Vas Guide: a novel device for looping blood vessels in robot-assisted surgery.

Looping blood vessels in robot-assisted surgery remains challenging because of limitations in instrument articulation, joint length, and the lack of tactile feedback. To address this critical issue, we developed the Vas Guide, a novel device, for safe blood vessel handling. This study aims to establish the efficacy, safety, and durability of the Vas Guide.The Vas Guide is a flat, curved stainless-steel strip with blunt, rounded ends and a hole near the distal end. After sufficient dissection of the posterior surface of the target blood vessel, the Vas Guide with a vessel loop tied to the distal end was passed around the blood vessel in a single step using a suturing-like motion, thereby enabling secure vessel management. It is reusable and has a unit price of approximately $600. We analyzed 83 patients undergoing robot-assisted partial nephrectomy or nephroureterectomy at Tokushima University Hospital: 39 in the Vas Guide group and 44 in the conventional group. Outcomes including looping time, looping-related complication rates, such as collisions between instruments and bleeding, and additional instrument usage were recorded. The National Aeronautics and Space Administration task load index (NASA-TLX) scores were assessed.The patients' characteristics were comparable between the two groups. The Vas Guide group demonstrated significantly better outcomes, including faster looping times (31 vs. 90 s, p < 0.001), fewer looping-related complications (0% vs. 30%, p < 0.001), no additional instrument usage (0% vs. 50%, p < 0.001), and better NASA-TLX scores (26.5 vs. 75.7, p < 0.001). The Vas Guide showed no usability issues, with only minor surface scratches and a slight radius change (8.60 mm to 8.69 mm).This reusable device combines high efficacy, safety, and durability and can be implemented at a relatively low cost.


Cutaneous ureterostomy following robot-assisted radical cystectomy: a multicenter comparative study of transperitoneal versus retroperitoneal techniques.

Compared with r-CUS, t-CUS was associated with a shorter operative time and lower incidence of perioperative complications, including gastrointestinal complications. We believe that t-CUS can be performed safely and effectively.

Compared with the r-CUS group, the t-CUS group had significantly shorter operative times (p < 0.001); significantly less estimated blood loss (p < 0.001); and significantly lower incidence of complications (Clavien-Dindo classification grade ≤ 2) within 30 days (p = 0.005). Unexpectedly, the incidence of ileus within 30 days was lower, though the difference was not statistically significant (p = 0.064). During the median follow-up period of 24.3 months, no ileus was observed in either group after 30 days postoperatively. There was no significant difference in the stent-free rate between the groups (p = 0.449). There were also no significant differences in the rates of change in estimated glomerular filtration rate from preoperatively at 3, 6, 12, and 24 months postoperatively between the groups (p = 0.590, p = 0.627, p = 0.741, and p = 0.778, respectively).


Robot-assisted nephroureterectomy using the GelPoint Platform with a focus on optimizing the port position and specimen retrieval.

One of the factors that makes robot-assisted nephroureterectomy difficult is that the optimal port position differs between nephrectomy and bladder cuff excision. In addition, how best to retrieve the specimen after resection while minimizing the size of the wound is a challenge in robot-assisted surgery. To solve these problems, we designed a surgical technique for robot-assisted nephroureterectomy using the GelPoint Platform with a focus on port position optimization and specimen retrieval. This study describes the surgical technique of GelPoint robot-assisted nephroureterectomy and reports our initial experience with this technique. Between January 2023 and May 2024, seven patients underwent robot-assisted nephroureterectomy using the GelPoint Platform and 11 underwent conventional robot-assisted nephroureterectomy. We compared the patients' characteristics and surgical outcomes between the two groups. Compared with the conventional robot-assisted nephroureterectomy group, the median operative time tended to be shorter in the GelPoint robot-assisted nephroureterectomy group (280 vs. 357 min, respectively; p = .135). The maximum incision length tended to be longer in the GelPoint robot-assisted nephroureterectomy group (7.0 vs. 6.0 cm, respectively; p = .078). The incidence of 30-day complications was similar between the two groups (28.5% vs. 18.2%, respectively; p = 1.000). No complications were associated with the use of the GelPoint Platform. The surgical outcomes of GelPoint robot-assisted nephroureterectomy are comparable to those of conventional robot-assisted nephroureterectomy, and it can be performed safely and effectively. GelPoint robot-assisted nephroureterectomy can be considered a feasible alternative for selected patients with upper tract urothelial carcinoma.


Retroperitoneal cutaneous ureterostomy following radical cystectomy: A multicenter comparative study of robotic versus open surgery.

The aim of this study was to evaluate the differences in perioperative outcomes of cutaneous ureterostomy (CUS) between open surgery (open radical cystectomy, ORC) and robot-assisted surgery (robot-assisted radical cystectomy, RARC), including the stent-free rate, readmission rates due to urinary tract infection (UTI), and changes in renal function. Between 2005 and 2023, a total of 37 patients underwent CUS following ORC, while 24 patients underwent CUS following RARC. Perioperative outcomes were compared between these two groups. The patients in the RARC group were significantly older (p = 0.007) and had a significantly higher proportion of high-risk cases with ASA-PS 3 (p = 0.002). In addition, RARC was associated with a significantly lower estimated blood loss (p < 0.001) and a reduced transfusion rate (p = 0.003). Postoperative complication rates and the stent-free rate were comparable between the ORC and RARC groups. Throughout a median follow-up period of 2.6 years, rates of readmission due to UTI did not differ significantly between the two groups. Moreover, there were no differences in the change in estimated glomerular filtration rate before and after surgery and the 3-year survival rates were similar across both groups. CUS following RARC appears to offer a safer alternative compared with CUS following ORC, and the stent-free rates are comparable. The significantly lower estimated blood loss and transfusion rate associated with RARC are particularly favorable for elderly patients, those who are frail, and individuals with multiple comorbidities.


Efficacy of educational stepwise robot-assisted radical prostatectomy procedure for urology residents.

To evaluate the effectiveness of an educational stepwise robot-assisted radical prostatectomy (RARP) procedure for urology residents. We performed a detailed evaluation of 42 RARP procedures performed by a single urology resident from July 2019 to February 2022. The RARP procedures were divided into the following nine steps: (1) bladder dissection, (2) endopelvic fascia dissection, (3) bladder neck dissection, (4) seminal vesicle dissection, (5) Denonvilliers' fascia dissection, (6) dorsal vascular complex ligation, (7) dissection of the prostatic apex, (8) posterior anastomosis, and (9) urethro-vesical anastomosis. The procedures were further subcategorized as anatomical understanding, spatial recognition, and technical skills for evaluation of resident training. The surgeries were divided into first and second halves, and patient characteristics and operative outcomes were statistically analyzed. The operative time of each of the nine steps and the reasons for proctor intervention were compared. Among 42 patients, there were no significant differences in operative outcomes between the two groups. The median operative time was 169 min (164 vs. 179 min, p = .12), and the median console time was 128 min (127 vs. 130 min, p = .74). Although there were no significant differences in the time of the nine steps, the resident significantly overcame (7) dissection of the prostatic apex and (8) posterior anastomosis based on the evaluation of the proctored reasons for intervention. Urology residents can safely perform and efficiently learn RARP with this stepwise educational system. This educational stepwise RARP procedure can effectively help residents to develop their skills.


Radical prostatectomy using the Hinotori robot-assisted surgical system: Docking-free design may contribute to reduction in postoperative pain.

The docking-free design of the Japanese Hinotori surgical robotic system allows the robotic arm to avoid trocar grasping, thereby minimising excessive abdominal wall stress. The aim of this study was to evaluate the safety and efficacy of robotic-assisted radical prostatectomy (RARP) using the Hinotori system and to explore the potential contribution of its docking-free design to postoperative pain reduction. This study reviewed the clinical records of 94 patients who underwent RARP: 48 patients in the Hinotori group and 46 in the da Vinci Xi group. Hinotori group had significantly longer operative and console times (p = 0.030 and p = 0.029, respectively). Perioperative complications and oncologic outcomes did not differ between the two groups. On postoperative day 4, the rate of decline from the maximum visual analogue scale score was marginally significant in the Hinotori group (p = 0.062). The docking-free design may contribute to reducing postoperative pain.

The International Journal of Medical Robotics + Computer Assisted Surgery : MRCAS


Robot-assisted partial nephrectomy in younger versus older adults with renal cell carcinoma: a propensity score-matched analysis.

