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Open nephroureterectomy (ONU) is the current standard for muscle-invasive upper tract urothelial carcinoma (UTUC) in the European Association of Urology/Japanese Urological Association (JUA) guidelines. In this study, we compared the postsurgical survival of muscle-invasive UTUC patients treated with ONU or with laparoscopic nephroureterectomy (LNU), using the multi-institutional national database of the JUA.The 1509 patients with UTUC who were diagnosed at 348 Japanese institutions in 2005 were registered. We collected the clinical data of the patients in 2011. The muscle-invasive UTUC patients who underwent ONU or LNU were identified, and survival curves were estimated using the Kaplan-Meier method.Overall, 749 pT2≥cNxM0 patients underwent a nephroureterectomy (ONU, n = 527 and LNU, n = 222). The overall survival and cause-specific survival rates were not significantly different between the ONU and LNU groups (p = 0.1263 and p = 0.0893, respectively). In addition, 459 of the 749 (61.3%) patients experienced disease recurrence (bladder recurrence, local recurrence, or distant metastasis), with no significant difference between the ONU and LNU groups. Even when patients were stratified by pT3/pT4 and/or pN+, overall survival was not significantly different between the ONU and LNU groups (p = 0.2876). The results of a univariate analysis showed that lymphovascular invasion was an independent prognostic factor for overall survival, but the surgical approaches were not found to be associated with overall survival.Our data suggest that there is no evidence that the oncologic outcome of LNU is inferior to that of ONU in muscle-invasive UTUC, when the appropriate patients are selected.

Objectives To describe the nature of metastatic upper urinary tract urothelial cancer and determine the prognostic predictors or treatment modality associated with all-cause mortality. Methods Within the nationwide case series study of the Japanese Urological Association, consisting of 1509 patients with urinary tract urothelial cancer diagnosed in 2005, we identified 102 patients with metastatic urinary tract urothelial cancer. Univariate and multivariate survival analyses identified prognostic outcome variables. Results Predominant sites of distant metastasis at diagnosis were the lungs (54.9%), distant lymph nodes (37.3%), bone (32.4%) and liver (19.6%). Of 102 patients, 70 patients (68.6%) died during the median follow-up period of 6 months, and the 2-year overall survival rate was estimated at 22%. The median survival time to all-cause mortality was 8.5 months (95% confidence interval 6.4–10.7 months). On multivariate analysis, independent predictive factors for all-cause mortality were age (hazard ratio 2.36, P = 0.015) and liver metastasis (hazard ratio 2.35, P = 0.037). Patients who received multimodal treatment including chemotherapy and surgery showed significantly better prognosis (median survival time 25.8 months) compared with patients treated with chemotherapy alone (median survival time 7.3 months) or best supportive care (median survival time 4.3 months). Conclusions Age at diagnosis and the presence of liver metastasis seem to have an impact on survival of metastatic urinary tract urothelial cancer patients. Multimodal treatment including systemic chemotherapy and surgery might result in better prognosis in some of these patients.

Objectives To explore predictive factors of disease recurrence after radical nephroureterectomy in patients with upper urinary tract urothelial cancer. Methods A multi-institutional national database promoted by the Japanese Urological Association including 293 institutions and 1172 patients was used for the present study. Patient with non-metastatic upper urinary tract urothelial cancer who underwent primary radical nephroureterectomy with curative intent were analyzed. Univariate analysis using the Kaplan–Meier method and multivariate Cox regression models with stepwise selection was used to evaluate time to recurrence after surgery. Results The median duration of follow up was 55.8 months, and disease recurred in 325 (27.7%) patients at a median of 11.4 months after radical nephroureterectomy. According to a Cox proportional hazards model, the Union International Contre le Cancer 2002 pathological stage of the primary tumor, lymph node status, presence of lymphatic and/or vascular invasion, infiltrative growth pattern, and age were independent predictors (P

To determine the indications for post-chemotherapy consolidative surgery in patients with clinical lymph node (LN) metastatic (cN+) urothelial carcinoma (UC). Sixty UC patients with measurable cN+ but without detectable systemic visceral/bone dissemination received induction platinum-based chemotherapy. Consolidative surgery was offered to all patients except for those with progressive disease. We retrospectively analyzed the clinicopathological response to induction chemotherapy and identified prognostic factors for overall survival (OS). The primary cancer site was the urinary bladder in 31 patients (52 %) and upper urinary tract in 29 (48 %). The median number of chemotherapy courses was 4. Forty-five patients (75 %) showed a clinically objective response to the induction chemotherapy. Fifty-one patients (85 %) underwent subsequent consolidative surgery. Histopathological analysis indicated pT0 status in 10 (20 %) and pN0 in 17 (33 %). When all 60 patients were considered, clinical tumor response was found to be significantly correlated with achievement of pathological complete response. At the median follow-up of 22 months, the median progression-free survival and OS periods were excellent: 18.6 and 31.6 months, respectively. In the multivariate analysis, clinical tumor response was found to be an independent pre-surgical prognostic factor for OS, and pathologically negative lymph node, negative resection margin, more LNs removed, and negative lymphovascular invasion were found to be independent post-surgical prognostic parameters for OS. The median OS in induction chemotherapy followed by consolidative surgery was very encouraging. Our results suggest that achieving a good clinical response to pre-surgical induction chemotherapy is a good indication for subsequent consolidative surgery in UC patients with cN+ to improve OS through a good pathological response.

