[Metastatic Renal Cancer with Stevens-Johnson Syndrome after Nivolumab Treatment : A Case Report].

A 65-year-old male was admitted to our hospital with an abscess on his buttocks. Computed tomography (CT) on admission incidentally revealed left kidney cancer, and retroperitoneal nephrectomy was performed. Pathological examination confirmed a diagnosis of renal cell carcinoma. One month after surgery, CT showed findings suggesting primary liver cancer or liver metastasis along with retroperitoneal metastasis. Although metastatic kidney cancer was suspected, the possibility of primary liver cancer could not be ruled out. Therefore, we initiated treatment using sorafenib, which is indicated for both types of cancer, as first-line treatment for intermediate-risk based on the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk classification. After three months of sorafenib treatment, the patient showed hyponatremia, anemia, and hand-foot syndrome and was admitted to the hospital. CT showed an enlarged area that appeared to be a metastatic site, after which we suspended sorafenib. Four months after sorafenib treatment, nivolumab was initiated as a second-line treatment. However, on day 28 after the administration of nivolumab eruptions appeared all over the patient's body. The patient was diagnosed with Stevens-Johnson syndrome due to nivolumab. We initiated corticosteroid therapy, and the eruptions gradually improved. Prednisolone was gradually reduced to 5mg/day, after which the patient was discharged. Six months after discharge, the eruptions had generally become epithelialized and no metastatic lesions had grown. The patient remained under observation without proceeding to third-line treatment. It is crucial to carefully monitor the patient's condition, especially in cases involving serious immune-related adverse events.

Surgical management of mesh infection following laparoscopic sacrocolpopexy and tension-free vaginal mesh surgery: a report of two cases with a literature review.

INTRODUCTION: The standard management for pelvic abscess or spondylodiscitis after reconstructive surgery previously involved total mesh excision, abscess drainage, and intravenous antibiotic administration. However, only few reports exist regarding the possibility of nonoperative management. CASE PRESENTATION: Postoperative mesh infection occurred in two cases of transvaginal mesh and laparoscopic sacrocolpopexy surgery for pelvic organ prolapse. In the first case, intravenous antibiotics were administered and debridement was performed. In the second case, intravenous antibiotics were administered, and local drainage was performed postoperatively, as sacral promontory infiltration was suspected. Diabetes was a comorbidity in both cases. CONCLUSION: It is necessary to select patients suitable for vaginal or laparoscopic mesh placement for pelvic organ prolapse preoperatively on the basis of prior history of the patients and once the patients provide informed consent for surgery after being explained the possible complications of pelvic reconstructive surgery, such as mesh infection.

[LSC (LAPAROSCOPIC SACROCOLPOPEXY) VERSUS UPHOLD TYPE TVM: A CASE CONTROL STUDY].

(Objective) The comparative analysis of post-surgery condition of lower urinary tract symptoms of LSC and Uphold-type TVM. (Methods) Since August 2015, our hospital introduced LSC and launched Uphold-type TVM in May 2017. 25 cases were examined by December 2017. In comparison with 37 cases of LSC conducted simultaneously, OABSS, IPSS, ICIQ-SF as well as uroflowmetry and residual urine measurement were performed with focus on perioperative complications and postoperative (3 months) lower urinary tract symptoms. As can be observed from the patient background, the average age of subject patients were close to 77 years old for TVM group, 70 years old for LSC group. LSC group showed a tendency to be observed among younger patients. (Result) In Stage II of Pelvic organ prolapse quantification (POP-Q) most of the mild cases (8 cases in TVM group and 3 cases in LSC group) existied. The type of pelvic organ prolapse (most protruding part) was bladder. Many cystoceles in the TVM group (15 cases in the TVM group and 10 cases in the LSC group) were observed. The average operation time was 115 minutes in the TVM group and 214 minutes in the LSC group which was longer. The average bleeding amount was 54 ml in the TVM group and 10 ml in the LSC group, which was quite small. For the intraoperative complication, in 2 cases bleeding volume 100 ml or more were observed in the TVM group. Bladder injury was found in 1 case. (Conclusion) Regarding postoperative complications, one case of vaginal erosion in TVM group, one case of port suture failure in LSC group, one case of de novo OAB were observed respectively. OABSS, total urinary urgency, IPSS, residual urine were improved in both groups. Both types of surgery are expected to improve lower urinary symptoms and considered to be a useful tool for treatment of pelvic organ prolapse.

CHARACTERISTICS OF STRESS URINARY INCONTINENCE AFTER PELVIC ORGAN PROLAPSE SURGERY.

(Objective) We examined the morphology and function of lower urinary tract in order to know characteristics of stress urinary incontinence after pelvic organ prolapse (POP) surgery. (Methods) One hundred twenty-five female patients (mean age 64.9 years, mean parity 2.2, mean body mass index (BMI) 24.4) were performed anti-incontinence surgery for stress urinary incontinence. Sixty-one of 125 patients underwent POP surgery before anti-incontinence surgery. They were divided into groups as follows: post-POP surgery group and non-POP surgery group. All patients underwent one-hour pad test, chain cystourethrography (chain CG), Urodynamic studies (UDS) as preoperative assessment. Midurethral sling procedure was performed as an anti-incontinence surgery. Preoperative assessment criteria and postoperative treatment results were compared between two groups. (Results) Post-POP surgery group showed a significantly greater amount of urinary leakage per 1-hour pad test than non-POP surgery group (65.2±74.3 g vs 14.3±25.2 g, p<0.05). The diagnosis of type III urinary stress incontinence (Blaivas' classification) was more frequently diagnosed in post-POP surgery group than non-POP surgery group (50.0% vs 25.0%, p<0.05). Maximum urethral closure pressure (MUCP) and functional profile length (FPL) of post-POP surgery group were lower than those of non-POP surgery group (27.4±9.2 vs 35.7±14.7, p<0.05, 27.3±4.7 vs 29.9±5.0, p<0.05). Postoperative treatment results of post-POP surgery group were worse than those of non-POP surgery group (78.7% vs 92.2%, p<0.05). (Conclusions) Post-POP surgery group showed more severe urinary incontinence, lower urinary function and lower cure rate. Therefore we should keep in mind when approaching urinary stress incontinence.