Our study aimed to compare the surgical outcomes of robot-assisted partial nephrectomy (RAPN) between younger and older patients after adjusting for their background differences. We particularly assessed RAPN outcomes and safety in older patients.We retrospectively evaluated 559 patients clinically diagnosed with T1 renal cell carcinoma (RCC) and treated with RAPN between 2013 and 2022 at five institutions in Japan. The patients were classified into two groups according to their age during surgery (younger group: < 75 years, older group: ≥ 75 years). Propensity score matching (PSM) was performed to adjust for the differences in the backgrounds between younger and older patients, and surgical outcomes were compared.Among the 559 patients, 422 (75.5%) and 137 (24.5%) were classified into the younger and older groups, respectively; 204 and 102 patients from the younger and older groups were matched according to PSM, respectively. Subsequently, patient characteristics other than age were not significantly different between the two groups. In the matched cohort, the older group had more patients with major complications (younger, 3.0%; older, 8.8%; P = 0.045).Surgical outcomes of RAPN in older patients with RCC were comparable with those in younger patients, although older patients experiencedsignificantly more complications than younger patients. These results suggest the need for further detailed preoperative evaluation and appropriate postoperative management in older patients receiving RAPN.


Robot-assisted intracorporeal ileal conduit urinary diversion: A two-center comparative study of Bricker versus Wallace ureteroileal anastomosis

This study was performed to evaluate the differences in the perioperative results, renal function, and incidence of hydronephrosis over time between the use of Bricker anastomosis and Wallace anastomosis for robot-assisted intracorporeal ileal conduit urinary diversion (RICIC). Fifty-five patients who underwent RICIC at two institutions were evaluated (Bricker, n = 23; Wallace, n = 32). We investigated changes in estimated glomerular filtration rate and hydronephrosis before surgery and at 3, 6, and 12 months after surgery. The patients in the Bricker group were significantly older than those in the Wallace group. The urinary diversion time was significantly longer in the Bricker group. No significant difference in postoperative renal function was observed. Additionally, no significant difference was observed in the incidence of postoperative hydronephrosis. However, the incidence of right hydronephrosis tended to be high overall, especially in the Wallace group. No patients in either group required repair surgery or ureteral stent placement. In patients undergoing RICIC, there was no difference in postoperative renal function or the incidence of hydronephrosis between Wallace and Bricker anastomosis. Symptomatic hydronephrosis was not observed in either group. The present study showed that each method was equally effective and safe.


A new trick for scrotal surgery using Doyen intestinal forceps.


Impact of lymph node dissection on surgical and oncological outcomes in patients undergoing robot-assisted radical cystectomy for bladder cancer: a multicenter retrospective study

This study was performed to clarify the therapeutic and diagnostic roles of lymph node dissection (LND) by examining the impact of LND and lymph node yield (LNY) on oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC). Between 2014 and 2021, 216 patients underwent LND during RARC at Tokushima University Hospital and affiliated hospitals. Among the 216 patients, we compared 115 patients with an LNY of 20 and 101 with an LNY of < 20 to investigate the impact of LNY on surgical and oncological outcomes. Furthermore, we investigated the impact of LNY and the extent of LND on oncological outcomes by dividing the extent of LND into two groups (standard and extended). The 3-year rates of overall survival (OS) (p = 0.256), cancer-specific survival (CSS) (p = 0.791), and recurrence-free survival (RFS) (p = 0.953) did not differ between the two groups divided by the LNY. A higher LNY was associated with a significantly higher lymph node positivity rate (p = 0.020). The incidence of LND-related major complications was not significantly different between the two groups (p = 0.910). The 3-year survival rates did not differ between the two groups divided by the extent of LND: OS (p = 0.366), CSS (p = 0.814), and RFS (p = 0.689). The LNY and extent of LND were not associated with oncological outcomes in patients undergoing LND during RARC, whereas a higher LNY was associated with lymph node positivity. In the era of adjuvant therapy with immune checkpoint inhibitors, LND during RARC has an important diagnostic role in the detection of pathological node positivity.


This study was performed to clarify the therapeutic and diagnostic roles of lymph node dissection (LND) by examining the impact of LND and lymph node yield (LNY) on oncological outcomes in patients undergoing robot-assisted radical cystectomy (RARC). Between 2014 and 2021, 216 patients underwent LND during RARC at Tokushima University Hospital and affiliated hospitals. Among the 216 patients, we compared 115 patients with an LNY of ≥ 20 and 101 with an LNY of < 20 to investigate the impact of LNY on surgical and oncological outcomes. Furthermore, we investigated the impact of LNY and the extent of LND on oncological outcomes by dividing the extent of LND into two groups (standard and extended). The 3-year rates of overall survival (OS) (p = 0.256), cancer-specific survival (CSS) (p = 0.791), and recurrence-free survival (RFS) (p = 0.953) did not differ between the two groups divided by the LNY. A higher LNY was associated with a significantly higher lymph node positivity rate (p = 0.020). The incidence of LND-related major complications was not significantly different between the two groups (p = 0.910). The 3-year survival rates did not differ between the two groups divided by the extent of LND: OS (p = 0.366), CSS (p = 0.814), and RFS (p = 0.689). The LNY and extent of LND were not associated with oncological outcomes in patients undergoing LND during RARC, whereas a higher LNY was associated with lymph node positivity. In the era of adjuvant therapy with immune checkpoint inhibitors, LND during RARC has an important diagnostic role in the detection of pathological node positivity.


The importance of laparoscopic surgery for young urologists remains unwavering even in the era of robot assisted surgery

Robot-assisted surgery (RAS) cannot be achieved without the performance of laparoscopic surgical techniques by a patient-side surgeon (PSS). In many medical institutions in Japan, young urologists often take on the role of a PSS. Participating in RAS as a PSS provides a good opportunity to acquire not only the knowledge necessary for surgery, but also skills in laparoscopic surgical techniques. Learning laparoscopic surgery as a PSS may contribute to improving the quality of RAS. Furthermore, it will lead to skill improvement as an operator in laparoscopic surgery. However, notably, opportunities for young urologists to perform laparoscopic surgery are decreasing in the current era of RAS. Under these circumstances, we believe that cadaver surgical training will become increasingly important in the future. We believe that performance of cadaver surgical training will contribute to increased motivation, enhance the understanding of surgical procedures, and facilitate the acquisition of surgical techniques.


Effect of Positive Biopsy Core Rate on Low-dose-rate Brachytherapy Outcomes in Intermediate-risk Prostate Cancer.

Positive core ratios observed on prostate biopsy correlated with higher recurrence rates after LDR-BT. This indicates that the proportion of positive cores in the biopsy may be an important factor in predicting the likelihood of recurrence, especially for patients with GG3 PCa.


Assistent guide short: A new device for facilitating ureteric stenting in women.


Lymph node dissection during radical cystectomy for bladder cancer: A two-center comparative study of robotic versus open surgery.

This study was performed to evaluate the safety and efficacy of lymph node dissection (LND) during robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC). From October 2003 to December 2021, 122 patients underwent LND during RARC and 103 patients underwent LND during ORC at Tokushima University Hospital and Tokushima Prefectural Central Hospital. We investigated the safety and efficacy of LND during RARC by comparing the surgical and oncological outcomes between the two groups. The patients were significantly older in the RARC than the ORC group. The operative time was significantly shorter and the estimated blood loss was significantly lower in the RARC than the ORC group. Although the lymph node yield was significantly higher in the RARC than the ORC group, there was no significant difference in lymph node positivity between the groups. There was no significant difference in the incidence of local recurrence or distant metastasis between the two groups. The 5-year survival rates (overall survival, cancer-specific survival, and recurrence-free survival) were not different between the RARC and ORC groups. This study suggests that the surgical and oncological safety and efficacy of LND during RARC are greater than those of LND during ORC. We believe that LND during RARC is a higher-quality procedure than LND during ORC.


Insulin receptor expression to predict resistance to axitinib and elucidation of the underlying molecular mechanism in metastatic renal cell carcinoma.

Decreased INSR in RCC could be a biomarker to predict axitinib resistance. Regarding the resistant mechanism, vascular endothelial cells with decreased INSR in RCC may secrete interferon-β and induce PD-L1.


Efficacy of fresh-frozen cadaveric surgical training for arteriovenous fistula in vascular access.

CST for AVF creation is useful for surgical education because it enables learning of surgical techniques that are almost equivalent to those in living bodies. In addition, this study suggested that CST not only contributes to the improvement of surgical skills of young surgeons but also promotes the reduction of anxiety and stress about AVF creation.

