A man in his 70s underwent ABO-incompatible renal transplantation 19 years ago at another hospital for end-stage renal failure due to IgA nephropathy. The immunosuppressive regimen included tacrolimus 4mg/day, mycophenolate mofetil 500 mg/day, and prednisolone 5 mg/day. Renal function remained stable post transplantation, withserum creatinine levels ranging from 1.0 to 1.2 mg/dl. Contrast-enhanced computed tomography performed for the sudden onset of the aortic dissection showed a tumor 14 mm in diameter on the ventral side of the kidney allograft, with early contrast enhancement. The tumor was less than 10 mm deep into the renal cortex. Based on these findings, the patient was diagnosed with cT1aN0M0 renal cell carcinoma in a kidney allograft, and an open partial nephrectomy was performed without renal ischemia. Histopathological examination demonstrated clear cell renal cell carcinoma, WHO/ISUP Grade 2, without vascular invasion, and negative surgical margins. Postoperatively, renal function was preserved, and no recurrence has been observed during a 2-year follow-up period.
The present retrospective study investigated the efficacy and safety of keishibukuryogan for hot flashes associated with androgen deprivation therapy (ADT) in patients with prostate cancer. Between January 2018 and September 2024, 102 prostate cancer patients who were administered keishibukuryogan for the first time for treatment of hot flash were included in this study. Three months after the treatment, the efficacy of this drugs was assessed based on any improvement in subjective symptoms by the medical interview as follows ;"ineffective", "slightly effective", "moderately effective", and"excellently effective". Desire to continue this drug, the duration of continuation, and adverse effects were investigated. The cases in which efficacy was"slightly effective"or better were defined as the responder group, and patients'characteristics were compared between the responder and non-responder groups. The mean age was 72.2 years, and the mean period from the start of ADT to keishibukuryogan administration was 14.5 months. The efficacy of this drug was excellent in 3 cases, moderately effective in 11, slightly effective in 36, and ineffective in 52. Fifty-six patients desired to continue the treatment after three months. The average duration of drug continuation in the responder group was 13.7 months. In the responder group, the cases with a history of radiation therapy were significantly frequent (p＝0.0277). Six patients discontinued the drug administration due to adverse effects, with 3 experiencing itching, and 1 each experiencing loose stools, nightmares, and difficulty taking the drug. Keishibukuryogan was effective in approximately half of the cases with hot flash.
We report a case involving an 81-year-old woman who developed pyogenic spondylitis following laparoscopic sacrocolpopexy (LSC) for a cystocele in November year X. During concomitant uterine resection, purulent discharge was observed, and oral levofloxacin was administered for 5 days postoperatively. Pathological examination revealed xanthogranulomatous endometritis, which was considered the source of the mesh infection. The patient was discharged on postoperative day 7 without complications. In early January year X＋1, she developed buttock pain that persisted for approximately 2 weeks without improvement, prompting her to return to our hospital. Magnetic resonance imaging findings indicated pyogenic spondylitis. She was admitted and treated with intravenous sulbactam/ampicillin for 1 week, but her symptoms did not improve. Laparoscopic mesh removal was subsequently performed. After surgery, the antibiotic regimen was switched to intravenous imipenem/cilastatin, resulting in good infection control. However, progressive bone destruction was noted, and on postoperative day 37, posterior spinal fusion from L3 to the pelvis was performed by our orthopedic team. The postoperative course following spinal surgery was favorable, with marked symptom relief. Oral minocycline was initiated on postoperative day 69 and continued until day 133. The patient was discharged ambulatorily on postoperative day 139. Although pyogenic spondylitis is recognized as a serious complication of LSC, this represents postoperative case encountered at our institution. On the basis of a review of the literature, we discuss this case and its clinical implications.
