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imaging technique used for the rapid histological diagnosis of renal cell carcinoma on percutaneous biopsy. METHODS: After institutional board approval, 50 total percutaneous biopsieswere obtained from20 patients undergoing either partial or radical nephrectomy from resected renal tissue after specimen removal. Biopsy specimens were sprayed with a dual topical fluorescent stain, and VR-SIM images obtained using a 4.2 megapixel, high-speed CMOS camera with fast ferroelectric spatial light modulators. Biopsy specimens were subsequently fixed and analyzed using standard hematoxylin and eosin (H&E) histopathologic methods. One blinded pathologist reviewed all VR-SIM images and H&E specimens. The presence of cancer was correlated between the twomodalities and final standard pathology result. RESULTS: Of the 50 biopsy specimens, fourteen were determined to be malignant on H&E, while 36 represented benign renal tissue. Thirteen of the 14 malignant specimens were diagnosed by VRSIM, with 1 specimen being assessed as indeterminant. Sensitivity and specificity of VR-SIM were 93% and 100%, respectively. CONCLUSIONS: VR-SIM is a promising and practical method for point of care renal biopsy assessment. This may translate into the ability to rapidly assess sufficiency of biopsy specimens and enable immediate diagnostic capability to aid in counseling patients regarding management options.

INTRODUCTION AND OBJECTIVES: Several studies have shown the impact of systemic inflammation on the prognosis in patients with various types of cancers, including urothelial carcinoma (UC). The aim of this study was to evaluate the prognostic significance of pretreatment inflammatory markers in patients with metastatic UC who underwent first-line gemcitabine plus cisplatin (GC) chemotherapy. METHODS: We reviewed the medical records of 214 metastatic UC patients who received first-line GC at 14 institutions between 2005 and 2014. The associations of pretreatment clinical factors, including the neutrophil-to-lymphocyte ratio (NLR), derived NLR, platelet-tolymphocyte ratio, Onodera’s prognostic nutritional index and C-reactive protein (CRP), with progression-free survival (PFS) and overall survival (OS) were assessed. The Cox proportional hazards model was used for multivariate analysis. RESULTS: After excluding 27 patients with missing data, 187 patients were finally enrolled. The median PFS and OS were 7.5 months (IQR 3.6-11.9) and 11.7 months (IQR 7.3-19.9), respectively. Multivariate analysis showed that pretreatment CRP 1.0 mg/dL and liver or bone metastasis were independent poor prognostic factors for PFS and OS (Table). A prognostic model predicting OS was constructed based on the number of these three variables present (0, 1 and 2). The classified patients showed significantly different OS (p < 0.0001, log-rank test, Figure) and Harrell’s concordance index was 0.66 (95%CI 0.58 0.74). CONCLUSIONS: Pretreatment CRP elevation is an independent poor prognostic factor for mUC in patients undergoing first-line GC chemotherapy. Our newly developed prognostic model using the pretreatment CRP is a good discriminator of OS in metastatic UC patients. Source of Funding: none

INTRODUCTION AND OBJECTIVES: We evaluated oncological and functional outcomes of muscle-invasive bladder cancer (MIBC) treatment with our bladder-sparing protocol consisting of transurethral resection of bladder tumor (TURB), low-dose chemoradiotherapy (LCRT), and consolidative partial cystectomy (PC) (Urol Oncol 2013, BJU Int 2012, 2009), comparing outcomes in elderly and younger patients. METHODS: This study included 143 patients with cT2-4aN0M0 MIBC whose tumors met all of the following criteria: 1) solitary and circumscribed within 25% of the bladder area, 2) not involving the bladder neck, 3) no broad carcinoma in situ and who were treated with our bladder-sparing protocol. After debulking TURB followed by LCRT (radiation at 40 Gy concurrently with two cycles of intravenous cisplatin at 20 mg/day for five days), the patients showing no massive residual disease were final candidates for bladder preservation with consolidative PC. The other patients were recommended for radical cystectomy. Oncological and functional outcomes were compared between patients 75 years of age (N1⁄446) and those