Objectives To identify risk factors and develop a model for predicting recurrence of upper urinary tract urothelial carcinoma (UTUC) in the bladder in patients without a history of bladder cancer after radical nephroureterectomy (RNU). Patients and Methods We retrospectively reviewed 754 patients with UTUC without prior or concurrent bladder cancer or distant metastasis at 13 institutions in Japan. Univariate and multivariate Fine and Gray competing risks proportional hazards models were used to examine the cumulative incidence of bladder recurrence of UTUC. A risk stratification model and a nomogram were constructed. Two prediction models were compared using the concordance index (c-index) focusing on predictive accuracy and decision-curve analysis, which indicate whether a model is appropriate for decision-making and determining subsequent patient prognosis. Results The cumulative incidence rates of bladder UTUC recurrence at 1 and 5 years were 15 and 29%, respectively; the median time to bladder UTUC recurrence was 10 months. Multivariate analysis showed that papillary tumour architecture, absence of lymphovascular invasion and higher pathological T stage were both predictive factors for bladder cancer recurrence. The predictive accuracy of the risk stratification model and the nomogram for bladder cancer recurrence were not different (c-index: 0.60 and 0.62). According to the decision-curve analysis, the risk stratification was an acceptable model because the net benefit of the risk stratification was equivalent to that of the nomogram. The overall cumulative incidence rates of bladder cancer 5 years after RNU were 10, 26 and 44% in the low-, intermediate- and high-risk groups, respectively. Conclusions We identified risk factors and developed a risk stratification model for UTUC recurrence in the bladder after RNU. This model could be used to provide both an individualised strategy to prevent recurrence and a risk-stratified surveillance protocol.

Objective To investigate the diagnostic performance and safety of a three-dimensional 14-core biopsy (3D14PBx) method, which is a combination of the transrectal six-core and transperineal eight-core biopsy methods. Patients and Methods Between December 2005 and August 2010, 1103 men underwent 3D14PBx at our institutions and were analysed prospectively. Biopsy criteria included a PSA level of 2.5–20 ng/mL or abnormal digital rectal examination (DRE) findings, or both. The primary endpoint of the study was diagnostic performance and the secondary endpoint was safety. We applied recursive partitioning to the entire study cohort to delineate the unique contribution of each sampling site to overall and clinically significant cancer detection. Results Prostate cancer was detected in 503 of the 1103 patients (45.6%). Age, family history of prostate cancer, DRE, PSA, percentage of free PSA and prostate volume were associated with the positive biopsy results significantly and independently. Of the 503 cancers detected, 39 (7.8%) were clinically locally advanced (≥cT3a), 348 (69%) had a biopsy Gleason score (GS) of ≥7, and 463 (92%) met the definition of biopsy-based significant cancer. Recursive partitioning analysis showed that each sampling site contributed uniquely to both the overall and the biopsy-based significant cancer detection rate of the 3D14PBx method. The overall cancer-positive rate of each sampling site ranged from 14.5% in the transrectal far lateral base to 22.8% in the transrectal far lateral apex. As of August 2010, 210 patients (42%) had undergone radical prostatectomy, of whom 55 (26%) were found to have pathologically non-organ-confined disease, 174 (83%) had prostatectomy GS ≥7 and 185 (88%) met the definition of prostatectomy-based significant cancer. Conclusions This is the first prospective analysis of the diagnostic performance of an extended biopsy method, which is a simplified version of the somewhat redundant super-extended three-dimensional 26-core biopsy. As expected, each sampling site uniquely contributed not only to overall cancer detection, but also to significant cancer detection. 3D14PBx is a feasible systematic biopsy method in men with PSA

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.

Objectives To develop and validate predictive models for postoperative estimated glomerular filtration rate and risk of chronic kidney disease after radical nephrectomy in Japanese patients. Methods The present retrospective study included a development cohort of 209 patients without preoperative chronic kidney disease who underwent radical nephrectomy between 1994 and 2008, and were followed up for longer than 3 years, and a validation cohort of 144 similar such patients. Univariate and multivariate linear regression or logistic regression analyses were carried out to identify the independent predictors of estimated glomerular filtration rate or chronic kidney disease 3 years after radical nephrectomy. Incorporating all independent predictors, predictive models for postoperative renal function were developed and externally validated. Results Age, the presence of diabetes mellitus, and preoperative estimated glomerular filtration rate were independent predictors of both postoperative estimated glomerular filtration rate and chronic kidney disease. A formula for predicting the postoperative estimated glomerular filtration rate and a nomogram for predicting the risk of postoperative chronic kidney disease were developed. The adjusted R2 of the formula and area under the receiver operating characteristic curves of the nomogram were 0.446 and 0.865 in the development cohort, and 0.396 and 0.787 in the validation cohort, respectively. Conclusions We developed and validated novel predictive models for the postoperative renal function 3 years after radical nephrectomy in Japanese patients.

