We developed a structured robot-assisted training curriculum for urology residents with limited prior experience in open and laparoscopic surgeries. We evaluated the curriculum by comparing outcomes of resident-performed robot-assisted radical prostatectomy with those of experienced, proctor-certified surgeons. From 53 resident-performed and 175 non-resident-performed robot-assisted radical prostatectomy cases, propensity score matching (up to 1:2 ratio) yielded 46 resident-performed and 83 non-resident-performed cases. We compared operative and console times, estimated blood loss, perioperative complications, positive surgical margins, and immediate urinary continence after catheter removal. Our training program included video lectures and dry-laboratory training using procedure-specific models (three-dimensional pelvic model and vesicourethral anastomosis models) and optional low-cost tasks. Operative time (median [IQR]) was longer in resident-performed cases (249 [227–284] vs 208 [182–237] min; p < 0.001), as was total console time (213 [188–244] vs 166 [144–192] min; p < 0.001) and console time excluding pelvic lymph node dissection (200 [186–222] vs 158 [137–180] min; p < 0.001). When the procedure was subdivided into five phases, from bladder takedown to vesicourethral anastomosis, residents required longer times for all phases (all p ≤ 0.002). There were no significant differences between the two groups in estimated blood loss, positive surgical margin rates, immediate urinary continence, or perioperative complications. In this study, residents trained under the curriculum performed surgery safely with acceptable surgical outcomes, despite longer operative times. These findings indicate that a structured training curriculum mitigates potential risks associated with resident participation in robotic surgery. Further refinement of standardized training models is necessary to enhance operative efficiency.

Salvage radical prostatectomy is a postradiation treatment for patients with localized prostate cancer. In 2016, Ozu et al. (Ozu C, Aoki K, Nakamura K, Yagi Y, Muro Y, Nishiyama T, et al. The initial case report: salvage robotic assisted radical prostatectomy after heavy ion radiotherapy. Urol Case Rep 2016;7:45-7) first reported salvage robotic-assisted radical prostatectomy (sRARP) after heavy-ion radiotherapy (HIRT). Thereafter, sRARP has been performed in >100 cases. However, it is currently avoided owing to some difficulties. Herein, we report about sRARP in a 67-year-old man who received two sessions of HIRT despite some expected challenges. He was initially treated with HIRT for prostate cancer in 2009 and received the second HIRT as salvage treatment for local recurrence in 2016. In 2019, he had biochemical recurrence and underwent sRARP. There were no significant peri- or postoperative complications. Subsequently, 12 months after sRARP, hormonal therapy was introduced after the diagnosis of biochemical recurrence. The patient's prostate-specific antigen level is currently undetectable.

Health-related quality of life (HRQOL) after the treatment must be one of the most important factor for the prostate cancer (PCa) patients for deciding treatment options. Objective of this study is to compare HRQOL of patients who underwent mono treatment of permanent seed implant brachytherapy (BT alone) or robot assisted radical prostatectomy (RARP) as their initial curative treatment.

Prostate brachytherapy with iodine-125 permanent seed implantation (BT) started in Japan in 2003. More than 3400 cases were performed at our institute during the past 15 years. Long term outcomes of BT and it’s predictors of recurrence were analyzed.

PURPOSE:To analyze outcomes following whole-gland salvage treatments applied to patients with pathology-proven, locally recurrent prostate cancer following primary definitive radiotherapy.MATERIAL AND METHODS:Eighteen consecutive patients who received whole-gland salvage treatments at our institution were retrospectively reviewed. All patients underwent transperineal template-guided mapping biopsy (TTMB) using the standard iodine-125 (125I) brachytherapy (BT) setup. Twelve patients received 125I BT, and six patients underwent robot-assisted laparoscopic prostatectomy (RARP). Prostate-specific antigen (PSA) failure was determined using the Phoenix definition (nadir + 2 ng/ml) following BT and a PSA level of > 0.2 ng/ml following RARP. Toxicities were graded according to CTCAE version 4.0.RESULTS:The median follow-up times were 71 and 11 months for the BT and RARP groups, respectively. In the BT group, the median dose to 90% of the prostate was 131 Gy. The median time to biochemical failure was 47 months, and the biochemical relapse-free survival (BRFS) rates were 56% (95% confidence interval [CI]: 33-94%) and 46% (95% CI: 25-88%) at 3 years and 5 years, respectively. Four patients (33%) developed grade 2 genitourinary (GU) toxicity, and two (17%) developed grade 3 GU toxicity. No patients developed grade ≥ 2 gastrointestinal (GI) toxicity. In the RARP group, three out of six patients (50%) had PSA failure, and four patients (67%) developed grade 2 GU toxicity. No patients developed grade 3 GU toxicity or grade ≥ 2 GI toxicity. On pre-salvage magnetic resonance imaging (MRI), no patients were suspected of having T3 or higher stage lesions. However, three patients (50%) had pT3a and two patients (33%) had pT3b (i.e., seminal vesicle invasion) stage lesions.CONCLUSIONS:Whole-gland salvage BT is an effective treatment with an acceptable toxicity profile. The pathology findings from RARP imply that there is a room for improvement in diagnoses made by MRI in the pre-salvage setting.