INTRODUCTION AND OBJECTIVES: Magnetic resonance imaging (MRI)-targeted prostate biopsy (MRBX) is an effective biopsy procedure for with suspicion of prostate cancer on MRI. However, some significant cancer (SC) is missed using MRBX. Use of systematic prostate biopsy (SBX) for negative areas on MRI to detect SC missed by MRBX is not established for this indication. In this study, we aimed to explore the optimal combination of SBX and MRBX in these patients. METHODS: Between 2014 and 2015 at our institution, 271 men underwent MRBX with or without SBX based on prebiopsy multiparametric 1.5T MRI. Of these, 52 were excluded from the analysis because of PSA levels>40 ng/ml, obvious clinical T3-4 disease or biopsy with an insufficient number of cores for severe comorbidity. The remaining 219 men who underwentMRBXandSBXinonesessionaccording toourbiopsyprotocolwere enrolled in this study. MRBX was performed under cognitive or MRI/transrectal ultrasound fusion. Using MRBX, four-core samples for one suspicious lesiononMRIwereperformed.TheSBXprotocolwasa transperineal18-core biopsy.SCwasdefinedasclinical stageT2borgreater,biopsyGleasonscore of 4+3orgreater, ormaximumcancer lengthof 5mmorgreater.Cancerother thanSCwasdefinedas indolent cancer (IC). SC thatwasnot detected or that wasdetectedas ICusingMRBX,but thatwasdetectedasSCusingSBXwas defined as MRBX-missed SC. The frequency of MRBX-missed SC was investigated. A SBX protocol that could sufficiently detect MRBX-missed SC with a minimum number of sampling cores was determined. RESULTS: The median PSA was 7.5 ng/ml, and one/two suspicious lesions were observed in 204/15 patients, respectively, using MRI. The detection rate of any cancer or SC using both MRBX and SBX was 76%or 61%, respectively. Frequency ofMRBX-missed SC to overall SC was 13% (21/135). MRBX results in MRBX-missed SC patients was no cancer in 8 and IC in 13. Of 21 MRBX-missed cancer, a maximum of 10, 13, 15, 17, 19, 20 and 21MRBX-missed SCwere detected using 2, 4, 6, 8, 10, 12and14SBXsamplingcores, respectively.Whenweset theSC detection rate using both MRBX and the transperineal 18-core SBX at 100%, aminimum of 6 sampling cores in SBX (in addition to MRBX) were required to detect 95% of overall SC as SC. The six SBX sampling locationswere bilateral transperineal anterior, posterior and far lateral sites. CONCLUSIONS: The combination of transperineal 6-core SBX and MRBX could be an optimal biopsy strategy that strikes a balance between SC detectability and sampling number for men with suspicion of prostate cancer on MRI.

baseline clinical and demographic characteristics stratified by AA or Caucasian race. Associations between AA versus Caucasian race with pathologic Gleason upgrade ( 3+4), major upgrade ( 4+3), upstage (pT3a or higher), positive margin status and biochemical recurrence were examined using chi-square, logistic regression, log-rank, and Cox proportional hazards analyses. RESULTS: We identified 355 AA and 540 Caucasian men with low-risk tumors within the SEARCH cohort followed for a median of 6.3 years (IQR 3.8-8.9). AA men were younger (mean 59.5vs. 62.0 years, p

RESULTS: 153 patients [23.5% (36 with >25% decline)/ 76.5% (117 with 25% decline); median follow up 48 months] were analyzed. More female (63.9% vs. 28.2%, p1⁄40.0001) and diabetic (41.7% vs. 26.2%, p1⁄40.021) patients had decrease of eGFR>25%. Median tumor size was significantly higher in the >25% eGFR decrease (2.8 vs. 2.4 cm, p1⁄40.005) as was median RENAL score (7 vs. 5, p 25% eGFR decline group. MVA demonstrated decreasing PPP (OR 1.4, p 25%. CONCLUSIONS: Absence of global renal ischemic insult does not protect the kidney from renal functional decline and a significant proportion of patients may yet go on to suffer significant decreases in GFR. Increasing tumor complexity and decreasing percentage parenchyma spared and female sex were independently associated with significant renal functional decline. Development of predictive computer modeling to aid in optimal patient selection and procedure planning may aid in optimizing renal functional outcomes.

Objectives To determine the relationship between body mass index and prostate cancer risk at biopsy in Japanese men, and to compared the risk with that of Caucasian men. Methods We retrospectively evaluated 3966 men with prostate-specific antigen levels from 2.5 to 19.9 ng/mL who underwent an initial extended prostate biopsy. Using logistic regression, odds ratios of each body mass index category for risk of prostate cancer and high-grade disease (Gleason score ≥4 + 3) were estimated after controlling for age, prostate-specific antigen, %free prostate-specific antigen, prostate volume, digital rectal examination findings, family history of prostate cancer and the number of biopsy cores. Patients were divided into six categories according to their body mass index (kg/m2) as follows

We present an application of a new three-dimensional head-mounted display system that combines a high-definition three-dimensional organic electroluminescent head-mounted display with a high-definition three-dimensional endoscope to minimally invasive surgery, using gasless single-port radical nephrectomy procedures as a model. This system presents the surgeon with a higher quality of magnified three-dimensional imagery in front of the eyes regardless of head position, and simultaneously allows direct vision by moving the angle of sight downward. It is also significantly less expensive than the current robotic surgery system. While carrying out gasless single-port radical nephrectomy, the system provided the surgeon with excellent three-dimensional imagery of the operative field, direct vision of the outside and inside of the patient, and depth perception and tactile feedback through the devices. All four nephrectomies were safely completed within the operative time, blood loss was within usual limits and there were no complications. The display was light enough to comfortably be worn for a long operative time. Our experiences show that the three-dimensional head-mounted display system might facilitate maneuverability and safety in minimally invasive procedures, without prohibitive cost, and thus might mitigate the drawbacks of other three-dimensional vision systems. Because of the potential benefits that this system offers, it deserves further refinements of its role in various minimally invasive surgeries.