Objectives: Obese men with benign prostate hyperplasia might have lower serum prostate-specific antigen because of hemodilution, resulting in underestimation of total prostate volume by serum prostate-specific antigen. The aim of this study was to compare the performance of prostate-specific antigen mass as the absolute amount of prostate-specific antigen protein secreted into circulation with that of serum prostate-specific antigen in the prediction of total prostate volume. Methods: A total of 1517 men with serum prostate-specific antigen up to 10 ng/mL, including 1425 with biopsy-proven benign prostate hyperplasia, were enrolled in this study. Height and weight were used to estimate body mass index, body surface area and plasma volume. Prostate-specific antigen mass was calculated as serum prostate-specific antigen multiplied by plasma volume. The association between serum prostate-specific antigen or prostate-specific antigen mass and transrectal ultrasound-measured total prostate volume were evaluated by Pearson's correlation coefficient (Υ), linear regression analyses and receiver operating characteristic curves. Results: Serum prostate-specific antigen had an inverse relationship with plasma volume, decreasing as plasma volume increased, after adjustment of total prostate volume. Larger total prostate volume per serum prostate-specific antigen was found in men with higher body mass index or plasma volume. Among all participants, the correlation (Υ = 0.456) between prostate-specific antigen mass and total prostate volume was apparently stronger than that (Υ = 0.442) between serum prostate-specific antigen and total prostate volume. Prostate-specific antigen mass outperformed serum prostate-specific antigen at estimating total prostate volume cut-off values of 30 and 40 mL. These findings were more significant in men aged ≥60 years. Conclusions: Prostate-specific antigen mass performs better than serum prostate-specific antigen in estimating TPV, especially in men aged ≥60 years.

Objective To compare rates of early morbidity after radical cystectomy in patients treated with or without induction chemoradiotherapy (CRT) using a standardized reporting methodology. Methods All 193 consecutive patients undergoing radical cystectomy for bladder cancer between 1989 and 2010 were retrospectively reviewed. Induction chemoradiotherapy consists of radiation at 40 Gy to the small pelvis and two cycles of concurrent cisplatin at 20 mg/day for 5 days. Deaths within 90 days after radical cystectomy and complications arising within 30 days were recorded and graded according to the Clavien-Dindo classification. Grades 1-2 were considered minor; Grades 3-5 were considered major. Results Eighty-seven patients underwent radical cystectomy following chemoradiotherapy (chemoradiotherapy group) while the remaining 106 primarily underwent radical cystectomy (no chemoradiotherapy group). No Grade 4-5 complication was observed. Overall, 118 patients (61%) experienced 36 major and 122 minor complications. There was no significant difference in the incidence of overall complications between the chemoradiotherapy and no chemoradiotherapy groups (67 vs. 57%). Overall urinary anastomosis-related complications and major gastrointestinal complications, most of which were Grade 3 ileus, were more frequent in the chemoradiotherapy group than the no chemoradiotherapy group (11 vs. 2%, P = 0.007; and 14 vs. 4%, P = 0.02; respectively). Multivariate analysis identified induction chemoradiotherapy as an independent risk factor for overall urinary anastomosis-related complications (relative risk 6.0, P = 0.01) but not for major gastrointestinal complications. Conclusions Induction chemoradiotherapy at 40 Gy in bladder-sparing protocols against MIBC is unlikely to increase the rate of severe complications of radical cystectomy.

Study Type – Diagnostic (exploratory cohort) Level of Evidence 3a What's known on the subject? and What does the study add? Initial transrectal 12-core biopsy has a small but definite risk of missing anterior significant prostate cancers irrespective of age, PSA, prostate volume and DRE findings. Our study yields valuable information for diagnosis and treatment decision of prostate cancer based on transrectal 12-core biopsy. OBJECTIVE • To characterize prostate cancers missed by initial transrectal 12-core biopsy. PATIENTS AND METHODS • Between 2002 and 2008, 715 men with prostate-specific antigen levels in the range 2.5–20 ng/mL or abnormal digital rectal examination underwent three-dimensional 26-core prostate biopsy (i.e. a combination of transrectal 12-core biopsy and transperineal 14-core biopsy) on initial examination. • Of the 257 patients diagnosed with cancer, 120 patients subsequently underwent radical prostatectomy. • Cancers were grouped into TR12-negative cancers (i.e. not detected through transrectal 12-core biopsy but detected through transperineal 14-core biopsy) and TR12-positive (i.e. detected through transrectal 12-core biopsy) cancers. • Clinicopathological characteristics of the TR12-negative and TR12-positive cancers were evaluated. RESULTS • TR12-negative cancers comprised 21% of the three-dimensional 26-core biopsy-detected cancers. • The frequency of cancers with a biopsy Gleason score ≤6 and that of cancers with a biopsy primary Gleason grade ≤3 was higher in TR12-negative cancers, at 58% and 83%, respectively, than in TR12-positive cancers, at 25% (P < 0.001) and 53% (P < 0.001), respectively. • The median number of positive cores in TR12-negative cancers was two out of 26. • TR12-negative cancers were more frequently located anteriorly than posteriorly. • The incidence of the TR12-negative cancers was not associated significantly with any clinical variable. CONCLUSION • Many of the cancers missed by initial transrectal 12-core biopsy are probably low-grade and low-volume diseases, although initial transrectal 12-core biopsy has a small but definite risk of missing anterior significant cancers.

