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Objective: To clarify the diagnostic performance of the three-dimensional reconstructed virtual image (3D-RVI) in evaluating RENAL nephrometry score (RENAL-NS).Methods: This study included 130 patients who underwent preoperative contrast-enhanced computed tomography followed by partial nephrectomy for renal tumors suggestive of renal cell carcinoma. RENAL-NS was calculated prior to the surgery, and tumor resection was performed referring to the score. We retrospectively reviewed preoperative contrast-enhanced computed tomography images. We calculated the inter-observer variability of RENAL-NS using 3D-RVI vs two-dimensional (2D) imaging and compared the ability of RENAL-NS using 3D-RVI vs 2D imaging to predict the risk of opening of the urinary collecting system. We also compared the two modalities for the time required to evaluate RENAL-NS.Results: RENAL-NS evaluated using 3D-RVI showed a higher inter-observer agreement compared to 2D-imaging (rs = 0.85 vs rs = 0.65). The "nearness to sinus" score was more strongly associated with the opening of the urinary collecting system when evaluated using 3D-RVI than 2D-imaging (AUC = 0.71 vs AUC = 0.57, P = .016). RENAL-NS using 2D-imaging required a significantly longer time compared to 3D-RVI (P = .036).Conclusion: Using 3D-RVI improves the accuracy, reliability and efficiency of RENAL-NS evaluation in preoperative assessment and can play an important role in preoperative assessment and intraoperative navigation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the long-term effect of the processus vaginalis transection method, which we previously developed to prevent postradical prostatectomy inguinal hernia. Methods: Our hernia prevention procedure is designed to prevent postoperative indirect hernias. The procedure is performed in the following order: (1) the spermatic cord is isolated and mobilized in the pelvis, (2) the vas deferens is isolated from the spermatic cord and ligated, and (3) the processus vaginalis is dissected free of the other spermatic cord elements, mainly spermatic vessels, ligated near the peritoneum, and transected. Between February 2006 and August 2008, 435 consecutive patients underwent the inguinal hernia prevention procedure concurrently with open radical retropubic prostatectomy. The control group comprised 433 patients who had undergone radical retropubic prostatectomy without hernia prevention immediately before the introduction of this hernia prevention procedure was introduced (between January 2001 and January 2006). Results: No significant complications associated with the hernia prevention procedure were observed, except for a few minor peritoneal injuries that were easily repaired during surgery. An inguinal hernia developed postoperatively in 109 of the 433 control patients (25.2%) during the median follow-up of 68 months. In contrast, 4 of the 435 patients (0.9%) who underwent the hernia prevention procedure developed an inguinal hernia during the median follow-up of 42 months. Conclusion: The processus vaginalis transection method is safe and effective in the long-term prevention of postradical prostatectomy inguinal hernia. [ABSTRACT FROM AUTHOR]

Objectives: To present a novel technique to prevent inguinal hernias after radical retropubic prostatectomy (RRP). The incidence of inguinal hernia after RRP has been reported to occur in the range 12%-21%. Indirect hernias are more common than direct hernias after RRP. Methods: A total of 569 Japanese patients with prostate cancer underwent antegrade RRP between January 2001 and February 2007. Since February 2006, 138 patients underwent procedures for concurrent inguinal hernia prevention at the time of RRP. For hernia prevention, the processus vaginalis was ligated close to the peritoneal cavity and transected. The remaining 431 patients who underwent the same RRP procedures without hernia prevention were considered control group. The incidence rates of postoperative inguinal hernia in the 2 groups were statistically compared. Results: An inguinal hernia developed postoperatively in 105 (24%) of the 431 control patients during follow-up of median 42 months. Hernia-free survival rates were 87%, 81%, and 77%, for 1-, 2-, and 3-year, respectively. By contrast, 2 of the 138 patients (1.4%) who underwent hernia prevention developed an inguinal hernia during follow-up of median 24 months. Hernia-free survival rates were both 99% for 1- and 2-year (P <.0001). The hernia prevention procedure added approximately 10 minutes to the surgery time. There were no significant complications associated with the hernia prevention procedure. Conclusions: Our results suggest that this prophylactic measure is safe and effective to prevent post-RRP inguinal hernias. However, a longer follow-up period is needed to confirm the results. [Copyright &y& Elsevier]

