[Efficacy of Recombinant Thrombomodulin for Sepsis-Associated Disseminated Intravascular Coagulation Caused by Urinary Tract Infections].

Severe urinary tract infections occasionally cause sepsis and disseminated intravascular coagulation (DIC). We examined the efficacy of recombinant thrombomodulin (rTM) for treating DIC caused by urosepsis. We enrolled 40 patients who were diagnosed with DIC caused by urosepsis at our hospital between April 2018 and May 2022. Twenty-six patients were treated with rTM (rTM group), while 14 patients did not receive rTM (non-rTM group). The DIC score before treatment in the rTM group was significantly higher than that in the non-rTM group (P＜0.01). There was no significant difference in disease-specific survival between the two groups. There was a significant improvement in DIC scores on days 1-3 after administering rTM. However, the duration of DIC in the rTM group was significantly longer than that in the non-rTM group (P＝0.038). The administration of rTM may have benefits in patients with DIC caused by urosepsis.

Hierarchical surface wrinkles and bumps generated on chitosan films having double-skin layers comprising topmost carrageenan layers and polyion complex layers.

Surface wrinkling to fabricate hierarchical surface topographies has attracted much attention because of the potential and multifunctional applications of hierarchical surface wrinkles beyond uniform wrinkles. Although many reports have described the preparation of hierarchical wrinkles induced by mechanical stress and heat, fabrication through drying-induced shrinkage has hardly been reported. Here we introduce hierarchical surface wrinkles and bumps generated on a chitosan film via the preparation of double-skin layers with κ- and ι-carrageenans, respectively, and subsequent drying. Double-skin layers are fabricated on a swollen chitosan film, called a chitosan hydrogel film, that is soaked first in κ- or ι-carrageenan solution and then in water to remove excess adsorbed κ- or ι-carrageenan. After the film is dried, hierarchical microscopic surface architectures are observed. In the case of the κ-carrageenan system, the wrinkles are hierarchical, consisting of wrinkles (6.2 ± 2.8 µm) that have smaller buckles (0.23 ± 0.09 µm). We reveal that the wrinkles or the smaller buckles are caused by plane inhomogeneous shrinkage between the κ-carrageenan layer and the chitosan film or by the aggregation of the κ-carrageenan layer upon drying, respectively. Interestingly, the ι-carrageenan system showed hierarchical bumps consisting of semispherical bumps (5.6 ± 2.1 µm) that have smaller bumps (0.78 ± 0.27 µm). We reveal that the larger bumps are generated during the immersion of the chitosan hydrogel film into ι-carrageenan solution. The smaller bumps are generated by the aggregation of the ι-carrageenan layer that occurs during drying; this process requires the plane compression strain caused by the shrinkage of the chitosan hydrogel film.

[A Case of Nephrocutaneous and Enterorenal Fistula Associated with Pyonephrosis].

A 57-year-old woman was referred to our hospital with a palpable mass in the left lumbar area. Computerized tomography revealed a diffusely enlarged destructed left kidney with impacted ureteropelvic junction stones and intense inflammatory stranding of the perirenal fat. This infiltration extended into the subcutaneous tissue. Since she refused to undergo nephrectomy, we performed transurethral ureterolithotripsy (TUL) two times. Retrograde ureterography before the third TUL showed communication between the renal pelvis and the jejunum. We performed a left-sided nephrectomy with a wedge resection of the jejunum. This is a rare case of nephrocutaneous and enterorenal fistula caused by pyonephrosis.

Clinical outcomes after intravesical bacillus Calmette-Guérin for the highest-risk non-muscle-invasive bladder cancer newly defined in the Japanese Urological Association Guidelines 2019.

