Preoperative Immunonutrition Significantly Reduced Surgical Site Infection After Urinary Diversion for Invasive Bladder Cancer: A Retrospective Cohort Study.

BACKGROUND: Radical cystectomy and ileal conduit have a high incidence of surgical site infection. In this study, we evaluated the effects of preoperative immunonutrition on its incidence following these procedures. MATERIALS AND METHODS: We retrospectively enrolled 86 patients who underwent radical cystectomy and ileal conduit at our hospital between 2014 October and 2021 July. They were sequentially divided into the Immunonutrition group (n = 43) and Control group (n = 43). Patients in the Immunonutrition group drank 4 packs of IMPACT (Nestle, Japan) per day for 5 days before surgery. IMPACT contains arginine and eicosapentaenoic acid. We compared levels of plasma arginine and eicosapentaenoic acid before and after surgery and the rate of surgical site infection between the groups. Factors related to surgical site infection were analyzed using univariate and multivariable logistic regression analysis. RESULTS: No statistically significant differences were observed in patient characteristics between the groups except for surgical operative method (P < .001) and transfusion (P = .009). Levels of plasma arginine and eicosapentaenoic acid were significantly increased the day before surgery in the immunonutrition group (P < .001). However, the levels of plasma arginine on the day after surgery did not vary significantly between the groups. The incidence of surgical site infection was significantly lower in the immunonutrition group (P = .014). Multivariate analyses showed a significant association of surgical site infection with immunonutrition (OR = 0.14, CI 0.03-0.72, P = .019) and with ASA classification (OR = 4.76, CI 1.23-18.40, P = .024). CONCLUSIONS: Preoperative immunonutrition significantly reduced the incidence of surgical site infection following radical cystectomy and ileal conduit.

Pilot study of an artificial intelligence-based deep learning algorithm to predict time to castration-resistant prostate cancer for metastatic hormone-naïve prostate cancer.

The object in this study is to develop an artificial intelligence-based deep learning algorithm for prediction of time to castration-resistant prostate cancer by combined androgen blockade therapy in metastatic hormone-naïve prostate cancer. We included 180 metastatic hormone-naïve prostate cancer patients who initially received combined androgen blockade. We first evaluated whether time to castration-resistant prostate cancer was a significant prognostic factor. Then, using the patients' needle-biopsy specimen images, we developed and validated our deep learning algorithm. The results are shown below. First, we confirmed that time to castration-resistant prostate cancer correlated with overall survival (P < 0.001). Next, we selected two groups by time to castration-resistant prostate cancer of >24 months (n = 18) and <6 months (n = 6) and developed a deep learning algorithm by artificial intelligence-based machine deep learning. In 16 other metastatic hormone-naïve prostate cancer patients used as an external validation set, we confirmed the prediction accuracy remained significant (P < 0.05). In conclusion, our obtained deep learning algorithm has high predictive ability for the effectiveness of combined androgen blockade.

A case of long-term complete remission of locally advanced T4 bladder cancer treated with pembrolizumab.

A 69-year-old man with a history of non-muscle invasive bladder cancer 12 years ago presented complaining of gross hematuria. He was diagnosed as having invasive T4 bladder cancer with invasion to a branch of the internal iliac artery and received platinum-based chemo-radiation therapy. However, the tumor progressed to extensively infiltrate the pelvic wall, and left leg pain and swelling developed. Pembrolizumab was started, which entirely resolved the tumor after 14 courses of treatment. Pembrolizumab was discontinued after 20 courses of treatment because of adverse events. However, the patient has remained in complete response for over 2 years after pembrolizumab cessation.

Recurrent urinary retention due to clots caused by a congenital renal arteriovenous malformation that forms a complex vascular network: Report of two cases.

INTRODUCTION: Repeated urinary retention due to clots caused by congenital renal arteriovenous malformation is rare. CASE PRESENTATION: A 40-year-old woman (case 1) and a 66-year-old man (case 2) experienced recurrent urinary retention due to clots. Neither patient had a history of renal trauma nor was taking any medications. Contrast-enhanced abdominal computed tomography revealed a large hematoma in the renal pelvis and ureter with no masses, stones, or vascular lesions and only dilated blood vessels in the arterial phase in case 1. Angiography of the kidney in both patients revealed an arteriovenous malformation, and embolization of the arteries feeding the arteriovenous malformation was performed. Soon after embolization, hematuria disappeared completely with no recurrence for 5 years in case 1 and 2 years in case 2. CONCLUSION: Congenital renal arteriovenous malformation should be considered as a cause of recurrent clot retention, and angiographic embolization of the feeding arteries can be an effective treatment.