Primary malignant lymphoma of the renal pelvis is extremely rare ; only 13 cases have been reported to date, and it is often difficult to distinguish from urothelial carcinoma. A 63-year-old woman presented with fever and right flank pain. Computed tomography revealed right hydronephrosis, a renal pelvic mass, and para-aortic lymphadenopathy. Selective urinary cytology was negative, and ureteroscopic examination showed no visible tumor. Because of recurrent febrile urinary tract infections, retroperitoneal laparoscopic right nephrectomy was performed. The resected specimen showed mucosal thickening and a mass lesion in the renal pelvis. Histopathological examination demonstrated diffuse proliferation of atypical lymphoid cells positive for CD20 and CD79a, consistent with diffuse large B-cell lymphoma (DLBCL). The patient received eight cycles of R-THP-COP (rituximab, pirarubicin, cyclophosphamide, vincristine and prednisolone) chemotherapy, and para-aortic lymphadenopathy regressed. She remains in complete remission 60 months after surgery. As imaging findings are nonspecific and urinary cytology is usually negative, preoperative diagnosis of renal pelvic lymphoma is challenging. Nephroureterectomy can serve as both a diagnostic and therapeutic procedure, and malignant lymphoma should be considered in the differential diagnosis of renal pelvic tumors.
A 66-year-old man receiving medication for Castleman disease was found to have a gradually enlarging renal mass on a computed tomography (CT) scan. Contrast-enhanced CT and magnetic resonance imaging scan were performed for diagnostic evaluation, and renal cell carcinoma was suspected, prompting consideration of surgical resection. However, we determined that histopathological confirmation was necessary to rule out recurrent Castleman disease and other conditions. Therefore, we performed a tumor biopsy before any surgical intervention. An ultrasound-guided percutaneous needle biopsy revealed extramedullary hematopoiesis. Currently, the lesion is under observation without intervention.
According to the 5th edition of the Japanese General Rule for Clinical and Pathological Studies on Prostate Cancer, clinical T2c is defined as"a tumor involving both lobes". It is not defined whether this refers only to continuous lesions spreading across both lobes or also includes small, non-continuous lesions present in both lobes. Furthermore, the General Rule stated that"it is generally understood that pathological findings from biopsies are not taken into consideration when determining T categories". We investigated how physicians interpret the General Rule and perform T classification in real-world clinical practice. We prepared five hypothetical cases with negative digital rectal examination findings but with lesions identified on magnetic resonance imaging (MRI) and conducted a questionnaire survey targeting board-certified urologists certified by the Japanese Urological Association. We received responses from 58 participants. Twenty-six participants (44.8%) diagnosed cases with discontinuous lesions in both lobes as cT2a, and 32 participants (55.2%) diagnosed them as cT2c. In addition, 41 participants (70.7%) diagnosed cases in which lesions were found in one lobe on MRI and cancer was detected in both lobes by biopsies as cT2a, while 17 participants (29.3%) diagnosed them as cT2c. Furthermore, three participants (5.2%) diagnosed cases in which cancer was detected by biopsies only from the contralateral side where lesions were found on MRI as cT1c, 49 participants (84.5%) diagnosed them as cT2a, and six participants (10.3%) diagnosed them as cT2c. In staging prostate cancer, the General Rule can have multiple meanings and there are cases in which even specialists disagree. Since T classification affects treatment strategies, it is desirable to have a uniform understanding based on a clear definition.
A 68-year-old woman presented to a local physician with lower abdominal pain. Urinary bladder stones were identified, and the patient was referred to our department. She had undergone laparoscopic sacrocolpopexy (LSC) for uterine prolapse 2 years ago. Transurethral cystolithotripsy (TUCL) was performed, and a suture was found in the stone arising from the posterior bladder wall. We speculated that the suture migrated into the urinary bladder after LSC and formed a bladder stone. The sutures could not be removed transurethrally using a laser. A nephroscope was employed to attempt suture division using laparoscopic scissors ; however, the suture remained difficult to grasp or cut. The second surgery was performed using a transurethral nephroscope and a transvaginal laparoscopic trocar. The suture was grasped using forceps inserted through the trocar and excised through a nephroscope using scissors. No postoperative complications or recurrences were observed. Combined transurethral and transvesical approaches are useful for treating foreign bladder bodies that require grasping for removal.