OBJECTIVE: To assess the clinical outcomes of highest-risk non-muscle-invasive bladder cancer patients treated with intravesical bacillus Calmette-Guérin. METHODS: The medical charts of patients with non-muscle-invasive bladder cancer treated with intravesical bacillus Calmette-Guérin between 2000 and 2018 at a single institution were retrospectively reviewed. Patients were stratified into three groups (intermediate-, high- and highest-risk groups) according to the risk classification of the updated Japanese Urological Association guidelines 2019. Among the three groups, the intravesical recurrence-free survival and progression-free survival were estimated and compared, respectively. Furthermore, the different types of risk factors in the highest-risk group were analyzed. RESULTS: Of the 165 patients, 49 (30%) patients had intravesical recurrence and 23 (14%) patients showed progression to muscle-invasive disease during a median follow-up period of 53 months. Significant differences were not noted in the recurrence-free survival and progression-free survival among the three groups. Multivariable survival analysis of 74 patients in the highest-risk group showed that carcinoma in situ in the prostatic urethra was a significant predictor associated with recurrence (hazard ratio 3.20, P = 0.026) and progression (hazard ratio 4.36, P = 0.013). CONCLUSIONS: Intravesical bacillus Calmette-Guérin can control highest-risk non-muscle-invasive bladder cancer in most patients. Our findings might aid in decision-making regarding the treatment of this subset of patients who require intensive treatment, such as intravesical therapy with bacillus Calmette-Guérin and radical cystectomy.

[Clinical Significance of Stone Cultures for Patients Undergoing Transurethral Lithotripsy].

This study aimed to evaluate the concordance of the microbiologic findings of preoperative urine cultures and intraoperative stone cultures in patients undergoing transurethral lithotripsy (TUL). A total of 164 patients treated with TUL for whom preoperative urine cultures and intraoperative stone cultures were performed were included in this study. The preoperative urine cultures were positive in 57 patients (34.8%) and the stone cultures were positive in 58 patients (35.4%). Enterococcus faecalis was the most common organism detected in the intraoperative stone cultures (22. 9%). The concordance rate between the preoperative urine cultures and intraoperative stone cultures was 45.6%. Eleven patients (6.7%) developed a fever of >38.5°C postoperatively. Among the 11 patients, 9 patients showed positive preoperative urine cultures and 10 patients showed positive stone cultures. The results of the urine culture performed when the patient had a fever of 38.5°C or higher showed 54.5% consistency with the results of the preoperative urine culture or stone culture. Although the results of the preoperative urine cultures and intraoperative stone cultures may not be highly consistent, these cultures should be actively performed because they provide useful information regarding postoperative infections.

Nodule Size After Chemotherapy and Primary-Tumor Teratoma Components Predict Malignancy of Residual Pulmonary Nodules in Metastatic Nonseminomatous Germ Cell Tumor.

BACKGROUND: The treatment goal for visceral metastatic nonseminomatous germ cell tumor (NSGCT) is to remove any residual teratoma or viable NSGCT after chemotherapy. However, this provides no therapeutic benefit to patients whose metastases necrotize on their own. This study therefore analyzed NSGCTs with pulmonary metastases to determine preoperative factors that predict necrosis and could help identify patients who might be treated with monitoring rather than surgery. METHODS: The study retrospectively analyzed 41 patients (135 metastatic pulmonary nodules) treated from 1997 to 2016 for NSGCT who showed tumor marker normalization after chemotherapy. Relationships between clinicopathologic characteristics and necrosis in resected pulmonary specimens were analyzed. RESULTS: Receiver operating characteristic analysis of the pulmonary nodules showed 9 mm to be the optimal cutoff length for predicting necrosis. The logistic regression model showed that absence of teratoma components in the primary tumor and all pulmonary nodules shorter than 10 mm after chemotherapy both were independent predictors of pathologic necrosis in pulmonary specimens. No patients experienced late recurrence (i.e., > 2 years afterward). CONCLUSIONS: The presence of teratoma components in primary tumors and nodular size after chemotherapy predict the pathology of residual pulmonary nodules. Patients whose residual nodules all are shorter than 10 mm and who have no primary-tumor teratoma components might be candidates for careful monitoring before pulmonary resection.

Neoadjuvant crizotinib in ALK-rearranged inflammatory myofibroblastic tumor of the urinary bladder: A case report.

