[A Case of General Fatigue Caused by Enzalutamide that was Evaluated Using the Cancer Fatigue Scale and Overcome by Switching to Nighttime Treatment].

An 81-year-old man with castration-resistant prostate cancer experienced general fatigue while receiving enzalutamide treatment. In some patients we encountered the enzalutamide treatment had to be interrupted or the dose decreased because of this adverse effect. We evaluated the patient's general fatigue using the Cancer Fatigue Scale (CFS) score and clarified the quantitative information about his general fatigue. In order to maintain the optimal dose, we advised the patient to take enzalutamide at night. This alleviated the adverse effect, and he could maintain the optimal dose of this medicine. We compared the CFS score before and after switching to nighttime treatment and found improvement. This is the first report of a CFS-based evaluation of the improvement in general fatigue caused by enzalutamide by switching to nighttime treatment.

Long-term follow-up of penile glans necrosis due to paraphimosis.

INTRODUCTION: Paraphimosis is a urologic emergency in which the foreskin of the penis becomes trapped behind the coronal sulcus and forms a tight band of constricting tissue. Surgical or conservative release of this constriction is required for the treatment. Delayed treatment will cause devastating outcomes, such as penile glans necrosis. A few studies have reported penile glans necrosis/gangrene, but long-term follow-up of the recovery from glans necrosis due to paraphimosis has not been previously reported. CASE PRESENTATION: A 25-year-old man who experienced glans necrosis following paraphimosis was not treated promptly with circumcision. The patient underwent conservative treatment with debridement of necrotic tissue and cystostomy for urethral meatal necrosis. We were able to prevent partial penectomy. His penile glans was covered with healthy epithelium and retained its natural shape and voiding and erectile functions were normal 2 years after the treatment. CONCLUSION: We report successful conservative management of penile glans necrosis.

Silodosin versus naftopidil in the treatment of premature ejaculation: A prospective multicenter trial.

OBJECTIVES: To determine the efficacy of two α1-adrenoceptor antagonists with different affinities for α1-adrenoceptor subtypes, silodosin and naftopidil, in the treatment of premature ejaculation. METHODS: This was a prospective, open-label, multicenter trial. A total of 26 patients with untreated acquired premature ejaculation were enrolled. Premature ejaculation was defined based on the International Society for Sexual Medicine recommendation. Patients self-administered on demand silodosin 4 mg or naftopidil 25 mg 1 h before intercourse, alternating drugs at least three times each. Clinical global impression change for premature ejaculation, premature ejaculation profile, and intravaginal ejaculation latency time were evaluated at baseline and during treatment. RESULTS: Due to clinical global impression change, 24 patients (92%) and 12 patients (46%) reported improvement in their own premature ejaculation problems under silodosin and nafitopidil administration, respectively. Silodosin treatment produced a significantly higher improvement rate compared with naftopidil (P = 0.0002). Objectively, silodosin significantly prolonged intravaginal ejaculation latency time compared with baseline and naftopidil (P < 0.01). Mean intravaginal ejaculation latency times were 1.9, 4.1, and 7.6 min at baseline, control and with silodosin, respectively. The rate of reduced semen volume during silodosin treatment was higher than during naftopidil treatment. There were no adverse systemic effects in either group. CONCLUSIONS: Silodosin, a highly selective α1A-adrenoceptor antagonist, produces greater improvements in premature ejaculation profiles and related symptoms along with intravaginal ejaculation latency time in acquired premature ejaculation patients with or without erectile dysfunction. This result supports the clinical use of silodosin as an alternative treatment for premature ejaculation.

Simple and reliable predictor of urinary continence after radical prostatectomy: serial measurement of urine loss ratio after catheter removal.