You have accessJournal of UrologyProstate Cancer: Localized: Radiation Therapy1 Apr 2018MP22-19 PREDICTION AND STRATIFICATION OF THE BIOCHEMICAL RECURRENCE IN PATIENTS WITH HIGH-RISK PROSTATE CANCER AFTER LOW DOSE RATE PERMANENT SEED IMPLANTATION Yu Ozawa, Masanori Hasegawa, Noriaki Santo, Yasuto Yagi, Toru Nishiyama, Ryo Yabusaki, Keisuke Aoki, Ken Nakamura, Choichiro Ozu, Kazuhito Toya, Masanori Yorozu, and Shiro Saito Yu OzawaYu Ozawa More articles by this author , Masanori HasegawaMasanori Hasegawa More articles by this author , Noriaki SantoNoriaki Santo More articles by this author , Yasuto YagiYasuto Yagi More articles by this author , Toru NishiyamaToru Nishiyama More articles by this author , Ryo YabusakiRyo Yabusaki More articles by this author , Keisuke AokiKeisuke Aoki More articles by this author , Ken NakamuraKen Nakamura More articles by this author , Choichiro OzuChoichiro Ozu More articles by this author , Kazuhito ToyaKazuhito Toya More articles by this author , Masanori YorozuMasanori Yorozu More articles by this author , and Shiro SaitoShiro Saito More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.730AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Treatment of high-risk prostate cancer (PCa) remains challenging for urologists. The present study was undertaken to identify risk factors for the biochemical recurrence (BCR) in patients with high-risk PCa who underwent low dose rate permanent seed implantation brachytherapy with iodine-125 (LDR). METHODS Medical records of 335 patients with high-risk PCa identified by NCCN risk stratification treated with LDR during the period of 2004-2015 at our institution have been reviewed. All patients received extra beam radiation therapy after LDR. Possible risk factors assessed for the future BCR included age, PSA, prostate volume, histological findings of biopsy specimens, neoadjuvant hormone therapy and local extent of disease evaluated by pelvic MRI. BCR free survival rates were constructed using the Kaplan-Meier method. Risk factors for BCR were evaluated by the log-rank test and multivariate Cox proportional hazard model with a stepwise selection procedure. RESULTS The Kaplan-Meier analysis showed that the 5- or 10-year BCR free survival rates were 86.7%, and 78.8%, respectively. Multivariate analysis demonstrated that grade group 5 (Hazard ratio; HR 3.75, p<0.01), cT3 (HR 2.03, p<0.04), PSA >20ng/ml (HR 2.45, p<0.05) and no neoadjuvant hormone therapy (HR 2.16, p<0.05) were significant prognostic factors. The patients were stratified into a good-risk group (0 or 1 risk factor), intermediate-risk group (2 risk factors), and poor-risk group (3 risk factors). There were significant differences in the BCR free survival among the groups; p<0.01 for low- vs. intermediate-risk group, and p<0.01 for intermediate- vs. high-risk group. The 5- or 10-year BCR free survivals rates were 92.4%, 83.1%, and 75.3%, 72.5%, and 26.7%, 26.7% in good-, intermediate-, and poor-risk patients, respectively. CONCLUSIONS These results indicate that grade group 5, cT3, PSA >20ng/ml and no neoadjuvant hormone therapy were independent risk factors for the BCR in patients with high-risk PCa treated with LDR. The combination of these factors may be helpful to identify candidates for additional treatments to control disease progression. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e280 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Yu Ozawa More articles by this author Masanori Hasegawa More articles by this author Noriaki Santo More articles by this author Yasuto Yagi More articles by this author Toru Nishiyama More articles by this author Ryo Yabusaki More articles by this author Keisuke Aoki More articles by this author Ken Nakamura More articles by this author Choichiro Ozu More articles by this author Kazuhito Toya More articles by this author Masanori Yorozu More articles by this author Shiro Saito More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