[Usefulness of Fluorescent Urine Cytology in the Diagnosis of Urothelial Carcinoma].

Five-aminolevulinic acid, an amino acid that is metabolized in the cytoplasm to become protoporphyrin IX, is used in photodynamic diagnosis in various carcinomas because it accumulates in higher concentrations in tumor tissue than in normal tissue. 5-Aminolevulinic acid-induced fluorescent urine cytology is more sensitive than conventional urine cytology only in low grade urothelial carcinoma (UC), but it showed a tendency for higher sensitivity in high grade UC. To increase the number of patients and reconsider our previous findings, we compared the sensitivity and specificity of preoperative urine cytology and fluorescent urine cytology in 343 patients diagnosed as having UCs pathologically (215 bladder cancers, 128 upper tract UCs) and 197 non-cancer patients at Osaka Rosai Hospital from March 2013 to December 2019. The sensitivities of fluorescent urine cytology and conventional urine cytology were 81.1% and 63.3% (p<0.001), respectively, and specificities were 92.9% and 93.9% (p=0.84), respectively. The sensitivity of fluorescent urine cytology was superior to that of conventional urine cytology in both low grade UC (76.8% vs 41.1%, p<0.001) and high grade UC (83.1% vs 74.0%, p=0.023).

Complete remission of metastatic renal cell carcinoma to the bone with sunitinib.

Target agents such as tyrosine kinase inhibitors have improved renal cell carcinoma (RCC) patient outcomes. However, complete remission (CR) with target agents is rare. Furthermore, CR of bone metastasis is much less common. We report a case of CR in bone and lung metastatic RCC. Radical nephrectomy was performed first, and clear cell RCC was diagnosed. Thereafter, sunitinib was started, and bone and lung metastases resolved entirely after 8 months of treatment. Sunitinib therapy was discontinued after 2 years because of the adverse event of proteinuria. However, the patient has remained in CR for over 1 year after sunitinib cessation.

[Late Recurrence of Seminoma Diagnosed by Endoscopic Ultrasound-Guided Fine Needle Aspiration in a Retroperitoneal Lymph Node].

The patient was a 43-year-old man. At 30 years of age, he underwent high-inguinal orchiectomy for a right testicular tumor and was diagnosed with seminoma pT1N0M0. The patient had been followed without additional treatment and had dropped out 7 years after surgery. At 43 years of age, abdominal ultrasonography performed for screening revealed a swollen 4 cm-wide intra-abdominal lymph node, and he was referred to our department. Abdominal contrast-enhanced computed tomography (CT) showed a mass with a 5 cm-wide contrast effect that contacted the anterior surface of the inferior vena cava from the duodenum to the aortic bifurcation. Histological examination by trans-duodenal ultrasound-guided fineneedle aspiration suggested late recurrence of seminoma. After receiving three courses of BEP (bleomycin, etoposide, and platinum) therapy, the patient underwent laparoscopic lymphadenectomy. Pathological examination showed no residual tumor, and the patient was free of recurrence at 13 months after surgery.

High performance of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology.

