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Background We report the case of a patient with syphilitic testicular gumma and vasculitis with adrenal failure due to chronic steroid use. Case presentation A 63-year-old male presented with hard right eye swelling and very firm bilateral testes on palpation, which he had for 2 years. Testicular tumor markers were negative; syphilis test was positive. Radiological examination suggested aortitis and bilateral testicular malignancy. The patient received ampicillin for the infection and prednisolone for vasculitis. Left orchidectomy was performed to confirm the presence of testicular tumor; histological examinations revealed granulomatous orchitis. The prednisolone doses were adjusted because of relapses and adverse effects of steroid use. Unfortunately, the patient died in the intensive care unit because of uncontrolled blood pressure and pneumonia. Conclusions This is a rare case of syphilis with testicular involvement and vasculitis. This report shows the importance of broadening the differential diagnoses of testicular firmness.

Perineal recurrence after brachytherapy is an exceedingly rare complication. Moreover, ductal adenocarcinoma is a rare histological variant of prostate cancer. Herein, we describe a case of perineal recurrence from ductal adenocarcinoma of prostate after low-dose-rate brachytherapy (LDR-BT) in a 65-year-old male patient. The patient had localized prostate cancer, for which he received LDR-BT; however, he experienced perineal recurrence 2 years after receiving LDR-BT. Surgical excision was attempted, but we were unable to remove the whole tumor, owing to invasion to surrounding tissue. Pathological examination of resected tumor showed ductal adenocarcinoma of the prostate. External beam radiation therapy and high-dose-rate brachytherapy (HDR-BT) were performed for residual tumor. Mild mediastinal lymph node swelling was observed during clinical course of the disease. Hence, androgen deprivation therapy was administered with abiraterone after radiation therapy, and prostate-specific antigen level decreased to undetectable level. Biochemical failure after transperineal brachytherapy for prostate cancer should be considered as a perineal recurrence.

Segmental testicular infarction is a rare condition. Patients present with clinical features similar to torsion and testicular tumors, with most undergoing surgery. A 55-year-old male patient presented with left scrotal pain. We did a Doppler ultrasonogram and magnetic resonance imaging to diagnose his condition and rule out testicular torsion and tumor. We decided not to operate and asked the patient for follow-up. There was no pain in the left testis, and magnetic resonance imaging showed a reduction in the left testicular lesion after 4 months.

OBJECTIVES The aim of the present study was to report on our early experience with hydrogel spacer (SpaceOAR) placement in combination with iodine-125 low-dose-rate brachytherapy for prostate cancer. METHODS From April 2018, SpaceOAR hydrogel spacer was placed in 100 consecutive patients undergoing iodine-125 low-dose-rate brachytherapy. Complications and the status of the placement were evaluated. Deformation of the prostate by the spacer was examined measuring prostate diameters and evaluating the change from preoperative status. The position of the prostate was similarly examined by evaluating the change in distance between the pubic symphysis and the prostate. Post-plan dosimetric data were compared with 200 patients treated without a spacer. RESULTS No complications were found during either the intraoperative or perioperative periods. The mean displacement distance of 11.64 mm was created, the mean value before spacer placement was 0.28 mm (P

We present a case of lung adenocarcinoma metastasizing to the right clear cell renal cell carcinoma diagnosed by computed tomography (CT)-guided renal biopsy and immunohistochemistry. A 72-year-old male patient had right lower abdominal pain for 3 days, followed by right loin pain for 10 days. On CT scan, renal cell cancer was suspected with multiple metastases. Renal cell cancer with metastatic lung adenocarcinoma was diagnosed on CT-guided renal biopsy with positive immunohistochemical markers. The patient, unfortunately, expired after few days of diagnosis. Tumor-to-tumor metastasis is an unusual disease, and its tumors are aggressive. A definite diagnosis of tumor-to-tumor metastasis is a clinical challenge. Immunohistochemistry helped us in the diagnosis without the primary lesion biopsy.

Castleman's disease (CD) is a unique lymphoproliferative disorder. It commonly occurs in the mediastinum, neck, axilla, and abdomen, and retroperitoneal involvement is rare. Here we report a unique case of CD in the pelvis. Laparotomy was performed and surgery was complicated by adhesions and vascularity. Total surgical duration was Five hours and 45 min with 4.5 L of blood loss. Ten pints of blood was transfused. The mass was histopathologically diagnosed as hyaline-vascular CD. The patient was free of recurrence after 10 years of follow-up.