Objectives: To investigate the prognostic effect of the prostate cancer (PCa) volume involving the seminal vesicles (CVSVs) in the radical prostatectomy specimen from patients with Stage pT3bpN0 PCa. Methods: We retrospectively reviewed the clinical records of 27 patients with Stage pT3bpN0 PCa who had undergone radical prostatectomy alone. We measured the CVSVs using a grid method on the glass slide under microscopic inspection and investigated the association of the CVSVs with clinicopathologic variables. Results: Prostate-specific antigen (PSA) failure was confirmed in 11 of the 27 patients (41%) during a median follow-up of 34 months. The 3-year PSA failure-free survival rate was 48%. The median CVSVs was 1.14 cm3. On univariate analysis, a CVSVs of >1.63 cm3 was associated with positive surgical margins (P = .018), bilateral seminal vesicle involvement (P = .03), a long maximal tumor dimension (P = .031), and a greater preoperative PSA level (P = .0007). The 3-year PSA failure-free survival rate for those with a CVSVs of ≤1.63 cm3 vs >1.63 cm3 was 80% and 0%, respectively (P = .0009). On multivariate analysis, only the PSA level and CVSVs were identified as significant and independent predictors of PSA failure. Stratifying patients into 3 risk groups by these predictors, the PSA failure-free survival rate for patients with a PSA level ≥10 ng/mL and a CVSVs of >1.63 cm3 was significantly worse than for any other group. Conclusions: The CVSVs is useful and invaluable as an independent predictor of PSA failure in patients with Stage pT3bpN0 PCa. The measurement of the CVSVs is simple and helped to determine the indication for adjuvant treatment after radical prostatectomy. [Copyright &y& Elsevier]

Objective: To describe a novel and simple technique of preliminary kidney parenchymal ligation using Endoloop ligatures during laparoscopic partial nephrectomy (PN) without hilar clamping for polar complex tumor cases.Methods: The subjects were 17 patients who had a renal mass with a R.E.N.A.L. nephrometry score ≥7 (7/8/9/10 in 3/6/6/2 patients, respectively) located in the pole of the kidney. Patient-specific 3D reconstructed kidney images were created for preoperative planning in all cases. The renal hilar vessels were meticulously dissected and definitive tumor feeders were sacrificed when the branches directly perfused the peri-tumor area. Following the vascular microdissection, a circumferential cortex-depth incision on the kidney was made all around the tumor. Consequently, several Endoloop ligatures were placed in the incised tumor base to ligate the parenchyma preliminarily. Step-by-step Endoloop tightening facilitated effective parenchymal dissection without the urinary tract. After confirming that the tumor base parenchyma was ligated sufficiently, tumor resection was completed. Neither inner- nor outer-layer renorrhaphy sutures were placed.Results: Perioperative outcomes were satisfactory and all patients had negative surgical margins with no damage in the tumor capsule. Urological complications and renal function lower than predicted at 3 months after surgery involved 1 and 3 cases, respectively. The rate of PN trifecta achievement was 82% (14/17) despite the complexity of the 17 tumors.Conclusion: The current technique helped surgeons achieve the trifecta in patients with polar complex masses treated with laparoscopic PN. Use of this technique can provide surgeons with a bloodless operative field even during PN without hilar clamping. [ABSTRACT FROM AUTHOR]