Twelve CST sessions were performed on nine FFCs. All training sessions allowed completion of AVF creation with a median operative time of 78.5 min. Although veins and arteries were more difficult to identify than in a living body, other surgical operations could be performed in the same way as in a living body. All the respondents stated that it was good for them to experience CST. In addition, 86% of surgeons responded that CST improved their surgical techniques, and 71% of surgeons responded that they were less anxious about AVF creation.


THE NEXT TEN YEARS OF SYSTEMIC THERAPY FOR METASTATIC RENAL CELL CARCINOMA

有転移腎細胞癌に対する薬物療法のNext 10 Years


Assistent guide: A novel device for ureteral stent placement in robot-assisted intracorporeal ileal conduit.

We showed the safety and efficacy of the Assistent guide for ureteral stent placement in RICIC.

The International Journal of Medical Robotics + Computer Assisted Surgery : MRCAS


Drug-induced de novo thrombotic microangiopathy diagnosed 2 years after renal transplantation: A case report and literature review


Prostate-specific Antigen Levels Following Brachytherapy Impact Late Biochemical Recurrence in Japanese Patients With Localized Prostate Cancer.

PSA levels at 5 years post-treatment were associated with long-term recurrence of localized prostate cancer, which can help alleviate patient anxiety concerning prostate cancer recurrence if PSA levels remain low at 5 years after LDR-BT.


Impact of early urinary catheter removal on successful voiding and physical function in stroke patients.

The aim of the present study was to identify factors related to the success of trial without catheter (TWOC) in patients with stroke and to examine the effect of the timing of urinary catheter removal on the course of stroke. Patients who were admitted to the Stroke Care Unit of our institution between March 2018 and October 2021 were included. To identify factors related to success of TWOC, a multivariate analysis was performed on the patient's condition at admission and catheter indwelling time. The patients were divided into two groups by the timing of catheter removal, and we assessed the relationship between the timing of catheter removal successful TWOC and recovery of physical function. A total of 118 patients were included. The presence of comorbidities and scores of severity and function at admission were not predictors of successful voiding. The time to achieve voiding sussess was significantly shorter in the early catheter removal group than in the later group (p<0.005). Interestingly, the early group also showed better improvements in physical function. Early removal of catheters may lead to early recovery of bladder function, improvement of physical function, and lower risk of complications in patients with stroke. J. Med. Invest. 70 : 436-442, August, 2023.

The Journal of Medical Investigation : JMI


The impact of nutritional status and changes of body composition on the prognosis of metastatic renal cell carcinoma patients.

Nutritional status of mRCC patients may predict changes in body composition and be associated with their prognosis. J. Med. Invest. 70 : 80-87, February, 2023.


未固定凍結遺体を用いた心停止下献腎摘出教育の試み

未固定凍結遺体を用いた心停止下献腎摘出教育の試み

Journal of Japanese Society for Clinical Renal Transplantation


Comparison of robot-assisted partial nephrectomy with soft coagulation and double-layer technique for complex and non-complex tumors.

Single-layer suturing with soft coagulation achieves renal function and perioperative outcomes comparable to those of double-layer suturing regardless of complexity.


A propensity score matching study on robot-assisted radical cystectomy for older patients: comparison of intracorporeal ileal conduit and cutaneous ureterostomy.

In older patients, the ICIC group showed non-inferior surgical and oncological outcomes compared with the CUS group. Urinary diversion following RARC in older patients should be carefully selected by considering not only the age but also the general condition (including comorbidities) of the patient.

The median age was lower in the ICIC group compared with the CUS group, and the proportion of high-risk cases (ECOG-PS ≥ 2 or ASA-PS ≥ 3) did not differ. The median operation time was longer in the ICIC group, and estimated blood loss was higher, compared with the CUS group. There were no significant differences in the incidence of complications within the first 30 postoperative days, incidence of complications 30-90 days after surgery, 2-year overall survival, 2-year cancer-specific survival, and 2-year recurrence-free survival. The stent-free rate was significantly lower in the CUS group than that in the ICIC group.


The Association of Tumor Immune Microenvironment of the Primary Lesion with Time to Metastasis in Patients with Renal Cell Carcinoma: A Retrospective Analysis.

Biological or immunological differences in primary lesions between synchronous and metachronous metastatic renal cell carcinoma (mRCC) have been reported. However, the association between the tumor immune microenvironment (TIME) of primary lesions and time to metastasis remains unknown. We investigated the differences in the TIME of primary lesions based on time intervals to metastasis, mainly between the synchronous group (SG; metastasis within 3 months) and metachronous group (MG; metastasis after 3 months), and its association with clinicopathological parameters in patients with mRCC. Overall, 568 patients treated first-line with vascular endothelial growth factor receptor inhibitors comprised the analysis population (SG: N = 307 [54.0%]; MG: N = 261 [46.0%]). SG had a higher proportion of patients with poor prognostic pathological feature tumors: WHO/ISUP grade 4, necrosis, lymphovascular invasion, infiltrative growth pattern, and sarcomatoid differentiation. Regarding the TIME, more immunogenic features were seen in SG than MG, with a higher PD-L1 positivity and a lower proportion of the desert phenotype. This is the first study to examine the differences in the TIME of primary lesions in patients with mRCC based on the time intervals to metastasis. The TIME of primary lesions could affect the time to metastasis.


Recurrent multiple liver metastases of clear cell renal cell carcinoma with a significant response to sunitinib after nivolumab treatment.

Sunitinib after an IO-drug showed a significant effect in spite of only slight efficacy with other VEGFR-TKIs, which may have occurred through the alteration of the immunological microenvironment.

The patient was a 65-year-old man who underwent open nephrectomy for RCC. After the nephrectomy, he had recurrences several times, and metastasectomy had been performed for each recurrence. At 13 years after the nephrectomy, multiple liver, and lung metastases appeared. The treatment was switched to axitinib, followed by cabozantinib, then nivolumab. The best response was PR, SD, and PD for these three drugs, and treatment duration was 14, 3, and 3 months, respectively. As the fifth line, sunitinib was administered, with significant shrinkage of the multiple liver metastases, and PR has been maintained for 34 months.


Morin improves dexamethasone-induced muscle atrophy by modulating atrophy-related genes and oxidative stress in female mice.

This study investigated the effect of morin, a flavonoid, on dexamethasone-induced muscle atrophy in C57BL/6J female mice. Dexamethasone (10 mg/kg body weight) for 10 days significantly reduced body weight, gastrocnemius and tibialis anterior muscle mass, and muscle protein in mice. Dexamethasone significantly upregulated muscle atrophy-associated ubiquitin ligases, including atrogin-1 and MuRF-1, and the upstream transcription factors FoxO3a and Klf15. Additionally, dexamethasone significantly induced the expression of oxidative stress-sensitive ubiquitin ligase Cbl-b and the accumulation of the oxidative stress markers malondialdehyde and advanced protein oxidation products in both the plasma and skeletal muscle samples. Intriguingly, morin treatment (20 mg/kg body weight) for 17 days effectively attenuated the loss of muscle mass and muscle protein and suppressed the expression of ubiquitin ligases while reducing the expression of upstream transcriptional factors. Therefore, morin might act as a potential therapeutic agent to attenuate muscle atrophy by modulating atrophy-inducing genes and preventing oxidative stress.

Bioscience, Biotechnology, and Biochemistry


Leptomeningeal carcinomatosis in small cell carcinoma of the prostate.

Careful monitoring of the central nervous system should be considered in small cell carcinoma of the prostate patients.

A 69-year-old man visited our hospital due to dysuria and edema. Bilateral hydronephrosis and lymph node metastases due to a pelvic tumor were observed. Although the prostate-specific antigen level was normal, the tumor was suspected to originate from the prostate. He underwent percutaneous nephrostomy and prostate biopsy. Histopathology revealed small cell carcinoma accompanied by increased pro-gastrin-releasing peptide and neuron-specific enolase levels. After receiving systemic chemotherapy with carboplatin and etoposide and radiation therapy for prostate, these lesions gradually decreased in size, and tumor markers normalized. Ten months after the initial diagnosis, he developed consciousness disorder and seizure. Magnetic resonance imaging revealed leptomeningeal carcinomatosis without any other recurrences and elevated tumor markers. He died 4 weeks after these symptoms appeared.