To report the outcome of whole gland salvage treatments applied to patients with pathology-proven, locally recurrent prostate cancer following primary definitive radiotherapy.

To figure out risk factors for PSA relapse in patients with low-risk prostate cancer who received iodine-125 permanent prostate seed implantation (PI) as monotherapy.

PURPOSE:To identify patients at extremely low risk of biochemical recurrence (BCR) of prostate cancer after low-dose-rate brachytherapy (LDR-BT) to determine when prostate-specific antigen (PSA) monitoring can be stopped. METHODS AND MATERIALS:We retrospectively reviewed clinicopathologic data of patients with prostate cancer who underwent LDR-BT between 2003 and 2011. Of 1569 patients reviewed, 689 (43.9%) received combination external beam radiotherapy, and 970 (61.8%) had neoadjuvant hormonal therapy. We stratified patients according to risk factors identified by multivariate analysis and assessed the factors for an association with BCR (defined as ≥2 ng/mL higher than the nadir). RESULTS:The median followup was 96 months. Of 1531 patients who were BCR-free at 3 years after treatment, 76 subsequently developed BCR; of 1500 who were BCR-free at 5 years, 45 eventually had BCR. On multivariate analysis, independent risk factors for BCR were the National Comprehensive Cancer Network risk group at diagnosis and PSA levels at 3 or 5 years after radiotherapy. In the low-risk group, no patient with a PSA level ≤0.2 ng/mL at 3 years after radiotherapy subsequently developed BCR. In the intermediate-risk group, no patients with a PSA level ≤0.2 ng/mL at 5 years subsequently developed BCR. CONCLUSIONS:The National Comprehensive Cancer Network risk group at diagnosis and PSA values at 3 and 5 years after LDR-BT are independently associated with a risk of later BCR. Using these two factors may help to select patients for whom PSA monitoring could be stopped because they have an extremely low risk of later BCR.

Salvage radical prostatectomy is one of treatments after radiation therapy to patients with prostate cancer. To date, no case of the salvage robotic assisted radical prostatectomy (RARP) following heavy ion radiotherapy (HIRT) has been published. We report on a 70-year-old man with a history of HIRT for prostate cancer in 2011. For 3 years after. HIRT, his serum PSA levels were permissible range. However, his PSA levels were increased. We had diagnosis localized prostate cancer after HIRT. We had carried out salvage RARP. Until 10 months after salvage RARP, his PSA level was not detectable.