A 43-year-old man visited our clinic to have surgeryfor contraception. Vasectomywas performed under local anesthesia. The scrotal skin was incised with a scalpel. The vas deferens was cut and the bilateral ends were ligated twofold using 2-0 silk and 4-0 polyglycolic acid suture without mucosal cautery of the vas deferens. Semen analysis revealed two nonmotile sperms in the entire high-power field one month after the surgery. However, eight months later, his partner was pregnant, and subsequent semen analysis revealed 10 to 20 motile sperms per high-power field. Post vasectomyrecanalization of the vas deferens was suspected. It is important to inform couples of the possibilityof pregnancypost vasectomydue to recanalization of the vas deferens. Therefore, obtaining prior informed consent not onlyfrom the patient but also from the partner is needed to avoid litigation.
We report a case of high-risk prostate cancer (pT3bN1Gleason score 4＋5), in a 63-year-old male who underwent robot-assisted radical prostatectomy with extended pelvic lymph node dissection in May 2019, followed by adjuvant combined androgen blockade (CAB) therapy. In June 2022, the case progressed to castration-resistant prostate cancer (CRPC), and enzalutamide was initiated. Bone metastases to the sacrum and seventh thoracic vertebra were identified concurrently and treated with radiotherapy. In January 2024, the patient presented with lower back pain and left thigh pain. Computed tomography revealed a right iliac fracture and multiple fractures of the left sacroiliac joint, consistent with radiotherapy-related pelvic insufficiency fractures (PIFs). While PIFs are well-documented in patients with gynecologic malignancies, reports on prostate cancer patients remain limited. We analyzed cases of pelvic fractures following pelvic radiotherapy for prostate cancer at our institution, including the present case, and discussed them in the context of the existing literature.
We conducted a web-based questionnaire survey targeting urologists in Japan on the real-world treatment selection for patients with advanced prostate cancer. The results were stratified by medical institution category and compared with those reported in the Advanced Prostate Cancer Consensus Conference 2024 (APCCC24). The survey included 124 urologists working at cancer centers/university hospitals (n＝48), public hospitals (n＝32), and general hospitals (n＝44). The proportion of respondents who selected triplet therapy for the majority of patients with metastatic hormone-sensitive prostate cancer (mHSPC) was higher among doctors at cancer centers/university hospitals or public hospitals, as was reported in the APCCC24, when compared with that among doctors at general hospitals. There are differences in opinions regarding the discontinuation of systemic therapy after achieving a deep prostate-specific antigen response. For cases which had progressed to metastatic castration-resistant prostate cancer after androgen receptor signaling inhibitor (ARSI) therapy and had mutations in the BRCA2 gene, the most commonly selected first line treatment was combination therapy of a poly ADP-ribose polymerase (PARP) inhibitor and an ARSI among doctors at cancer centers/university hospitals, and PARP inhibitor monotherapy among doctors at public and general hospitals. Opinions vary within the APCCC24 on whether to choose combination therapy or monotherapy. The survey results suggest that treatment selection of Japanese doctors may differ from those of the APCCC24. More extensive surveys are needed for further discussion on the treatment selection for patients with advanced prostate cancer in Japan.
Pyoderma gangrenosum is a non-bacterial inflammatory disease that forms ulcers and abscesses and can be exacerbated by mechanical stimulation. Surgical intervention for abscesses in the corpora cavernosa may exacerbate penile pyoderma gangrenosum. We report a case of penile pyoderma gangrenosum that was diagnosed minimally invasively by biopsy alone and treated with steroids. A 77-year-old man with penile swelling and pain was referred to our institution by his primary care physician for suspected penile cancer. Both infectious diseases and penile cancer were ruled out based on physical examination and laboratory test results. Magnetic resonance imaging revealed fluid accumulation in the corpora cavernosa, leading to the decision to perform a penile biopsy. The biopsy revealed no malignancy, but an abscess was identified. Based on the clinical presentation, penile pyoderma gangrenosum was suspected and steroid therapy was initiated, resulting in rapid symptomatic improvement. The steroid dose was gradually tapered, and after 18 months of treatment, the steroids were discontinued. The patient has remained asymptomatic with no recurrence of the abscess or other subjective complaints.