OBJECTIVES: To investigate the efficacy of selective upper tract urinary cytology using extracorporeal 5-aminolevulinic acid for the diagnosis of upper urinary tract urothelial carcinoma. METHODS: We evaluated 104 patients who underwent radical nephroureterectomy and were diagnosed pathologically as having upper urinary tract urothelial carcinoma between March 2013 and May 2019 in Osaka Rosai Hospital. Preoperatively, we collected upper tract urinary cytology from both sides, and compared the sensitivity and specificity between conventional urine cytology and 5-aminolevulinic acid-induced fluorescent urine cytology. RESULTS: The sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than conventional cytology (90.4% vs 66.3%, P < 0.001), whereas the specificity was equally high (100% vs 98.2%, P = 1.0). In more detailed analysis, the sensitivity of 5-aminolevulinic acid-induced fluorescent selective upper tract urinary cytology was significantly higher than that of conventional cytology unrelated to patients' age (<76 years: 90.2% vs 68.6%, P = 0.013; ≥76 years: 90.6% vs 64.2%, P = 0.021), sex (male: 89.2% vs 67.5%, P = 0.001; female: 95.2% vs 61.9%, P = 0.02) or pT stage (pT1 or less: 91.4% vs 69.0%, P = 0.005; pT2 or more: 89.1% vs 63.0%, P = 0.006), tumor grade (high grade: 91.0% vs 70.5%, P = 0.002; low grade: 88.5% vs 53.8%, P = 0.013), and tended to be more efficacious for tumors that could not be detected by imaging techniques (83.3% vs 50.0%, P = 0.075). CONCLUSIONS: 5-Aminolevulinic acid-induced fluorescent selective upper tract urinary cytology is more sensitive than conventional cytology for the diagnosis of upper urinary tract urothelial carcinoma, regardless of pT stage and tumor grade.

Renal cell carcinoma in a horseshoe kidney treated with robot-assisted partial nephrectomy.

Horseshoe kidney is one of the most common congenital renal fusion anomalies and the incidence of renal cell carcinoma in horseshoe kidney is predicted to be approximately 5.2/100000 individuals. Because horseshoe kidney merges malformations and vascular changes, open surgery is the standard for treatment. There are no reports of robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma in horseshoe kidney. We describe for the first time the safety and the utility of RAPN in a horseshoe kidney with renal cell carcinoma.

High diagnostic efficacy of 5-aminolevulinic acid-induced fluorescent urine cytology for urothelial carcinoma.

BACKGROUND: In general, urine cytology is often problematic because of its low sensitivity, especially for low-grade urothelial carcinoma (UC) in clinical practice. To improve the sensitivity, we focused on 5-aminolevulinic acid (5-ALA), because recent studies suggested that 5-ALA-induced urine cytology can be used for photodynamic diagnosis. In this study, we evaluated the diagnostic efficacy of 5-ALA-induced fluorescent urine cytology for UC. METHODS: We included in this study 318 patients comprising 158 non-cancer patients, 84 bladder tumor patients, and 76 upper urinary tract urothelial carcinoma (UUT-UC) patients treated in our institution from March 2013 to September 2018. Using the same voided urine sample, we compared sensitivity and specificity between conventional urine cytology and 5-ALA-induced fluorescent urine cytology. RESULTS: Overall, the sensitivity of 5-ALA-induced fluorescent urine cytology was significantly higher than that of conventional urine cytology (86.9% vs. 69.4%; p = 0.0002), and the specificity was equivalently high (96.2% vs. 95.6%; p = 1.0). In subgroup analysis, the high sensitivity of 5-ALA-induced fluorescent urine cytology was also detected regardless of age, sex, and tumor type. However, in terms of stage and grade, differences were only detected in patients with less than pTa stage (89.2% vs. 52.1%; p = 0.0001) and low-grade tumor (91.5% vs. 51.1%; p < 0.0001). CONCLUSIONS: 5-ALA-induced fluorescent urine cytology was significantly more effective for UC diagnosis when compared with the conventional cytology, especially in patients with low-stage and low-grade tumors. These findings indicate that 5-ALA-induced fluorescent urine cytology may potentially be a very useful tool for clinical use.

[CLINICAL STUDY OF INTEGRATED URINARY CARE TO SUPPORT SELF-RELIANCE AGAINST URINARY DYSFUNCTION WITH INVOLVEMENT BY UROLOGISTS].