Background: Many patients undergo unwanted prostate biopsy due to unreliability of prostate-specific antigen (PSA). PSA density (PSAD), free PSA, free-to-total PSA ratio, prebiopsy MRI are used to diagnose prostate cancer (PCa). Since 1863, correlations between inflammation and cancer have been identified and explored; thus, the role of various blood parameters in detecting cancer has been studied, especially neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Here, we evaluated whether these parameters before prostate biopsy can diagnose prostate cancer in our hospital.Methods: We conducted a retrospective study from January 2014 to January 2018. Prostate cancer patients were divided into significant cancer (Gleason Score ≥ 7) and insignificant cancer (Gleason Score < 7). NLR, PLR, and other clinical parameters were taken before the prostate biopsy. We then analyzed the associations of NLR and PLR alone or with PSA, with significant prostate cancer. Results: We included 463 patients, of whom 60.3% (279) had prostate cancer and 75.6 % (211) had a Gleason score (GS) of ≥ 7. PSA and PSAD in the clinically significant prostate cancer patient group were around two times more than those in the insignificant prostate cancer group. PV, NLR, PLR, and combined markers were more in the GS ≥ 7 population group. PSA combined with PLR (PPLR) and PSA with NLR (PNLR) had better area under a curve (AUC) (0.732 and 0.730, resp.), with statistical significance, than PSA, NLR, and PLR alone (0.723, 0.585, and 0.590). In the multivariate analysis using separate models with PSA and NLR or PLR compared to age, DRE-positive lesions, PV, PSAD; PNLR, and PPLR were statistically significant in finding aggressive prostate cancer. When combined markers were used together, despite the high correlations, PSA and NLR were nearly significant (p = 0.062) in detecting the GS ≥ 7 population.Conclusion: The combined use of PSA with PLR and PSA with NLR helps detect the differences between clinically significant and insignificant prostate cancer.

OBJECTIVE: This study aimed to assess the relationship of the prostate cancer and Gleason scores (GSs) or ISUP Grade system with prostate volume (PV) as assessed by magnetic resonance imaging (MRI) cognitive biopsy and standard biopsy. MATERIAL AND METHODS: Data were collected from 659 patients who underwent MRI cognitive biopsy and standard biopsy from January 2014 to January 2018. The biopsies were performed because of increased prostate-specific antigen (PSA) levels (>4 ng/mL) and/or abnormal digital rectal examination findings. Transrectal ultrasound was used to measure PV. RESULTS: Prostate cancer detection rates in patients with increased PVs of ≤40 cc and >40 cc were 68.8% and 51.6% (p40 cc were 68% and 73%, and 22.3% and 37.8%, respectively, for those with ISUP Grade group ≥4 (Gleason score ≥8) (p=0.003). Among the patients with PV>40 cc, univariate logistic regression showed a significant relationship between ISUP Grade group ≥2 and PSA, free/total PSA, PSA density, and MRI (p40 cc. CONCLUSION: Although the detection rates of prostate cancer decreased as PV increased, the detection of prostate cancer aggressiveness increased as PV increased. This increase in high ISUP Grade lesions with the rise in PV is due to the use of MRI during prostate biopsy with standard biopsy.

Background: The AR-V7 splice variant is a cause of castration-resistant prostate cancer (CRPC). However, testing for the presence of AR-V7 by real-time polymerase chain reaction (RT-PCR) shows AR-V7 positivity in healthy individuals. We hypothesized that the positivity reflects contamination by hematopoietic cells. We tried a novel circulating tumor cell (CTC) enrichment instrument, using Celsee, to clear hematopoietic cells. Methods: We tested whole blood or Celsee-enriched samples for AR-V7 by RT-PCR, and included samples from 41 CRPC patients undergoing sequential therapy. We evaluated the associations between AR-V7 status and clinical factors. We evaluated factors affecting AR-V7 positivity. Results: AR-V7 positivity was lower in Celsee-enriched than in whole blood specimens. AR-V7 and clinical factors did not predict the therapy effectiveness. We found no significant differences in the effectiveness of enzalutamide/abiraterone (Enz/Abi) upon AR-V7 evaluation. All AR-V7 positive patients had resistance to Enz/Abi. Docetaxel (DTX), cabazitaxel (CBZ), and Radium223 treatment showed no significant difference in the treatment effectiveness, regardless of AR-V7 presence. AR-V7 was more frequently positive than Extent of disease (EOD) 2 in cases with bone metastases. Conclusion: Celsee CTC enrichment suppresses AR-V7 false positivity. All AR-V7 positive patients presented resistance to Enz/Abi. DTX, CBZ, and Radium223 were effective and remain treatment options. AR-V7 positivity should progressively appear in patients with advanced bone metastases.

