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Introduction: Magnetic resonance imaging (MRI) has helped clarify the relationship between pelvic anatomical structures and functional outcomes after robot-assisted radical prostatectomy (RARP). Th...

Introduction To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan. Methods This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed. Results Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases. Conclusions Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Cabazitaxel has played an important role in the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC); however, several types of sequential therapy against mCRPC have been performed in routine clinical practice. The objective of this study was to investigate the impact of third-line treatment on prognostic outcomes of mCRPC patients. This study retrospectively analyzed the clinical outcomes of 166 patients who received 3 agents following the diagnosis of mCRPC, consisting of 81 sequentially treated with either abiraterone or enzalutamide and then docetaxel, followed by third-line cabazitaxel (group A) and 85 treated with 3 agents, including abiraterone, enzalutamide, and docetaxel (group B). There were no significant differences in major characteristics at the introduction of the third-line agent between these 2 groups. The proportion of patients with prostate-specific antigen (PSA) reduction > 50% by cabazitaxel in group A was significantly greater than that by either third-line agent in group B. Both PSA progression-free survival (PFS) and overall survival (OS) following third-line therapy in group A were significantly longer than those in group B. Furthermore, OS after the diagnosis of mCRPC in group A was significantly longer than that in group B. Multivariate analysis identified independent predictors of favorable prognostic outcomes after third-line therapy as follows: high-performance status (PS), low PSA level and third-line cabazitaxel for PSA PFS, and high PS, low lactate dehydrogenase level and third-line cabazitaxel for OS. The introduction of cabazitaxel as a third-line agent could markedly improve the prognostic outcomes of mCRPC patients.

Background/Aim: Transurethral resection of bladder tumors (TURBT) guided by photodynamic diagnosis (PDD) with 5-aminolevulinic acid (5-ALA) has been shown to be superior to conventional white light (WL) cystoscopy with regard to diagnostic accuracy, for non-muscle invasive bladder cancer (NMIBC); however, PDD is usually performed prior to WL TURBT. The objective of this study was to investigate the diagnostic significance of 5-ALA-mediated PDD following TUR of NMIBC. Patients and Methods: In 83 NMIBC patients, all visible tumors were completely resected under the conventional WL guidance followed by additional resection if fluorescent lesions were observed under the blue light (BL) guidance, and random biopsy was further conducted. Results: With the BL source, 39 (47.0%) patients were judged to have fluorescent lesions. Twenty (51.3%) of the 39 patients with positive findings by PDD were diagnosed with residual cancer by additional resection, while random biopsy detected cancers in 2 (4.5%) of the 44 patients with negative findings by PDD. Accordingly, the sensitivity, specificity, positive predictive value and negative predictive value in diagnosing residual cancer by our PDD system were 90.9, 68.9, 51.3 and 95.5%, respectively. Univariate analysis showed that the presence of residual cancers shown by WL TURBT was significantly associated with the preoperative findings of urinary cytology, tumor multiplicity, pathological T stage and tumor grade, of which only the preoperative finding on urinary cytology was shown to have an independent impact on the diagnosis of residual cancer. Conclusion: 5-ALA-mediated PDD following standard WL TURBT could improve the diagnostic accuracy in NMIBC patients, particularly those who are positive for preoperative urinary cytology.

Background: Surgical treatment of synchronous multifocal renal tumors arising in a solitary kidney remains an extremely unique and stressful challenge, since it is not easy to completely remove multiple tumors and effectively preserve the renal function without perioperative complications. In this report, we describe our experience of three patients with multifocal renal tumors detected in a solitary kidney who were treated by robot-assisted partial nephrectomy (RAPN). Case Presentation: Two men and one woman were found to have two small renal tumors in a solitary kidney, and subsequently underwent RAPN at our institution. The location of the renal tumors and surgical approach in each patient were as follows: one tumor on the abdominal side and another on the dorsal side with a transperitoneal approach, both on the abdominal side with a transperitoneal approach, and both on the dorsal side with a retroperitoneal approach. In this series, after clamping the main renal artery and resection of one tumor, an inner running suture was placed, followed by early declamping of the renal artery and then renorrhaphy, and the same procedure was repeated to manage the remaining tumor. In all patients, the trifecta outcomes were achieved, and there were no changes in the chronic kidney disease stage 1 month after RAPN, resulting in no requirement of postoperative dialysis. Conclusion: Although it is necessary to carefully select optimal candidates, RAPN with an early declamping technique could be a safe and feasible approach for the treatment of patients with synchronous multifocal renal tumors arising in a solitary kidney, facilitating the complete resection of tumor foci, minimization of warm ischemic injury, and effective preservation of the renal function.

