A 50-year-old male was diagnosed with acute epididymitis and treated with levofloxacin, however, no improvement was noted. The patient was thus referred to our department for further examinations and treatment. While there were no results indicating pyuria, ceftriaxone was started for acute epididymitis based on clinical findings, though the condition did not improve. Epididymal abscess was suspected, and CT and MRI examinations were performed, which only revealed swelling of the epididymis. The patient was then referred to the Department of Rheumatology for a fever of unknown origin and tested for various autoantibodies, all of which were negative, though gallium scintigraphy showed accumulation in multiple joints. Behcet's disease was suspected and colchicine treatment started, which resulted in a dramatic relief of symptoms. Subsequently, fundus angiography revealed fern-like fluorescent leakage. Furthermore, painful ulcers were found in the oral cavity, leading to a final diagnosis of incomplete Behcet's disease. Presently, colchicine treatment is continuing and there has been no recurrence.
A 73-year-old male presented to our clinic with a chief complaint of painful urination. He had complete phimosis and a papillary tumor occupying the glans foreskin. Urination occurred through a fistula destructively created by the tumor on the side of his foreskin. Contrast-enhanced computed tomography (CT) and positron emission tomography scans revealed a tumor with irregular margins and a heterogeneous internal contrast effect, measuring 55 mm in its longest diameter within the glans, and a 10 mm lymphadenopathy in the left inguinal region. Magnetic resonance imaging findings suggested that the tumor had invaded the corpus cavernosum of the penis, leading to a diagnosis of penile cancer, cT3N1M0. A pathological examination of a biopsy from the tumor tip initially suggested condyloma acuminatum. However, due to the potential for malignancy and the significant urinary obstruction caused by the tumor, a partial penectomy was performed with an 8 mm surgical margin. Inguinal lymph node dissection was not performed concurrently. The excised specimen revealed a cauliflower-shaped tumor, 45 × 40 mm in size, located peripherally from the annular sulcus of the penis, with no invasion into the corpus cavernosum or urethra. Histopathological analysis confirmed the tumor as verrucous carcinoma, pT1. The postoperative course was uneventful, and the patient's urinary pain resolved. A follow-up CT scan one month later showed no evidence of recurrence or metastasis. The preoperative inguinal lymph node swelling resolved spontaneously after surgery, leading to a retrospective diagnosis of inflammatory lymphadenopathy.Obtaining sufficient and deep tissue samples can be challenging, and biopsy alone has limitations in achieving an accurate diagnosis. Therefore, a comprehensive preoperative diagnosis should incorporate physical and imaging finding along with biopsy results.
(Purpose) Muscles shrink and stretch in the longitudinal direction along the running axis of muscle fibers. The "bi-metal", a widely utilized industrial instrument, is a device composing two metal plates pasted together. Since the coefficient of thermal expansion of the two metal plates differ from one another, the device bends in the lateral direction by heating. In the case of muscles, it may be possible to bend in the lateral direction, if the adjoining neighbor contracting units within them are adequately pasted together and contract to slightly different extents. We named this presumed movement as the "lateral creeping" of muscles. (Object and method) As an example, the movement of the abdominal rectus muscles was analyzed by a newly proposed biomechanical model for the "lateral creeping". (Results) It has been proved that the rectus muscle moves according to the pattern of the "lateral creeping", anatomically, mechanically and electromyographically. (Conclusion) There is a possibility that all the muscles may move as the "lateral creeping". Although this effect of muscles has not been considered in conventional physiology, if it is possible, the analysis of complicated movements in various muscles in the body, --- such as cardiac, lingual, or sphincter muscles ---, might be feasible in a simple way.
We report our experience with a case in which eroded mesh used for an inguinal herniorrhaphy migrated into the bladder. The patient was a sixty-four years old man, who underwent surgery for a left inguinal hernia three years ago. After the herniorrhaphy, he had several episodes of pain on urination. Various tests including cystoscopy were performed, but there was nothing abnormal. The symptoms improved, and the patient was kept under observation. Three years later, he reported urinary frequency. Abdominal computed tomography and magnetic resonance imaging and cystoscopy revealed a bladder tumor with extramural invasion. We performed transurethral bladder tumor resection. During resection, we found surgical mesh in the bladder tumor, and later we performed partial cystectomy with removal of surgical mesh. After the surgery the patient revealed good operative course and symptoms had disappeared.