PurposeTo evaluate the urinary toxicities of the patients who underwent transurethral resection of the prostate (TURP) before or after the seed implantation.Materials and MethodsIn a total of 2600 patients who received iodine-125 brachytherapy of the prostate with or without external beam radiotherapy (EBRT) in our institute, 19 patients had history of TURP before seed implantation, and 9 patients underwent TURP after seed implantation because of urinary retention. The primary outcomes of this study were urinary toxicities and the necessity for any further operation for lower urinary tract.ResultsOf 19 patients who had TURP before seed implantation, 4 (21%) patients developed urinary retention, 1 (5.2%) had gross hematuria requiring blood transfusion, and none of them developed total urinary incontinence after brachytherapy. None of these patients underwent further urinary tract operation. The median time between TURP and brachytherapy was 8.4 months (range, 3.1-74.7). The median followup time after brachytherapy was 36.9 months (range, 9.7-146.5). Of 9 patients who underwent TURP after seed implantation, 4 (44.4%) patients developed urinary retention, 2 (22.2%) had gross hematuria requiring blood transfusion, 1 (11.1%) developed total urinary incontinence after TURP. Furthermore, 4 (44.4%) of them underwent internal urethrotomy for urethral stricture and 2 (22.2%) underwent transurethral coagulation for gross hematuria. The median time between brachytherapy and TURP was 33.4 months (range, 19.8-77.0). The median followup time after TURP was 54.6 months (range, 1.2-103.8). None of the patients in this study developed biochemical failure (Phoenix definition).ConclusionsThe patients who had a history of TURP were able to tolerate brachytherapy of the prostate. The results of this study suggests that previous TURP is not a contraindication of iodine-125 brachytherapy. On the other hand, TURP after seed implantation seemed to be more toxic. The patients should be thoroughly informed of the adverse events before undergoing TURP after brachytherapy of the prostate. PurposeTo evaluate the urinary toxicities of the patients who underwent transurethral resection of the prostate (TURP) before or after the seed implantation. To evaluate the urinary toxicities of the patients who underwent transurethral resection of the prostate (TURP) before or after the seed implantation. Materials and MethodsIn a total of 2600 patients who received iodine-125 brachytherapy of the prostate with or without external beam radiotherapy (EBRT) in our institute, 19 patients had history of TURP before seed implantation, and 9 patients underwent TURP after seed implantation because of urinary retention. The primary outcomes of this study were urinary toxicities and the necessity for any further operation for lower urinary tract. In a total of 2600 patients who received iodine-125 brachytherapy of the prostate with or without external beam radiotherapy (EBRT) in our institute, 19 patients had history of TURP before seed implantation, and 9 patients underwent TURP after seed implantation because of urinary retention. The primary outcomes of this study were urinary toxicities and the necessity for any further operation for lower urinary tract. ResultsOf 19 patients who had TURP before seed implantation, 4 (21%) patients developed urinary retention, 1 (5.2%) had gross hematuria requiring blood transfusion, and none of them developed total urinary incontinence after brachytherapy. None of these patients underwent further urinary tract operation. The median time between TURP and brachytherapy was 8.4 months (range, 3.1-74.7). The median followup time after brachytherapy was 36.9 months (range, 9.7-146.5). Of 9 patients who underwent TURP after seed implantation, 4 (44.4%) patients developed urinary retention, 2 (22.2%) had gross hematuria requiring blood transfusion, 1 (11.1%) developed total urinary incontinence after TURP. Furthermore, 4 (44.4%) of them underwent internal urethrotomy for urethral stricture and 2 (22.2%) underwent transurethral coagulation for gross hematuria. The median time between brachytherapy and TURP was 33.4 months (range, 19.8-77.0). The median followup time after TURP was 54.6 months (range, 1.2-103.8). None of the patients in this study developed biochemical failure (Phoenix definition). Of 19 patients who had TURP before seed implantation, 4 (21%) patients developed urinary retention, 1 (5.2%) had gross hematuria requiring blood transfusion, and none of them developed total urinary incontinence after brachytherapy. None of these patients underwent further urinary tract operation. The median time between TURP and brachytherapy was 8.4 months (range, 3.1-74.7). The median followup time after brachytherapy was 36.9 months (range, 9.7-146.5). Of 9 patients who underwent TURP after seed implantation, 4 (44.4%) patients developed urinary retention, 2 (22.2%) had gross hematuria requiring blood transfusion, 1 (11.1%) developed total urinary incontinence after TURP. Furthermore, 4 (44.4%) of them underwent internal urethrotomy for urethral stricture and 2 (22.2%) underwent transurethral coagulation for gross hematuria. The median time between brachytherapy and TURP was 33.4 months (range, 19.8-77.0). The median followup time after TURP was 54.6 months (range, 1.2-103.8). None of the patients in this study developed biochemical failure (Phoenix definition). ConclusionsThe patients who had a history of TURP were able to tolerate brachytherapy of the prostate. The results of this study suggests that previous TURP is not a contraindication of iodine-125 brachytherapy. On the other hand, TURP after seed implantation seemed to be more toxic. The patients should be thoroughly informed of the adverse events before undergoing TURP after brachytherapy of the prostate. The patients who had a history of TURP were able to tolerate brachytherapy of the prostate. The results of this study suggests that previous TURP is not a contraindication of iodine-125 brachytherapy. On the other hand, TURP after seed implantation seemed to be more toxic. The patients should be thoroughly informed of the adverse events before undergoing TURP after brachytherapy of the prostate.