Introduction The aim of this study was to investigate the effects of renal tumor complexity on perioperative outcomes in patients receiving robot-assisted partial nephrectomy (RAPN). Methods This study included 153 consecutive patients with cT1 renal masses undergoing RAPN and analyzed their perioperative outcomes, particularly tumor complexity. In this series, cT1b, completely endophytic, hilar, and cystic tumors were considered complex tumors. Patients with tumors that met at least one of the complex criterion were placed in the complex tumor group; patients with tumors that did not meet any of the complex criteria were placed in the non-complex tumor group. Results Of the 153 patients, 54 (35.3%) had complex tumors; specifically, 18 (11.8%) had cT1b tumors, 15 (9.8%) had completely endophytic tumors, 28 (18.3%) had hilar tumors, and 8 (5.2%) had cystic tumors. The non-complex group included 99 patients (64.7%). The complex tumor group had significantly longer warm ischemia and console times than the non-complex tumor group, but there was no significant difference between them in the achievement of the trifecta. Both warm ischemia and console times were significantly correlated with the number of complex factors. Multivariate analyses of complex factors demonstrated that completely endophytic and cT1b tumors were independently associated with warm ischemia time and console time, respectively. Conclusions For patients with complex tumors, RAPN may be a feasible procedure with acceptable perioperative outcomes. However, special attention should be paid to long warm ischemia and console times, particularly in those with completely endophytic and/or cT1b tumors.

Background/aim Despite recent introduction of several novel agents, limited data exist regarding parameters that help predict the progression of non-metastatic castration-resistant prostate cancer (nmCRPC). The objective of this study was to identify prognostic predictors in nmCRPC patients. Patients and methods This study included 127 consecutive Japanese nmCRPC patients treated in routine clinical practice. Prognostic outcomes in these patients were analyzed to evaluate the impact of several parameters on prostate-specific antigen progression-free survival (PSA PFS) and metastasis-free survival (MFS). Results When the 127 patients were diagnosed with nmCRPC, the PSA and PSA doubling time (PSADT) were 13.5 ng/ml and 17.9 months, respectively. Of these, 77 (60.6%) and 50 (39.4%) were treated with first-generation anti-androgen (FGA) and novel androgen-receptor-axis-targeted agent (ARATA), respectively, as first-line therapy for nmCRPC. The median PSA PFS and MFS after the diagnosis of nmCRPC in these patients were 29.5 months and not reached, respectively. Multivariate analyses identified the following independent prognostic factors: PSA at nmCRPC, PSADT and first-line therapy for nmCRPC for PSA PFS, and PSA at nmCRPC and PSADT for MFS. Conclusion nmCRPC patients with higher PSA and/or shorter PSADT should be treated with ARATA rather than FGA.

Introduction Renal artery fibromuscular dysplasia is generally considered a contraindication of kidney transplantation, since fibromuscular dysplasia occasionally induces hypertension or renal insufficiency in the recipient and/or donor. To date, limited information remains available with respect to whether kidneys with renal arterial fibromuscular dysplasia can be successfully transplanted. Case presentation A 53‐year‐old potential donor was diagnosed with fibromuscular dysplasia of the right renal artery. Laparoscopic right nephrectomy was performed, and the affected portion was resected and reconstructed using the harvested internal iliac artery. Transplantation was successful and the serum creatinine level was

Background/aim The prognosis of patients with invasive bladder cancer remains poor. The objective of this study was to evaluate the efficacy of NVP-BEZ235 (NVP), a dual PI3K/mTOR inhibitor, combined with the inactivation of p62/SQSTM1 (p62) in a human bladder cancer KoTCC-1 model. Materials and methods An expression plasmid with short hairpin RNA targeted against p62 was transfected into KoTCC-1 cells (KoTCC-1/sh-p62). The antitumor effects of NVP on KoTCC-1/sh-p62 were investigated in comparison with those on KoTCC-1 transfected with a control plasmid alone (KoTCC-1/C). Results KoTCC-1/sh-p62 showed significantly higher sensitivity to NVP than KoTCC-1/C. Treatment of both cell lines with NVP markedly inactivated the PI3K/Akt/mTOR signaling pathway. However, NVP treatment stimulated the autophagic pathway in KoTCC-1/C, but not in KoTCC-1/sh-p62. Furthermore, compared with KoTCC-1/C, NVP treatment induced apoptosis of KoTCC-1/sh-p62 cells, which was accompanied by significant downregulation of c-IAP-1 and XIAP as well as upregulation of Bax. Moreover, the in vivo growth of KoTCC-1/sh-p62 tumors was significantly suppressed by treatment with NVP compared to KoTCC-1/C tumors. Conclusion Inhibition of p62 expression combined with NVP may represent an effective therapeutic approach for patients with invasive bladder cancer.

Background We aimed to evaluate the effect of transvaginal mesh surgery on overactive bladder symptoms in women with pelvic organ prolapse and to identify predictive factors for persistence of a preoperative overactive bladder after surgery. Materials and methods We retrospectively evaluated 102 patients who underwent transvaginal mesh surgery. All patients had stage 2 or greater pelvic organ prolapse accompanied by cystocele. The Overactive Bladder Symptom Score, International Prostate Symptom Score, uroflowmetry, and postvoid residual urine volume were evaluated preoperatively and 6 months postoperatively. To identify predictive factors for the persistence of a preoperative overactive bladder after surgery, preoperative parameters were statistically compared between patients with and without the persistence of preoperative overactive bladder symptoms. Receiver operator characteristic curves were generated, and the area under the curve was calculated. Results Preoperatively, 54 women (53%) had an overactive bladder. After surgery, the symptoms disappeared in 34 (63%) and persisted in 20 (37%) women. There were no significant differences in preoperative parameters including age, body mass index, parity, or severity of pelvic organ prolapse between patients with and without persistent preoperative overactive bladder. Preoperative Overactive Bladder Symptom Score and International Prostate Symptom Score were significantly higher in patients with persistent preoperative overactive bladder symptoms. The International Prostate Symptom Score storage subscore had the highest area under the curve, with a cutoff value of 9.5. Conclusion Transvaginal mesh surgery eliminates overactive bladder symptoms in about two-thirds of pelvic organ prolapse patients. The preoperative International Prostate Symptom Score storage subscore was the most useful predictive factor for the persistence of preoperative overactive bladder symptoms after surgery.