[Study on the treatment of pelvic organ prolapse complicated with uterine myoma].

OBJECTIVE: We studied the association between uterine myoma and recurrent pelvic organ prolapse (POP) after transvaginal mesh (TVM) repair. METHODS: Between June 2010 and January 2012, 103 female patients (mean age 67.8 years, mean parity 2.3, mean body mass index (BMI) 23.7) with POP underwent TVM procedures at our hospital. Sixtynine patients were qualified as stage 3 according to the POP quantification (POP-Q) system and 34 patients were stage 4. Twenty-six patients underwent anterior TVM (A-TVM) and 77 patients underwent anterior and posterior TVM (AP-TVM). All patients underwent a physical examination using the POP-Q system before and 6 month after surgery. Recurrence of prolapse was defined according to the International Continence Society by a measured value ≥ - 1, as most dependent portion of POP stage 2 or greater. One hundred-three patients were divided into group with uterine myoma larger than 5 cm in diameter and group without uterine myoma. Anatomical outcomes before and after TVM repair were compared between two groups. RESULTS: Preoperative Aa value, Ba value and gh value in group with uterine myoma were greater than in group without uterine myoma. Postoperative Aa value and Ba value in group with uterine myoma were greater than in group without uterine myoma, too. Postoperative recurrence of prolapse of stage 2 or greater was not found a statistical difference between two groups. CONCLUSIONS: The risks of anterior vaginal wall descent seem to be high in POP with uterine myoma. Therefore it should be kept in mind on treatment choice.

[Tubulocystic carcinoma of the kidney].

A 55-year-old man who presented himself with gross hematuria and right back pain was found to have a right renal mass with evidence of metastasis to the lymph nodes, bone and lung (cT1bN1M1). He underwent a transperitoneal right nephrectomy. Tumor expressed markers of CD10, P504S and CK19 immunohistochemically, so histopathological examination revealed tubulocystic carcinoma of the right kidney (pT3a). After the patient received sunitinib therapy, computed tomography revealed reduction in the size of the metastatic lung nodule and lymph nodes, indicating a partial response. He is alive without disease progression at 12 months after nephrectomy. Tubulocystic carcinoma has been referred to by Amin et al as low-grade collecting duct carcinoma and is not yet included in the World Health Organization (WHO) 2004 classification of renal tumors. The cells lining the tumor range from cuboidal to columnar and have large nuclei with low-grade changes and abundant eosinophilic or amphophilic cytoplasm. Hobnail cells are commonly seen. Immunohistochemically, tubulocystic carcinomas are strongly positive for markers of the proximal nephron (CD10, P504S) and the distal nephron (parvalbumin, CK19). Despite a low nuclear grade, tubulocystic carcinomas occasionally show progressive behavior clinically. Although there is no established salvage therapy, sunitinib was found to be effective for this patient.

Two von Recklinghausen's disease cases with pheochromocytomas and gastrointestinal stromal tumors (GIST) in combination.

We here document two cases of von Recklinghausen's disease with both pheochromocytomas and gastrointestinal stromal tumors (GIST). It is very rare that these three disorders are found to occur simultaneously, although the fact that preoperative detection of GIST is difficult except with large tumors may be important in this respect. In the present cases, GIST were not evident on preoperative computed tomography and magnetic resonance imaging, and were identified unexpectedly during surgery. Our findings indicate that investigation of the intraperitoneal space should be performed during adrenalectomy for pheochromocytomas with von Recklinghausen's disease.

[Survey of factors underlying treatment choice for patients with localized prostate cancer (radical prostatectomy vs extrabeam radiotherapy)].

PURPOSE: Little is known regarding factors for decision-making on treatment by localized prostate cancer patients. We therefore conducted a survey series of cases for influence on treatment decision making, and also satisfaction after therapy. MATERIALS AND METHODS: A total of 51 patients with localized prostate cancer treated with radical prostatectomy (RP) or external beam radiation therapy (EBRT) were mailed original questionnaires about their treatment decision-making factors and satisfaction and the results compared between the two groups. RESULT: Some 48 (94.1%) patients responded to the questionnaire, 38 (79.2%) and 10 (20.8%) after RP and EBRT, respectively. The major factor determining the decision as to treatment approach was the physician in both groups (more than 90%). Excluding physicians, family or others were more important in the RP group than the EBRT group (p = 0.023). RP group patients desired removal of their prostate for cancer control, while, EBRT group patients favored the less invasive approach in consideration of side effects. Over 80% patients indicated they would definitely or probably choose the same treatment again, although some of the RP group would switch to watchful-waiting because of sexual dysfunction, urinary incontinence and the invasive nature of the procedure. CONCLUSION: Physicians are in a most important position to help patients understand prostate cancer and treatment, outcomes, and need to help them make their best choice, with appropriate follow up including mental care.