Peripheral blood stem cell transplantation (PBSCT) allows multiple intensive chemotherapy treatments and hematopoietic progenitor cell rescues for poor-risk patients with a variety of malignancies. We report false surges of a tumor marker, serum human chorionic gonadotropin (hCG), evoked by PBSCT in the course of chemotherapy for a poor-risk testicular cancer patient. We confirmed that this phenomenon resulted from reinfusion of peripheral blood stem cells (PBSCs) containing hCG at a high concentration, collected when the patient's serum hCG levels were remarkably elevated. This is the first report to demonstrate false tumor marker surges caused by PBSCT. Because a rapid rise in tumor markers may demand an immediate change in the therapeutic strategy, physicians should be aware of the possibility of this phenomenon when treating poor-risk cancer patients whose tumor markers are remarkably elevated at the time of PBSC harvest.

Objective: From the critical stand point against the overuse of antimicrobial agents, appropriate reduction of antimicrobial prophylaxis (AMP) should be considered. We have prospectively reduced AMP and evaluated the occurrence of surgical site infection (SSI) following radical retropubic prostatectomy (RRP) by minimum incision endoscopic surgery (MIES). Methods: A total of 101 consecutive patients who underwent MIES-RRP for prostate carcinoma were classified into two groups according to AMP dose. The 3-day group of 52 patients received tazobactam sodium/piperacillin sodium (TAZ/PIPC) 2.5 g intravenously before the operation and continued twice daily until postoperative day 2, and the single dose group of 49 patients received TAZ/PIPC 2.5 g intravenously only once before the operation. Additional antimicrobial agents were given only when SSI occurred. The occurrence of SSI and remote infection (RI) were analyzed. Results: There was no significant difference in the rate of SSI occurrence between the 3-day group (3.8%) and single dose group (6.1%) (P = 0.6). RI did not increase in the single dose group. Conclusion: Antimicrobial prophylaxis dose was successfully reduced without increasing SSI or RI. A single dose of AMP is feasible to prevent SSI and RI and would be a standard regimen in MIES-RRP. Active surveillance of postoperative infection is mandatory to promptly administer antimicrobial treatment as the need arises.

Since 1998, we have performed minimum incision endoscopic surgery (MIES) for renal cell carcinoma (RCC). For seven dialysis patients with bilateral RCC, we have performed sequential bilateral MIES radical nephrectomy. It was carried out by retroperitoneal approach through a single minimum incision that narrowly permitted extraction of the specimen using endoscopy and direct stereovision, without trocar ports, without gas insufflation and without the insertion of the hands of operators into the operative field. Although six of the seven patients had multiple complications in addition to chronic renal failure (CRF), bilateral kidneys were successfully removed by sequential MIES radical nephrectomy without major operative complication. Postoperative recovery was prompt with all patients resuming oral feeding and walking by the second postoperative day. Sequential bilateral MIES radical nephrectomy, leaving the peritoneal cavity intact and without imposing circulatory stress caused by gas insufflation, is a feasible treatment for bilateral RCCs in dialysis patients.

Objective We aimed to survey treatment modalities for the patients with Stage II/III urothelial cancer in Japan. Methods We used the multi-institutional national database of the Japanese Urological Association from 348 Japanese institutions, in which a total of 3707 patients with muscle-invasive bladder cancer and 1538 with upper urinary tract urothelial carcinoma were registered in 2008 and 2011, respectively. Primary treatment was classified as surgery alone, surgery with chemotherapy, surgery with radiation, radiation alone, chemotherapy alone, combination of radiation and chemotherapy and observation. Overall and cancer-specific survivals were examined using the Kaplan-Meier method, and survival in the subgroups was analyzed using the log-rank test. Results In Stage II/III bladder cancer patients, 49.7% of those were treated with radical operation and 22.3% received observation only. A total 97.2% of Stage II/III upper urinary tract urothelial carcinoma patients treated with radical surgery. A total 30.4% of Stage II/III bladder cancer patients received chemotherapy. Majority of the patients received cisplatin-based regimen, however, regimens of chemotherapy was rich in variety up to 13 regimens. Chemotherapy regimens for the patients with upper urinary tract urothelial carcinoma were also various up to eight regimens. Overall and cancer-specific survivals were statistically significantly stratified according to the clinical stage. The upper urinary tract urothelial carcinoma patients diagnosed with clinical stage T3 had significantly poor prognosis compared with those diagnosed with clinical stage T2. Conclusions This study demonstrated the variety of treatments used for Japanese patients with Stage II/III urothelial cancer. Treatment standardization for these entities may be necessary.

Objectives To examine the influence of smoking history on the diagnosis and other tumor characteristics of upper tract urothelial carcinoma in Japan. Methods A total of 1509 patients with upper tract urothelial carcinoma who were diagnosed in 2005 from 348 Japanese institutions were registered using the multi-institutional national database of the Japanese Urological Association and included in this analysis. Clinical data of the patients were collected in 2011. The associations between the patients’ self-reported smoking history and their age at the diagnosis of upper tract urothelial carcinoma, sex, pathological T stage and tumor grade were analyzed. Results The mean age at the diagnosis of upper tract urothelial carcinoma was approximately 5 years earlier for the 238 current smokers than for the 618 current non-smokers (P