Purpose To evaluate whether hydrodistention with fulguration of Hunner lesions (HD/FUL) plus maintenance dimethyl sulfoxide (DMSO) therapy prolongs the recurrence-free time in patients with Hunner type interstitial cystitis (IC). Methods The study enrolled patients with Hunner type IC who required repeat HD/FUL due to recurrence of IC symptoms after the first HD/FUL at our institution. All patients received a second HD/FUL plus maintenance DMSO therapy. The maintenance DMSO therapy was performed every 2 weeks for a total of 8 instillations, and then once every 4 weeks thereafter. The recurrencefree time from HD/FUL to therapeutic failure was estimated using the Kaplan-Meier method. The recurrence-free time between the first HD/FUL and second HD/FUL plus maintenance DMSO therapy was statistically compared using the log-rank test. Results A total of 21 patients (mean age, 66.3±10.8 years) with Hunner type IC were evaluated. The recurrence-free time for the second HD/FUL plus maintenance DMSO therapy was significantly longer than that for the first HD/FUL (P

Background The objective of this study was to evaluate our experience with robot-assisted partial nephrectomy (RAPN) in comparison with conventional open partial nephrectomy (OPN). Patients and methods This study included 37 and 50 patients undergoing OPN and RAPN for small renal masses, respectively. A single surgeon performed RAPN for all 50 cases using the da Vinci Xi. Trifecta was defined as satisfying all of the following 3 criteria: ischemic time of ≤ 25 minutes, negative surgical margin and no major postoperative complications. Results After adjusting patient variables by 1:1 propensity-score matching, 37 patients were included in each group, and no significant differences in major clinicopathological characteristics were noted between these 2 groups. RAPN was significantly superior to OPN with respect to operative time, estimated blood loss and postoperative length of hospital stay. The rate of trifecta achievement was significantly higher in the RAPN group than in the OPN group (91.9 vs. 62.2%). Furthermore, the operative procedure and R.E.N.A.L. nephrometry score were found to be independently associated with trifecta outcome by multivariate analysis of the entire cohort. Conclusions Although this is our early experience with 50 initial cases, RAPN using the da Vinci Xi resulted in more favorable perioperative outcomes than OPN.

Background/aim In renal cell carcinoma (RCC), sorafenib was the first targeted agent demonstrating a definitive benefit in a large phase III clinical trial. The objective of this study was to assess the clinical outcomes of 42 consecutive RCC patients with metastases solely to the lung who received sorafenib as a second-line systemic agent. Patients and methods Of the 42 patients, 14 (33.3%) and 28 (66.7%) received cytokine therapy and sunitinib, respectively, prior to treatment with sorafenib. In this series, all patients initially received 400 mg of sorafenib twice daily on a continuous dosing schedule. The efficacy and safety of second-line sorafenib in these 42 patients were retrospectively evaluated. Results As the best response to sorafenib, 2 (4.8%), 14 (33.3%), 22 (52.4%) and 4 (9.5%) patients were judged to show a complete response, partial response, stable disease and progressive disease, respectively. The median progression-free survival (PFS) and overall survival (OS) after the introduction of sorafenib was 10.6 and 30.2 months, respectively. Multivariate analyses of several parameters identified the following independent prognostic predictors: C-reactive protein (CRP) level for PFS, and International Renal Cell Carcinoma Database Consortium classification and CRP level for OS. The common adverse events associated with sorafenib were hand-foot syndrome, hypertension and diarrhea, which developed in 22 (52.4%), 17 (40.5%) and 13 (31.0%), respectively; however, any AEs corresponding to ≥grade 3 occurred in only 16 (38.1%). Conclusion Favorable disease control with acceptable tolerability might be expected by introducing sorafenib as second-line therapy for RCC patients with metastases solely to the lung; therefore, sorafenib could be the optimal option for this category of patients.

Objectives: Systematic regional lymph node dissection (LND) combined with radical nephroureterectomy (RNU) has been reported to improve the outcomes of upper tract urothelial carcinoma (UTUC) patients. The objective of the present study was to assess the prognostic outcomes of UTUC patients undergoing systematic regional LND combined with RNU. Patients and methods: We conducted a retrospective evaluation of prognostic outcomes of 68 consecutive UTUC patients treated with RUN and systematic regional LND. Results: The median durations of recurrence-free survival (RFS) and overall survival (OS) were 45 and 166 months, respectively. Univariate analyses of several parameters showed that despite the lack of a significant predictor for RFS, the presence of lymph node metastasis correlated with poor OS. Conclusion: These results suggest that comparatively favorable outcomes are achievable in UTUC patients by RNU and systematic regional LND; however, special attention is needed for patients with nodal involvement even after systematic regional LND due to the adverse impact of this factor on OS.