OBJECTIVES: To evaluate urine loss ratio after catheter removal as a predictive factor of urinary continence after radical prostatectomy. METHODS: A total of 190 patients who had undergone retropubic radical prostatectomy were evaluated. Urine loss ratio was measured using the 24-h pad test during 7 consecutive days after removal of urethral catheters. Continence rates at 1, 3, 6 and 12 months after operation were evaluated with the urinary function domain of the University of California, Los Angeles Prostate Cancer Index. The desirable urine loss ratio for continent condition at 12 months after the operation was calculated. As desirable target urine loss ratio continence at 12 months was determined by using logistic analysis. RESULTS: Continence rates of all patients at 1, 3, 6 and 12 months after surgery were 13%, 37.8%, 58.9%, and 85.8%, respectively. Continence rates of patients who achieved ≤1% of urine loss ratio within 7 days or ≤5% urine loss ratio within 3 days after catheter removal was 100% at 12 months. Logistic regression analysis proved these urine loss ratio values were significant predictors of continence at 12 months. CONCLUSIONS: Urine loss ratio after catheter removal within 7 days is a significant determinant of urinary continence after radical prostatectomy. This parameter could have clinical usefulness to estimate future recovery of urinary continence.

[Masturbation device (EGG) as a new penile rehabilitation tool: a pilot study].

Erectile dysfunction following radical prostatectomy (RP) is still a significant burden as a post-operative morbidity, despite advances in nerve-sparing techniques and penile (erectile function) rehabilitation (PR) programs. We assessed the effects of stimulation with the masturbation device "EGG" on enhancement of erectile response along with administration of phospho diesterase type 5 inhibitor. We also studied the change of self-esteem and motivation for continuation of PR after stimulation with EGG. Eight nonresponders for PDE5-I who underwent retropubic RP were enrolled. Patients' median age was 71.5 years old. No patients received adjuvant therapy for prostate cancer. The patients' erectile response in the penile rehabilitation session (masturbation) with PDE5-I＋manual stimulation and PDE5-I＋stimulation with EGG were evaluated by erection hardness score (EHS). Changes of self-esteem and motivation for penile rehabilitation were assessed by the self-esteem subscale of the Self-Esteem and Relationship (SEAR) questionnaire and one original question, respectively. PDE5-I ＋ stimulation with EGG significantly enhanced EHS compared to PDE5-I＋manual stimulation in the eight patients (p＝0.027). Transformed score of self-esteem subscale score of SEAR questionnaire was significantly increased in the PR session with EGG compared to the PR session with manual stimulation (p＝0.043). Six patients who showed a better erectile response with EGG retained motivation for continuation of PR. PDE5-I＋stimulation with EGG improved the erectile response in post-RP patients. EGG as a masturbation device may have a potential for contribution to successful PR.

Dissociation between patients and their partners in expectations for sexual life after radical prostatectomy.

OBJECTIVE: To analyze expectations for sexual life after radical prostatectomy in patients and their partners, and its influence on sexual motivation and bothers in the postoperative period. METHODS: A total of 162 patients who underwent retropubic radical prostatectomy and their partners were evaluated. The patients' sexual function, sexual bother and expectations for postoperative sexual life were assessed prospectively at baseline, and at 1, 3, 6 and 12 months after radical prostatectomy. The partner was asked questions about postoperative sexual life before the operation. Sexual function and sexual bother were evaluated by the University of California Los Angeles Prostate Cancer Index. Expectations for postoperative sexual life were studied using three ad hoc questions. RESULTS: The rate of having sexual intercourse and adequate penile rigidity for vaginal penetration at baseline was 29.0% and 21.6%, respectively. A significantly higher rate of patients considered "sexual life is important" (patient 35.2%, partner 13.0%), hoped for "preservation of erectile function" (patient 66.0%, partner 33.3%) and accepted "use of phosphodiesterase type 5 inhibitor" (patient 65.4%, partner 43.2%) compared with their partners (P < 0.001). Patients who had partners with a negative sexual attitude lost sexual motivation 1 year after operation. However, patients with cooperative partners maintained sexual motivation, although they felt greater sexual bother 1 year after radical prostatectomy. CONCLUSIONS: There was a significant dissociation in perspectives of postoperative sexual life between patients undergoing radical prostatectomy and their partners. Partners' low expectations are associated with patients' low sexual bother and motivation. Partners' cooperative attitude might contribute to maintaining patients' sexual desire and motivation.

[Follow-up method for patients with non-muscle-invasive bladder cancer who remained recurrence-free for a long time].