Study Type – Prognosis (retrospective cohort analysis) Level of Evidence 2b What's known on the subject? and What does the study add? The additional use of anti-androgen (deferred combined androgen blockade [CAB] therapy) for patients with castration-resistant prostate cancer (CRPC) initially treated with androgen deprivation monotherapy (ADMT) can provide a clinical response, although the reported response rates vary widely. Our previous study, which reported a response rate of 66% to deferred CAB therapy, suggested that deferred CAB responders would also respond better to subsequent therapies than non-responders because the difference in cancer-specific survival between the deferred CAB responders and the non-responders was much larger than the progression-free survival rates for the responders. The present study showed that PSA response to deferred CAB therapy predicts clinical outcomes after subsequent oestrogen and docetaxel therapy. We propose that PSA response to deferred CAB be used for planning individualized treatment that includes secondary hormonal therapy and chemotherapy. OBJECTIVE • To evaluate whether there is any association between prostate-specific antigen (PSA) response to deferred combined androgen blockade (CAB) therapy using bicalutamide in patients with castration-resistant prostate cancer (CRPC), initially treated with castration monotherapy, and the clinical outcomes after subsequent oestrogen and docetaxel therapies. PATIENTS AND METHODS • Fifty-six patients with advanced prostate cancer, who were refractory to both initial castration monotherapy and subsequent deferred CAB, received oestrogen therapy (estramustine phosphate 140 or 280 mg/day in 50 patients, diethylstilbestrol diphosphate 100 mg/day orally in six patients). Of the 56 patients, 33 underwent docetaxel therapy (median dose 55 mg/m2, every 4–8 weeks, median 6 courses) when they became refractory to oestrogen therapy. • A deferred CAB response was defined as a decrease of >50% in PSA levels after the addition of bicalutamide. The difference in cancer-specific survival (CSS) after confirmation of resistance to initial castration monotherapy between the deferred CAB responders and the non-responders was evaluated, and outcomes after oestrogen and docetaxel therapies were also compared between the two groups. RESULTS • A response to deferred CAB was observed in 27 (48%) of the 56 patients. There was no significant difference between the responders and the non-responders in pretreatment clinical variables, including Gleason score, metastatic sites, PSA level at diagnosis, and PSA nadir during castration monotherapy. • A deferred CAB response was a significant predictor of CSS after confirmation of resistance to initial castration monotherapy. • The deferred CAB responders had significantly longer progression-free survival (PFS) (median 3.2 months in the responders, 2.1 month in the non-responders, P= 0.04) and CSS (median 3.0 years in the responders, 1.5 years in the non-responders, P= 0.04) after oestrogen therapy. Likewise, PFS (median 8.2 months in the responders, 2.2 months in the non-responders, P < 0.01) and CSS (median not reached in the responders, 1.4 years in the non-responders, P < 0.01) after docetaxel therapy was significantly longer in the deferred CAB responders. CONCLUSION • PSA response to deferred CAB predicts clinical outcomes after subsequent oestrogen and docetaxel therapies in patients with CRPC, and provides useful information for planning individualized optimum treatment courses that include secondary hormonal therapy and chemotherapy.

Introduction: This study is aimed at evaluating the incidence and predictors of adherent perinephric fat (APF) in Asians during partial nephrectomy (PN), and determining the impact of APF on perioperative outcomes. Materials and Methods: A total of 231 Asian patients with renal tumors underwent PN, and their Mayo adhesive probability (MAP) score was calculated. APF was intraoperatively determined, and the perioperative data were compared according to the presence of APF. The predictors of APF were examined using logistic regression analyses. Results: APF was observed in 40 (17%) patients. In multivariate analysis, male gender and higher MAP score were the independent predictors of APF. The estimated blood loss was higher in patients with APF, however, the complication rates did not differ between the 2 groups. Conclusions: The MAP score can predict APF in an Asian population. The presence of APF was associated with greater blood loss; however it did not increase the postoperative complications in PN.

We report a case of metastatic testicular germ-cell tumor (GCT) with malignant transformation (MT) successfully treated with a GCT-oriented chemotherapy followed by surgery. A 48-year-old man presented with a right testicular tumor with retroperitoneal lymph node metastases. Pathological examination revealed that the primary tumor was rhabdomyosarcoma with mature teratoma, and the rhabdomyosarcoma element expressed placental alkaline phosphatase (PLAP) which is a marker of primitive germ cells or GCTs. After 4 cycles of GCT-oriented chemotherapy (VIP: etoposide, ifosfamide, and cisplatin), radiological partial response of retroperitoneal metastases was achieved, and subsequent retroperitoneal lymph node dissection revealed no remaining tumor cells. Our report suggests that GCT-oriented chemotherapy may be effective in treatment of patients with metastatic GCT with MT, particularly tumors which express PLAP in the MT element, although this disease entity has traditionally been considered to be chemoresistant.