(Objective) Patient characteristics and treatment outcomes of a rare histologic type of bladder neuroendocrine carcinoma were evaluated. (Methods) 2,133 cases of bladder cancer treated by transurethral resection of bladder tumor from August 2005 to August 2022 were histopathologically reevaluated, and clinicopathological factors, treatment methods, and prognosis of cases with a confirmed diagnosis of bladder neuroendocrine cancer were analyzed. (Results) Of 2,133 cases, 12 (0.56%) were diagnosed as neuroendocrine carcinoma. Immunohistochemical staining revealed small cell carcinoma in 10 cases (83.3%) and large cell carcinoma in 2 cases (16.7%). The median age was 79 years, and performance status 2 or higher was reported in 3 cases. Seven cases had localized cancer at the time of diagnosis, five cases had distant metastasis, and radical cystectomy was performed in four cases. Of the 3 cases who received chemotherapy, first-line platinum-based chemotherapy achieved disease control in two cases. After second-line treatment, no cases responded to pembrolizumab or enfortumab vedotin. The median overall survival (OS) of all cases was 12.5 months. The median OS of cases who underwent total cystectomy was 26 months, and that of cases who did not undergo total cystectomy was 8.2 months, showing a significant difference (p=0.05). (Conclusion) Neuroendocrine carcinoma of the urinary bladder often develops in older patients and has a poor prognosis. In cases of localized cancer, total cystectomy should be performed if possible.
A 79-year-old male patient with urothelial carcinoma with squamous differentiation, pT2N0M0, was referred to our hospital. A computed tomography (CT) scan showed left hydronephrosis associated with the bladder tumor and reticular shadows in the lung fields. After neoadjuvant chemotherapy with gemcitabine and cisplatin, the patient underwent robot-assisted radical cystectomy and cutaneous ureterostomy for bladder cancer on March X. On postoperative day 2, SpO2 decreased with increased oxygen demand, and a CT scan revealed a diffuse reticular shadow in both lungs. The patient was diagnosed with acute exacerbation of interstitial pneumonia (IP). Steroid pulse therapy with 1,000 mg/day methylprednisolone (mPSL) was initiated immediately, and nasal high-flow (NHF) oxygen was introduced. After a positive response to mPSL was confirmed, the patient was weaned from NHF on postoperative day 9. As the IP did not worsen, he was discharged after receiving home oxygen therapy. Six months after the acute exacerbation of IP, CT showed no tumor recurrence or progression.
A 47-year-old male had previously undergone internal urethrotomy three times for bulbar urethral stricture. During the third internal urethrotomy, the iatrogenic rectal injury occurred and resulted in the rectourethral fistula. Subsequently, the urethral stricture became obliterative, and the patient voided through the fistula via the rectum. Twelve years after the initial diagnosis of bulbar urethral stricture, he was referred to our hospital for urethral reconstruction. We performed excision and primary anastomosis along with fistula closure. However, shortly after initiating voiding, stricture recurred at the anastomosis site. Six years after the initial surgery, we performed a re-do excision and primary anastomosis, but stricture recurred again. He was managed with intermittent self-dilation, but the stricture progressed to involve a longer urethral segment. Five years after the second surgery, we performed salvage penile skin flap tube urethroplasty. A 3 cm circumferential incision was made to harvest the foreskin flap, which was transferred to the perineum and tubularized. After complete excision of the scarred bulbar urethra, the tubularized foreskin flap was interposed to the urethral defect. The patient could void on postoperative day 24 and remains stricture-free with good voiding sixteen months postoperatively. While transurethral treatment is a simple and widely used for urethral strictures, it is essential to recognize that repeated procedures can lead to increase stricture complexity and negatively impact subsequent urethroplasty outcome.