To the Editor, Axitinib is a potent, selective, second-generation inhibitor of vascular endothelial growth factor receptor (VEGFR) 1, 2, and 3, and has been approved for the treatment of advanced r...

Bone is the third most common site of metastasis from upper tract urothelial carcinoma after radical nephroureterectomy. Although bone biopsy is the gold standard for the diagnosis of bone metastases, they can usually be diagnosed on the basis of imaging tests. We describe a case of upper tract urothelial carcinoma after radical nephroureterectomy presenting with a Schmorl node in the third lumbar vertebra, mimicking lytic bone metastasis. Differentiation of bone metastases from Schmorl nodes is essential for the appropriate management of patients with malignancy. (C) 2015 Elsevier Inc.

From September 2003 to March 2014, 2275 patients with localized prostate cancer were treated with permanent iodine-125 seed implantation brachytherapy (BT) at Tokyo Medical Center. From the beginning, we aggressively performed BT combined with external beam radiotherapy (EBRT) ± neoadjuvant androgen deprived therapy for patients with high risk (NCCN definition; PSA≧20 ng/ml or Gleason score≧8 or clinical stage≧T3a) localized prostate cancer. From September 2003 to August 2008, 103 patients with high risk localized prostate cancer received BT combined with EBRT ± neoadjuvant androgen deprivation therapy (combined androgen blockade: 39 cases, LH-RH agonist alone: 25 cases, antiandrogen alone: 32 cases, none: 7 cases). Prescription dose of BT was 100-110 Gy, and EBRT was performed with 3D-CRT with prescription dose of 45 Gy(1.8Gy ×25). According to our protocol, none of them have received adjuvant hormone therapy. Ten-year over all survival (OS), disease specific survival (DSS), clinical relapse free survival (CRFS) and biochemical relapse free survival (BRFS) were evaluated by Kaplan-Meier analysis. The Phoenix definition (nadir + 2.0 ng/ml) was used to determine biochemical failure. Univariate and multivariate regression analysis were performed by log-rank test and Cox's proportional hazard regression model, respectively. Toxicity was assessed by using the Common Terminology Criteria for Adverse Events v.4.0. Median follow-up period was 6.8 years. Ten-year OS rate was 83.5%, CSS rate was 99.0%, CRFS rate was 81.4% and BRFS rate was 78.0%. A multivariate analysis revealed PSA≧20 ng/ml, Gleason score≧8, clinical stage T≧3a, positive core rate (PCR) of prostate biopsy at diagnosis ≧50% were the statistically significant risk factors for BRFS. The number of these risk factors was also related to the rate of biochemical relapse. Furthermore, cases without neoadjuvant hormone therapy showed higher rate of biochemical relapse in our series. Accumulative number of late gastrointestinal (GI) toxicity≧ grade 3 was seen in just one case and genitourinary (GU) was none. Out of 103 cases, 19 patients were diagnosed as BRFS and 5 out of that 19 patients histologically revealed positive for local cancer recurrence diagnosed by template guided transperineal prostate saturation biopsy (TPBx). Positive cores at TPBx tend to be located at posterior side of prostate near rectum and periuretheral area where radiation cold spot may exert. None of 5 TPBx positive cases showed higher Gleason score than initial biopsy at cancer diagnosis. Among 5 TPBx positive cases, 3 received salvage BT (2nd BT), 2 received androgen deprived therapy. BT combined with EBRT ± neoadjuvant hormone therapy is highly effective treatment with good local cancer control and low incidence of adverse events. It can be strongly recommended as the treatment option for high risk prostate cancer.

e16052 Background: This study is to evaluate long-term outcomes of prostate brachytherapy (BT) with I-125 permanent seed implantation. Methods: Between September 2003 and September 2008, 1054 patients underwent BT for cT1-3N0M0 prostate cancer at single institution. Among those patients, 1036 were able to be followed for more than 5 years. Kaplan-Meier analysis was performed to evaluate their overall survival rate (OS), disease-specific survival rate (DSS), clinical progression-free survival rate (CPFS) and biochemical progression-free survival rate (BPFS). The Phoenix definition was used to determine biochemical failure after the treatment. However, clear prostate-specific antigen (PSA) bounce cases were excluded from failure for the analysis. Univariate and multivariate regression analysis were performed by log-rank test and Cox’s proportional hazard regression model, respectively. Toxicity was scored by the Common Terminology Criteria for Adverse Events v.4.0. Results: The median follow-up period was 6...