INTRODUCTION: Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor that involves various organs, but has a predilection for the urinary bladder in the genitourinary tract. Given that approximately half of all IMT cases have anaplastic lymphoma kinase (ALK) rearrangements, the ALK inhibitor crizotinib is suggested as a promising treatment for unresectable cases. No reports on neoadjuvant crizotinib therapy for locally advanced IMT of the bladder are available. PRESENTATION OF CASE: We report a case of a 17-year-old Japanese boy referred to our institution for painful urination and increased urinary frequency. He was diagnosed with ALK-positive IMT via transurethral resection of the bladder tumor. Computed tomography (CT) revealed a 5-cm mass and extramural invasion at the bladder dome. The diagnosis was locally advanced IMT of the bladder. We decided that partial cystectomy can be performed if neoadjuvant crizotinib therapy reduced the tumor size. After 2 months of administration, CT showed that the longest tumor diameter was reduced by 48%. Thus, we performed partial cystectomy, and the surgical margin was negative. No recurrence developed for over 1 year. DISCUSSION: IMT has intermediate malignant potential because its clinical course is relatively indolent with low risk of distant metastasis. As this patient is young and IMT of the bladder has good prognosis after surgical resection, bladder-preserving surgery is the most preferred approach. CONCLUSION: Neoadjuvant crizotinib therapy may be effective for large, locally advanced, and difficult to resect tumors.

[Bladder Rupture during Intravesical BCG Therapy : A Case Report].

A 69-year-old man received transurethral resection (TUR) ofbladder tumor. The histopathological diagnosis was urothelial carcinoma, high grade, pT1＋pTis. The surgical specimens obtained by second TUR showed no residual malignancy histopathologically. Intravesical Bacillus Calmette-Guerin (BCG) instillation therapy was initiated 2 months after the second TUR. He complained of lower abdominal pain and painful urination on the day following the second instillation of BCG. Computed tomography and cystography demonstrated rupture ofthe urinary bladder. During 2 weeks ofconservative treatment, the symptoms persisted. Then, open repair ofthe bladder was performed. Intravesical BCG therapy has been a widely accepted treatment for bladder cancer with high grade Ta and T1, and carcinoma in situ. In the present case, thinning ofthe bladder wall, delayed wound healing caused by 2 TURs, and abdominal pressure may have been the factors leading to the bladder rupture in addition to inflammation of the bladder due to BCG instillation. Although bladder rupture caused by intravesical BCG therapy has not been reported, we must be aware ofthe possibility ofthis rare condition, especially after 2 consecutive TURs.

Prevention Technique of Postoperative Inguinal Hernia in Patients Undergoing Radical Prostatectomy for Localized Prostate Cancer.

To prevent inguinal hernia after retropubic radical prostatectomy, many urologists have utilized a prevention technique of inguinal hernia at the same time as retropubic radical prostatectomy. Here, we report the clinical benefit of the prevention technique of inguinal hernia as well as risk factors for the incidence of inguinal hernia. We investigated the medical records of 223 men who underwent retropubic radical prostatectomy for clinically localized prostate cancer between January 2007 and March 2013 at our medical center. We assessed the association between the postoperative inguinal hernia and variables such as age, body mass index, and previous abdominal surgery. Inguinal hernia-free survival was analyzed to verify risk factors of postoperative inguinal hernia. Of 223 patients, 67 (30 %) received prevention of inguinal hernia and 156 (70 %) did not. The median follow-up period after retropubic radical prostatectomy was 36 months (range, 3-58 months). Thirty one (14 %) patients developed unilateral or bilateral inguinal hernia after retropubic radical prostatectomy. The rate of postoperative inguinal hernia in prevented and non-prevented group was 3 % (2 of 67) and 19 % (29 of 156), respectively (P < 0.01, Mann-Whitney U test). Moreover, postoperative inguinal hernia-free survival in the prevention group was significantly longer than that in the non-prevented group (P < 0.01, log-rank test). In the prevention group, 1-, 2-, and 3-year inguinal hernia-free survival rates were 100 %, 96 %, and 96 %, respectively. Other clinical factors including age, body mass index, previous abdominal surgery, and previous inguinal hernia were not associated with the incidence of inguinal hernia in our cohort. The prevention technique was simple and safe to perform, and it could increase inguinal hernia-free survival rates after retropubic radical prostatectomy.

[A Case of Penile Squamous Cell Carcinoma, Sarcomatoid Subtype].

A 70-year-old man was referred to our department for further examination and treatment of a painless penile mass of about 2cm. The patient first noticed the mass onlya few weeks before presentation. Diagnostic biopsy was interpreted as leiomyosarcoma. Through systemic examinations the clinical stage of his disease was diagnosed as cT2N0M0 and we performed total penectomy. Histopathological examination for the totallyresected tissue disclosed the concomitant presence of regions compatible to squamous cell carcinoma and the results of immunohistochemistrywere compatible with the diagnosis of squamous cell carcinoma, sarcomatoid subtype of the penis. One month after the surgery, multiple metastases to left inguinal lymph nodes and lungs developed, for which systemic chemotherapy by doxorubicin was ineffective and the patient died of respiratoryinsufficiencyfive months after presentation.