Objective To assess the change in disease-specific health-related quality of life and to evaluate patient-perceived satisfaction after radical prostatectomy (RP) or intensity-modulated radiotherapy (IMRT) with androgen deprivation therapy (ADT) for patients with high-risk prostate cancer (PCA) that has been defined by the European Association of Urology guideline. Methods Between 2006 and 2010, 150 patients with high-risk PCA who underwent either RP (n = 97) or IMRT with ADT (n = 53) were enrolled in this prospective health-related quality of life study. Disease-specific health-related quality of life at baseline, 3, 6, 12, and 24 months and patient-perceived satisfaction at 12 and 24 months after these treatments were estimated using the Expanded Prostate Cancer Index Composite. Results Urinary bother and irritation and obstruction scores did not change significantly between both treatment groups throughout the 2-year follow-up. ADT greatly influenced sexual and hormonal functions and bothers in patients who received IMRT with ADT. The patient-perceived satisfaction at 12 months after the treatments was approximately 80% in both treatment groups, and there was no significant difference between the 2 groups. At 12 months after the treatments, urinary function ( P = .001) was identified as the most significant predictor of patient-perceived satisfaction, although it was not associated with the treatment type. Conclusion The majority of patients with high-risk PCA who received RP or IMRT with ADT reported high patient-perceived satisfaction after the treatments. This study showed that improvement in urinary function might contribute to patient-perceived satisfaction after the treatments. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation of the relationships existing among 3 histologic types of urothelial tumors, chromosomal instability, and telomere length. Patients and methods: We examined 37 consecutive cases of papillary urothelial neoplasm, from which 26 (70.3%) were suitable for karyotype analysis, comprising 7 papillary urothelial neoplasms of low malignant potential (PUNLMPs), 10 low-grade papillary urothelial carcinomas (PUCs), and 9 high-grade PUCs. We performed karyotype and anaphase bridge analyses, and measured telomere lengths by quantitative fluorescence in situ hybridization. Results: PUNLMPs were always diploid and had anaphase bridges. Low-grade PUCs showed diploidy (n = 2), hypoploidy (n = 4) and polyploidy (n = 4), and high-grade PUCs showed diploidy (n = 1) and polyploidy (n = 8); both had anaphase bridges. The incidence of anaphase bridges did not differ significantly between PUNLMPs and high-grade PUCs (P = 0.105). The telomere lengths of PUNLMP, low-grade PUC, and high-grade PUC, expressed as mean telomere fluorescence units (TFU)±SD, were 7906±3197, 4893±1567, and 3299±1406, respectively. The differences among the 3 groups were significant. However, 42.9% of the PUNLMPs had shorter telomeres than the mean value for low-grade PUCs, and 30.0% of the low-grade PUCs had shorter telomeres than those for high-grade PUCs. There was an inverse correlation between telomere length and the incidence of anaphase bridges. Conclusions: PUNLMP appears to progress to low-grade PUC and high-grade PUC in association with telomere shortening and chromosomal instability. Our data suggest that critically shortened telomeres cause chromosomal instability during progression of papillary urothelial neoplasms. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association of diabetes mellitus (DM) with prostate cancer (PCa) risk and grade among Japanese patients undergoing extended biopsy and to investigate how obesity modifies these relationships. Methods: We retrospectively evaluated the data from 2038 patients with a prostate-specific antigen (PSA) level <10 ng/mL undergoing initial extended biopsy at our institutions. The DM history was determined by self-report and medication use. Multivariate analyses of DM for PCa risk and grade were done using logistic regression. Moreover, we examined whether these associations were modified by the body mass index using subgroup analyses (nonobese <25 kg/m2 or obese ≥25 kg/m2) and interaction tests. Cancer grade was classified according to the Gleason score (GS): low-grade (GS ≤6), intermediate-grade (GS 7), and high-grade (GS 8-10). Results: Of 2038 patients, obesity and DM was observed in 606 (30%) and 213 (11%), respectively. Also, 836 patients (41%) had positive biopsy findings. On multivariate analysis, we found no significant association of DM with the risk of overall PCa (P = .106) or the risk of low-grade (P = .735), intermediate-grade (P = .119), or high-grade (P = .110) disease. When stratified by obesity, the relative risk (RR) of PCa detection for diabetic men apparently increased with higher cancer grade (low grade, RR = 1.19, P = .71; intermediate grade, RR = 2.01, P = .099; high-grade, RR = 4.03, P = .025). However, in the nonobese men, no association was noted between DM and PCa risk, irrespective of grade. Obesity modified the effect of DM on high-grade disease risk with a trend (P for interaction = .087). Conclusion: DM was associated with more aggressive PCa detection among Japanese obese patients with gray-zone PSA levels undergoing extended biopsy. [ABSTRACT FROM AUTHOR]

Objective: To verify the prognostic impact of C-reactive protein (CRP) for patients with castration-resistant prostate cancer (CRPC) treated with docetaxel in a single institution. Methods: A group of 80 consecutive patients with CRPC were treated with docetaxel in our institution from January 2005 to May 2010. The patients received 75 mg/m2 of docetaxel intravenously every 3 weeks. The prognostic value of all covariables, including CRP, was assessed using the Cox proportional hazard model. Risk stratification for overall survival was described from the results of the multivariable analysis. Results: The median survival period for all patients was 14.5 months. The multivariable analysis showed that CRP and hemoglobin levels were independent prognostic factors for overall survival. Based on the presence of an elevated CRP concentration and/or a low hemoglobin level, all patients were stratified into 3 risk groups: those with no risk factors (low-risk group), those with 1 risk factor (intermediate-risk group), and those with 2 risk factors (high-risk group). The overall survival curves were clearly tiered according to the risk groups, with the 1-year overall survival rates being 86.3%, 60.5%, and 23.0% for the low-, intermediate-, and high-risk groups, respectively (P <.001). Conclusion: CRP is an independent prognostic factor for overall survival of patients with CRPC treated with docetaxel. Risk stratification based on CRP and hemoglobin could be helpful for estimating the overall survival. [ABSTRACT FROM AUTHOR]