Immune checkpoint inhibitors (ICIs), a widely adopted therapeutic option for metastatic renal cell carcinoma, are also associated with a range of immune-related adverse events, some of which can be severe and life-threatening. Here, we describe the case of a 70-year-old man with renal cell carcinoma and brain, lung, and bone metastases who developed ICI-associated encephalitis, which was fatal. Initial computed tomography imaging revealed a 9.8 cm mass in the right kidney, multiple pulmonary nodules, and an osteolytic lesion in the left fifth rib. Brain magnetic resonance imaging revealed metastatic lesions in the right parietal lobe and left lateral ventricle. The patient underwent therapy with pembrolizumab and lenvatinib in combination with stereotactic radiotherapy targeting the brain metastases. On day 20 of treatment, the patient developed a generalized seizure, followed by a rapid deterioration in consciousness. He died the following day. Post-mortem examination revealed widespread lymphocytic infiltration of the brain parenchyma, which was consistent with the diagnosis of ICI-associated encephalitis.
A 58-year-old man presented with anal pain and fecal incontinence. He was diagnosed with locally advanced rectal cancer (cT4bN3M0) with prostate invasion and referred for combined surgery. Robotic abdominoperineal resection and retzius-sparing robot-assisted radical prostatectomy (RS-RARP) were performed. On postoperative day 14, cystography showed no evidence of vesicourethral anastomotic leakage, and the urethral catheter was removed. The postoperative course was uneventful without urinary incontinence. Pathological findings confirmed prostate invasion with negative surgical margins. Adjuvant chemotherapy was administered, and no recurrence has been observed at one year. In cases of rectal cancer with prostate invasion, concomitant prostate and seminal vesicle resection is often required, which carries a high risk of vesicourethral leakage and incontinence. RS-RARP preserves the anterior structures of the prostate and may reduce the risk of anastomotic failure while maintaining continence and sexual function. This case suggests that RS-RARP combined with APR could be a feasible surgical option for achieving curative resection and functional preservation in selected patients with locally advanced rectal cancer invading the prostate.
A 66-year-old female patient received a total of six intravesical Bacillus Calmette-Guérin instillations as treatment for bladder carcinoma in situ. Six months later, she visited our hospital with a complaint of abdominal pain. Computed tomography revealed enlarged para-aortic and left common iliac lymph nodes. A laparoscopic retroperitoneal biopsy of the left common iliac lymph node was performed. Acid-fast bacteria culture of the resected specimen and a multiplex polymerase chain reaction assay showed lymph node tuberculosis. There was no evidence of Bacillus Calmette-Guérin infection. We administered four anti-tuberculosis drugs. After one year of treatment, the enlarged lymph nodes showed regression. This reduction in lymph node size was sustained for four years.
A 53-year-old man underwent testicular fixation for a left undescended testicle at the age of 10 and a right high orchiectomy for a testicular tumor at the age of 35. He presented to our hospital with awareness of swelling in the left scrotal contents for the past month. Scrotal ultrasonography revealed a left testicular tumor, and contrast-enhanced abdominal CT showed a heterogeneous mass in the left scrotum with infiltration of the scrotal skin, as well as pathologically enlarged left inguinal and para-aortic lymph nodes. The pathology confirmed seminoma. The patient was treated with four courses of postoperative chemotherapy, resulting in a complete resolution (CR) of the lymph node metastasis. He has since remained free of recurrence.