C-reactive protein (CRP) has been reported as a useful biomarker for renal cell carcinoma (RCC). Here, we report a case in which CRP kinetics of a continuous increase in CRP levels led to the detection of RCC metastasis to the stomach, a rare metastatic site. A 58-year-old man diagnosed with metastatic RCC underwent cytoreductive nephrectomy. Four months after the surgery, his CRP level started to increase continuously. Thus, we suspected disease progression. Extensive studies, including thoracoabdominal computed tomography and bone scan, however, detected neither local recurrences nor metastatic lesions. A further increase in CRP levels and gradual progression of anemia prompted us to investigate the digestive tract. Gastric endoscopy finally revealed gastric metastasis. After partial gastrectomy, his CRP level immediately decreased to a normal level. The patient is currently alive with no evidence of disease progression and his CRP level remains within the normal range, 44 months after his metastatic RCC diagnosis. The continuous increase in CRP levels reflected the development of gastric metastasis. The decrease in CRP levels after partial gastrectomy was indicative of a good response to treatment. This case demonstrates that CRP kinetics may be helpful in predicting disease progression as well as response to therapeutic intervention.

INTRODUCTION AND OBJECTIVES: F-FDG PET/CT is widely used to diagnose metastases in many kinds of cancer, including bladder cancer. It may also be useful in patients with upper tract urothelial carcinoma (UTUC); however, the utility of PET/CT in the management of UTUC has not been reported. In the current study, the clinical course of patients with UTUCwho underwent PET/CTwas retrospectively analyzed to investigate its clinical value and impact on patient management. METHODS: Between October 2012 and September 2013, 59 consecutive patients with UTUC underwent F-FDG PET/CT for initial staging (n 1⁄4 48) or restaging (n 1⁄4 11) following conventional CT or MRI. The imaging findings were validated using histopathology or serial imaging, and the diagnostic accuracy of PET/CT and CT/MRI for detecting metastases were assessed and compared statistically using McNemar0s test in both patient-based and lesion-based analyses. In addition, the clinical impact of PET/CT on patient management was analyzed by comparing questionnaires that were completed by the attending physicians before and after PET/CT. RESULTS: In the patient-based analysis, 26 (44%) of the 59 patients were diagnosed as having metastases. The sensitivity/specificity/accuracy were 96%/94%/95% in PET/CT and 81%/88%/85% in CT/MRI. The accuracy of PET/CT was significantly superior to CT/MRI (P 1⁄4 0.031). There were 212 lesions analyzed in 59 patients. In the lesion-based analysis, 179 (84%) of the 212 lesions were diagnosed as metastases. PET/CT had a significantly better sensitivity (77%) than CT/MRI (57%, P

We report a very rare case of collecting or Bellini duct carcinoma (CDC) found in a 60-year-old male who had received hemodialysis therapy for 21 years. Screening with ultrasonography revealed a solid tumor originating from the cyst wall in the right kidney with acquired cystic disease of the kidney. Subsequent computed tomography (CT) and angiography could not detect another renal tumor. Right radical nephrectomy was performed. The tumor detected preoperatively was composed of papillary renal cell tumor (RCC) and multiple clear cell carcinoma, pathologically. In addition to the tumors, CDC was revealed in the central medulla with the involvement of regional lymph nodes. Three months later, left nephrectomy was performed because left RCC was suspected during CT. The histological diagnosis was multiple clear cell carcinomas. Peritonitis carcinomatosa appeared and the patient died 13 months later.

Background: This study re-evaluated the efficacy and tolerability of cisplatin, etoposide, and ifosfamide (VIP) combination chemotherapy as an alternative first-line regimen for patients with disseminated germ cell cancer (GCC) in this granulocyte colony-stimulating factor (G-CSF) era. Methods: The medical records of 91 consecutive patients with previously untreated disseminated GCC who received first-line VIP between 1995 and 2011 were retrospectively reviewed. Results: The 5-year overall survival rates for patients with good (n = 49), intermediate (n = 22) and poor (n = 20) prognoses according to the International Germ Cell Cancer Collaborative Group classification were 100, 79 and 83%, respectively. G-CSF was given to all patients, and no treatment-related deaths due to myelosuppression occurred. Conclusion: The present study is the first to examine the therapeutic outcomes and safety profile of first-line VIP after routine G-CSF use. VIP might be an alternative first-line regimen for patients with disseminated GCC in this G-CSF era.

Background: The purpose of this study is to investigate the prognostic impact of C-reactive protein (CRP) on patients with advanced urothelial carcinoma and to develop a novel nomogram predicting survival. Methods: A total of 223 consecutive patients were treated at Tokyo Medical and Dental Hospital. A nomogram incorporating V was developed based on the result of a Cox proportional hazards model. Its efficacy and clinical usefulness was evaluated by concordance index (c-index) and decision curve analysis. Results: Of the 223 patients, 184 (83%) died of cancer. Median follow-up periods of patients who died and those who remained alive were 5 and 11 months, respectively. We developed a novel nomogram incorporating Eastern Cooperative Oncology Group Performance Status, presence of visceral metastasis, haemoglobin and age. The c-index of the nomogram predicting survival probability 6 and 12 months after diagnosis was 0.788 and 0.765, respectively. Decision curve analyses revealed that the novel nomogram incorporating CRP had a superior net benefit than that without CRP for most of the examined probabilities. Conclusion: We demonstrated the prognostic impact of CRP that improved the predictive accuracy of a nomogram for survival probability in patients with advanced urothelial carcinoma.