We have recently reported favorable responses to a combination treatment comprising cimetidine, a cyclooxygenase-2 inhibitor and a renin-angiotensin-system inhibitor in metastatic renal cell carcinoma (RCC). In view of the potential synergistic effects of these three agents and interferon-α (I-CCA therapy), we conducted a phase-II trial to examine the efficacy and toxicity of I-CCA as first-line treatment. Fifty-one patients with advanced RCC received natural interferon-α (3-6 million U thrice/week) and cimetidine (800 mg), cyclooxygenase-2 inhibitor meloxicam (10 mg), and renin-angiotensin-system inhibitor candesartan (4 mg) or perindopril (4 mg) orally daily. Memorial Sloan-Kettering Cancer Center prognostic categories were favorable, intermediate and poor in 10 (20%), 31 (61%) and 10 (20%) patients, respectively. The primary end-point was the objective response rate (ORR) and the secondary end-points included clinical benefit, progression-free survival (PFS), overall survival (OS) and safety. Median follow-up was 19 months. Complete response (CR) was observed in four patients (8%) and partial response in seven (14%), yielding an ORR of 22%. None of the four patients who achieved CR relapsed during the 16- to 81-month follow up. The ORR were 17% in the favorable- or intermediate-risk group and 40% in the poor-risk group. The other 24 patients (45%) had stable disease for at least 6 months, resulting in a clinical benefit rate of 67%. The median PFS and OS were 12 and 30 months, respectively. Grade 3/4 toxicities were never observed. The I-CCA therapy, providing favorable responses and low toxicity profiles, is worthy of further consideration as a first-line therapy for metastatic RCC.

OBJECTIVE To investigate the interactions between inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in response to ischaemia-reperfusion (I/R) of rabbit bladder. MATERIALS AND METHODS Rabbit bladders were exposed to 2 h of ischaemia by bilaterally clamping the major arteries entering the bladder and then a subsequent 36 h of reperfusion (I/R) with or without intraperitoneal administration of a selective iNOS inhibitor n-(3-(amynomethyl)benzyl)acetamidine (1400W) or a selective COX-2 inhibitor NS-398 given 1 h before killing. The bladder tissues were processed for isometric tension experiments, enzymatic NOS activitiy, tissue contents of nitrite/nitrate (NOX), cyclic guanosine monophosphate (cGMP) and COX activity determined by prostaglandin E2 (PGE2) production. RESULTS iNOS and constitutive NOS (cNOS) activities, NOX and PGE2 contents in the bladder tissues at 36 h after reperfusion were significantly higher than those in the sham group with no significant increase in cGMP. Treatment with 1400W abrogated the increases in iNOS activity and NOX as well as PGE2 without changing cNOS activity. In the tension experiments, a NOS substrate, l-arginine, induced detrusor contraction only in the I/R group, which was inhibited by 1400W or NS-398 but not by a selective soluble guanylate cyclase inhibitor 1H-[1,2,4] oxadiazole[4,3-a]quinoxalin-1-one (ODQ). 8-Br-cGMP induced detrusor relaxation in the sham and I/R groups. Also, l-arginine increased NOX and PGE2 in the bladder tissues only in the I/R group, which were inhibited by pretreatment with 1400W. While, l-arginine increased cGMP contents in the I/R group and this increase was suppressed by ODQ but not by 1400W. CONCLUSION These results show that NO derived from an up-regulation of iNOS after I/R increases COX-2-derived PG via a cGMP-independent mechanism. NO-mediated activation of COX-2 may be an important mechanism for the modulation of bladder function after I/R injury.

490 Background: Trimodality bladder-sparing therapy has become an accepted treatment for selected patients with muscle-invasive bladder cancer (MIBC). As some of the histologic variants of urothelial carcinoma (VUC) are more resistant to chemotherapy and radiotherapy compared with pure urothelial carcinoma (PUC), it is still controversial whether bladder-sparing therapy provides comparable disease control in VUC. We have developed a tetra-modality bladder-sparing therapy consisting of maximal transurethral resection (TUR), chemoradiotherapy (CRT), and consolidative partial cystectomy, which has theoretical advantage in locoregional control by surgically eliminating chemo- and radio-resistant cells (Koga et al, Urol Oncol 2013, BJU Int 2012). Methods: After maximal TUR and CRT (40Gy + cisplatin), treatment response was evaluated by cytology, imaging and tumor-site rebiopsy. Complete responders were candidate for consolidative partial cystectomy, while radical cystectomy was recommended for others. VUC identified in maximal TUR samples were categorized according to the 2004 World Health Organization Classification. Response rate to CRT, MIBC recurrence-free survival and cancer-specific survival (CSS) were compared between patients with PUC and VUC. Results: Between 1997 and 2016, 153 consecutive patients with cT2-3N0M0 bladder cancer (median age 69, female/male = 33/120, cT2/3 = 99/54) entered tetra-modality bladder-sparing protocol. VUC was identified in 37 (24%) of the patients, including glandular in 12 (8%), squamous in 11 (7%), micropapillary in 8 (5%), sarcomatoid in 2 (1%), microcystic in 2 (1%), and lymphoepithelioma-like in 1 (0.7%). There was no difference in the response rate to CRT between PUC and VUC (71% vs 84%, p = 0.13). Among the patients with PUC (n = 75) and VUC (n = 31) who underwent partial cystectomy, 5-yr MIBC recurrence-free rates were 92% and 100% (p = 0.21), and 5-yr CSS rates were 93% and 94% (p = 0.64), respectively. Conclusions: Tetra-modality bladder-sparing therapy incorporating partial cystectomy could provide favorable locoregional control and survival for patients with VUC.