To determine the follow-up schedule in patients with non-muscle-invasive bladder cancer who had remained recurrence-free for 5 or more years, we retrospectively reviewed 258 patients with Ta and T1 bladder cancer who had been free of recurrence for at least 5 years. Of these 258 patients, subsequent recurrences developed in 100 patients. In spite of our recommendation that cystoscopic follow-up be done at 12-month intervals for patients who remained recurrence-free for more than 5 years, 45 had been followed at intervals of more than 12 months (range, 13-77 months) when the recurrences were found. Of 100 recurrent tumors, 20 (20.0%) showed bladder muscle invasion. Muscle-invasive cancer was identified more often in the patients with cytoscopic intervals of more than 12 months than in those of less than 12 months (35.6% versus 7.3%). Therefore, we recommend that cystoscopy be performed at intervals of less than 12 months in patients with non-muscle invasive bladder cancer for recurrence detection before tumors become muscle invasive, even when patients remain free of recurrence for a long period.

Silodosin and its potential for treating premature ejaculation: a preliminary report.

Premature ejaculation is a common sexual problem, as is erectile dysfunction. We evaluated silodosin, a highly selective α1A-adrenoceptor antagonist, as a new treatment option for premature ejaculation. α1-Adrenoceptor antagonists are widely used for lower urinary tract symptoms, and clinical studies on silodosin have shown excellent clinical efficacy for lower urinary tract symptoms. However, compared with other α1-adrenoceptor antagonists, silodosin appeared to suppress ejaculation in a relatively higher percent of trial participants. This suppression of ejaculation by silodosin suggested its potential for treating premature ejaculation. Consequently, we evaluated the feasibility of off-label silodosin as a new treatment option for premature ejaculation. Eight patients suffering premature ejaculation were treated with silodosin. Silodosin (4 mg) was given 2 h before sexual intercourse. Intravaginal ejaculatory latency time, premature ejaculation profile item, clinical global impression change in premature ejaculation and systemic adverse events were recorded. Intravaginal ejaculatory latency time was significantly prolonged (from 3.4 min to 10.1 min, P = 0.003). All patients answered better (much better) or slightly better for their own premature ejaculation problem compared with pretreatment condition in the clinical global impression change. Premature ejaculation profile also significantly improved. Two (25%), three (37.5%) and seven patients (87.5%) experienced anejaculation, reduced semen volume and discomfort during orgasm, respectively. However, these problems were not of major concern for the participants. No systemic adverse effects were reported. The current results support the possible use of silodosin as a new treatment option for premature ejaculation, and suggest that a placebo controlled study assessing its clinical usefulness would be worthwhile.

Isolated ACTH deficiency in self referred patients for LOH syndrome: two case reports.

We experienced two cases of isolated ACTH deficiency (IAD) in patients self referred for late-onset hypogonadism (LOH) syndrome. IAD is secondary adrenal insufficiency due to lack of secretion of ACTH and delayed diagnosis of this rare condition may be life-threatening. The predominant symptoms of IAD, such as general malaise and weakness, resemble those of LOH syndrome creating the possibility that IAD may be referred as LOH syndrome. Two middle aged men with severe general malaise visited our clinic requesting evaluation for LOH syndrome. Previous treatments had been ineffective and based on varying incorrect diagnoses by previous doctors. The patients self referred themselves for LOH syndrome. Some of their symptoms were consistent with LOH syndrome but others were atypical, in particular, the severity of malaise and appetite loss. Hormonal assays were compatible with adrenal insufficiency secondary to ACTH deficiency. Steroid replacement dramatically improved their symptoms. The clinical course of our two patients and points of differential diagnosis between IAD and LOH syndrome are reported here.

[Spontaneous rupture of the ureter as the primary symptom of malignant lymphoma].

We report a rare case in which upper ureteral rupture was the primary symptom of malignant lymphoma. A 74-year-old female visited our hospital with left flank pain. Computed tomography showed urinoma around the left kidney and retrograde pyelography showed a diffuse filling defect in the left ureter and a rupture of the upper portion of that ureter. A urine cytology specimen from the left ureter was class V, suggesting undifferentiated carcinoma or malignant lymphoma. An open laparotomy revealed a nodule on the omentum and diffuse fibrosis around both ureters, and the histopathological diagnosis was diffuse large B-cell lymphoma. The patient' s ureteral stenosis disappeared after she received six cycles of R-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone and rituximab) chemotherapy. We should be aware that malignant lymphoma can be the cause of a spontaneous ureteral rupture.