Reversible Posterior Leukoencephalopathy Syndrome Developing After Restart of Sunitinib Therapy for Metastatic Renal Cell Carcinoma.

A 64-year-old Japanese man had started molecular-targeted therapy with sunitinib for lymph node metastasis 5 years after nephrectomy for left renal cell carcinoma (clear cell carcinoma, G2, pT2N0M0). He was transported to our emergency department because of generalized tonic-clonic seizure, vision loss, and impaired consciousness with acute hypertension after 8 cycles of treatment (2 years after the initiation of sunitinib therapy, including a drug withdrawal period for one year). MRI of the brain (FLAIR images) showed multiple high-intensity lesions in the white matter of the occipital and cerebellar lobes, dorsal brain stem, and left thalamus. Reversible posterior leukoencephalopathy syndrome caused by sunitinib was suspected. In addition to the immediate discontinuation of sunitinib therapy, the administration of antihypertensive agents and anticonvulsants improved the clinical symptoms without neurological damage. Physicians should be aware that sunitinib causes reversible posterior leukoencephalopathy syndrome. The early recognition of reversible posterior leukoencephalopathy syndrome is critical to avoid irreversible neurological damage.

[Multiple Recurrences in Perirenal Fatty Tissue 10 Years after Enucleation for Treatment of T1a Renal Cell Carcinoma : A Case Report].

A 71-year-old man underwent simple enucleation for T1a renal cell carcinoma of the left kidney 10 years ago, and, the capsule of the tumor was injured during that surgery. The histopathological diagnosis of the tumor was papillary renal cell carcinoma type1 pT1a, G2 and the surgical margin was negative. Eight years after the surgery, computed tomography (CT) scan imaging showed a mass 13 mm in diameter which was adjacent to the left kidney. In the following year, the mass had grown to 22 mm in diameter. Thus it was suspected as local recurrence of renal cell carcinoma. Magnetic resonance imaging revealed multiple tumors in the left perirenal fatty space and positron emission tomography CT showed abnormal uptake in the same lesions with a maximal standardized uptake value of 3.2. We diagnosed multiple local recurrences of renal cell carcinoma and planned open radical nephrectomy and extirpation of perirenal fat including tumors entirely. The histopathological diagnosis of the tumor was papillary renal cell carcinomas type 1, Fuhrman grade 2＞3. The patient had no recurrence or metastases 10 months after the surgery. It is possible that the tumor cells were disseminated during the first surgery due to an injury to the capsule of the tumor and resulted in multiple local recurrences.

[Case of xanthogranulomatous pyelonephritis complicated by simultaneous septic pulmonary embolism].

A 57-year-old man with fever-up and multiple nodules in the peripheral area of the lungs on the chest CT was referred to the department of respiratory medicine of our hospital for further examination. The whole body CT disclosed a space-occupying lesion in the left frontal lobe of his brain, an irregular mass in the left kidney, and swelling of paraaortic lymph nodes. A pathological diagnosis could not be made from the results of the bronchoscopic examination and percutaneous needle biopsy for the renal mass. Left nephrectomy and lymph node dissection were carried out because of possible renal malignancy with distant metastases. The renal lesion was diagnosed as xanthogranulomatous pyelonephritis histopathologically. After the nephrectomy, the multiple lung nodules disappeared spontaneously leaving scars in some lesions. Septic pulmonary embolism was highly suspected on the basis of the clinical course. The brain nodule also decreased in size significantly and is currently under careful surveillance.

[A case of giant bladder stone in a young man with neither lower urinary tract dysfunction nor foreign body in the bladder].

A 38-year-old man visited our hospital complaining of lower urinary tract symptoms. He had undergone extracorporeal shockwave lithotripsy to remove a right renal stone two times when he was 24 years old. Since examinations revealed right staghorn calculi and a giant bladder stone, vesicolithotomy was carried out. The removed stone measured 95 × 75 × 55 mm and weighed 250 g. We hypothesized that a fragment of the upper urinary tract stone had reached the bladder which could not be discharged spontaneously, and grew in the bladder. After the operation, uroflowmetry and voiding cystourethrography were performed and the results indicated no abnormalities in the lower urinary tract function.