The end product of the heme oxygenase pathway, bilirubin, is the most abundant endogenous antioxidant in mammals. We report the heme oxygenase-1 mediated production of bilirubin and its cytoprotective roles in cyclophosphamide induced hemorrhagic cystitis in rats.Female Sprague-Dawley rats received intraperitoneal administration of cyclophosphamide. In the first experiment hemin (an inducer of heme oxygenase-1) with or without zinc protoporphyrin IX (an inhibitor of heme oxygenase activity) was given before cyclophosphamide injection. Endogenous bilirubin production was analyzed in bladder tissues immunohistochemically. In another experiment bilirubin solution was administered before the cyclophosphamide injection. Changes in bladder weight, microscopic feature and expression levels of inducible nitric oxide synthase, proinflammatory cytokines and heme oxygenase were evaluated using polymerase chain reaction and immunostaining.Bilirubin was generated in bladders with cyclophosphamide induced cystitis, especially in the urothelium and suburothelium. Hemin pretreatment provided increased production of endogenous bilirubin, which was decreased by zinc protoporphyrin IX. In an evaluation of the roles of bilirubin exogenous bilirubin administration ameliorated cyclophosphamide induced inflammatory changes and reduced the increase in bladder weight. The elevated expression of inducible nitric oxide synthase and interleukin-1beta in cyclophosphamide induced cystitis was significantly down-regulated by exogenously applied bilirubin. The expression of heme oxygenase-1 and 2 was not modified by bilirubin administration.Cyclophosphamide induced hemorrhagic cystitis is accompanied by endogenous bilirubin production through heme oxygenase-1 induction in the bladder. Bilirubin has cytoprotective roles in association with the down-regulation of inducible nitric oxide synthase expression. Our results suggest that bilirubin may have therapeutic potential against bladder inflammatory insults such as cyclophosphamide induced cystitis.

OBJECTIVES To investigate the effects of reactive oxygen species (ROS) on the micturition reflex in vivo, especially in bladder afferent signalling in rats, as several pathophysiological conditions in the urinary bladder (e.g. ischaemia/reperfusion and inflammation) are characterized by the formation of ROS. MATERIALS AND METHODS Adult female Sprague-Dawley rats under urethane anaesthesia (normal or pretreated with 125 mg/kg capsaicin, subcutaneously, 4 days before) were assessed by continuous cystometrography (CMG) with or without the intravesical administration of H(2)O(2) (0.003-3%) to stimulate ROS damage. To investigate the mechanism of H(2)O(2), catalase (a H(2)O(2) scavenger) was applied intravesically (2000 IU/mL), or rats were given intravenous injections with superoxide dismutase (SOD, 20,000 IU/kg, a superoxide anion scavenger), dimethylthiourea (DMTU, 100 mg/kg, a hydroxyl radical scavenger), deferoxamine (20 mg/kg, an iron-chelator that prevents the formation of hydroxyl radical), indomethacin (3 mg/kg, a cyclooxygenase inhibitor) or ketoprofen (1 mg/kg, a cyclooxygenase inhibitor) just before or during the intravesical administration of H(2)O(2). Prostaglandin (PG) levels (PGE(2) and 6-keto-PGF(1 alpha)) were measured in the bladder of rats treated with intravesical 0.3% H(2)O(2) for 30 min with or without indomethacin. RESULTS Intravesical administration of H(2)O(2) induced detrusor overactivity, as shown by a reduction in the mean (sem) intercontraction interval (ICI), in a dose-dependent manner in normal rats (0.3% H(2)O(2,) P < 0.01, 36.2 (4.7)% of the control ICI). H(2)O(2)-induced detrusor overactivity was almost abolished by catalase and significantly suppressed by DMTU, deferoxamine, capsaicin pretreatment, indomethacin or ketoprofen but not by SOD. The level of PGs was significantly increased by H(2)O(2) instillation, and indomethacin significantly inhibited the increase in PGs. CONCLUSION These results indicate that oxidative stress induced by H(2)O(2) activates capsaicin-sensitive C-fibre afferent pathways, at least in part, mediated via stimulation of the cyclooxygenase pathway, thereby inducing detrusor overactivity. Thus, rats treated with intravesical H(2)O(2) appear to be a suitable model for the study of detrusor overactivity.