(Purpose) We reviewed 207 patients with urinary dysfunction who were managed by voiding care team at Osaka Rosai Hospital between November 2016 and June 2018. (Materials & methods) The study involved 112, 32, 24, 19, 10, 7, and 3 patients in the Urology, Orthopedics, Surgery, Internal Medicine, Neurosurgery, and Otorhinolaryngology departments, respectively. The average age was 72.7 years, ranging from 27 to 94 years, and the patients were170 males and 37 females. The average body mass index was 23.3, ranging from 11.6 to 43.7. The degree of activity of daily life (ADL) was distributed from J (independent ADL) to C (bedridden), and consisted of 132 in J category, 23 in A, 28 in B, 24 in C. Forty-seven patients had diabetes mellitus (DM), 36 had a cranial nerve disease, 25 had a history of urinary retention, 17 had indwelling urethral catheters on admission, 53 had an emergency hospital admission, and 174 underwent ≥1 operations during admission. (Results & conclusions) Among the 112 patients treated in the Urology department, 60 underwent robot-assist radical prostatectomy (RARP), 36 transurethral resection of prostate (TUR-P) and Holmium laser enucleation of the prostate (HoLEP), and 16 other procedures. A total of 93% were indwelling urethral catheter free, and 92% were pad-free (≤1 pad per day) at 1 year. In contrast, only 66% of the 95 patients in other departments were indwelling urethral catheter free at 1 year and were indwelling urethral catheter-free within 100 days, except for only one patient. The self-reliant voiding rate, including patients who have their indwelling urethral catheter removed or managed clean intermittent self-catheterization, was 91% at 1 year. A univariate analysis indicated that an ADL of J, independent ambulation, self-care/undiapered, self-reliant voiding score ≤4 (on a scale from 0 to 10, with higher score indicating a poorer ADL), and a urinary function ≤4 (on a scale from 0 to 10, with a higher score indicating greater urinary dysfunction) were significantly associated with freedom from urethral catheter. A multivariate analysis with Cox's proportional hazard model revealed a urinary function of ≤4 to be an independent good prognosticator for being catheter-free. Furthermore, a univariate analysis indicated that ADL J, a scheduled hospital admission, ≥1 operations during admission, independent ambulation, self-care/independent portable toilet, self-care/undiapered, self-reliant voiding score (≤4), and a urinary function of ≤4 were significantly associated with the acquisition of self-reliant voiding. A multivariate analysis with Cox's proportional hazard model revealed a self-reliant voiding of ≤4 to be an independent good prognosticator for self-reliant voiding. (Conclusions) Achieving freedom from an indwelling urethral catheter and acquiring a self-reliant voiding function are suggested to be very important for integrated urinary care.

[Renal Pelvic Cancer with Delayed Diagnosis Due to Left Renal Injury : A Case Report].

We report a case of renal pelvic cancer found after left renal trauma. A 63-year-old man was admitted to our hospital because of gross hematuria after he had fallen down the stairs two days earlier. He had asymptomatic severe anemia (Hb : 3. 6 g/dl). Abdominal computed tomography (CT) scan revealed bilateral ureteropelvic stones, bilateral severe hydronephrosis and hematoma of the left upper renal pelvis. We diagnosed him with left renal pelvic hemorrhage by trauma, and transcatheter arterial embolization (TAE) was performed. After TAE, gross hematuria improved, but some hematuria continued to be noted. We suspected malignancy, and examined the patient with contrast-enhanced CT, transurethral resection and retrograde pyelography combined with urine cytology in the upper urinary tract, all with no evidence of malignancy. However, four months after the left renal injury, follow-up CT revealed multiple metastatic lesions. We performed a left nephrectomy, and the resulting pathological diagnosis was invasive urothelial carcinoma with squamous differentiation of the renal pelvis. We performed 7 courses of chemotherapy, but the multiple metastatic lesions progressed, and he died of the disease 19 months after the operation.

A Rare Case of Vascular Leiomyosarcoma Originating from a Branch Vessel of the External Iliac Vein.

Leiomyosarcoma arising from the external iliac vein is uncommon. This is a report of a 51-year-old Japanese man with venous leiomyosarcoma originating from a branch vessel of the left external iliac vein. The tumor was found during a medical examination, and the patient had no symptoms. Computed tomography showed a 72 × 49 mm mass adjacent to the left external iliac vein. The tumor was resected en-block along with ligation of the external iliac vein due to strong adhesion with the tumor. Histological examination showed venous leiomyosarcoma, and its origin was thought to be a branch vessel of the left external iliac vein. The patient has remained free from recurrence at 30 months after surgery.

Liposarcoma of the spermatic cord associated with scrotum lipoma: A case report and review of the literature.