[Chronic urinary retention in women caused by primary bladder neck obstruction : report of two cases treated successfully with transurethral resection of bladder neck].

A 60-year-old female was referred to our hospital for the treatment of chronic urinary retention which had compelled her to continue clean intermittent self catheterization (CIC) for several years. After further examination including physical examinations, urodynamic study, cystography, and urethrocystoscopy, she was diagnosed with primary bladder neck obstruction (PBNO). Transurethral resection of the bladder neck (TURBN) was performed to relieve the bladder outlet obstruction and she was free from CIC thereafter. Another 61-year-old female on CIC was also referred to our hospital and diagnosed with PBNO through detailed examinations including urodynamics. She was also successfully relieved of CIC after TURBN. Primary bladder neck obstruction is a condition which can be effectively treated by a less-invasive procedure when properly diagnosed by urodynamic examination. Urologists must keep this rare condition in mind as a possible cause of chronic urinary retention in women.

[Brain metastasis which appeared during complete response of lung metastatic lesion by sunitinib treatment in a patient with renal cell carcinoma].

A 59-year-old man underwent radical nephrectomy for left renal cell carcinoma with multiple lung metastases (cT3bN0M1) in May 2010. Pathological diagnosis was clear cell carcinoma, G2 and pT3b. After sunitinib treatment for 7 months computed tomography (CT) revealed complete response of lung lesions and the treatment was continued. After 10 months, the patient complained of right hemiplegia. Brain magnetic resonance imaging (MRI) revealed a 3 cm tumor in his frontal lobe of cerebrum. He underwent surgical resection of the tumor and pathological diagnosis was metastatic renal cell carcinoma. He has been well without local recurrence or distant metastasis for 18 months.

[A case of prostatic urethral calculus associated with perineal abscess and urethrocutaneous fistula].

A 37-year-old male who had sustained a lumbar vertebral fracture presented with the chief complaint of high fever and urine leakage from the perineal region. Computed tomography and urethroscopy showed a huge prostatic urethral calculus. He had a urethrocutaneous fistula in the perineal region. Transvesical prostate-urethrolithotomy, debridement of perineal abscess and cystostomy were performed. After operation, he had total incontinence during clamping of the cystostomy. Four months later, ileal-conduit formation and simple cystectomy were performed to improve urinary management. The pathogenesis of prostatic urethral calculus and the management of neurogenic bladder patients with spinal cord injury are reviewed.

[Testicular mature teratoma with onset during childhood and removed 40 years later: a case report].

A 56-year-old man presented with a painless mass in the left scrotum. The mass was first noticed when he was a junior high school student,and it had been left for about 40 years. The intrascrotal tumor of 7 cm in diameter was elastic soft and smooth. The serum levels of α -fetoprotein, ß -human chorionic gonadotropin and lactate dehydrogenase were within each individual normal range. He was diagnosed as having a left testicular tumor (cT1N0M0) and underwent left high orchiectomy. Histopathological diagnosis was mature teratoma without any malignant germ cell components. No evidence of recurrence has been observed for 4 years after the operation.

[A case of cystic pheochromocytoma mimicking liver abscess].

A 64-year-old man presented to our hospital feeling ill with epigastralgia. Computed tomography (CT) showed right suprarenal cystic tumor. High urinary catecholamine level was noted. Based on metaiodobenzylguanidine (MIBG) scintigraphy, magnetic resonance imaging and blood tests, preoperative diagnosis was adrenal pheochromocytoma. En-bloc resection of the tumor and the right kidney was performed. The cyst contained yellowish serous fluid, which had a catecholamine level about 3,000 times that in the blood. The histological diagnosis was cystic pheochromocytoma. Pathogenesis of cystic adrenal tumor is discussed briefly.

[A case of neobladder-cutaneo fistula after cystectomy].

A 69-year-old man was admitted for the treatment of muscle-invasive bladder carcinoma. Total cystectomy was performed and an ileal neobladder was constructed by a modification of Studer's method. However, a week later, a subcutaneous abscess occurred withwound dehiscence. Open drainage and wound debridement was carried out. Three weeks later, a neoblader-cutaneous fistula was seen on cystography. We managed it conservatively by means of wound debridement and washing with physiological saline. The fistula was closed on the 95th day after operation. The patient can now pass urine by himself.