[Primary testicular leiomyosarcoma].

Leiomyosarcoma is a malignant soft-tissue cancer arising from tissues containing smooth muscle. It commonly occurs in the gastrointestinal system and retroperitoneum, but is rare in the genito-urinary system. We experienced a case of primary testicular leiomyosarcoma. A 71-year-old man presented with painless swelling of the right scrotal contents for 4 months. A high orchiectomy was performed. Histological examination revealed primary testicular leiomyosarcoma. The patient did not receive any adjuvant therapy. Seven months after the operation, there has been no recurrence. Cases of primary intratesticular leiomyosarcoma are rare. To the best of our knowledge, only sixteen cases have been reported in the literature.

[Case of primary amelanotic malignant melanoma of the female urethra].

We report a rare case of primary amelanotic malignant melanoma of the female urethra. A 58-year-old female with complaint of nodule on the external urethral meatus was referred to our hospital. Pathological diagnosis of the biopsy specimen from the nodule was malignant melanoma. Computed tomography of the chest and abdomen as well as bone scan showed no evidence of metastasis. Sentinel biopsy from the inguinal lymph nodes revealed no metastasis. Thereafter, the patient underwent radical urethrectomy, whose limits of resection were the bulbocavernosal muscles bilaterally, the arch of the pubic symphysis anteriorly, the anterior vaginal wall posteriorly, and the urethra up to the level of the bladder neck superiorly. The histopathological diagnosis was amelanotic malignant melanoma of the urethra. The patient had received six cycles of DAV-Feron (dacarbazine, nimustine, vincristine, and interferon-beta) in an adjuvant setting, and there is no sign of recurrence 25 months after operation.

Severe polyuria after the resection of adrenal pheochromocytoma.

A 73-year-old male patient with hypertension and hyperglycemia was referred to our hospital because of a diagnosis regarding his left adrenal tumor. Because the levels of urinary metanephrine and normetanephrine were elevated, and (131) I-MIBG scintigraphy showed intense uptake in the adrenal tumor, the tumor was diagnosed as a pheochromocytoma. An adrenalectomy was carried out. Severe polyuria, which was accompanied by a rapid decrease in central venous pressure, started 1 hour after the operation. Urine output of more than 8000 mL/day continued until the 16th postoperative day. Plasma antidiuretic hormone (ADH) levels were within the normal range. Plasma human atrial natriuretic peptide (hANP) and brain natriuretic peptide (BNP) were elevated postoperatively, and the elevation of these peptides was one possible cause for the severe polyuria. Because ADH levels in the tumor fluid were not elevated, the tumor was not an ADH-secreting tumor. Urinary ß2-microglobulin was significantly elevated after the operation, thus suggesting that renal tubule dysfunction might also have been involved in the polyuria. However, the mechanism of polyuria after the resection of adrenal pheochromocytoma is not fully understood. Polyuria after the resection of adrenal pheochromocytoma is extremely rare, and the present subject is the second case to date.

Bilateral adrenal leiomyosarcoma treated with multiple local therapies.

A 62-year-old woman presented with right flank pain, and computed tomography (CT) showed bilateral adrenal tumors (right, 8 cm; left, 4 cm). There were no abnormal findings on physical examination, and adrenal hormone levels in serum and urine were within normal limits. Radiological studies showed a right adrenal tumor with intratumoral hemorrhage, a cystic tumor in the left adrenal gland, and no sign of distant metastasis. Because laboratory tests showed normal levels of adrenal hormones, we considered the tumors to be nonfunctioning adrenal tumors. The right adrenal tumor was surgically removed because it was thought to be malignant, and histological examination revealed that it was a leiomyosarcoma. Postoperative CT showed a pleural metastasis in the right chest wall. The patient received combination chemotherapy with cyclophosphamide, vincristine, adriamycin, and dacarbazine. The metastasis was also treated with radiofrequency ablation (RFA). Because the left adrenal tumor grew rapidly despite two courses of the chemotherapy, it too was surgically removed. After the operation, metastasis in the right iliac bone was treated with RFA and radiotherapy. Positron emission tomography detected bilateral femoral metastases, and these were treated with radiotherapy in combination with a low dose of cisplatin. A liver metastasis and a small metastasis in the left kidney were treated with RFA and a metastasis in the pancreatic tail was removed surgically. Sixteen months after the right adrenalectomy, the patient died due to systemic spread of the disease. Multiple local treatments including RFA, radiotherapy, and resection were effective for the local control of metastatic lesions of adrenal leiomyosarcoma.