You have accessJournal of UrologyProstate Cancer: Markers I1 Apr 2014MP74-08 A NEW DEFINITION OF BIOCHEMICAL FAILURE FOR PROSTATE CANCER TREATED WITH BRACHYTHERAPY Toru Nishiyama, Kaoru Nakamura, Keishiro Fukukmoto, Mitsuyoshi Tamaki, Yasuto Yagi, Choichiro Ozu, Atsunori Yorozu, and Shiro Saito Toru NishiyamaToru Nishiyama More articles by this author , Kaoru NakamuraKaoru Nakamura More articles by this author , Keishiro FukukmotoKeishiro Fukukmoto More articles by this author , Mitsuyoshi TamakiMitsuyoshi Tamaki More articles by this author , Yasuto YagiYasuto Yagi More articles by this author , Choichiro OzuChoichiro Ozu More articles by this author , Atsunori YorozuAtsunori Yorozu More articles by this author , and Shiro SaitoShiro Saito More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2341AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Phoenix definition (PSA nadir + 2ng/mL) is commonly used for biochemical failure (BF) after brachytherapy (BT) for prostate cancer (PCa), and it is thought to be a more robust determinant of patient outcome compared with the American Society for Therapeutic Radiology and Oncology (ASTRO) definition (three consecutive increases of PSA). However, the Phoenix definition is not suitable for comparing BF of BT and that of radical prostatectomy (RP) because BF after RP is diagnosed when PSA >0.2ng/mL and a large portion of the patients undergo salvage therapy before PSA reaches 2.0 ng/mL. The objective of this study is to compare a new definition of BF, PSA>0.2ng/mL with three consecutive increases (NTMC definition), with the Phoenix definition and the ASTRO definition. METHODS A total of 1442 patients with clinically localized PCa were treated with BT between September 2003 and October 2010 at our institution, and followed at least 36 months (22 to 118, median 70.0 months). The patients were treated with seed implantation using I-125 with or without EBRT combination. The patients may have neoadjuvant androgen deprivation therapy (ADT), but ADT after BT was not performed in any of the cases before the diagnosis of disease recurrence. Sesitivity and specificity of each definition are calculated and compared. True failure is confirmed by clinical failure. Possible failure (PF) is defined as rising PSA toward the end of observation without clear evidence of clinical recurrence. There were 46 PF cases and they were excluded from the study. RESULTS Sensitivity and specificity of the Phoenix, the ASTRO, and our definition are shown in a table. NTMC definition showed much higher sensitivity and slightly lower specificity compared to the Phoenix definition. NTMC definition had similar sensitivity and higher specificity to the ASTRO definition. Neoadjuvant ADT lowered sensitivity of the Phoenix definition, and raised specificity of the Phoenix and our definition. CONCLUSIONS NTMC definition of BF after BT such as PSA>0.2ng/mL with three consecutive increases showed sufficiently high sensitivity and specificity. The definition is useful especially the cases with neoadjuvant ADT, or when comparing therapeutic effect of BT and RP. Definition Phoenix ASTRO NTMC Whole cases Sensitivity 87.8% 96.3% 95.1% Specificity 96.7% 90.2% 94.3% Without neoadjuvant ADT Sensitivity 89.7% 93.1% 93.1% Specificity 94.7% 91.3% 91.8% With neoadjuvant ADT Sensitivity 86.8% 98.1% 96.2% Specificity 97.6% 91.3% 95.0% © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e858-e859 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Toru Nishiyama More articles by this author Kaoru Nakamura More articles by this author Keishiro Fukukmoto More articles by this author Mitsuyoshi Tamaki More articles by this author Yasuto Yagi More articles by this author Choichiro Ozu More articles by this author Atsunori Yorozu More articles by this author Shiro Saito More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...