Liposarcoma of the spermatic cord is a rare disease and often mistakenly diagnosed as inguinal hernia, hydrocele, and lipoma. We report the case of a 58-year-old man who presented with persistent discomfort and swelling on the left inguinal region. He was diagnosed with left scrotum lipoma when he was 12 years old. He underwent high orchiectomy and wide resection of the inguinal tumor. Histopathological examination revealed a well-differentiated liposarcoma of the spermatic cord with negative resection margin and scrotum lipoma. To our knowledge, this is the first report of liposarcoma of the spermatic cord with scrotum lipoma in English literature.

First adult case of sporadic localized glomerulocystic kidney mimicking a tumor.

Glomerulocystic kidneys (GCKs) are mainly observed in infants and young children, and are characterized by the cystic dilatation of Bowman's space to form glomerular cysts (GCs). GCKs are associated with various conditions. Additionally, the cystogenesis of GCKs remains controversial. The present study describes a rare adult case of a sporadic localized GCK that radiologically mimicked a multilocular cystic tumor, and analyses the features of GC. A 42-year-old male with hematuria underwent a right partial nephrectomy for a cystic mass. The majority of the cyst was distributed in the cortex and contained a single collapsed glomerulus. Using serial sections, narrow and serpiginous proximal tubules that continued to the GCs were detected. These findings suggested that obliteration at the glomerulotubular junction was not the primary cause of GC in this case. To the best of our knowledge, this is the first adult case of a sporadic localized GCK mimicking a tumor. Unnecessary surgical procedures may be avoided by careful evaluation of computed tomography scans and magnetic resonance imaging, although localized GCKs are quite rare.

[Urinary re-diversion using afferent limb as an ileal conduit for urethral recurrence after ileal neobladder reconstruction by Studer method : a case report].

A 68-year-old man who had previously undergone radical cystectomy and ileal neobladder reconstruction by the Studer method for invasive bladder cancer one year ago was urgently admitted to our hospital with gross hematuria and severe anemia. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed an expanded ileal neobladder with a huge coagulum and tumor. Cystoscopy showed a non-papillary tumor occurring from the urethral anastomotic region toward the ileal neobladder and suggested the possibility of partial invasion to the ileal neobladder wall. The pathologic diagnosis of transurethral resection was invasive urothelial carcinoma, high grade, G3. We performed resection of ileal neobladder and urinary re-diversion using an afferent limb as ileal conduit. Unfortunately, in this case, a radical cure was not provided, but we considered that urinary re-diversion using an afferent limb as ileal conduit can be a useful option for urethral recurrence after ileal neobladder reconstruction.

Survey of overactive bladder symptoms influencing bother before and after treatment with tamsulosin hydrochloride in Japanese patients with benign prostatic hyperplasia.

OBJECTIVE: To evaluate the relation between bother and overactive bladder (OAB) symptoms in patients with benign prostatic hyperplasia (BPH) patients using questionnaires: the BPH Impact Index (BII) and the OAB symptom score (OABSS). Annoyance from BPH usually provides the basis for a patient's decision to seek medical treatment. However, a study investigating the bother caused by OAB symptoms in patients with BPH and OAB has not been fully conducted. METHODS: The present study included 100 male patients who were diagnosed with BPH and OAB according to questionnaire criteria. All patients were instructed to take tamsulosin for 28 days. The relation between the BII and OABSS was assessed to determine the factors influencing OAB symptoms on the BII before and after treatment. RESULTS: The BII correlated positively with the OABSS, and multivariate analysis showed that the subscore of urgency was the only independent factor influencing the BII. Even after treatment, lower urinary tract symptoms were diagnosed as OAB using the OABSS criteria in 45 (45.0%) of the 100 patients. In these patients, the BII still correlated positively with the OABSS. However, multivariate analysis showed that the subscore of urgency incontinence, not urgency, was the only independent factor influencing the BII, although the subscore of urgency incontinence was significantly decreased with tamsulosin treatment. CONCLUSION: The degree of bother correlated with the degree of OAB symptoms in patients with BPH and OAB at baseline and after treatment with tamsulosin. The OAB symptom causing the bother was altered by treatment with tamsulosin in these patients.