We performed a urodynamic study (UDS) and voiding cystourethrography (VCUG) or videourodynamics for three female patients with urinary dysfunction to differentiate between bladder outlet obstruction (BOO) and detrusor underactivity (DU). Case 1: A 72-year-old woman with a history of urinary retention and chief complaint of dysuria. UDS showed detrusor contraction (detrusor pressure at maximum flow: PdetQmax 86.6 cmH2O) and low urinary flow (maximum flow rate: Qmax 2.2 ml/s). VCUG showed poor bladder neck opening and bilateral vesicoureteral reflux and we diagnosed BOO due to bladder neck dysfunction. Case 2: A 74-year-old woman with dysuria. UDS showed detrusor contraction (PdetQmax 27.7 cmH2O) and low urinary flow (Qmax 5.3 ml/s). VCUG showed the open bladder neck and narrowing of the middle urethra during voiding. We diagnosed BOO due to abnormal urethral function during voiding. Case 3: An 85-year-old woman with a chief complaint of nocturia. UDS showed weak detrusor contraction (PdetQmax 18.3 cmH2O) and low urinary flow (Qmax 3.8 ml/s). VCUG revealed urethral dilatation. We diagnosed DU. The combination of UDS and VCUG for female urinary dysfunction may be a useful tool for the differential diagnosis of DU and BOO.
(Objective) Venous thromboembolism (VTE) is a significant complication during the perioperative period in urological cancer surgery. However, the study of perioperative VTE among Japanese patients remains insufficient. We conducted a retrospective investigation into the incidence of perioperative VTE in bladder cancer patients who underwent open radical cystectomy (ORC). (Materials and methods) From April 2020 to October 2023, 60 patients received ORC at our hospital. Of these, we included 57 patients in this retrospective study. Preoperatively, lower limb venous ultrasound was conducted to assess for deep vein thrombosis in patients with high D-dimer levels, and postoperatively, it was performed on all patients the day after surgery. We analyzed the incidence of perioperative VTE and the factors associated with it. (Results) Preoperatively, of 57 patients, 13 (22.8%) were diagnosed with VTE, and of these 13, 4 had pulmonary embolism (PE). Postoperatively, among the 44 patients without preoperative VTE, 7 (15.9%) developed new VTE immediately after surgery, and an additional 4 (9.1%) developed VTE during hospitalization. Of these 11 patients, 3 (6.8%) had concurrent PE. There were no fatal cases associated with VTE either before or after surgery. The patients with preoperative VTE had a significantly higher proportion of females who had undergone two or more courses of neoadjuvant chemotherapy (NAC) compared to the patients without preoperative VTE. Furthermore, both pre-and post-operatively, patients with VTE had significantly higher D-dimer levels. (Conclusion) In patients undergoing ORC, there was a connection between NAC and preoperative VTE. However, early intervention prevented fatal outcomes. As a result, we believe perioperative VTE screening is useful, particularly in patients treated with ORC.
A 70-year-old man with prostate cancer (cT3aN0M0), with a prostate-specific antigen (PSA) level of 38.9 ng/mL, and a Gleason score of 4+4 = 8, was treated with maximum androgen blockade for 1 year, resulting in a PSA reduction to 0.1 ng/mL. He subsequently underwent robot-assisted laparoscopic radical prostatectomy (RARP). Pathological examination revealed pT3bN1with negative surgical margins. Postoperatively, without additional treatment, PSA levels were 0.007 ng/mL and 0.019 ng/mL at 2 and 5 months, respectively. Six months after surgery, the patient developed left hydronephrosis with upper ureteral urine leakage but no signs of ureteral cancer. However, PSA slightly increased to 0.055 ng/mL, whereas carcinoembryonic antigen (CEA) levels increased to 19.2 ng/mL. Despite this, gastro-colonoscopy failed to detect any evidence of cancer. Nine months after surgery, multiple lung tumors, a solitary hepatic tumor, intraperitoneal lymphatic swellings, and port site masses were identified. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan did not reveal any other malignancies. At that time point, PSA increased to 0.185 ng/mL, while neuron-specific enolase and pro-gastrin-releasing peptides levels were within normal limits. Subsequent gastro-colonoscopy did not detect any malignancies. Ten months after surgery, bilateral orchiectomy and docetaxel chemotherapy were initiated for recurrent prostate cancer with aggressive variants but without neuroendocrine differentiation. Immunohistochemistry (IHC) of a biopsy sample from the port site mass suggested enteric adenocarcinoma distinct from the prostatic tissue observed in the original RARP specimen. The metastases progressed, and CEA levels continued to rise despite three cycles of docetaxel chemotherapy. Genomic testing identified KRAS and other mutations, confirming the tumor's compatibility with enteric adenocarcinoma. Fourteen months after surgery, chemotherapy for colon cancer was initiated. Unfortunately, the patient succumbed to respiratory failure 19 months after surgery. In cases of unusual recurrence patterns, as observed in this case, IHC and genomic testing of the recurrent mass can be crucial for accurate diagnosis.