Appropriate management reduces radiation exposure in daily urological practice

To identify and raise awareness of the radiation exposure of urologists due to X-ray fluoroscopic procedures in daily practice. This was a single-center, cohort study of 30 consecutive patients who underwent periodic percutaneous or transurethral replacements of urinary tract catheters. A total of 55 replacements every 3 months with cases aligned were performed by a single urologist. The urologist's radiation exposure and the incident dose to patients per case were measured with thermoluminescent dosimeters. In the latter 3-month period, the pulse fluoroscopy condition was changed from 15 to 7.5 pulses per second, and collimation was added to the field of view. In the analysis of all patients, the use of a modified pulse rate and collimation did not affect the fluoroscopy time, but it did significantly reduce the air kerma and dose area product; in addition, with respect to the medical exposure dose during percutaneous catheter replacement, fluoroscopy time was longer, but air kerma and dose area product showed significant decreases. As with decreases in medical exposure of patients, the equivalent dose for eye lenses of the urologist decreased from 1.2 mSv in the first 3-month period to 0.2 mSv in the second 3-month period. Similarly, the exposure dose for the extremities also decreased significantly, from 33.9 mSv to 8.1 mSv. Urologists are exposed to non-negligible amounts of radiation due to fluoroscopy. Appropriate management such as modified pulse fluoroscopy condition and precautions are required.


Efficacy of the Mercedes-Benz closure technique for vaginal reconstruction in female robot-assisted radical cystectomy

Vaginal reconstruction using the posterior vaginal wall is required following radical cystectomy in women with resection of the uterus, adnexa, and anterior vaginal wall. Roll closure and clamshell closure are two widely known techniques. Of these, clamshell closure is recommended because roll closure has a high likelihood of breakdown or a resultant canal that is too narrow for sexual intercourse. In clamshell closure, however, folding the posterior vaginal wall anteriorly can be difficult. Therefore, we devised Mercedes-Benz closure, in which the vaginal wall is sutured from three directions to form a Mercedes-Benz shape, for anastomosis without tension on the vaginal wall. The present study was performed to investigate the efficacy of this alternative surgical technique for vaginal reconstruction. Twenty-six patients who underwent vaginal reconstruction following robot-assisted radical cystectomy were divided into two groups: 15 underwent clamshell closure and 11 underwent Mercedes-Benz closure. The patients' characteristics and surgical outcomes were compared between the two groups. There were no significant differences in clinical characteristics, including age, body mass index, and prior abdominal surgery between the two groups. The median vaginal reconstruction time tended to be longer in the Mercedes-Benz closure group than in the clamshell closure group (35.0 vs. 27.0 min, p = 0.102). No complications associated with vaginal reconstruction were identified. The surgical outcomes were comparable between Mercedes-Benz closure and clamshell closure. If vaginal reconstruction with clamshell closure is difficult, Mercedes-Benz closure is a valuable alternative technique.


A Case of Pappilary Renal Cell Caircinoma which Responded Well to the Combination Therapy of Ipilimumab and Nivolumab --A CASE REPORT--

イピリムマブ・ニボルマブ併用療法が著効した乳頭状腎細胞癌の1例

We report a case of papillary renal cell carcinoma that responded well to the combination of ipilimumab and nivolumab. The patient was a 68-year-old male who was being followed up for a small left renal mass without treatment. Two years later, computed tomography (CT) showed enlarged cervical and para-aortic lymph nodes, and lymph node biopsy suggested metastases of the cancer. After resection of the renal tumor, we performed pararenal aortic lymph node biopsy, and we diagnosed the case as papillary renal cell carcinoma type 1 with lymph node metastasis. The combination of ipilimumab and nivolumab each metastatic site showed regression on CT. Since immune-related adverse events occurred during the therapy nivolumab was discontinued, but partial response of the metastases was maintained.


Micropapillary Variant of Urothelial Carcinoma in a Hemodialysis Patient

The micropapillary variant of urothelial carcinoma (MPUC) is an aggressive form of urothelial carcinoma with high metastatic potential and a poor prognosis. Although various therapies have been reported, there is still no established treatment strategy for MPUC due to its rarity. The incidence of urinary tract malignancies is higher in patients undergoing hemodialysis (HD) than in healthy individuals. Here, we report the case of an 82-year-old man on HD with end-stage kidney disease who visited our hospital for macrohematuria. Cystoscopy followed by computed tomography and urine cytology revealed a sessile papillary tumor around the left bladder wall. We performed transurethral resection of the bladder tumor. Based on histopathological and imaging findings indicative of clinical-stage T3N0M0 MPUC, we performed radical cystectomy. Histopathology revealed a pathological stage T4aN0M0 MPUC. Two months after the cystectomy, the patient complained of constipation and painful defecation due to local recurrence and rectal invasion. While colostomy was performed to improve defecation 3 months after cystectomy, he did not receive any chemotherapy due to his progressively worsening general condition. Six months after cystectomy, he died following rapid metastases. Our findings, in this case, confirm that bladder cancer in HD patients tends to be pathologically more advanced. Therefore, regular screening is recommended for its early detection in HD patients.


The patient-side surgeon plays a key role in facilitating robot-assisted intracorporeal ileal conduit urinary diversion in men

The influence of the console surgeon on the feasibility and outcome of various robot-assisted surgeries has been evaluated. These variables may be partially affected by the skills of the patient-side surgeon (PSS), but this has not been evaluated using objective data. This study aimed to describe the surgical techniques of the PSS in robot-assisted radical cystectomy (RARC) and intracorporeal ileal conduit (ICIC) urinary diversion and objectively examine the changes in surgical outcomes with increasing PSS experience. During a 3-year period, 28 men underwent RARC and ICIC urinary diversion. Clinical characteristics and surgical outcomes were compared between patients who underwent surgery early (first half group) or late in the study period (second half group). The pre-docking incision enabled easy specimen removal. The glove port technique widened the working space of the PSS. The stay suture allowed the PSS to control the distal portion of the conduit, facilitating the passage of the ureteral stents. During stoma creation, pneumoperitoneum pressure was lost by opening the abdominal cavity. To overcome this problem, the robotic arm was used to lift the abdominal wall to maintain the surgical field and facilitate the PSS procedure. Compared with the first half group, the second half group had significantly shorter times for urinary diversion (202 min vs 148 min, p < 0.001), ileal isolation and anastomosis (73 min vs 45 min, p < 0.001), and stenting (23.0 min vs 6.5 min, p < 0.001). As the experience of the PSS increased, the time of the PSS procedures decreased.


Poor Outcome due to the Plasmacytoid Variant of Urothelial Carcinoma

A 72-year-old man visited our hospital due to pollakiuria and lower abdominal pain. Urinary cytology was positive, and cystoscopy revealed diffuse edematous nonpapillary tumor. We performed transurethral biopsy, and clinical stage T3 plasmacytoid variant of urothelial carcinoma (PUC) was diagnosed. Although we planned for radical cystectomy, peritoneal dissemination and lung and pelvic lymph node metastases appeared 3 weeks after the initial visit. We also planned for chemotherapy; however, the metastases rapidly progressed, and he died 7 weeks after the biopsy. PUC is rare and shows an aggressive clinical course and poor prognosis.


Additional effects of simultaneous treatment with C14-Cblin and celastrol on the clinorotation-induced rat L6 myotube atrophy

Two novel reagents, N-myristoylated Cbl-b inhibitory peptide (C14-Cblin) and celastrol, a quinone methide triterpene, are reported to be effective in preventing myotube atrophy. The combined effects of C14-Cblin and celastrol on rat L6 myotubes atrophy induced by 3D-clinorotation, a simulated microgravity model, was investigated in the present study. We first examined their effects on expression in atrogenes. Increase in MAFbx1/atrogin-1 and MuRF-1 by 3D-clinorotation was significantly suppressed by treatment with C14-Cblin or celastrol, but there was no additive effect of simultaneous treatment. However, celastrol significantly suppressed the upregulation of Cbl-b and HSP70 by 3D-clinorotation. Whereas 3D-clinorotation decreased the protein level of IRS-1 in L6 myotubes, C14-Cblin and celastrol inhibited the degradation of IRS-1. C14-Cblin and celastrol promoted the phosphorylation of FOXO3a even in microgravity condition. Simultaneous administration of C14-Cblin and celastrol had shown little additive effect in reversing the impairment of IGF-1 signaling by 3D-clinorotation. While 3D-clinorotation-induced marked oxidative stress in L6 myotubes, celastrol suppressed 3D-clinorotation-induced ROS production. Finally, the C14-Cblin and celastrol-treated groups were inhibited decrease in L6 myotube diameter and increased the protein content of slow-twitch MyHC cultured under 3D-clinorotation. The simultaneous treatment of C14-Cblin and celastrol additively prevented 3D-clinorotation-induced myotube atrophy than single treatment. J. Med. Invest. 69 : 127-134, February, 2022.