[Two cases of unilateral adrenalectomy for bilateral adrenal Cushing syndrome].

For treatment of bilateral adrenal Cushing syndrome (CS) unilateral adrenalectomy (UAdx) is less invasive than bilateral adrenalectomy and lifetime replacement of glucocorticoids can be avoided. Laparoscopic UAdxs was performed on 2 patients with bilateral adrenal CS. In both cases, symptoms associated with CS were improved after UAdx. Although serum adrenocorticotropic hormone levels remained lower than normal after UAdxs, cortisol levels in both serum and urine have been maintained within normal ranges for more than 1 year in both cases.

[Case of pelvic retroperitoneal fibrosis].

A 66-year-old man visited his nearby clinic with a complaint of left lower abdominal pain. Abdominal CT scan showed left hydronephrosis due to lower ureteral involvement by infiltrative retroperitoneal mass located outside of the left posterior wall of the bladder and left seminal vesicle. He was referred to our hospital for further examination. Pathological diagnosis of the percutaneous CT-guided biopsy of retroperitoneal mass was fibrosis without any malignant tumor. Because we could not rule out the possibility of the secondary fibrosis accompanied by malignant tumor, we performed surgical resection of the retroperitoneal mass involving left ureter and confirmed that the mass contains no malignant tumor by frozen section analysis. We augmented the defected ureter by Boari flap method. We should be noticed that retroperitoneal fibrosis could be a differential diagnosis of retroperitoneal pelvic mass.

[Transurethral resection of prostate just following high intensity focused ultrasound in localized prostate cancer--trial for early removal of the urethral catheter].

We studied the impact of combined transurethral resection of the prostate (TURP) and high intensity focused ultrasound (HIFU) for localized prostate cancer (CaP) to decrease side effects such as prolonged urinary voiding disturbance observed after HIFU treatment. Included in this study were 18 patients with clinically localized CaP indicated for HIFU just followed by TURP (TUR combination group). Complete response was defined in accordance with ASTRO consensus statement and negative sample in biopsies performed 6 months after the HIFU treatment. Prostate specific antigen (PSA) nadir, International Prostate Symptom Score (IPSS) and morbidity during follow-up of TUR combination group were compared with those of a control of 18 patients who took HIFU treatment alone (HIFU monotherapy group). No statistical significances on the values of preoperative parameters (PSA, prostate volume, Gleason score, and IPSS) between these two groups. The median follow-up duration was 10 (5-15) months in both groups. A statistically significant impact was observed between TUR combination group and HIFU monotherapy group on median catheter time (5 versus 13 days, P<0.0001), PSA nadir (0.096 ng/ml versus 0.430 ng/ml in median, P<0.05) and the evolution of the post-treatment IPSS (8 versus 13.5 in median, P<0.0003) at 3 months after treatment. Urethral stricture necessary for urethral dilation was noted in 1 patient (5.6%) in the TUR combination group while in 2 (11.1%) in the HIFU monotherapy group. CR was obtained in 88.9% in the TUR combination group and 83.3% in the HIFU monotherapy group. Our study suggests that the combination of TURP with HIFU treatment improves posttreatment urinary status without additional morbidity.

[A case of calculus in male urethral diverticulum].

A 39-year-old man was admitted to our hospital because of micturition pain and swelling of the penoscrotal junction. On physical examination,a hard mass was palpated in the penoscrotal junction. Retrograde urethrography demonstrated a calculus in the diverticulum of the anterior urethra. After the suprapubic cystostomy, resection and debridment of the diverticulum were performed and the stone was removed by two-staged urethroplasty. After the operation, retrograde urethrography revealed the tissue-like urethral valve, and there was bleeding from the anastomosis of the urethra, but the patient was finally free of the disease.