Objectives: To develop a nomogram based on a cohort examined with 3-dimensional (3D) protocol for diagnosis of prostate cancer on repeat biopsy. Methods: Of 4074 consecutive men undergoing prostate biopsy at our institutions between 2000 and 2009, 775 men with at least 1 previous negative biopsy underwent repeat biopsy with a 3D protocol. Men with previous atypical glands or atypical small acinar proliferation and/or without available prostate-specific antigen (PSA) kinetics information were excluded. The remaining 515 men constituted the study cohort. We developed a logistic regression–based nomogram with 70% of the cohort selected randomly; we validated it with the remaining 30%. Predictive accuracy and performance characteristics were assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots, respectively. The threshold probability was evaluated with decision curve analysis. Results: We developed a novel repeat biopsy nomogram incorporating age, free to total PSA ratio, prostate volume, history of previous extended biopsy, and PSA doubling time. Validation confirmed predictive accuracy with an AUC value of 0.791. Calibration plots showed good agreement. The decision curve of the nomogram was superior to the decision curve of biopsying all men in a range of threshold probability over 0.15. At the threshold of 0.2, the number of unnecessary biopsies could be reduced by 10 per 100, without missing prostate cancer. Conclusions: We developed a novel repeat biopsy nomogram based on a cohort examined with 3D protocol. This repeat biopsy nomogram is clinically beneficial, preventing a substantial number of unnecessary biopsies. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the correlations between the initial tumor size and size reduction rate in patients treated with targeted agents. To select the patients who can benefit the most from treatment with targeted agents, it will be necessary to find a tumor characteristic that predicts their effectiveness. Methods: The data from 139 metastatic and 16 primary lesions treated with the targeted agents were retrospectively analyzed. They consisted of 86 sunitinib-treated and 69 sorafenib-treated lesions in 54 patients with metastatic renal cell carcinoma who had undergone treatment from April 2008 to July 2010. The relationship between the longest tumor diameter at baseline and the rate of reduction in tumor size was assessed using the Spearmancorrelation test. Results: A linear, moderate to strong association between the initial tumor size and tumor size reduction rate was shown (correlation coefficient −0.441, P < .001). When these tumors were divided into 2 groups at the threshold value (23.95 mm), which was decided by the receiver operating characteristic curve analysis, the smaller tumors demonstrated a significantly greater size reduction than the larger tumors according to the Mann-Whitney U test (P < .001). Both univariate and multivariate linear regression analyses revealed that only the initial tumor size was associated with the rate of reduction in individual tumors (P < .001). Conclusions: The initial tumor size was a good predictor of the tumor size reduction. This simple observation could be useful for physicians who treat patients with metastatic renal cell carcinoma. In addition, in assessing clinical trials of targeted agents for metastatic renal cell carcinoma using the ResponseEvaluation Criteria in Solid Tumors, perhaps this association should be considered. [ABSTRACT FROM AUTHOR]

Abstract: A 19-year-old student who had presented with acute urinary retention was referred to our hospital with biopsy diagnosis of proliferating mesenchymal tumor of the prostate. Magnetic resonance imaging showed enlarged prostatic masses. Suspecting prostate sarcoma, we performed a nerve-sparing radical prostatectomy. Histologic diagnosis of the tumor was prostatic malignant phyllodes tumor. Five months after the operation, bilateral obturator lymph node metastases appeared, which were treated with etoposide, ifosfamide, and cisplatin chemotherapy. After a good response was achieved with four cycles of the chemotherapy, pelvic irradiation was added. Since then, there has been no evidence of recurrence for more than 4 years. [Copyright &y& Elsevier]

