively reduces intraoperative blood loss, surgeons with limited experience should be careful with the use of dutasteride, because its administration might increase surgical difficulty during holmium laser enucleation of the prostate.

Mature Testicular Teratoma with Positive Estrogen Receptor Beta Expression in a Transgendered Individual on Cross-Sex Hormonal Therapy: A Case Report.

Estrogen exposure has been linked to a risk of testicular germ cell cancers, although predominantly in animal studies. In the human testis, estrogen receptor beta (ER-ß) mediates the physiological action of estrogen. We describe a case of a 30-year-old transgender woman (male-to-female [MtF]) with gender dysphoria who developed a mature testicular teratoma with positive estrogen receptor beta expression while receiving cross-sex hormonal therapy with estradiol and progesterone. Although the presence of hormone receptors does not always imply that hormones have played a role in the development of the tumor, a contribution of exposure to exogenous estrogen in this case cannot be ruled out.

Hormonal therapy (hCG and rhFSH) for infertile men with adult-onset idiopathic hypogonadotropic hypogonadism.

Adult-onset idiopathic male hypogonadotropic hypogonadism (IMHH) is a very rare but treatable disease. This study was conducted to examine the efficacy and safety of a combination of human chorionic gonadotropin (hCG) and recombinant human follicle-stimulating hormone (rhFSH) for inducing spermatogenesis in men with adult-onset IMHH. Seven men (34-45 years of age) with azoospermia and/or sexual dysfunction, with a low serum testosterone concentration, and apulsatile secretion of luteinizing hormone, were referred to our hospital for infertility. All had normal secondary sexual characteristics. Thorough endocrinologic examination and magnetic resonance imaging revealed no identifiable cause of hypogonadotropic hypogonadism. Adult-onset IMHH was diagnosed in all cases and treatment was started with 150 IU rhFSH and 5,000 IU hCG, both administered two times per week. Spermatogenesis was restored in five of the seven patients. During treatment one patient achieved spontaneous pregnancy with his wife, and spermatozoa recovered from the other four patients were frozen for future use in intracytoplasmic sperm injection.

Role of male pelvic floor muscles and anterior fibromuscular stroma in males on α(1)-blocker treatment: a magnetic resonance imaging study.

Dynamic motion of the pelvic floor muscles during voiding was analyzed using real-time magnetic resonance imaging. To evaluate the contraction of the pelvic floor muscles, striated urethral sphincter distance, levator ani muscle thickness and anterior fibromuscular stroma distance were measured. The percent contraction of the striated urethral sphincter from before voiding to just before initiation of voiding was 14% in the normal group and 5% in the voiding dysfunction group. The percent contraction of the anterior fibromuscular stroma from before voiding to just before initiation of voiding was 11% in the normal group and 1% in the voiding dysfunction group; the percent contraction of the muscles was significantly greater in the normal group (P < 0.05). Striated urethral sphincter and anterior fibromuscular stroma contraction at initiation of voiding open the bladder neck and urethra. This plays an important role in the smooth initiation of voiding.

Novel germ line mutation p53-P177R in adult adrenocortical carcinoma producing neuron-specific enolase as a possible marker.

Adrenocortical cancer (ACC) is a rare and aggressive endocrine tumor. The patient presented with a large retroperitoneum tumor and lung metastases. Removal of the adrenocortical tumor with part of the transverse colon and tail of the pancreas, spleen and kidney was successfully performed following chemotherapy. Levels of serum neuron-specific enolase (NSE) were found to be markedly high before surgery and may be clinically useful markers for monitoring tumor status during management. Immunohistochemical studies showed that the cancer cells were positive for NSE and overexpression of p53. We identified a novel germ line variant of the 177 mutant (Pro to Arg; P177R) of p53 by genomic sequencing. The genetic and biochemical data presented in this case confirm the importance of screening for p53 status in ACC with inherited cancer syndrome.

Development of a nomogram for predicting high-grade prostate cancer on biopsy: the significance of serum testosterone levels.

BACKGROUND: A screening method that focuses on the early detection of high-grade prostate cancer is required. In this study, two sets of nomograms were developed, one to predict the presence of prostate cancer, and the other to predict the presence of high-grade prostate cancer (defined as Gleason Score > or =7). PATIENTS AND METHODS: Prostate biopsies were obtained from 396 men with an abnormal serum level of prostate-specific antigen (PSA). Using factors including age, PSA, follicle stimulating hormone (FSH), serum teststerone level and prostate volume of the transitional zone (TZ), nomograms were created that incorporated these factors. External validations were performed involving 174 males, including 103 normal and 71 prostate cancer cases from our institution. RESULTS: Out of the 396 patients referred for prostate biopsy, 146 were found to have prostate cancer. On logistic regression analysis, age, PSA, prostate volume of the TZ and FSH were significant predictors of prostate cancer, while serum PSA, and testosterone levels were significant predictors of high-grade prostate cancer. The pretreatment testosterone level was found to be a significant biomarker for predicting the pathological features. CONCLUSION: The testosterone level might be a useful biomarker to be included in conventional PSA screening programs to further improve the efficacy of detecting potentially lethal carcinomas.

Salivary 8-OHdG: a useful biomarker for predicting severe ED and hypogonadism.