We performed robot-assisted radical prostatectomy (RARP) for 221 patients from December 2015 to May 2023. In 218 patients, the prostatic anterior fat pad was submitted separately for histopathological evaluation. Fourteen patients (6.4%) had lymph nodes in the prostatic anterior fat pad, and three (1.4%) had lymph node metastasis in the prostatic anterior fat pad. The details of three cases are presented here.Case 1 was a 63-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial prostate-specific antigen (PSA) concentration of 24.522 ng/ml and a Gleason score of 3+4. The pathological results indicated adenocarcinoma, pT3a, Gleason score: 3+4. The postoperative PSA nadir was 0.205 ng/ml, and the patient was diagnosed with biochemical recurrence. Subsequently, the patient underwent hormone therapy and salvage radiation therapy, with no recurrence to date.Case 2 was a 62-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial PSA of 10.418 ng/ml and a Gleason score of 4+4. The pathological results indicated adenocarcinoma, pT2c, Gleason score: 4+4. The postoperative PSA nadir was 0.401 ng/ml, and the patient was diagnosed with biochemical recurrence. The patient subsequently underwent hormone therapy.Case 3 was a 76-year-old patient who underwent RARP for prostate cancer (cT2aN0M0), with an initial PSA of 4.676 ng/ml and a Gleason score of 4+3. The pathological results indicated adenocarcinoma, pT2c, Gleason score: 3+4. The postoperative PSA nadir was 0.031 ng/ml, and the patient has not experienced recurrence to date.
(Background) The purpose of this study was to investigate the current status of urologists regarding the prevention of perioperative infections in preparation for the revision of the Guidelines for the Prevention of Perioperative Infections in Urological Field (2015). (Methods) From January 26 to March 30, 2022, we administered questionnaires to members of the Japanese Urological Association on their adherence to the guidelines and administration methods of antimicrobial prophylaxis for perioperative infections. There were 362 respondents. (Results) The respondents reported adhering to the guidelines completely (15.5%), to some extent (55.5%), poorly (24.3%), and not at all (4.7%). Adherence rates also varied for surgical procedures, ranging from 73.8% in transurethral resection of bladder tumor to 32.9% in laparoscopic (robot-assisted) contaminated surgery. Excluding contaminated surgery and transurethral resection of prostate, where long-term administration is relatively acceptable, open clean-contaminated surgery had the highest rate of long-term administration (≥72 h) (27.2%) and transurethral resection of bladder tumor had the lowest rate (7.3%). Adherence rates for clean surgery and transurethral ureteral lithotripsy shortened to a single dose of antimicrobial agents were low. (Conclusion) The selected antimicrobial agents were generally in compliance with the guidelines. With the exception of contaminated surgery, they were administered long-term in clean-contaminated surgery where the urinary tract and genitalia were exposed. Surgical procedures in which a single prophylactic dose of antimicrobial agents was administered had a low compliance rate. After the revision of the guidelines, it is considered important to update the clinical paths at each facility.
Osteomyelitis pubis is rare among the various complications following radical prostate cancer surgery. A 70-year-old man with type 2 diabetes mellitus was diagnosed with prostate cancer (cT2aN0M0) based on a transrectal prostate biopsy performed after an elevated PSA revealed at an examination. Subsequently, we performed a retroperitoneoscopic radical prostatectomy to resect the localized prostate cancer. No intra- or postoperative complications were observed, and the patient was discharged 10 days postoperatively. The patient visited the outpatient clinic 76 days postoperatively presenting with lower abdominal pain and difficulty walking. He had played tennis two days earlier, and thus, was presenting the symptoms. A pelvic MRI revealed inflammation in the bilateral pubic bone marrow centered on the pubic symphysis after which a diagnosis of osteomyelitis pubis was made. A urine culture revealed Pseudomonas aeruginosa and the patient was started on levofloxacin hydrate medication. Although his symptoms were ameliorated, the treatment was discontinued because of taste disturbance followed by repeated flare-ups. Consequently, the patient was switched to inpatient antibiotic treatment and was administered intravenous tazobactam piperacillin hydrate for 2 weeks, which improved his symptoms. He was discharged from the hospital after an additional 2-week course of the antibiotic treatment. One and a half years after discharge, there was no evidence of recurrent osteomyelitis pubis, urinary incontinence, and recurrent prostate cancer.