Objectives: To examine Japanese patients who had received androgen-deprivation therapy (ADT) for longer periods, as it is known that ADT of patients with prostate cancer reduces their bone mineral density (BMD). However, our previous cross-sectional study revealed that short-term ADT (average, 23.5 months) does not significantly increase the prevalence of osteoporosis in Japanese patients. Methods: The subjects consisted of 201 native Japanese patients with prostate cancer. They comprised 113 ADT-treated and 88 hormone-naive patients. Lumbar spine, total hip, and femoral neck BMDs were measured by dual-energy x-ray absorptiometry and expressed in standard deviation units relative to the scores of young adult men (T-score) or age-matched men (Z-score). Serum levels of bone metabolism markers were also measured. Results: The ADT-treated patients had significantly lower BMD values, T-scores, and even Z-scores than the hormone-naive patients (P <.001). For patients who were hormone-naive, ADT-treated for less than 2 years, and ADT-treated for more than 2 years, the osteoporosis prevalence was 4.5% (4/88), 12.1% (4/33), and 10.8% (4/37), respectively. The ADT-treated patients had significantly higher serum amino-terminal telopeptide levels than the hormone-naive patients (P = .014), but significantly lower serum carboxy-terminal telopeptide of type-I collagen levels than the ADT-treated patients with bone metastasis (P <.001). Conclusions: Our cross-sectional study confirmed that both ADT-treated and hormone-naive Japanese patients with prostate cancer have low rates of osteoporosis. These findings are different from those of studies in western countries. Genetic and hormonal or other environmental factors may result in population differences in the characteristics of prostate cancer and BMD. [Copyright &y& Elsevier]

Objectives: To determine the incidence of benign pathologic findings at elective partial nephrectomy for renal masses thought to be renal cell carcinoma (RCC) on preoperative imaging in Japanese patients. Methods: From 1993 to 2007, 176 patients (46 women and 130 men) underwent elective partial nephrectomy for presumed RCC masses in 2 Japanese centers. The mean size of the resected lesions was 2.3 cm (range 0.3-5.8). Overall, 97 and 79 patients had a renal mass of ≤2 cm and >2 cm, respectively. Of the 176 patients, 100%, 89%, and 32% had preoperatively undergone computed tomography, ultrasonography, and magnetic resonance imaging, respectively. Results: Of the 176 masses resected, the pathologic examination revealed benign findings in 19 (11%), angiomyolipoma in 10 (5.7%), oncocytoma in 5 (2.8%), complicated cysts in 2 (1.1%), and a solitary fibrous tumor and scar of the kidney 1 each (0.6%). Of the 46 women, 12 (26.1%) had benign lesions compared with 7 of the 130 men (5.3%; P = .0003). Of the 10 angiomyolipomas diagnosed, 8 were diagnosed in women (P = .0004). Tumor size was not associated with benign histologic findings. The incidence of benign lesions was equivalent (10% and 12%) between the 2 centers. Conclusions: The present incidence (11%) of benign lesions in presumed RCC masses at surgery in Japanese patients was lower than the incidence of 20%-30% previously reported from Western countries, probably because of the low incidence of oncocytomas in Japanese patients. Women had almost 5 times the likelihood of having a benign lesion compared with men, because of the high incidence of angiomyolipomas in women. [Copyright &y& Elsevier]

Abstract: Objectives: This study sought to examine the combination chemotherapy of gemcitabine, etoposide, and cisplatin (GEP) as a first-line treatment for advanced urothelial carcinoma (UC) to assess its antitumor activity and toxicity. Methods and materials: Eligible patients with advanced UC had undergone no previous chemotherapy. Advanced UC was defined as unresectable or metastatic disease. Subsequent recurrent disease, either locally or distantly following primary radical surgery, was not excluded. GEP was recycled every 4 weeks. Etoposide and cisplatin were given on days 1 through 3 at doses of 60mg/m2 and 20mg/m2, respectively, and gemcitabine was given on days 1, 8, and 15 at a dose of 800mg/m2. The primary end point was objective response rate, and the secondary end points included progression-free survival, overall survival (OS), and toxicity. Results: Forty-two patients were enrolled and subsequently treated with GEP. Nineteen had visceral/bone metastases, 16 had disease restricted to the lymph nodes, and the remaining 7 had unresectable disease at the primary site. The median number of GEP courses was 4. Thirty of the 42 assessable patients (71.4%, 95% confidence interval [CI]: 56.4%–82.8%) demonstrated objective responses. At a median follow-up of 14.6 months, median progression-free survival and OS periods were 8.7 months (95% CI: 6.9–14.6mo) and 16.2 months (95% CI: 13.1–25.4mo), respectively. In the multivariate analysis, anemia and visceral/bone metastasis were significant pretreatment prognostic factors for OS. Grade 4 hematologic events were neutropenia (83.3%), thrombocytopenia (23.8%), and anemia (7.1%). There were no toxic deaths and no instances of severe nonhematologic toxicity. Conclusions: GEP as a first-line chemotherapy treatment was very active and moderately tolerable for advanced UC. Anemia and visceral/bone metastasis were important negative predictive factors of GEP for OS. [Copyright &y& Elsevier]