Anthropometric measurements, e.g., body weight (BW), body mass index (BMI), as well as serum prostate-specific antigen (PSA) and percent-free PSA (%fPSA) have been shown to have positive correlations with total prostate volume (TPV). We developed an equation and nomogram for estimating TPV, incorporating these predictors in men with benign prostatic hyperplasia (BPH). A total of 1852 men, including 1113 at Tokyo Medical and Dental University (TMDU) Hospital as a training set and 739 at Cancer Institute Hospital (CIH) as a validation set, with PSA levels of up to 20 ng ml(-1), who underwent extended prostate biopsy and were proved to have BPH, were enrolled in this study. We developed an equation for continuously coded TPV and a logistic regression-based nomogram for estimating a TPV greater than 40 ml. Predictive accuracy and performance characteristics were assessed using an area under the receiver operating characteristics curve (AUC) and calibration plots. The final linear regression model indicated age, PSA, %fPSA and BW as independent predictors of continuously coded TPV. For predictions in the training set, the multiple correlation coefficient was increased from 0.38 for PSA alone to 0.60 in the final model. We developed a novel nomogram incorporating age, PSA, %fPSA and BW for estimating TPV greater than 40 ml. External validation confirmed its predictive accuracy, with AUC value of 0.764. Calibration plots showed good agreement between predicted probability and observed proportion. In conclusion, TPV can be easily estimated using these four independent predictors.

INTRODUCTION AND OBJECTIVES: MRSA results in longer hospitalization, increased expenses, and poorer patient prognosis. The indiscriminate use of antibiotics has been identified as an important factor in the increasing dissemination of MRSA. Although most hospitals control the inappropriate use of antibiotics, the incidence of MRSA has continued to increase. To eradicate MRSA, since 2001 we have implemented a stepwise infection control strategy that includes an avoidance in antimicrobial prophylaxis (AMP) based on surgical wound classification. Elsewhere, we have reported that AMP could be gradually reduced in gasless single port urologic surgery without increasing surgical site infections (Int J Urol. 2007 and 2008). METHODS: The study was conducted at a university hospital in central Tokyo. Until 2000, no active infection control program had been implemented. In 2001, we introduced a stepwise infection control strategy in the urology ward. In 2007, active surveillance for MRSA in all urological patients was commenced. MRSA was classified as ‘imported’ when it was identified within 72 hrs of admission or if the patient was previously known to be an MRSA carrier, whereas it was classified as ‘acquired’ when it was identified more than 72 hrs after admission. Clinically significant MRSA infection (CSMI) was defined as an MRSA infection associated with clinical symptoms. The incidence rate (IR), expressed as the annual number of cases per 1000 patient years, was calculated and the trend analysis was assessed using a Poisson regression. RESULTS: Over the study period, 139,866 patients (pts), including 10,201 urology pts, were admitted to our Hospital. Of them, 3,719, including 134 urology pts, were diagnosed with MRSA. Although the IR of MRSA increased in the hospital, it decreased significantly in the urology ward (p 0.01). Of the urology pts with MRSA, 33.6% were classified as ‘imported’, and 66.4% were ‘acquired’. In the urology ward, the IR of acquired MRSA decreased significantly with time (p 0.01), although the IR of imported MRSA did not change. 69 CSMI were identified and the IR of CSMI decreased (p 0.01). CONCLUSIONS: Avoidance of AMP in minimally invasive surgery might contribute to reduction of hospital-acquired MRSA. Source of Funding: None

procedure as indicated. The mean age was 27.2 (range 20-38) years old. VAS was remarkably improved from baseline to the end-point (8.4 1.7 vs 2.1 1.6, p 0.001), CBC increased from 50.9 16.3 to 321.8 56.7 ml (p 0.001), Qmax increased from 6.5 3.3 to 15.5 6.5 ml/s (p 0.05) and Pdet reduced from 33.5 19.6 to 17.8 10.6 cmH2O (p 0.06). All patients reported improvement in quality of life and the PPBC was markedly improved. All hydronephrosis and vesicoureteral reflux disappeared after AE with or without ureteral reimplantation. CONCLUSIONS: This study was the pilot study of AE on KC-related ESBD. The results suggested that AE is effective for pain relief and improvement of objective bladder condition as well as the subjective PPBC in patients with KC-related bladder dysfunction.

INTRODUCTION AND OBJECTIVES: Many patients develop chronic kidney disease (CKD) with an estimated glomerular filtration rate (eGFR) 60 ml/min/1.73 m after radical nephrectomy (RN) which is the most commonly performed surgery for kidney cancer even today. We recently reported that 35% of Japanese patients who underwent RN developed CKD within 2 years after surgery (J Urol, 2011). However, predictive models for post-nephrectomy renal function have not been established. In this study, we investigated the predictors of post-nephrectomy renal function in a Japanese patient cohort. We then developed a nomogram to predict the risk of CKD after RN and a formula to predict postoperative eGFR. We validated these predictive models in an external cohort. METHODS: This retrospective study included 257 patients that underwent RN between 1994 and 2009 in a development cohort and 76 in a validation cohort. In the development cohort, univariate and multivariate logistic regression or linear regression analyses were performed to identify the independent predictors for CKD or eGFR 2 years after RN. Then, a logistic regression-based nomogram to predict postoperative CKD and a linear regression-based formula to predict postoperative eGFR were developed. These predictive models were subsequently validated in the external cohort. RESULTS: Age, presence of diabetes mellitus (DM), and preoperative eGFR were significant and independent predictors of both postoperative CKD and eGFR. In a logistic regression-based nomogram (Figure 1), the probability of developing CKD within 2 years after RN (P) was given by the following formula with an area under the receiver operating characteristic curve (AUC) of 0.876: P 1 / (1 exp(Y)), where Y 5.438 0.048 age (years) 0.094 preoperative eGFR (ml/min/1.73 m) 1.633 (if DM was present). The predicted eGFR value 2 years after RN was given by the following formula with adjusted R of 0.483 (p 0.001): postoperative eGFR (ml/min/1.73 m) 35.05 0.228 age (years) 0.450 preoperative eGFR (ml/min/1.73 m) 9.446 (if DM was present). In the validation cohort, the AUC of the nomogram and the adjusted R of the formula were 0.857 and 0.584 (p 0.001), respectively. CONCLUSIONS: We developed and validated novel predictive models for CKD and eGFR 2 years after RN with high predictive accuracy.