Introduction: There have been insufficient data regarding the impact of partial nephrectomy (PN) with minimal invasive approaches, including robot-assisted PN (RAPN), on postoperative quality of li...

The aim of the present study was to investigate the impact of the combined use of corticosteroid on adverse events (AEs) induced by enzalutamide (Enz) in patients with metastatic castration-resistant prostate cancer (mCRPC). The cohort of the present study included 121 consecutive patients with mCRPC who sequentially received androgen receptor-axis-targeted (ARAT) agents, abiraterone acetate (AA) and Enz, in any order, without prior docetaxel therapy. Detailed assessments of AEs during treatment with Enz were conducted according to whether or not corticosteroid was administered. Of these patients, 63 and 58 received ARAT therapy with the Enz-to-AA sequence (group 1) and the AA-to-Enz sequence (group 2), respectively. No patient in group 1 received corticosteroid during treatment with Enz, while corticosteroid was continuously administered in combination with Enz to all patients in group 2 following AA failure. When ARAT therapy was initiated, no significant differences in the major baseline characteristics were observed between the two groups. During Enz therapy, there were no significant differences in the incidence of any AEs or AEs ≥ grade 3 between the two groups. However, the incidences of fatigue and appetite loss in group 1 were significantly higher when compared with those in group 2. Furthermore, the combined use of corticosteroid was revealed to be independently associated with the prevention of fatigue and appetite loss during Enz therapy. The results of the present study suggested that the combined use of corticosteroids could reduce the incidence of certain types of AE, particularly fatigue and appetite loss, in mCRPC patients treated with Enz.

Background The objective of the present study was to assess the oncologic outcomes of patients receiving second-line therapy against metastatic castration-resistant prostate cancer (mCRPC). Patients and Methods The present study included 222 consecutive mCRPC patients with progression during initial androgen receptor-axis-targeted agent (ARATA) therapy with either abiraterone acetate (AA) or enzalutamide (Enz). Of these 222 patients, 108 subsequently received an alternative ARATA (AA-to-Enz, n = 49; Enz-to-AA, n = 59) and 114 received docetaxel (DTX; AA-to-DTX, n = 54; Enz-to-DTX, n = 60). Results The prostate-specific antigen (PSA) level in the 114 patients receiving DTX was significantly greater than that in the 108 patients receiving ARATA. However, no significant differences were found in the remaining parameters between the 2 groups. The PSA response rate, PSA progression-free survival (PFS), and overall survival (OS) during second-line therapy in the DTX group (n = 114) were significantly superior to those for the ARATA group (n = 108; PSA response rate, 42.1% vs. 21.3%; median PSA PFS, 7.2 vs. 4.2 months; median OS, 17.5 vs. 14.5 months). Similar trends were confirmed by comparing these outcomes among 4 therapy groups, with significant differences (PSA response rate, Enz-to-AA vs. AA-to-DTX and Enz-to-AA vs. Enz-to-DTX; PSA PFS, AA-to-Enz vs. Enz-to-AA, AA-to-Enz vs. AA-to-DTX, Enz-to-AA vs. AA-to-DTX, and Enz-to-AA vs. Enz-to-DTX; and OS, Enz-to-AA vs. AA-to-DTX and Enz-to-AA vs. Enz-to-DTX). Furthermore, the introduction of DTX was independently associated with improved PSA PFS, but not OS, on multivariate analysis. Conclusion Favorable oncologic outcomes can be expected with DTX treatment, rather than with alternative ARATA, for mCRPC patients after failure of an initial ARATA.

To evaluate the oncological outcomes of patients with metastatic renal cell carcinoma (mRCC) involving the inferior vena cava (IVC) who received cytoreductive nephrectomy. This study included 75 consecutive metastatis renal cell carcinoma (mRCC) patients with inferior vena cava (IVC) tumor thrombus undergoing cytoreductive nephrectomy and tumor thrombectomy followed by systemic therapy. Of the 75 patients, 11, 33, 24 and 7 had level I, II, III and IV IVC thrombus, respectively. Following surgical treatment, 25 (group A), 27 (group B) and 23 (group C) received cytokine therapy alone, molecular-targeted therapy alone and both therapies, respectively, as management for metastatic diseases. The median overall survival (OS) of the 75 patients was 16.2 months. No significant differences in OS were noted according to the level of the IVC tumor thrombus. There were no significant differences in OS among groups A, B and C; however, OS in groups B and C was significantly superior to that in group A. Furthermore, multivariate analysis of several parameters identified the following independent predictors of poor OS—elevated C-reactive protein, liver metastasis and postoperative treatment with cytokine therapy alone. The prognosis of mRCC patients with IVC thrombus undergoing cytoreductive nephrectomy may be significantly affected by the type of postoperative systemic therapy rather than the level of the IVC tumor thrombus. Accordingly, cytoreductive nephrectomy should be considered as a major therapeutic option for patients with mRCC involving the IVC, particularly in the era of targeted therapy.