The patient was a 69-year-old male. Eight years ago, he underwent radical prostatectomy for locally advanced prostate cancer at another hospital, and then underwent endocrine therapy due to biochemical recurrence. Five years later, progression to castration-resistant prostate cancer was confirmed, and abiraterone treatment was started. Macroscopic hematuria persisted, so he visited our department. Magnetic resonance imaging revealed a mass at the bladder neck. A tissue biopsy was performed, and prostate cancer was identified. The patient was diagnosed with local recurrence at the prostatectomy site. Salvage radiotherapy with a total dose of 70. 2 Gy was promptly administered. The recurrent lesion subsequently disappeared on imaging ; however, shortly thereafter, multiple liver metastases were detected on computed tomography. Treatment with docetaxel was initiated. The liver metastases promptly disappeared thereafter, and the prostate specific antigen (PSA) level decreased to 0.001 ng/ml. Since then, 17 courses were administered. Docetaxel was effective ; however, the patient's bone marrow function, indicated that the treatment was approaching its limit, and a gene panel test, Foundation One-CDx, was performed. Inactivating mutations in BRCA2 were identified. The diagnosis made was prostate cancer associated with hereditary breast and ovarian cancer syndrome. The patient was started on olaparib, a poly (ADP-ribose) polymerase inhibitor. To date, his PSA level has remained below 0.001 ng/ml. He has been taking the medication for more than 42 months without any side effects, and imaging studies have consistently shown a complete response.
Immune checkpoint inhibitors (ICIs) are increasingly used as adjuvant therapy in high-risk renal cell carcinoma (RCC), but may cause serious immune-related adverse events, such as myocarditis. We report a rare case of myocarditis followed by steroid-induced myopathy during adjuvant pembrolizumab therapy. A 74-year-old man underwent partial and radical nephrectomy for bilateral clear cell RCC (pT1b and pT3a). Pembrolizumab was initiated postoperatively. On day 22, he developed exertional fatigue and cardiac enzyme levels were elevated. Myocardial biopsy confirmed myocarditis, and corticosteroid pulse therapy was started. Although cardiac markers improved initially, they rose again, requiring a second steroid pulse and higher maintenance doses. After 27 days of steroid therapy, the patient developed severe proximal muscle weakness. Myasthenia gravis and other autoimmune diseases were excluded. Steroid-induced myopathy was diagnosed, and steroid tapering plus rehabilitation led to functional recovery. He was later discharged without recurrence of myocarditis. This case highlights the importance of early detection and treatment of ICI-related myocarditis and awareness of secondary complications such as steroid myopathy. Multidisciplinary care is essential in managing these rare but serious conditions.
A 66-year-old female patient visited another hospital complaining of frequent urination. Computed tomography scan revealed a 3 cm urethral stone, and she was referred to our hospital for surgery. The patient had a history of tension-free vaginal tape (TVT) surgery for stress urinary incontinence approximately 15 years ago. When transurethral lithotripsy was initiated, the lower end of the stone was found near the external urethral meatus, and an attempt to push it into the bladder was unsuccessful. When fragmentation of the stone was performed using a Ho-YAG laser, exposure of the mesh, presumably from the previous TVT surgery, was detected. A loop electrocautery was used to remove as much of the exposed mesh and the stone as possible. Cystoscopic observation was not possible, but no stone recurrence or mesh-related complications have been noted six months after the surgery. Cases of urethral stones caused by mesh exposure in the urethra after TVT are rare, and we report this case together with a literature review.
Testicular epidermoid cysts are relatively rare benign testicular tumors that are primarily observed in young adults. Most testicular tumors in adults tend to be malignant, and high inguinal orchiectomy is often performed to treat testicular epidermoid cysts. However, accurate preoperative and intraoperative diagnoses can make testis-sparing surgery a viable option. A 25-year-old man presented with a painless mass in the right scrotum. Ultrasonography revealed a hypoechoic lesion with an echogenic rim and an onion ring sign. Magnetic resonance imaging showed the target sign in the right testis. These imaging findings are considered to be highly specific to testicular epidermoid cysts. Intraoperative rapid testicular frozen sections were also useful for performing testis-sparing surgery. For this patient, an accurate preoperative diagnosis and intraoperative pathological examination enabled testis-sparing surgery.
A 73-year-old man presented to our hospital with a giant scrotal tumor. Physical examination revealed a right-sided scrotal tumor measuring the size of the child's head. Blood and urine tests results showed no significant findings ; however, computed tomography and magnetic resonance imaging findings suggested a liposarcoma arising within the scrotum. Tumor resection was performed, and the subsequent pathological diagnosis was cellular angiofibroma. The patient's postoperative course was uneventful without any recurrence. Here, we report a case of cellular angiofibroma that was preoperatively suspected to be a malignant tumor.