Objectives To investigate longitudinal changes in renal function after radical nephrectomy, and to explore risk factors of postoperative severe renal impairment in a Japanese multicenter cohort. Methods The present retrospective study included 701 patients who had no metastasis, end-stage kidney disease or bilateral kidney cancer, who underwent radical nephrectomy and who were followed up for at least 1 year. The longitudinal change in postoperative renal function during a 10-year follow-up period was evaluated according to the presence or absence of potential risk factors including greater age, chronic kidney disease, hypertension, diabetes mellitus and cardiovascular disease. A slope of annual change in estimated glomerular filtration rate was analyzed using a linear mixed model. Associations between the potential risk factors and a >50% estimated glomerular filtration rate decrease were evaluated using a multivariate Cox regression model. Results Overall, the postoperative estimated glomerular filtration rate recovered over time with a significant positive slope of 0.34 mL/min/1.73 m2/year. Renal function did not tend to recover in patients with chronic kidney disease, hypertension, diabetes mellitus or cardiovascular disease. The multivariate analysis showed that greater age and diabetes mellitus were independent risk factors for severe renal impairment. Conclusions Overall, patients who had deteriorated renal function immediately after radical nephrectomy recovered over time. However, patients with chronic kidney disease, hypertension, diabetes mellitus and cardiovascular disease did not tend to recover renal function postoperatively. Greater age and diabetes mellitus were independent risk factors for a >50% decrease in estimated glomerular filtration rate.

RESULTS: Each mosaic image consisted of 200-1000 images, with an average of 597 images per prostate. Imaging and interpretation was performed in 30 minutes on average. All four surgical margins were pathologically determined to be free of tumor glands at the time of VRSIM image review, and each specimen was confirmed as negative for prostate cancer at the margin on final histopathology. Figures 1 and 2 represent the images obtained using VR-SIM. CONCLUSIONS: VR-SIM is a promising and practical method for assessing intra-operative prostate margins during RP that could replace or augment frozen section analysis with improved area of sampling. This may translate into decreased positive margins and thus decreased need for adjuvant treatment modalities.

rates at 2 years were not different between ORC and RARC patients. However, the distribution of sites of first recurrence was significantly different between the two surgical techniques. Specifically, extrapelvic lymph node locations (4/26 ORC patients with distant recurrence vs 10/ 43 RARC patients with distant recurrence) and peritoneal carcinomatosis (2/26 ORC patients with distant recurrence vs 9/43 RARC patients with distant recurrence) were numerically more frequent in RARC patients than in ORC patients. In multivariable analyses, RARC was not an independent predictor of recurrence, adjusting for age, gender, clinical stage, perioperative chemotherapy, pathologic stage, nodal stage, positive surgical margin, and lymphovascular invasion (HR 0.78, 85%CI 0.5-1.21; p1⁄40.2). CONCLUSIONS: In our series, recurrence-free survival was similar following ORC and RARC, and RARC provided no additional risk of recurrence compared to ORC. However, the distribution of distant recurrences was statistically different between the two techniques, with extrapelvic lymph node locations and peritoneal carcinomatosis found more frequently in RARC patients. If confirmed in larger studies, these findings may lead to a reappraisal of the value of RARC.

Gasless two-port access RoboSurgeon retroperitoneoscopic nephroureterectomy, which is an affordable procedure for patients with upper tract urothelial carcinoma, combines two single-port surgeries in that the kidney and upper ureter are isolated via the ipsilateral flank port and the lower ureter with bladder cuff via the ipsilateral lower abdominal pararectal port. This surgery is performed with the assistance of the RoboSurgeon system, which consists of three components: a three-dimensional (3D) head-mounted display (3D-HMD), handheld robot-like devices, and an endoscope manipulation robot. Depending on the situation, part or all of this system is used, but the 3D-HMD, which provides six fields of vision in front of the eyes regardless of head position, is always used by surgeons. When cosmetic results are most important, transumbilical single-port access can be selected. This surgery achieves four key “no’s”: no high costs, no CO2, no multiple ports, and no intraperitoneal injury. The adjustable port size ensures safety and ease of learning. The direct view, obtained by moving the angle of sight downwards while wearing on the 3D-HMD, coupled with the adjustable port size, facilitates the transition from open surgery. Without the RoboSurgeon system, single-port-like surgery can be performed using the procedures described herein.

Gasless single-port RoboSurgeon retroperitoneoscopic adrenalectomy, which is an affordable procedure for patients with various types of adrenal tumors, is carried out through a coin-sized single port and is assisted by a system (RoboSurgeon) that involves the robotization of the surgeon. The RoboSurgeon system consists of three components: a three-dimensional head-mounted display (3D-HMD), handheld robot-like devices, and an endoscope manipulation robot. Depending on the situation, part or all of this system is used. The 3D-HMD, which provides six fields of vision in front of the eyes regardless of head position, is always used by surgeons. The direct view obtained by moving the angle of sight downward allows the surgeons to see a wide panoramic operative field, which ensures safety. This surgery achieves four key “no’s”: no high costs, no CO2, no multiple ports, and no intraperitoneal injury. For patients with large pheochromocytoma, however, a transperitoneal approach with similar surgical maneuvers is an alternative. The aforementioned direct vision and adjustable port size provide safety, ease of learning, and transition from open surgery without difficulty. Without the RoboSurgeon system, a single-port-like adrenalectomy in which the port size is somewhat larger can be performed using the procedures described herein.