A 75-year-old man was hospitalized for acute pyelonephritis. Seven months earlier, he had undergone radical cystoprostatectomy and ileal conduit urinary diversion. On the second day of hospitalization, he experienced a stroke in the right cerebral hemisphere. No significant residual effects were identified. On the fifth day of hospitalization, he suffered cardiopulmonary arrest. Fortunately, he was quickly rescued by cardiopulmonary resuscitation. Blood analysis revealed severe hyperchloremic metabolic acidosis and a marked decrease in urinary chloride levels. Hyperchloremic metabolic acidosis and his physical condition quickly improved with continuous hemodiafiltration and antimicrobial treatment. The patient was discharged after stroke rehabilitation. He experienced pyelonephritis twice more, but no cancer recurrence was reported.
(Objective) It is well known that sperm DNA fragmentation (SDF) affects not only natural conception but also in vitro fertilization (IVF) outcomes, and the importance of sperm quality has received renewed attention. In this study, we investigated the effects of coenzyme Q10 (CoQ10), which is thought to have potent antioxidant properties, on SDF and IVF outcomes. (Materials and methods) Patients whose SDF was measured at our clinic and diagnosed as high (>16%) were given a supplement containing CoQ10 as the main ingredient (MySeed®) for 3 months, and then SDF, general semen analysis, and semen oxidation-reduction potential (sORP) were reanalyzed. In addition, in cases where IVF including intracytoplasmic sperm injection (ICSI) was performed before and after supplementation, laboratory results including fertilization rate, blastocyst development rate before and after supplementation were analyzed. (Results) Of the 46 patients who consented to participate in this study, 35 patients who completed to the second semen analysis were included. SDF improved significantly from 31.6% to 25.3% (p<.05) before and after supplementation. Sperm concentration, motility rate, sperm motility index (SMV) and sORP showed no statistically significant difference. When restricted to cases with high sORP (≥1.38), the differences were more pronounced as follows. SDF decreased significantly from 34.0% to 26.1% (p<.05). Similarly, there was a significant improvement in sperm concentration and SMV from 12.5 million/ml to 24.3 million/ml (p<.05) and from 73.6 to 114.4 (p<.05) respectively. When IVF outcomes were compared before and after supplementation, the blastocyst rate (42.4% vs. 51.2%) and good blastocyst rate (45.5% vs. 54.5%) showed a trend towards improvement, but no significant differences were observed due to the small sample size. (Conclusion) Myseed® Supplementation significantly reduced SDF, which was more pronounced in patients with higher sORP levels, suggesting that SDF and sORP may serve as clinical indicators for antioxidant use.
(Purpose) To translate the Female Decreased Sexual Desire Screener (DSDS) into Japanese and perform linguistic validation of the translated DSDS. (Methods) Translation was conducted in the following order: 1) obtaining permission from the original author to create a Japanese version; 2) forward translation; 3) community review; 4) back-translation; and 5) review and approval of the back-translation by the original author. First, permission to create the Japanese version was obtained from the original author by e-mail. The initial translation was done by two urologists, and an additional four urologists then refined and completed the Japanese translation. Linguistic validation was performed as follows. For the community review, semi-structured interviews were conducted with a total of 11 participants (6 sexually active women and 5 non-sexually active women), and some wording changes were made based on the input from the participants. A total of 10 different participants were asked to respond to the questionnaire again, and additional modifications were made. The forward translation with modifications was then back-translated and e-mailed to the original author. (Results) In accordance with the original author's comments on the back-translation, further modifications were made to the Japanese version, which was then back-translated again and confirmed and approved by the original author. (Conclusion) After a multi-step review process, the Japanese version of the DSDS was completed with linguistic validation.