In 1977, Dunnill et al. from Oxford at first reported that 14 of 30 dialysis patients with end stage renal disease (ESRD) examined at autopsy had acquired cystic disease of the kidney (ACDK) and that six of these 14 patients had renal cell carcinoma (RCC), including one with distant RCC metastatsis.1 It is now well established that patients with ESRD are more prone to RCCs with an incidence of approximately 3 to 5 %.2-5 These studies may misrepresent the true incidence RCC because they primarily relay upon screening radiology, particularly ultrasonography (US), for detection. Better estimate was provided by a single-center study in which most renal transplant patients undergo ipsilateral native nephrectomy at surgery. Based upon strict pathologic criteria reported by Denton et al., prevalence of ACDK, renal adenoma and RCC and oncocytoma were found in 33%, 14%, 4.2% and 0.6% of 260 patients6, which may be lower than the true incidence given that only one kidney was removed. Chen et al. found higher incidence of RCCs vs. the general population, with a standardized incidence ratio of RCC in dialysis patients of 24.1 (p

INTRODUCTION AND OBJECTIVES: Multiple studies have revealed that it is difficult to predict the presence of purely unilateral prostate cancer for the purpose of hemiablative focal therapy. However, the contralateral untreated lobe in the prostate exposed to this type of therapy does not have to be a lobe without cancer, but could also be a lobe without significant cancer (SC). The aim of this study is to evaluate the ability of extended 26-core prostate biopsy (3D26PBx: a combination of transrectal 12-core biopsy and transperineal 14-core biopsy) to predict the lobe without SC for the purpose of hemiablative focal therapy. METHODS: We studied 165 patients in whom prostate cancer was diagnosed by 3D26PBx and who underwent radical prostatectomy (RP) without neoadjuvant treatment between 2002 and 2009. RP specimens were divided into right and left lobes, and a total of 330 lobes were analyzed. Pathological specimens were evaluated according to the 2005 ISUP consensus. Considering an upward Gleason score (GS) shift after the 2005 consensus, significant cancer was defined as extraprostatic extension and/or a tumor volume of 0.50 cc or greater and/or GS of 4 3 or greater. We believed that the lobe without SC identified possible areas in which the prostate gland could be preserved without treatment. Whether clinical and pathological variables could be used to predict the lobe without SC was also investigated. RESULTS: The median PSA was 6.6 ng/mL. Biopsy GS were / 6, 3 4, 4 3 and 8 / in 35, 47, 37 and 46 patients, respectively. In the entire cohort, 6.7% of the cases (22/330) revealed the presence of the lobe without cancer while 34% (111/330) revealed the lobe without SC. The positive predictive value (PPV) and negative predictive value (NPV) of unilateral negative biopsy for the lobe without cancer were 22% (19/85) and 99% (242/245) in 3D26PBx, respectively. The PPV/NPV/sensitivity/specificity of unilateral negative biopsy for the lobe without SC were 85/77/56/94% in 3D26PBx, respectively. In the cohort of biopsy negative side, standard clinical variables including prostate-specific antigen, prostate volume, digital rectal examination findings and age were not significantly associated with the lobe without SC. CONCLUSIONS: With PPV of 85%, 3D26PBx predicted the lobe without SC. If follow-up treatment of the contralateral untreated lobe was appropriately performed, hemiablative focal therapy may be a reasonable option in patients with a cancer negative side, as detected by 3D26PBx, and with suspected organ-confined disease.

since 2007 were reviewed from our institution’s prospectively maintained database. Urologic surgeons assigned R.E.N.A.L. scores excluding cases without images available for review. Groups were divided into tertiles by total R.E.N.A.L. score as well as individual components of the score. Statistical analyses were performed. RESULTS: No difference was observed in pre-operative characteristics between low (n 108), intermediate (n 122) and high (n 6) R.E.N.A.L groups. Higher overall R.E.N.A.L. scores were associated with an increased length of stay (LOS), estimated blood loss (EBL), and average warm ischemia time (WIT). Compared to the low score group, the intermediate group had higher rates of malignant pathology (p 0.03), overall complications (p 0.04), and complications of Clavien 3 or greater (p 0.04). Distance to the renal sinus and tumor diameter were associated with statistically significant differences in LOS (p 0.0001, 0.004), WIT (p 0.0001, 0.04), and EBL (p 0.001, 0.002), while tumor polarity only significantly impacted WIT (p 0.04). Anterior-posterior location and exophytic nature of the tumor were not associated with significant differences in outcomes. CONCLUSIONS: The R.E.N.A.L. Nephrometry score can be a useful tool in stratifying small renal masses, as higher scores are associated with significant differences in peri-operative outcomes. Tumor diameter and distance to the renal sinus appear to be the two most important features of the scoring system in terms of predicting risk of complications.