To investigate whether the response to an androgen receptor-axis-targeted (ARAT) agent is associated with the efficacy of subsequent docetaxel in metastatic castration-resistant prostate cancer (mCRPC) patients. This study included 114 consecutive mCRPC patients, comprising 54 and 60 patients who progressed with abiraterone acetate (AA) and enzalutamide (Enz), respectively, before the introduction of docetaxel. The impact of the response to either ARAT agent on the activity of docetaxel was assessed. Following ARAT therapy, a prostate-specific antigen (PSA) response was observed in 73 of the 114 patients, of whom 33 and 40 received AA and Enz, respectively. In the 114 patients, PSA response to docetaxel was achieved in 48 (42.1%) patients, and median PSA progression-free survival (PFS) and overall survival (OS) with docetaxel were 7.2 and 17.5 months, respectively. No significant difference was noted in PSA response rate, PSA PFS or OS with docetaxel between responders and non-responders to a prior ARAT agent in the overall 114 patients, 54 receiving AA and 60 receiving Enz. Despite the absence of a significant impact of the response to a prior ARAT agent on PSA PFS or OS by univariate analysis, independent prognostic predictors were identified by multivariate analysis, as performance status (PS) for PSA PFS, and PS and visceral metastasis for OS. Disease control by docetaxel may not be affected by the response to a prior ARAT agent. Therefore, a prior response to an ARAT agent should not influence the decision on the subsequent introduction of docetaxel for mCRPC patients.

PURPOSE To assess the performance of four-dimensional phase-contrast vastly undersampled isotropic projection reconstruction (4D PC-VIPR) at 3.0T in depicting intrarenal arteries compared with computed tomography angiography (CTA), and its correlation with arterial flowmetry in comparison with Doppler ultrasonography (DUS). MATERIALS AND METHODS In our prospective single-arm study, subjects were 25 patients who underwent renal transplant-related surgery at our hospital between July 2011 and June 2015. In the morphological study, depictions of renal artery branches delineated by magnetic resonance angiography (MRA)/4D PC-VIPR without gadolinium contrast agent were compared in seven living transplant recipients with the same kidney delineated by CTA in seven living transplant donors. In the flowmetric study, flow velocities in the renal (main stem), segmental, and interlobar arteries during systole and diastole were measured in 12 recipients using noncontrast MRA/4D PC-VIPR, and were compared with those obtained from DUS. RESULTS Concerning MRA, average confidence levels of delineation rated by six observers for secondary to third level renal artery branches were 82.9-100% and for the fourth to fifth branches were 60.8-89.7% (average kappa value of 0.588 [95% confidence interval: 0.522-0.653]). Total flow velocities measured using 4D PC-VIPR and DUS demonstrated significant correlations during both systole and diastole with acceptable bias (r = 0.902; P < 0.001 in systole and r = 0.734; P < 0.001 in diastole). CONCLUSION 4D PC-VIPR was useful in generating both morphological and hemodynamic information for evaluation of transplant intrarenal arteries without the need for contrast media. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:595-603.

Second transurethral resection (TUR) is recommended for patients diagnosed with high-risk non-muscle invasive bladder cancer (NMIBC); however, there have been several studies showing conflicting findings regarding the advantage of second TUR. The objective of this study was to investigate the prognostic significance of second TUR using propensity score-matched analysis. This study retrospectively included 164 consecutive patients who underwent initial TUR and were diagnosed with high-risk NMIBC. Of these, 56 subsequently received second TUR, and the remaining 108 underwent initial TUR alone. After adjusting patient variables by propensity score matching, 44 patients were included in each group. There was no significant difference in recurrence-free, progression-free, or overall survival between these two groups. These findings suggested no significant impact of second TUR on the prognosis of high-risk NMIBC patients; therefore, it may be necessary to perform a reassessment focusing on the indication for second TUR by conducting a large-scale prospective study., MINI-ABSTRACT: We investigated the prognostic significance of second transurethral resection for patients with high-risk non-muscle invasive bladder cancer using propensity score-matched analysis. There were no significant impacts on oncological outcomes.

The aims of the current study were to analyze the oncological outcomes of patients with high-risk non-invasive bladder cancer (NMIBC) and to identify prognostic factors in these patients. The present study included 186 consecutive patients who underwent transurethral resection of the bladder tumor (TURBT) between January 2007 and June 2017 at Hamamatsu University School of Medicine and were subsequently diagnosed with high-risk NMIBC according to the classification of the European Urological Association guidelines. The oncological outcomes, including recurrence-free survival (RFS), progression-free survival (PFS) and overall survival (OS) in the 186 patients were evaluated. Additionally, the effects of several clinicopathologiocal parameters on these outcomes were investigated. After the initial TURBT, the second transurethral resection and intravesical bacillus of Calmette-Guerin (BCG) therapy were performed for 47 (25.3%) and 108 (58.1%) patients, respectively. During the observation period of the current study, disease recurrence, disease progression and overall deaths occurred in 54 (29.0%), 14 (7.5%) and 19 (10.2%) patients, respectively. The 5-year RFS, PFS and OS rates in the 186 patients were 66.6, 90.2 and 87.2%, respectively. Multivariate analyses using the Cox proportional hazards regression model identified the following independent factors for the oncological outcomes: Tumor multiplicity and introduction of BCG therapy for RFS (P=0.018 and P