INTRODUCTION: Erectile and endothelial dysfunction are common pathologies of multiple cardiovascular risk factors and are considered longitudinal predictors of cardiovascular events. Oxidative stress and decreases in testosterone levels play an important role in the pathogenesis of endothelial dysfunction. AIM: We sought to determine whether the severity of erectile dysfunction (ED) was associated with individual levels of testosterone and oxidative stress, and whether treatment with a phosphodiesterase type 5 inhibitor could reduce oxidative stress and increase testosterone availability. METHODS: We evaluated the association of salivary 8-hydroxy-2'-deoxyguanosine (8-OHdG), salivary testosterone, International Index of Erectile Function-erectile function domain (IIEF-EF) scores, and Medical Outcome Study (MOS) 36-item Short-Form Healthy Survey (SF-36) questionnaires in 128 middle-aged male volunteers. We investigated the changes in testosterone levels, salivary 8-OHdG levels, IIEF-EF scores, and SF-36 scores in 20 ED patients (according to the IIEF-EF) who took 50 mg of sildenafil once a week for 6 months. MAIN OUTCOME MEASURES: IIEF-EF scores were used to assess ED severity. Antioxidant status was defined by salivary 8-OHdG. Salivary testosterone was used to evaluate serum bioavailable testosterone availability. RESULTS: Salivary 8-OHdG (OR = 9.88, 95% CI: 1.52-64.10), salivary testosterone (Odds ratio [OR] = 0.96, 95% CI: 0.93-0.98), and vitality on the SF-36, version 2 (SF-36 v2) (OR = 0.92, 95%CI: 0.84-0.98) were significantly associated with the severity of ED in healthy volunteers. Treatment with sildenafil for 6 months significantly increased the total serum testosterone (426.4 +/- 174.8 vs. 569.6 +/- 146.1 ng/dL, P = 0.021) and salivary testosterone levels (56.1 +/- 22.3 vs. 110.0 +/- 48.4 pg/mL, P < 0.001), whereas it decreased salivary 8-OHdG levels (2.30 +/- 0.23 vs. 0.90 +/- 0.05 ng/mL, P = 0.0046). CONCLUSIONS: Salivary 8-OHdG is a useful biomarker for predicting severe ED and hypogonadism in middle-aged men. Once-a-week treatment with sildenafil can have beneficial effects on men's health by decreasing oxidative stress and increasing testosterone levels.

Real-time MRI of orthotopic ileal neobladder voiding: preliminary findings.

OBJECTIVES: The purpose of this preliminary study was to analyze the dynamic changes in the configuration of the neobladder and naïve bladder during voiding using real-time MRI. METHODS: This study included 10 male patients who had a radical cystectomy and an ileal orthotopic neobladder due to organ-confined bladder cancer and had good urinary function, and 5 male control volunteers. With the subjects in the lateral decubitus position, real-time MRI was performed during micturition. A sagittal slice orientation was used to depict the bladder and the entire length of the urethra; individual movements along the X-axis and Y-axis of the bottom and top of the neobladder and the naïve bladder were recorded and analyzed. Urodynamic studies (UDS) and video voiding cystourethrography were performed in patients. RESULTS: Five of the 10 neobladder patients could void in the lateral decubitus position. In normal controls and patients who could void, the bladder outlet bladder moved ventrocranially during micturition. The ileal bladder outlet moved a significantly longer distance than the naïve bladder during micturition (X-axis, -13.4+/-1.5 vs. -3.6+/-4.3 cm, p=0.0014; Y-axis, -10.6+/-0.5 vs. -2.0+/-6.5 cm, p=0.0187). The distance that the bladder top moved between the naïve bladders and the neobladder did not differ. UDS did not show a difference between patients who could and could not void at lateral position. CONCLUSIONS: During micturition, the neobladder was found to rotate and move more dynamically than the naïve bladder. Real-time MRI is useful for assessing dynamic voiding function of orthotopic neobladders.

[A case of a giant adrenal myelolipoma in a man with spinal cord injury].

A 38-year-old man in a wheelchair for spinal cord injury from a traffic accident was referred to our hospital with complaint of dull right flank pain. The patient had a history of skin ulcer formation on both toes due to poor circulation. Abdominal ultrasonography and computed tomographic scan revealed a huge retroperitoneal tumor compressing the right kidney. Serum levels of cortisol, adrenocorticotropic hormone, aldosterone, adrenalin, noradrenalin, urinary levels of vanillylmandelic acid, homovanillic acid, 17-ketosteroid and 17-hydroxycorticosteroid were all within normal limits. Combining all preoperative diagnostic information, the possibility of retroperitoneal liposarcoma could not be thoroughly ruled out. The patient consented to undergo resection of the tumor with the right kidney. Prior to the scheduled operation simulation of the positioning on the operation table was done to evaluate the compressing pressure. During operation decompressing pads were used to minimize the compressing pressure and intermittent pneumatic compression was also used to prevent pressure ulcer and facilitate circulation to the lower extremities. Five thousands units of heparin (FragminR, Pfizer, USA) was used daily to prevent deep vein thrombosis until the patient could use his wheelchair. Perioperative rehabilitation was conducted by a team of physical therapists. The excised tumor weighed 1,320 g. Pathologic diagnosis was an adrenal myelolipoma. Convalescence was uneventful and the patient was discharged on the 10th post operative day. Between 1992 and 2006, 80 cases of adrenal myelolipoma were reported in Japan. Our case was found to be the second largest one. We reviewed these 80 cases and discussed the diagnosis and treatment strategy of the adrenal myelolipoma. We also discussed the perioperative management for patients with spinal cord injury.