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.

We explored the prognostic impact of lymphovascular invasion in patients with localized upper urinary tract urothelial carcinoma.The clinical records of 135 patients treated surgically for localized upper urinary tract urothelial carcinoma (pTa-3N0M0) were reviewed retrospectively. Lymphovascular invasion was defined as cancer cells in an endothelium lined space. Actuarial survival curves were calculated by the Kaplan-Meier method. Differences between survival curves were evaluated by the log rank test. Multivariate analysis was performed using the Cox proportional hazard model.Median followup was 55 months (range 3 to 232). Lymphovascular invasion was present in 57 patients (42.2%) and it was associated with higher pathological T stage and higher tumor grade. Recurrence-free and disease specific survival rates in patients with lymphovascular invasion were significantly worse than those in patients without lymphovascular invasion (p = 0.001 and 0.001, respectively). Multivariate analysis revealed that lymphovascular invasion, patient age and pathological T stage were significant prognostic factors for recurrence-free and disease specific survival. Based on multivariate analysis patients were divided into 4 risk groups, including pT2 or less/negative lymphovascular invasion, pT2 or less/positive lymphovascular invasion, pT3/negative lymphovascular invasion and pT3/positive lymphovascular invasion. Recurrence-free and disease specific survival rates in patients with pT3/positive lymphovascular invasion were significantly worse than rates in the other 3 groups (each p0.001).The current study indicates that positive lymphovascular invasion predicts poor survival in patients with pathologically localized upper urinary tract urothelial carcinoma. Risk stratification based on lymphovascular invasion status and pathological T stage would be helpful for selecting patients at high risk who would be appropriate candidates for clinical trials.

We treated 6 patients with non-seminomatous extragonadal germ cell tumor (NSEGCT) by VP-16 + ifosfamide + cisplatin (VIP) chemotherapy as an induction therapy to investigate the effectiveness and safety. Primary lesions were located at the mediastinum in 4 patients and the retroperitoneum in 2 patients. As a rule, all patients were treated with VIP chemotherapy of 4 courses with or without second-line treatment such as chemotherapy, residual tumor resection and/or radiation. Following the induction therapy (VIP), 4 of 6 patients (67%) achieved complete or partial responses. After salvage therapy, 4 patients (67%) achieved complete responses and two other patients also achieved partial responses. However, only 2 of the 5 patients who had been follow-up for more than 2 years have remained disease free. The effects of VIP chemotherapy on non-seminomatous extragonadal germ cell tumor appeared to be similar to those of the conventional chemotherapies though the number of patients was small in the current study. It appears to be necessary to design more effective regimen.

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 60 mg/m 2 and 20 mg/m 2 , respectively, and gemcitabine was given on days 1, 8, and 15 at a dose of 800 mg/m 2 . 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: 6.9–14.6 mo) and 16.2 months (95% CI: 13.1–25.4 mo), 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.

262 Background: We had previously reported the phase I/II study of a combination regimen of gemcitabine, etoposide, and cisplatin (GEP) in second-line treatment for patients with advanced UC. This study sought to examine the combination chemotherapy of GEP as first-line treatment for advanced urothelial carcinoma (UC) to assess efficacy, feasibility, prognostic factors, and the impact of postchemotherapy surgery on outcomes. Methods: Forty-two patients were treated with GEP as first-line treatment for metastatic or unresectable locally advanced UC. GEP was recycled every 4 weeks. Etoposide and cisplatin were given on days 1 through 3 at doses of 60 mg/m2 and 20 mg/m2, respectively, and gemcitabine was given on days 1, 8, and 15 at a dose of 800 mg/m2. Results: The median patient age was 64 years. Twenty-three male patients and 19 female patients were included. The primary cancer site is urinary bladder in 21 patients, and upper urinary tract in 21 patients. Nineteen had visceral/bone metastases, 16 had disease restricted to lymph nodes, and the remaining 7 had unresectable disease at primary site. The median number of GEP courses was 4. Thirty of 42 assessable patients (71.4%) demonstrated objective responses. At a median follow-up of 14.6 months, the median overall survival time (OS) was 16.2 months. Twenty-four of 30 responders underwent postchemotherapy surgeries. Median OS in the patients with postchemotherapy surgery was 25.4 months. In the multivariable analysis, anemia and visceral/bone metastasis were significant pretreatment prognostic factors for OS. In addition, being male and anemic were independent poor prognostic factors in patients with postchemotherapy surgery. Grade 3-4 neutropenia, anemia and thrombocytopenia occurred in 84%, 73% and 57%. There were no treatment-related deaths. Conclusions: GEP as first-line chemotherapy in combined-multimodality treatment is active and moderately tolerable for advanced UC. Postchemotherapy surgery may yield favorable outcomes in patients who achieved objective responses. Anemia and visceral/bone metastasis were independent pretreatment predictors for OS.