The Journal of Medical Investigation : JMI


Clinical application of virtual imaging guided Robot-assisted partial nephrectomy.

Objectives : To evaluate whether virtual partial nephrectomy images could help surgeons identify vascular and collecting system around tumors during actual surgery. Materials & methods : We retrospectively analyzed 36 patients who underwent robot-assisted partial nephrectomy (RAPN) between 2016 and 2017. Virtual partial nephrectomy images were created from preoperative CT images using computer software, and then analyzed. For analysis, blood vessels and collecting system portions within a 5-mm-thick safety margin around the tumor were examined. During analysis, we predicted whether targeted vasculature around the tumor would require clipping or suturing during surgery, and also whether the collecting system would require opening during resection. Surgical outcomes for virtual partial nephrectomy analyses and actual RAPNs were compared and analyzed for sensitivity and specificity. Results : In 36 cases, 119 arteries and 100 veins were targeted on virtual partial nephrectomy images. Arterial suturing or clipping for hemostasis showed a sensitivity and specificity of 83.3% and 84.5%, respectively. For veins, the sensitivity and specificity were 39.1% and 92.2%, respectively. Collecting system opening prediction sensitivity was 85.7%, and specificity was 65.2%. Conclusion : Virtual partial nephrectomy imaging is useful for RAPN planning, particularly regarding arteries and the collecting system. It is hoped that techniques for visualizing veins will improve. J. Med. Invest. 69 : 237-243, August, 2022.


Daily Dietary Supplementation with Steamed Soybean Improves Muscle Volume and Strength in Healthy People Lacking Exercise.

Various dietary protein supplements are used by the elderly and bedridden to maintain their skeletal muscle mass and functions. High-quality proteins act as an anabolic driver and help to improve muscle strength and performance. Previously, we reported that soy protein significantly attenuates denervation-induced loss of muscle mass and myofiber cross sectional area in mice with inhibition of ubiquitination and degradation of IRS-1 in tibialis anterior muscle. It also increased muscle volume and strength in bedridden patients. In the present study, we investigated the effects of dietary soybean supplementation on muscle functions in taxi drivers lacking vigorous physical exercise. We conducted a case-control study on 25 healthy, male taxi drivers between the ages of 36 and 71 y performing minimal physical exercise. They were divided into two dietary groups: the soybean diet group (n=13) who ate daily meals (dinner) supplemented with 50 g of steamed soybean for 30 d and the control diet group (n=12) who received no soybean supplement. Next, we measured the muscle cross-sectional area (CSA) and muscle strength and function in both the groups before and after 30 d of soybean intake. The body weights of both diet groups did not differ significantly over time. However, after 30 d of soybean supplementation, the soybean-fed group developed significantly higher muscle CSA and grip strength compared to the control groups. In conclusion, dietary soybean supplementation improved muscle function in taxi drivers who lacked exercise.

Journal of Nutritional Science and Vitaminology


腎移植後のリンパ漏にリンパ管造影が効果的であった3例

腎移植後のリンパ漏にリンパ管造影が効果的であった3例


Two Cases of Robot-Assisted Total Pelvic Exenteration and Intracorporeal Ileal Conduit for Locally Advanced Rectal Cancer

局所進行直腸癌に対してロボット支援骨盤内臓全摘除術および体腔内回腸導管造設術を施行した2例

We describe two cases of locally advanced rectal cancer (LARC) treated with robot-assisted total pelvic exenteration (Ra-TPE) and intracorporeal ileal conduit (ICIC). The first case was in a 71-year-old man with LARC (RbP, T4bN2bM0, cStage IIIc). He was started on bevacizumab+S-1/oxaliplatin therapy in July 2019. In April 2020, he developed Fournier's gangrene due to subcutaneous penetration of rectal cancer. Emergency drainage and colostomy were performed simultaneously, and a percutaneous vesical fistula was created. In May 2020, Ra-TPE and ICIC were performed. Histopathological analysis revealed moderately differentiated tubular adenocarcinoma (ypT3N0, RM0). At postoperative 9 months, thoracoscopic right upper lobectomy was performed for a right metastatic lung tumor. At present, ie, at postoperative 12 months, the patient has been free of recurrence and metastasis, with a carcinoembryonic antigen (CEA) level of 1.4 ng/ml and carcinoma antigen (CA) 19-9 level of 11 U/ml. The second case was in a 61-year-old man with fistula-associated anal cancer (PRb, T4N3M1b, cStage IVb). In April 2019, he was started on FOLFOXIRI+cetuximab therapy. In August 2020, Ra-TPE, ICIC, and transperineal total mesenteric excision were performed. Histopathological analysis revealed adenocarcinoma (ypT4N0, RM0). At postoperative 11 months, thoracoscopic left lower lobectomy was performed for a left metastatic lung tumor. At present, ie, at postoperative 12 months, the patient remains free of recurrence and metastasis, with a CEA level of 7.3 ng/ml and CA19-9 level of 12 U/ml. Ra-TPE, which allows transperineal removal of a specimen, can be performed as a minimally invasive surgery in combination with ICIC.


A Case of Robot-Assisted Radical Cystoprostatectomy for Locally Advanced Prostate Cancer with Bladder Infiltration

膀胱浸潤を来たした局所進行性前立腺癌に対してロボット支援腹腔鏡下膀胱前立腺全摘除術を施行した1例

While robot-assisted radical cystoprostatectomy (RARC) for locally advanced prostate cancer (LAPC) may sometimes prove to be excessive treatment, it can significantly reduce the risk of positive surgical margins and lower urinary tract obstruction in some cases. Here, we report a case of LAPC treated with RARC in a patient with right hydronephrosis due to bladder infiltration and left hypoplastic kidney. A 71-year-old man presented with frequent urination in August 2019. Prostate-specific antigen (PSA) level was 8.633 ng/ml, and magnetic resonance imaging led to the suspicion that the prostate cancer extended beyond the prostate capsule without distant metastasis. Prostatic biopsy revealed Gleason score 10 (5+5) adenocarcinoma in 8 out of 8 specimens. We diagnosed left hypoplastic kidney and LAPC with right hydronephrosis due to bladder infiltration. We performed percutaneous right nephrostomy and started neoadjuvant hormone therapy. RARC and intracorporeal ileal conduit were performed in March 2020. The prostate was adherent to the anterior surface of the rectum and was difficult to remove. At present, five months after the surgery, the patient remains free of recurrence and metastasis with PSA level <0.003 ng/ml. RARC for LAPC with bladder infiltration can be an effective therapeutic strategy in some cases.


Efficacy of the direct grasping technique using pean forceps under fluoroscopy to replace ureteral stents in women

Purpose : To evaluate the efficacy of the direct grasping technique using pean forceps under fluoroscopic guidance for ureteral stent replacement in women. Methods : Between April 2018 and September 2020, 28 female patients underwent ureteral stent replacements at our facility, and 184 stent replacement procedures were performed. A total of 127 stents were replaced using pean forceps under fluoroscopic guidance (pean forceps group), and 57 stents were replaced using the cystoscope (cystoscopy group). Clinical characteristics and surgical outcomes were compared between the groups. Results : All stents were successfully replaced. There was a statistically significant difference in the procedure time between the two groups (median [interquartile range], pean forceps group : 10.8 [8.2-13.9] minutes vs. cystoscopy group : 15.8 [11.1-20.9] minutes, P < 0.001). There were no intraoperative complications in either group and no difference in the incidence of postoperative complications (pean forceps group : 1.6% vs. cystoscopy group : 1.8%, P = 1.000). Fluoroscopy time was longer in the pean forceps group, although this difference was not statistically significant (pean forceps group : 38.9 [22.6-60.1] seconds vs. cystoscopy group : 33.0 [20.0-48.9] seconds, P = 0.0558). Conclusion : The direct grasping technique using pean forceps under fluoroscopy may be a beneficial alternative to cystoscopy for ureteral stent replacement in women. J. Med. Invest. 68 : 326-329, August, 2021.


[A Case of Pelvic Organ Prolapse and Bladder Diverticulum Surgically Treated at the Same Time].