Objective Unlike for bladder cancer, the impact of regional lymph node dissection for upper tract urothelial carcinoma is unclear. We explored whether patient survival was influenced by systematic regional lymph node dissection, using resection templates according to the main tumor location, during radical nephroureterectomy for upper tract urothelial carcinoma. Methods The systematic regional lymph node dissection group was defined as cases in which the dissection of nodes and surrounding tissues followed the established template, and the non-systematic regional lymph node dissection group as cases undergoing limited or no lymph node dissection. We performed radical nephroureterectomy on 98 consecutive patients with various stages of upper tract urothelial carcinoma from May 1994 to September 2014 at our institution. Of these, 77 patients with cTanyN0M0 of upper tract urothelial carcinoma undergoing radical nephroureterectomy were grouped into systematic regional lymph node dissection or non-systematic regional lymph node dissection cohorts according to the extent of dissection, and their outcomes compared. Results Forty-four patients were categorized as systematic regional lymph node dissection and 33 as non-systematic regional lymph node dissection, including 17 with more limited nodal dissection and 16 with no nodal dissection. Five-year recurrence-free survival and cancer-specific survival were significantly higher in the systematic regional lymph node dissection (93% and 94%, respectively) than in the non-systematic regional lymph node dissection group (75% and 77% recurrence-free survival and cancer-specific survival, respectively). Further, 5-year recurrence-free survival and cancer-specific survival of muscle-invasive upper tract urothelial carcinoma (pT2-4) were significantly higher in the systematic regional lymph node dissection (87% and 91%, respectively) than in the non-systematic regional lymph node dissection group (59% and 62%, respectively) (P = 0.0237 and P = 0.0224). Neither recurrence-free survival nor cancer-specific survival was significantly prolonged by systematic dissection in patients with pTis-1 histology. Conclusions Systematic regional lymph node dissection during radical nephroureterectomy for cTanyN0M0 upper tract urothelial carcinoma patients has a significantly beneficial impact on survival compared with patients undergoing more limited dissection, especially in the cases involving muscle invasion.

This report presents a case of a 46-year-old woman in whom contralateral pneumothorax occurred during retroperitoneal laparoscopic donor nephrectomy without any evidence of diaphragmatic injuries. After the start of carbon dioxide-induced pneumoperitoneum, the patient's end-tidal carbon dioxide pressure and heart rate suddenly increased. The surgery was then paused, and a chest X-ray revealed a right pneumothorax accompanied by pneumomediastinum. After a thoracostomy tube was inserted, these symptoms immediately improved. After conversion to an open procedure, the surgery was completed. The thoracostomy tube was removed the next day, and the patient was discharged without any complications. As the pneumothorax occurred on the opposite side to the operative field and there was no evidence of diaphragmatic injury, it is suspected to have been caused by a pneumomediastinum-induced rupture of the barrier between the mediastinum and pleural space. This may have occurred due to the insufflated carbon dioxide gas passing directly into the mediastinum and then the pleural space.

Background/aim It is important to delay the emergence of castration-resistant phenotype to improve the prognosis in patients with metastatic castration-sensitive prostate cancer (mCSPC). The objective of this study was to investigate the prognostic impact of time to castration resistance (TTCR) in mCSPC patients. Patients and methods This study included 437 consecutive mCSPC patients whose primary androgen deprivation therapy was judged to have failed. Prognostic outcomes in these patients were investigated by dividing them into the following 4 groups of 82, 104, 133 and 118 patients with TTCR 0-6, 6.1-12, 12.1-18 and ≥18.1 months, respectively. Results The mean value of TTCR in the 437 patients was 18.7 months. Of several baseline parameters, significant differences among the 4 groups were noted in the performance status, prostate-specific antigen (PSA) level, lactate dehydrogenase (LDH) level, alkaline phosphatase (ALP) level and Gleason score, all of which favored longer TTCR groups. Furthermore, despite the lack of a significant difference in time from the development of castration-resistant disease to death among the 4 groups, there was a significant difference in overall survival (OS) from diagnosis among these groups, showing prolonged OS proportional to TTCR. Univariate analysis identified the age, PSA level, LDH level, ALP level, Gleason score, visceral metastasis and TTCR as significant predictors of OS, of which only age, ALP level and TTCR were shown to be independently associated with OS on multivariate analysis. Conclusion mCSPC patients with a longer TTCR are likely to achieve a more favorable OS.