Gasless single-port RoboSurgeon clampless sutureless partial nephrectomy is performed for a wide range of renal tumors. It is an affordable procedure for patients with renal cell carcinoma and is carried out in a wide retroperitoneal working space made along the anatomical plane through a coin-sized single port. This surgery can be accomplished without vascular clamping using “the mushroom technique” and is assisted by a system (RoboSurgeon) that involves the robotization of the surgeon. The RoboSurgeon system consists of three components: a three-dimensional head-mounted display (3D-HMD), handheld robot-like devices, and an endoscope manipulation robot. Depending on the situation, part or all of this system is used. The 3D-HMD, which provides six fields of vision in front of the eyes regardless of head position, is always used by surgeons. Using the direct view obtained by moving the angle of sight downward, surgeons can receive instruments from the scrub nurse and can also observe the operative field to ensure safety. This surgery achieves four key “nos”: no high costs, no CO2, no multiple ports, and no intraperitoneal injury. The adjustable port size provides safety and ease of learning. The aforementioned direct vision and adjustable port size facilitate the transition from open surgery. Without the RoboSurgeon system, single-port-like surgery, in which the port size is somewhat larger, can be performed using the procedures described herein.

The concept of the RoboSurgeon system can be applied to not only minimally invasive surgery but also to many types of medical procedures. The head-mounted display (HMD), which is a part of the RoboSurgeon system, is used as a personal integrated-image monitor. The HMD provides the wearer with six fields of vision, including magnified vision, stereovision, panoramic vision, multivision, navigated vision, and shared vision. Various types of imaging information can be input to the HMD by arranging the system components. Moreover, multiple streams of information can be seamlessly displayed on HMD by combining video splitters and multiplexers with the HMD. All the participants, including medical staff, and even students and patients can simultaneously share the information by each wearing an HMD. Furthermore, each HMD wearer can independently rearrange the images that make up the composite image displayed on his or her HMD depending on the step of the procedure. Importantly, the HMD system is compact and easily introduced due to its affordable cost. Therefore, we can apply this system even in transurethral procedures or outside the operating room. The RoboSurgeon system offers enormous potential for refining many types of medical procedures and practice.

Gasless single-port pelvic lymph node dissection and inguinal hernia prevention are carried out in the wide retroperitoneal pelvic working space made along the anatomical plane through an approximately coin-sized single port. These are affordable procedures often performed together with many gasless single-port RoboSurgeon surgeries for the pelvic organs including radical/partial cystectomy and radical prostatectomy, and they are assisted by a system (RoboSurgeon) that involves the robotization of the surgeon. The RoboSurgeon system consists of three components: a 3D head-mounted display (3D-HMD), handheld robot-like devices, and an endoscope manipulation robot. Part or all of this system is used depending on the situation, but the 3D-HMD, which provides six fields of vision in front of the eyes regardless of head position, is always used by surgeons. The direct view obtained by moving the angle of sight downward allows the surgeons to see a wide panoramic operative field to ensure safety. This surgery is safe and easy to learn, and transition from open surgery can be completed without difficulty. Without the RoboSurgeon system, single-port-like surgery, in which the port size is somewhat larger, can be performed using the procedures described herein.

Gasless single-port RoboSurgeon total cystectomy with urinary diversion is carried out in the wide pelvic retroperitoneal working space made along the anatomical plane through a single port, around 4–5 cm in diameter, assisted by the robotization of the surgeon using a system called RoboSurgeon. The RoboSurgeon system consists of three components: a three-dimensional head-mounted display (3D-HMD), handheld robot-like devices, and an endoscope manipulation robot. Part or all of this system is used depending on the situation, but the 3D-HMD, which provides six fields of vision in front of the eyes regardless of head position, is always used by surgeons. Using the direct vision obtained by moving the angle of sight downward, the surgeons receive instruments from the scrub nurse as well as observe the operative field to ensure safety. Along with total cystectomy, urinary diversion (either orthotopic neobladder or ileal conduit) is performed by extracting the ileum through the single port. Performing this surgery achieves three key “nos”: no high costs, no CO2, and no multiple ports, along with minimal intraperitoneal injury. Patients who had previously undergone extensive intraperitoneal surgery would benefit the most. Transition from open surgery can be accomplished without much difficulty. Without the RoboSurgeon system, single-port-like surgery, in which the port size is somewhat larger, can be performed using the procedures described herein.