骨盤臓器脱と膀胱憩室を同時に治療した1例

We report a case of bladder diverticulum presumably caused by lower urinary tract dysfunction due to pelvic organ prolapse (POP) simultaneously treated with transurethral coagulation (TUC) of the bladder diverticulum and laparoscopic sacrocolpopexy (LSC). A literature search showed this is the first report of bladder diverticulum and POP surgically treated at the same time. A 71-year-old woman was referred to our hospital for the treatment of cystocele. She had both storage and voiding symptoms. She had a POPQ stage III cystocele and stage I uterine prolapse. Ultrasonography and computed tomographic scan showed a large volume of residual urine along with a bladder diverticulum. Since urodynamic studies revealed a low compliance bladder and obstruction, we opined that the lower urinary tract symptoms were induced by the cystocele. TUC of the bladder diverticulum and LSC were performed at the same time. After the operation, clean intermittent catheterization (CIC) was needed once a day for one month. Gradually, residual urine decreased and CIC became unnecessary. The bladder diverticulum disappeared, and there has been no recurrence of POP.


Low Expression of Toll-like Receptor 4 Is Associated With Poor Prognosis in Bladder Cancer.

Low TLR4 expression was correlated with tumor progression.


Current knowledge of risk factors for testicular germ cell tumors.

The development of the human gonads is tightly regulated by the correct sequential expression of many genes and hormonal activity. Disturbance of this regulation does not only prevent proper development of the gonads, but it also contributes to the development of testicular germ cell tumors. Recent genetic studies, especially genome-wide association studies, have made great progress in understanding genetic susceptibility. Although there is strong evidence of inherited risks, many environmental factors also contribute to the development of testicular germ cell tumors. Histopathological studies have shown that most testicular germ cell tumors arise from germ cell neoplasia in situ, which is thought to be arrested and transformed primordial germ cells. Seminoma has features identical to germ cell neoplasia in situ or primordial germ cells, whereas non-seminoma shows varied differentiation. Seminomas and embryonic cell carcinomas have the feature of pluripotency, which is thought to be the cause of histological heterogeneity and mixed pathology in testicular germ cell tumors. Testicular germ cell tumors show high sensitivity to chemotherapies, but 20-30% of patients show resistance to standard chemotherapy. In the present review, the current knowledge of the epidemiological and genomic factors for the development of testicular germ cell tumors is reviewed, and the mechanisms of resistance to chemotherapies are briefly mentioned.


A DDX31/mutant-p53/EGFR axis promotes multistep progression of muscle invasive bladder cancer

The p53 and EGFR pathways are frequently altered in bladder cancer, yet their contributions to its progression remain elusive. Here we report that DEAD box polypeptide 31 (DDX31) plays a critical role in the multistep progression of muscle-invasive bladder cancer (MIBC) through its sequential interactions with mutant p53 (mutp53) and EGFR. In early MIBC cells, nuclear DDX31-bound mutp53/SP1 enhanced mutp53 transcriptional activation, leading to migration and invasion of MIBC. Cytoplasmic DDX31 also bound EGFR and phospho-nucleolin in advanced MIBC, leading to EGFR-Akt signaling activation. High expression of both cytoplasmic DDX31 and p53 proteins correlated with poor prognosis in patients with MIBC, and blocking the DDX31/NCL interaction resulted in downregulation of EGFR/Akt signaling, eliciting an antitumor effect against bladder cancer. These findings reveal that DDX31 cooperates with mutp53 and EGFR to promote progression of MIBC, and inhibition of DDX31/NCL formation may lead to potential treatment strategies for advanced MIBC. DDX31 cooperates with mutp53 and EGFR to promote progression of muscle invasive bladder cancer. .


Predictive Factors for Prolonged Urination Disorder After Permanent 125I Brachytherapy for Localized Prostate Cancer

We assessed the change in LUTS after prostate brachytherapy to reveal factors for prolonged urination disorder. Four hundred and four patients received prostate brachytherapy at our institution and were followed-up for at least 2 years. We evaluated the correlation of mean IPSS changes and clinical factors. Using multivariate analysis, we also evaluated clinical factors with potential to delay IPSS resolution. In cases with prostate volume more than 30 cm, radiation dose to 90% of prostate volume (D90) more than 160 Gy, and radiation dose to 30% of the urethral volume (UD30) more than 240 Gy, mean IPSS levels were significantly higher, even 30 months after treatment. On multivariate analysis, baseline IPSS more than 8 points and D90 more than 160 Gy were significant predictors for delayed IPSS resolution. Our data suggest that higher baseline IPSS and higher D90 were predictors for prolonged urination disorder.


The Involvement of Hepatocyte Growth Factor-MET-Matrix Metalloproteinase 1 Signaling in Bladder Cancer Invasiveness and Proliferation. Effect of the MET Inhibitor, Cabozantinib (XL184), on Bladder Cancer Cells.

To clarify the invasive mechanisms of muscle-invasive bladder cancer (BCa) would be useful for the determination of appropriate treatment strategies. We previously showed that hepatocyte growth factor (HGF)-MET signaling is correlated with invasiveness of BCa cells. Here, we investigated the effects of the MET inhibitor, cabozantinib (XL184), on BCa cells. We first conducted Western blot analysis to investigate MET expression in BCa cell lines. Next, we examined the effect of cabozantinib on their proliferation and invasive abilities using MTT and Matrigel invasion assays, respectively. Invasion assays were performed using the xCELLigence system. Additionally, to investigate the biological function of HGF-MET signaling, we analyzed gene expression profiles and performed real-time polymerase chain reaction analyses of 5637 cells that were cultivated with or without HGF stimulation, with or without cabozantinib. MET was highly expressed in 4 of 5 BCa cell lines, and 5637 and T24 cells showed especially high protein expression of MET. Cabozantinib suppressed cell proliferation and invasion (cell index; mock, 1.49 vs HGF, 2.26 vs HGF + XL184, 1.47, P < .05). Gene expression profile analysis indicated that matrix metalloproteinase 1 (MMP1) was significantly elevated at the mRNA level with addition of HGF. Moreover, cabozantinib suppressed HGF-induced MMP1 expression in 5637 T24 cells. These data indicate that cabozantinib suppressed MMP1 expression by blocking HGF-MET signaling and that HGF-MET-MMP1 signaling is involved in the invasiveness and proliferation of BCa cells. These results suggest that cabozantinib might prove useful for future treatment of muscle-invasive BCa.


Clinical Significance of Neoadjuvant Combined Androgen Blockade for More Than Six Months in Patients with Localized Prostate Cancer Treated with Prostate Brachytherapy.

The aim of this study is to clarify the clinical significance of neoadjuvant combined androgen blockade (CAB) for ≥ 6 months in patients with localized prostate cancer. A total of 431 patients with localized prostate cancer who underwent prostate brachytherapy (BT) with or without neoadjuvant CAB for ≥ 6 months with mean follow-up time of 64.6 months (range 24-108 months) were evaluated retrospectively. Of those 431, 232 patients received BT in combination with neoadjuvant CAB for ≥ 6 months. Biochemical recurrence-free rates (BRFRs) in 364 patients with at least 3 years of follow-up were evaluated by log-rank test. BRFR in patients with low-, intermediate- and high-risk prostate cancer were 98.1, 94.2 and 89.1%, respectively. In patients with intermediate-risk prostate cancer only, neoadjuvant CAB was significantly associated with BRFR (p = 0.0468). Especially in patients with intermediate-risk prostate cancer with radiation dose received by 90% of the prostate (D90) < 180 Gy, neoadjuvant CAB exerted a favorable impact on BRFR (p = 0.0429). On multivariate analyses, neoadjuvant CAB and D90 were independent predictors of BRFR (p = 0.0061 and p < 0.0001, respectively). Neoadjuvant CAB for ≥ 6 months has a favorable impact on BRFR in patients with intermediate-risk prostate cancer, particularly in patients with relatively low radiation doses of D90.


RETROPERITONEAL SCHWANNOMA WITH INCREASED F18-FLUORODEOXYGLUCOSE UPTAKE ON POSITRON EMISSION TOMOGRAPHY : A CASE REPORT

FDG-PETにて高集積を認めた後腹膜神経鞘腫の1例


Long-Term Administration of Docetaxel Over 70 Cycles for Castration-Resistant Prostate Cancer.