To compare the prognostic outcomes between first-generation antiandrogen (FGA) and novel androgen-receptor-axis-targeted agent (ARATA) as first-line therapy in patients with non-metastatic castration-resistant prostate cancer (nmCRPC). This study retrospectively included a total of 103 consecutive nmCRPC patients consisting of 47 (45.6%) and 56 (54.4%) who received FGA (bicalutamide or flutamide) and ARATA (abiraterone acetate or enzalutamide), respectively, as the first-line agent after the failure of primary androgen deprivation therapy (ADT). There were no significant differences in the major clinicopathological parameters and previous therapeutic histories between the FGA and ARATA groups. During the observation period, 31 (66.0%) and 29 (51.8%) discontinued first-line therapy in the FGA and ARATA groups, respectively, and of these, 27 (87.1%) and 23 (79.3%) in the FGA and ARATA groups, respectively, were subsequently treated with approved agents as second-line therapy. The prostate-specific antigen (PSA) response rate in the FGA group was significantly lower than that in the ARATA group. Although no significant difference in overall survival was noted between the FGA and ARATA groups, there were significant differences in the PSA progression-free survival on first-line therapy and metastasis-free survival between the two groups, favoring the ARATA group compared with FGA group. Collectively, these findings suggest that among nmCRPC patients who progressed following treatment with the primary ADT, the introduction of ARATA may result in the delay of disease progression compared with FGA.

The objective of this study was to evaluate the impact of the early unclamping (EU) technique on perioperative outcomes in patients who underwent robot-assisted partial nephrectomy (RAPN). This study included 96 patients with small renal masses who underwent RAPN performed by a single surgeon using the da Vinci Xi between April 2016 and September 2018. EU and conventional clamping (CC) procedures were defined as those removing the renal artery clamp before and after renorrhaphy, respectively. In this series, contrast-enhanced computed tomography was performed 3–5 days after RAPN to examine the incidence of renal artery pseudoaneurysm (RAP). After adjusting patient variables by 1:1 propensity score matching, 45 patients were included in both the EU and CC groups, and no significant differences in major clinical characteristics were noted between these two groups. Although there was no significant difference in the proportion of patients achieving trifecta or the margin, ischemia and complications score between the two groups, the EU group was significantly superior to the CC group regarding the operative time, console time, warm ischemia time, impairment of renal function 1 day after RAPN, incidence of RAP and postoperative length of hospital stay. Furthermore, RAP occurred in seven patients in the entire cohort (13.3%) receiving CC, including two who required trans-arterial embolization due to severe macrohematuria, whereas RAP was completely prevented by the use of EU. The introduction of the EU technique to RAPN may improve perioperative outcomes, particularly by markedly reducing the risk of RAP even with renorrhaphy.

INTRODUCTION The objective of this study was to evaluate the initial learning curve for robot-assisted partial nephrectomy (RAPN) using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, California). METHODS This study included the initial 65 consecutive patients with small renal tumors who had undergone RAPN at our institution. A single trained surgeon with extensive experience in robot-assisted radical prostatectomy, but not in laparoscopic partial nephrectomy, performed RAPN for all patients using the da Vinci Xi. The learning curve was analyzed by examining the perioperative outcomes among five groups each consisting of 13 consecutive patients. RESULTS In this series, the median tumor size and R.E.N.A.L. nephrometry score were 23 mm and 7, respectively, and the median console time and warm ischemia time (WIT) were 116 and 15 minutes, respectively. Fifty-eight patients (89.2%) achieved trifecta outcomes, meaning that the ischemic time was ≤25 minutes, there was a negative surgical margin, and no major postoperative complications occurred. Although there were no significant changes in R.E.N.A.L. nephrometry scores over time, increased surgeon experience was significantly associated with a shorter console time and WIT. Drawing logarithmic approximation curves enabled the achievement of a console time ≤150 minutes and WIT ≤20 minutes at the sixth and fourth procedures, respectively. Furthermore, multivariate analysis identified an independent correlation between surgeon experience with WIT, but not with console time. CONCLUSION These findings suggest that regardless of a surgeon's prior experience in laparoscopic partial nephrectomy, an experienced robotic surgeon can perform RAPN using the da Vinci Xi with acceptable perioperative outcomes after a small number of procedures.

The objective of this study was to investigate the significance of an alternative dosing schedule for sunitinib in metastatic renal cell carcinoma (mRCC) patients. This study included 154 patients treated with sunitinib as first-line systemic therapy for mRCC, consisting of 62, 47, and 45 receiving sunitinib based on a traditional schedule (TS, 4 weeks on and 2 weeks off) alone (TS group), alternative schedule (AS, 2 weeks on and 1 week off) alone (AS group), and TS followed by AS after the development of dose-limiting toxicities (TS-to-AS group), respectively. There were no significant differences in the major clinicopathological characteristics among these three groups. The progression-free survival in the TS group was significantly shorter than in the other two groups, while no significant differences in the overall survival were noted among the three groups. Adverse events (AEs) ≥ grade 3 in the TS and TS-to-AS groups occurred more frequently than in the AS group. Furthermore, there were significant differences in the incidences of AEs, including diarrhea, fatigue, and hypertension, among the three groups, favoring the AS compared with the other two groups. Despite the lack of a significant difference in the incidence of dose reduction among the three groups, the incidences of the interruption and discontinuation of sunitinib in the AS group were significantly lower than in the other two groups. These findings suggest that the introduction of AS for sunitinib during first-line treatment for mRCC patients may promote favorable clinical outcomes regarding the prognosis as well as tolerability compared with treatment on TS alone.