Purpose We tested a new head-mounted display (HMD) system for surgery on the upper urinary tract. Surgical Technique Four women and one man with abnormal findings in the renal pelvis on computed tomography and magnetic resonance imaging underwent surgery using this new system. A high definition HMD (Sony, Tokyo, Japan) is connected to a flexible ureteroscope (Olympus, Tokyo, Japan) and the images from the ureteroscope are delivered simultaneously to various participants wearing HMDs. Furthermore, various information in addition to that available through the endoscope, such as the narrow band image, the fluoroscope, input from a video camera mounted on the lead surgeon’s HMD and the vital monitors can be viewed on each HMD. Results Median operative duration and anesthesia time were 53 and 111 minutes, respectively. The ureteroscopic procedures were successfully performed in all cases. There were no notable negative outcomes or incidents (Clavien-Dindo grade ≥1). Conclusion The HMD system offers simultaneous, high-quality magnified imagery in front of the eyes, regardless of head position, to those participating in the endoscopic procedures. This affordable display system also provides various forms of information related to examinations and operations while allowing direct vision and navigated vision.

Because of the remarkably improved image quality and wearability of modern head-mounted displays, a monitoring system using a head-mounted display rather than a fixed-site monitor for sonographic scanning has the potential to improve the diagnostic performance and lessen the examiner's physical burden during a sonographic examination. In a preclinical setting, 2 head-mounted displays, the HMZ-T2 (Sony Corporation, Tokyo, Japan) and the Wrap1200 (Vuzix Corporation, Rochester, NY), were found to be applicable to sonography. In a clinical setting, the feasibility of the HMZ-T2 was shown by its good image quality and acceptable wearability. This modern device is appropriate for clinical use in sonography.

Objective: The aim of this study is to identify the pre-operative prognostic factors and create a risk stratification model for patients with renal cell carcinoma with extension into the renal vein or inferior vena cava. Methods: The study cohort included 61 patients with renal cell carcinoma extending into the renal vein or inferior vena cava that underwent operations between 1993 and 2012. Cancerspecific survival rates were estimated, and univariate and multivariate analyses were carried out to determine the prognostic factors. A simple risk stratification model was developed for these patients. Results: The median follow-up period of the current patient cohort was 33.7 months. Their 1, 3 and 5-year cancer-specific survival were 89, 70 and 65%, respectively. On multivariate analysis, the level of tumor thrombus extension (extension into the supradiaphragm), presence of distant metastasis and elevation of lactate dehydrogenase and C-reactive protein were independent negative prognostic factors for cancer-specific survival. Cancer-specific survival rates were clearly discriminated by the stratification according to the scoring model (P , 0.001). The concordance index of the new model was 0.80. Conclusions: We demonstrated a simple risk stratification model with four pre-operative independent prognostic factors for patients with renal cell carcinoma with venous involvement. This may be a useful decision-making model in the management of such patients.

To describe the technical aspects of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy for peripheral renal tumors, and to evaluate its outcomes, including surgical, pathological, and short-term oncological and functional outcomes.Between January 2010 and June 2013, 103 patients with peripheral renal tumors suggestive of renal cell carcinoma underwent gasless laparoendoscopic single-port partial nephrectomy. In all cases, an attempt was made to accomplish partial nephrectomy without vascular clamping using ultrasonic coagulating and bipolar sealing devices. Hemostasis was achieved by coagulation and hemostatic agents without reconstructing the renal parenchyma.Of the 103 patients, gasless laparoendoscopic single-port partial nephrectomy was accomplished without vascular clamping and parenchymal suture in all but two patients (98%). Median operative time and blood loss were 191 min and 244 mL, respectively. One patient (1%) received allogeneic blood transfusion. The median postoperative time to full recovery was 3 days. Three major complications (3%, all grade 3 urinary leakage) were observed. Of 92 renal cell carcinoma patients, four (4%) had positive surgical margins, most of which underwent thermal degeneration histologically. In 91 non-metastatic renal cell carcinoma patients, 3-year local recurrence-free, progression-free, cancer-specific and overall survival rates were 100%, 99%, 100%, and 100%, respectively (mean follow-up period, 21 months). In the 103 patients, the median percent decrease in estimated glomerular filtration rate 3 months after partial nephrectomy was 2.4%.Gasless laparoendoscopic single-port clampless sutureless partial nephrectomy can be accomplished in almost all cases of peripheral renal tumors. This surgery is technically feasible and safe, yielding acceptable short-term oncological outcomes and maximal preservation of renal function.

p1⁄40.038). At IC50 for HA synthesis, 4-MU inhibited proliferation (w 2.5fold) and induced apoptosis (3-fold) in BCa cells. 4-MU induced caspase-8, -9 and -3 activation and up-regulation of Fas and FADD. 4-MU caused 4-10-fold downregulation of HA-receptors (CD44, RHAMM), and EMT promoters Beta-catenin, Snail and Twist, but increased Ecadherin expression by 2-fold. In xenograft studies, 4-MU significantly decreased tumor growth (> 3-fold) when treatment was started either on the day of tumor cell injection or after tumors became palpable. No weight loss or serum or organ toxicity was observed in treated mice. Tumors showed reduced microvessel density (w3-fold) and HA expression but increased TURNEL positive cells. CONCLUSIONS: This study shows that expression of EMT determinants correlates with clinical outcome. Furthermore, the nontoxic dietary supplement 4-MU has potent antitumor activity and reverses EMT.