NON-MUSCLE INVASIVE BLADDER CANCER WITH MULTIPLE BONE METASTASIS WITHOUT LOCAL INVASION : A CASE REPORT

多発骨転移をきたした筋層非浸潤性膀胱癌の1例

A 66-year-old man with superficial bladder cancer was treated with transurethral resection (TURBT) in October 2011. The pathological diagnosis was urothelial carcinoma (UC), grade 2, T1. A second TURBT was performed one month later. The pathological diagnosis was UC, grade 3, T1. He was treated with intravesical bacillus Calmette-Guerin (BCG) after TURBT. His progress was satisfactory, but a small superficial bladder cancer was found on cystoscopy in August 2012. He was going to be treated with TURBT, but the serum alkaline phosphatase level was abnormally high on preoperative evaluation. Bone scintigraphy showed multiple bone metastases from non-muscle invasive bladder cancer (NMIBC) without local invasion. He was started on combined chemotherapy with 1,000 mg/m2 gemcitabine on days 1, 8 and 15 and 70 mg/m2 cisplatin on day 2 every four weeks. He received denosumab for multiple bone metastases at the same time. Although he subsequently developed severe hypocalcemia, treatment was continued, and he completed four courses of chemotherapy. Bone scintigraphy and contrast-enhanced computed tomography showed reduction of the multiple bone metastases, and alkaline phosphatase decreased to the normal range. It is rare for NMIBC without local invasion to metastasize to other organs. Thus, it is necessary to consider distant metastases in patients with NMIBC.


小児低形成腎/機能低下腎に対する腹腔鏡下腎摘除術の臨床的検討

小児低形成腎/機能低下腎に対する腹腔鏡下腎摘除術の臨床的検討

We reviewed the results of laparoscopic nephrectomy for children with a hypoplastic or poorly functioning kidney in our department. Laparoscopic nephrectomy was performed in 10 patients including 1 boy and 9 girls. The patients' median age was 5.5 years old. There were 8 patients with a hypoplastic kidney and an ectopic ureter, and 2 patients with a poorly functioning kidney and a megaureter or vesicoureteral reflux. Laparoscopic nephrectomy was conducted transperitoneally in 5 and retroperitoneally in 5 patients. The median operative time was 167 minutes. There was no intraoperative complication. Postoperatively, subcutaneous emphysema and fever developed in one patient each. 7 patients used an analgesic suppository once or several times, and 3 patients received no analgesics. Oral intake was started at a median of 1 day postoperatively. The median hospital stay after surgery was 4.5 days. Laparoscopic nephrectomy for a hypoplastic and poorly functioning kidney in children is a minimally invasive surgery.

当科において小児の低形成腎/機能低下腎に対する鏡視下腎摘除術を再検討した．1993年12月より，低形成腎/機能低下腎の小児10例に対し，鏡視下腎摘除術を施行した．年齢の中央値5.5歳，男1例，女9例．尿管異所開口に伴う低形成腎8例，巨大尿管症，高度VURによる機能低下腎が各1例．手術は，経腹膜的アプローチ5例，後腹膜的アプローチ5例，手術時間中央値は167分．術中合併症はなく，術後合併症は，皮下気腫1例，発熱1例．術後鎮痛剤は，3例は使用なし，7例は術後に坐薬を1∼数回使用．食事開始は中央値で術後1日目，歩行開始日中央値は術後1.5日．術後入院期間中央値は4.5日，術後から退院可能日までの中央値3.0日．小児の低形成腎/機能低下腎に対する鏡視下腎摘除術は，術後の疼痛も少なく，美容的にも良好で，標準的な低侵襲手術である．


Substitution of antiandrogens and tegafur-uracil combination therapy for castration-resistant prostate cancer: results of a multi-center randomized phase II study

We conducted this study to determine whether substitution with anti-androgen (SOA) and tegafur-uracil (a pro-drug of 5-FU) combination therapy is more effective than SOA alone after relapse from initial hormonal therapy. Patients who were histologically confirmed and relapsed after initial hormonal therapy were included. All patients were randomly allocated into two groups: SOA alone (group A) or SOA combined with tegafur-uracil (group B). The mRNA expression of four enzymes, including thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phospho-ribosyltransferase (OPRT) and thymidine phosphorylase (TP), in prostate cancer cells was analyzed by quantitative reverse-transcription polymerase chain reaction. Fifty-two patients were enrolled in this study. The median age was 77 (range: 47-92) years. The PSA response rate in group B (61.5%) tended to be higher compared to that in group A (34.6%) (p=0.095). Group B (median: 15.9 months) had a significantly longer time to PSA progression (TTP) compared to group A (6.4 months) (p=0.014). In patients with a lower TS expression or a higher OPRT expression, group B demonstrated a higher PSA response rate compared to group A (p=0.019 and p=0.041, respectively). In addition, in the patients with a lower TS expression, group B demonstrated a significantly longer TTP compared to group A (p=0.018). There were no severe adverse events in either treatment group. After relapse from initial hormonal therapy, SOA combined with tegafur-uracil is effective and well tolerated. The TS mRNA expression level may be a predictive factor for this combination therapy.


CLINICAL EXPERIENCE OF INTERSTITIAL CYSTITIS TREATED WITH HYDRODISTENSION

間質性膀胱炎に対する水圧拡張術の経験


Dual Involvement of Growth Arrest-specific Gene 6 in the Early Phase of Human IgA Nephropathy

Gas6 is a growth factor that causes proliferation of mesangial cells in the development of glomerulonephritis. Gas6 can bind to three kinds of receptors; Axl, Dtk, and Mer. However, their expression and functions are not entirely clear in the different glomerular cell types. Meanwhile, representative cell cycle regulatory protein p27 has been reported to be expressed in podocytes in normal glomeruli with decreased expression in proliferating glomeruli, which inversely correlated with mesangial proliferation in human IgA nephropathy (IgAN). The aim of this study is to clarify Gas6 involvement in the progression of IgAN. Expression of Gas6/Axl/Dtk was examined in 31 biopsy proven IgAN cases. We compared the expression levels with histological severity or clinical data. Moreover, we investigated the expression of Gas6 and its receptors in cultured podocytes. In 28 of 31 cases, Gas6 was upregulated mainly in podocytes. In the other 3 cases, Gas6 expression was induced in endothelial and mesangial cells, which was similar to animal nephritis models. Among 28 podocyte type cases, the expression level of Gas6 correlated with the mesangial hypercellularity score of IgAN Oxford classification and urine protein excretion. It also inversely correlated with p27 expression in glomeruli. As for the receptors, Axl was mainly expressed in endothelial and mesangial cells, while Dtk was expressed in podocytes. In vitro, Dtk was expressed in cultured murine podocytes, and the expression of p27 was decreased by Gas6 stimulation. Gas6 was uniquely upregulated in either endothelial/mesangial cells or podocytes in IgAN. The expression pattern can be used as a marker to classify IgAN. Gas6 has a possibility to be involved in not only mesangial proliferation via Axl, but also podocyte injury via Dtk in IgAN.


Mineralocorticoid receptor expression in human penile corpus cavernosum

Mineralocorticoid receptor (MR) is known to play physiological and pathophysiological roles in the cardiovascular system, and MR activation directly damages these organs. The aim of this study was to evaluate the expression of MR and 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) in the human penile corpus cavernosum. MR and 11β-HSD2 expression was assayed in human penile tissues, and also in human renal tissues as a positive control. Expressions of MR mRNA and 11β-HSD2 mRNA were evaluated using reverse transcription polymerase chain reaction (RT-PCR). MR and 11β-HSD2 were visually identified using immunofluorescence analysis. MR mRNA expression in human penis was confirmed by RT-PCR. On quantitative RT-PCR analysis, 11β-HSD2 mRNA expression was detected at minimal levels in penile tissue. Immunofluorescence analysis revealed positive staining for MR and negative staining for 11β-HSD2 in smooth muscle cells of the corpus cavernosum. This study demonstrated the presence of MR and the absence of 11β-HSD2 in human penile corpus cavernosum. Considering that MR activation causes various organ damages, MR blockade in human penile corpus cavernosum may have therapeutic benefits. Investigations for the penile effects of MR activation have the potential to provide new treatment approaches for erectile dysfunction.