(Objective) To evaluate prognostic factors of metastatic urothelial carcinoma treated with immunotherapy. (Materials and methods) Fifty patients treated with pembrolizumab at Osaka Rosai hospital during 2017-2022 were examined. The treatment efficacy was evaluated using Response Evaluation Criteria in Solid Tumors, Version 1.1. (Results) Radical surgery was performed in 40 of 50 patients. According to the Bellmunt risk classification, which considers the performance status, presence of anemia, presence of liver metastasis, and interval from previous chemotherapy, 10 cases had risk 0; 23, risk 1; 13, risk 2; and 4, risk 3. The objective response rate (complete and partial remission) during immunotherapy was achieved in 15 cases. The median times of overall survival (OS) from first-line treatment initiation and immunotherapy initiation were 18.7 and 10.9 months, respectively. Multivariate analysis revealed lower platelet counts (<200,000/μL), increased C-reactive protein levels (≥0.75 mg/dL), and NLR (elevated neutrophil-lymphocyte rate) (≥6) to be poor prognostic factors for OS. Considering these three factors, the median OS of the low-risk (0 or 1) and high-risk (2 or 3) groups was significantly different, at 13.8 and 3.5 months, respectively (p<0.001). (Conclusion) Early switching from immunotherapy to the next treatment should be considered for high-risk patients.
The patient was a 79-year-old male who underwent external-beam radiation therapy combined with hormone therapy for prostate cancer. A hydrogel SpaceOAR was implanted to prevent adverse rectal events before stereotactic radiotherapy using Cyberknife. After completion of external irradiation, the patient developed a fever and was diagnosed with a prostatic abscess based on clinical and computed tomography findings. Magnetic resonance imaging showed the prostatic abscess consistent with SpaceOAR insertion site. Despite treatment with antibiotic agents, the patient's inflammatory response did not improve. Transurethral resection of the prostatic abscess and vesicostomy were performed for drainage, following which the postoperative inflammatory response improved rapidly. In this case, the SpaceOAR may have partially penetrated into the prostatic capsule when it was implanted, and a urinary tract infection may have occurred due to urinary retention or placement of a urethral catheter, resulting in the formation of an abscess.
A 30-year-old man underwent a right high orchiectomy for a testicular tumor. A computed tomography (CT) scan revealed para-aortic and mediastinal lymph node and lung metastases, consequently he was diagnosed with pTxN3M1aS2 stage III B, mixed germ cell tumor (teratoma, fibrosis). The bleomycin, etoposide, and cisplatin protocol was initiated after the placement of an inferior vena cava filter for common iliac venous thrombus. Human chorionic gonadotropin (HCG) positivity was observed at the end of the fourth course despite the immediate decrease in tumor markers after the treatment's initiation. The HCG levels remained low and positive after three vinblastine sulfate, ifosfamide, and cisplatin protocol and two paclitaxel, ifosfamide, and cisplatin protocol courses. A subsequent CT scan revealed a developing lymph node metastasis; hence, retroperitoneal and mediastinal lymph node dissections were performed biphasically.Residual tumor resection is indicated for patients with non-seminoma having localized retroperitoneal lesions or resectable lesions and high alpha-fetoprotein. However, the lymph node dissection, performed here, stabilized the patient's condition in a non-HCG-negative and HCG stain-negative state, suggesting that elevated HCG may be attributed to abnormal feedback from chemotherapy.
A 80-year-old woman presented with a swelling and pain in the left thigh visited our hospital. CT showed an impacted stone in the left ureter, left hydronephrosis and abscess formation extending from the perirenal area to the left thigh. Immediately, the patient was admitted and left nephrostomy was placed. On day 3 of admission, drainage of abscess in the left thigh was performed with the cooperation of an orthopedic surgeon. On day 17, a contrast-enhanced CT showed shrinkage of the thigh abscess, however, showed the left non-functioning kidney and poor drainage of the left iliopsoas abscess. On day 24, open left nephrectomy and unroofing of the iliopsoas abscess were performed, and all the abscess showed shrinkage thereafter. To sum up, multiple drainage should be considered for widely extending abscess originated in the retroperitoneal space.