BACKGROUND/AIM To date, there have not been any established biomarkers predicting the efficacy of cabazitaxel in patients with metastatic castration-resistant prostate cancer (mCRPC). The objective of this study was to evaluate the significance of the aspartate aminotransaminase (AST)/alanine aminotransaminase (ALT) ratio (De Ritis ratio) as a biomarker for mCRPC patients receiving cabazitaxel. PATIENTS AND METHODS This study included 74 consecutive docetaxel-refractory mCRPC patients treated with cabazitaxel. It assessed the impact of the pretreatment De Ritis ratio, in addition to conventional clinicopathological parameters, on the oncological outcomes in these patients. RESULTS After treatment with cabazitaxel, 22 (29.7%) of the 74 patients achieved a prostate-specific antigen (PSA) response; however, there was no significant difference in the PSA response rate between patients with a low De Ritis ratio (

BACKGROUND/AIM To date, it has not been well characterized whether sunitinib is effective in elderly patients with metastatic renal cell carcinoma (mRCC). The objective of this study was to investigate the impact of age on clinical outcomes of mRCC patients receiving sunitinib. PATIENTS AND METHODS The efficacy and safety of first-line sunitinib in 154 consecutive mRCC patients were retrospectively compared between patients aged

Objective Hypertension and diurnal blood pressure (BP) variation are widely accepted as risk factors for renal damage. However, the effects of unilateral nephrectomy on BP and its circadian rhythm have not yet been clarified in patients with a compromised renal function, including dialysis patients. Methods We investigated 22 unilateral nephrectomized patients (16 men and 6 women, age: 64.5±14.3 years). The function of the circulating renin-angiotensin system (RAS) (plasma renin activity and plasma angiotensin II) and 24-h ambulatory BP monitoring (ABPM) were evaluated before and after nephrectomy. Daytime and nighttime 24-h ABPM values were determined based on sleep and waking times. Results In non-dialysis patients, the estimated glomerular filtration rate after nephrectomy was significantly lower than that before (before, 62.4±23.2 mL/min/1.73 m2 vs. after, 43.7±16.8 mL/min/1.73 m2; p

The objective of this study was to investigate the impact of prior treatment with androgen receptor-axis-targeted (ARAT) agents, abiraterone acetate (AA) and enzalutamide (Enz), on the activity of subsequently introduced docetaxel in patients with metastatic castration-resistant prostate cancer (mCRPC). This study included a total of 114 mCRPC patients consisting of 54 and 60 who progressed following treatment with AA and Enz, respectively, prior to the introduction of docetaxel, and compared oncological outcomes with docetaxel between these two groups. There were no significant differences in the major clinicopathological characteristics before treatment with docetaxel between the AA and Enz groups. The prostate-specific antigen (PSA) response rates to docetaxel in the AA and Enz groups were 40.7 and 43.3%, respectively, with no significant differences in the rates between these two groups. Following the introduction of docetaxel, the median PSA progression-free survival (PFS) and overall survival (OS) in the 114 patients were 7.2 and 17.5 months, respectively. There was no significant difference in the PSA PFS or OS between the AA and Enz groups. Despite the lack of a significant impact of the type of ARAT agent on PSA PFS or OS by univariate analysis, multivariate analyses identified the following independent prognostic predictors: performance status (PS) for PSA PFS and PS and visceral metastasis for OS. Collectively, these findings suggest that the type of ARAT agent may not have a significant impact on disease control by subsequent docetaxel therapy in mCRPC patients.

The objective of this study was to retrospectively analyze the oncological outcomes of Japanese patients with metastatic castration-resistant prostate cancer (mCRPC) who received cabazitaxel. This study included a total of 63 consecutive Japanese mCRPC patients treated with cabazitaxel following the failure of docetaxel, and assessed the prognostic significance of cabazitaxel therapy in these patients focusing on the association of efficacies between two taxane agents. After treatment with cabazitaxel (median 5 cycles), prostate-specific antigen (PSA) decline was observed in 39 patients (61.9%), including 13 (27.0%) achieving the response defined by PSA decline ≥50%. The median progression-free survival (PFS) and overall survival (OS) periods after the introduction of cabazitaxel were 4.1 and 14.8 months, respectively. The response rate to cabazitaxel was not significantly different between responders and non-responders to prior docetaxel, and there was no significant correlation between the PFSs with docetaxel and cabazitaxel. Furthermore, univariate analyses of several parameters identified the performance status (PS) and clinical symptoms, but not the cycles of docetaxel therapy, total amount of administered docetaxel or objective response to docetaxel therapy, as significant predictors of OS on cabazitaxel therapy, of which only PS was independently associated with OS on multivariate analysis. These findings suggest that oncological outcomes in Japanese mCRPC patients receiving cabazitaxel are generally satisfactory, irrespective of the profiles related to prior treatment with docetaxel, and that it might be preferable to introduce cabazitaxel to mCRPC patients with a good PS to maximize the prognostic benefit of this agent.

A 29-year-old man with gender identify disorder presented to our hospital complaining of scrotal pain. Two hours before the consultation, he tried to do self-castration by himself, but he stopped due to bleeding and scrotal pain. His testes were not removed, and his scrotal wound was closed at the emergency operation under spinal anesthesia. After the operation, he never repeated the same act.