The Journal of Medical Investigation : JMI


CLINICAL EXPERIENCE OF REITER'S SYNDROME FOLLOWING BCG INTRAVESICAL THERAPY

BCG膀胱内注入療法に合併したReiter症候群の経験


DDX31 regulates the p53-HDM2 pathway and rRNA gene transcription through its interaction with NPM1 in renal cell carcinomas

Studies of renal cell carcinoma (RCC) have led to the development of new molecular-targeted drugs but its oncogenic origins remain poorly understood. Here, we report the identification and critical roles in renal carcinogenesis for DDX31, a novel nucleolar protein upregulated in the vast majority of human RCC. Immunohistochemical overexpression of DDX31 was an independent prognostic factor for patients with RCC. RNA interference (RNAi)-mediated attenuation of DDX31 in RCC cells significantly suppressed outgrowth, whereas ectopic DDX31 overexpression in human 293 kidney cells drove their proliferation. Endogenous DDX31 interacted and colocalized with nucleophosmin (NPM1) in the nucleoli of RCC cells, and attenuation of DDX31 or NPM1 expression decreased pre-ribosomal RNA biogenesis. Notably, in DDX31-attenuated cells, NPM1 was translocated from nucleoli to the nucleoplasm or cytoplasm where it bound to HDM2. As a result, HDM2 binding to p53 was reduced, causing p53 stablization with concomitant G(1) phase cell-cycle arrest and apoptosis. Taken together, our findings define a mechanism through which control of the DDX31-NPM1 complex is likely to play critical roles in renal carcinogenesis.


BCG膀胱内注入療法後に発症した結核性精巣上体炎の1例

BCG膀胱内注入療法後に発症した結核性精巣上体炎の1例


SEQUENTIAL THERAPY WITH MOLECULAR TARGETED AGENTS FOR ADVANCED RENAL CELL CARCINOMA

進行性腎細胞癌に対する薬物療法 いつ，何を，どう使う? 進行性腎癌に対する分子標的薬のsequential therapy


Up-regulation of Plakophilin-2 and Down-regulation of Plakophilin-3 are Correlated With Invasiveness in Bladder Cancer

To examine plakophilin proteins (Pkp) and 3 expression levels in bladder cancer, in particular their levels during cellular growth and invasion. Pkp is associated with the binding of cadherin to intermediate filaments of the cytoskeleton. The relative mRNA and protein expression levels of Pkp2 and 3 in bladder cancer cell lines were determined using quantitative real-time polymerase chain reaction and Western blot analyses. The cellular localization of Pkp2 and 3 proteins in bladder cancer cells was also assayed using immunohistochemistry. The proliferation and invasive activities of bladder cancer cells were evaluated using cell growth and in vitro cell invasion assays, and were compared with those of bladder cancer cells treated with Pkp2 and 3 small interfering RNAs. Pkp2 mRNA and protein levels were elevated, and those of Pkp3 were reduced, in bladder cancer cells that are known to exhibit increased proliferation and invasive activity. Pkp2/3 protein expression was predominantly observed in the cytoplasm of invasive bladder cancer cells and tissues. Pkp2 knockdown inhibited, and Pkp3 knockdown enhanced, invasion of bladder cancer cells, but these knockdowns did not alter cell proliferation. We conclude that high Pkp2, and low Pkp3, expression is associated with bladder cancer cell invasion and that neither Pkp2 nor Pkp3 is associated with cell proliferation. We further hypothesize that accumulation of Pkp2 and 3 in the cell cytoplasm, rather than their recruitment to the cell membrane, is related to an increased ability of the tumor to invade and metastasize.


中間リスク群，高リスク群前立腺癌に対するI-125密封小線源療法の治療成績

中間リスク群，高リスク群前立腺癌に対するI-125密封小線源療法の治療成績


CLINICAL REVIEW OF ELDERLY PATIENTS WITH RENAL TUMORS IN OUR HOSPITAL

超高齢者の泌尿器がん治療 当科における初診時80歳以上の腎腫瘍患者の臨床的検討

初診時80歳以上の腎腫瘍患者24例(男17例・女7例・中央値81.5歳)の成績を報告した．ECOG performance status(PS)は0:9例，1:7例，2:3例，3:1例，4:3例，不明:1例，臨床病期はstage I:11例，II:2例，III:5例，IV:6例であった．腎摘出術を施行したのは6例で，PSは0:4例，1:1例，2:1例，病期はstage I:4例，II:1例，III:1例であった．非手術の理由は，本人・家族が希望しない，手術適応外，合併症の存在などであった．全生存期間の中央値は25ヵ月で，stage I:44ヵ月，II:10ヵ月，III:9ヵ月，IV:25ヵ月であった．癌特異生存期間の中央値はstage I:44ヵ月，II:10ヵ月，III:15ヵ月，IV:18ヵ月であった．stage I・IIの13例を手術施行5例と非手術8例に分け比較したが，全生存率，癌特異生存率ともに有意差はなかった．また，stage III・IVを治療介入7例と無治療3例に分けて行った比較でも，同様に有意差はなかった．


未固定新鮮凍結遺体を用いたECIRSでの職業被曝低減についての検討

未固定新鮮凍結遺体を用いたECIRSでの職業被曝低減についての検討

日本尿路結石症学会学術集会プログラム・抄録集

日本尿路結石症学会学術集会プログラム・抄録集


腎移植後のリンパ漏にリンパ管造成が効果的であった3例

腎移植後のリンパ漏にリンパ管造成が効果的であった3例


徳島大学泌尿器科におけるBCG膀胱内注入療法の臨床検討

徳島大学泌尿器科におけるBCG膀胱内注入療法の臨床検討


子宮頸癌副腎転移との識別が困難であった18F-FDG PET/CT陽性副腎皮質線種の1例


限局性前立腺癌に対する密封小線源療法のリスク分類別治療成績

限局性前立腺癌に対する密封小線源療法のリスク分類別治療成績


射精障害を契機に発見されたトルコ鞍空洞症を伴う汎下垂体機能低下症の1例

射精障害を契機に発見されたトルコ鞍空洞症を伴う汎下垂体機能低下症の1例


BCG膀胱内注入療法後に生じたReiter症候群の1例

BCG膀胱内注入療法後に生じたReiter症候群の1例


Training system of laparoscopic surgery for young urologists in the university of Tokushima

効果的効率的な泌尿器腹腔鏡手術医の育成 徳島大学における泌尿器腹腔鏡技術認定医の育成に対する試み


Clinical significance of Galectin-3 in clear cell renal cell carcinoma.

Overexpression of galectin-3 in a variety of cancer cell lines has been shown to correlate with tumor progression and metastasis. In this study, we investigated the expression of galectin-3 in clear cell renal cell carcinoma (CC-RCC) and evaluated the relationship between galectin-3 expression levels and the clinicopathological features of CC-RCC. Expression of galectin-3 in the kidney cancer cell lines Caki-1, Caki-2, A704, ACHN and KPK-1 were evaluated using western blot analysis, while galectin-3 expression in CC-RCC tissues and normal parenchyma were measured by real-time PCR and immunohistochemistry. We found that galectin-3 was overexpressed in the Caki-1, Caki-2, A704, ACHN and KPK-1 cell lines and that the expression level in CC-RCC was also significantly higher than that in renal parenchyma obtained from the same patient samples (p=0.039). Galectin-3 expression in CC-RCC with distant metastasis was also significantly higher than that in CC-RCC without distant metastasis (p=0.045). In conclusion, we revealed that galectin-3 is highly expressed in CC-RCC, especially in CC-RCC with distant metastasis, suggesting that galectin-3 may serve as a novel target molecule for predicting CC-RCC metastasis.


Long-term recurrence-free survivor after laparoscopic removal of solitary adrenal metastasis from endometrial adenocarcinoma.

Solitary adrenal metastasis from endometrial adenocarcinoma is extremely rare. We report herein the case of a laparoscopically resected solitary adrenal metastasis originating from endometrial adenocarcinoma. The patient was a 55-year-old woman who had undergone total abdominal hysterectomy for stage IIIc endometrial carcinoma, followed by 7 courses of adjuvant chemotherapy comprising carboplatin and paclitaxel. However, the patient developed an isolated right adrenal metastasis 15 months postoperatively. The solitary adrenal metastasis (diameter, 5.7 cm) was removed laparoscopically. The patient has now been in good health without recurrence for 5 years and 7 months after laparoscopic surgery. To the best of our knowledge, this is the first case of solitary adrenal metastasis originating from endometrial adenocarcinoma that is controlled for the long term by successful laparoscopic resection.


The role of actinin-4 in bladder cancer invasion.

To examine actinin-4 expression levels in bladder cancer, in particular its levels during cellular growth and invasion. Actinin-4 is an actin-binding protein that is associated with cell motility and cancer metastasis.