Background: The AR-V7 splice variant is a cause of castration-resistant prostate cancer (CRPC). However, testing for the presence of AR-V7 by RT-PCR shows AR-V7 positivity in healthy individuals. We hypothesized that the positivity reflected contamination by hematopoietic cells. We tried a novel CTC enrichment instrument using Celsee® to clear hematopoietic cells. Methods: We tested whole blood or Celsee-enriched samples for AR-V7 by RT-PCR and included samples from 41 CRPC patients undergoing sequential therapy. We evaluated the associations between AR-V7 status and clinical factors. We evaluated factors affecting AR-V7 positivity. Results: AR-V7 positivity was lower in Celsee-enriched than in whole blood specimens. AR-V7 and clinical factors did not predict the therapy effectiveness. We found no significant differences in the effectiveness of Enz/Abi upon AR-V7 evaluation. All AR-V7 positive patients had resistance to Enz/Abi. DTX, CBZ, and Radium223 treatment showed no significant difference in the treatment effectiveness, regardless of AR-V7 presence. AR-V7 was more frequently positive than EOD2 in cases with bone metastases. Conclusion: Celsee® CTC enrichment suppresses the AR-V7 false positivity. All AR-V7 positive patients presented resistance to Enz/Abi. DTX, CBZ, and Radium223 were effective and remained treatment options. AR-V7 positivity should progressively appear in patients with advanced bone metastases.

Objectives: Ureteropyeloscopy has recently become an essential technique in the diagnosis of upper urinary tract tumors. However, no consensus has been reached regarding its indications. In addition, it is accompanied by several limitations and potential adverse events such as dissemination of malignant cells, adhesion of the ureter to the surrounding tissue, ureteral stricture, and ureteral perforation. In order to determine when and what circumstances dictate the need for ureteropyeloscopy to detect upper urinary tract tumors, we investigated the indications for ureteropyeloscopy based on voided urine cytology and preoperative radiographic findings. Patients and Methods: In this retrospective study, we evaluated 92 patients (62 men and 30 women) with a mean age of 66.4 years (range, 15–87 years) who had undergone diagnostic ureteropyeloscopy at our institution for the past 10 years. All patients were divided into six subgroups based on voided urine cytology and preoperative radiographic findings: subgroups A1 (n = 18) and A2 (n = 2), positive cytology (positive catheter urine cytology/negative catheter urine cytology) and positive images; Subgroup B (n = 19), positive cytology and negative images; Subgroups C1 (n = 30) and C2 (n = 10), negative cytology and positive images (upper urinary tract carcinomas/other abnormal findings); Subgroup D (n = 13), negative cytology and negative images. Ureteropyeloscopic findings including histology were compared with urine cytology and radiographic findings. Results: Voided urine cytology exhibited 60.4% sensitivity and 77.3% specificity, while preoperative radiographic findings exhibited 70.8% sensitivity and 63.6% specificity. Carcinomas were detected in all patients in Subgroups A1 and A2. Carcinomas were also detected in 9 patients (47.4%) in Subgroup B, of whom 5 showed a history of bladder tumors. The remaining 10 patients all had a history of bladder cancer. In Subgroups C1, C2, and D, carcinomas were detected in 14 patients (46.7%), 1 patient (10%), and 4 patients (30.8%), respectively. These results suggested that ureteropyeloscopy should be recommended for patients with negative cytology. Three complications (pyelonephritis, renal failure, and urinary retention) were noted, but none of these was severe and all were cured within a few days. No malignant findings were obtained in any of the patients during follow-up after negative findings in ureteropyeloscopy. Conclusions: Ureteropyeloscopy is essential for detecting upper urinary tract carcinoma in patients with negative voided urine cytology and positive radiographic findings. In addition, ureteropyeloscopy seems to be used commonly among patients with positive urine cytology and negative radiographic findings, or those with bleeding from the ureteral orifice. However, unless conservative nephron-sparing treatment is considered, ureteropyeloscopy may be unnecessary for patients with positive urine cytology and positive radiographic findings.

Objectives: Prostatic abscesses are rare. The incidence of prostatic abscess has declined markedly with the widespread use of antibiotics. Obtaining improvement is difficult in many cases of prostate abscess. Today, there are no guidelines or algorithms for the treatment of prostatic abscess. In this study, the shape and size of the abscess, in addition to patient background characteristics and the clinical course, were evaluated, and the treatment strategy for prostatic abscess was examined. Methods and Material: All patients with a diagnosis of prostatic abscess in Showa University Hospital between 2003 and 2017 were retrospectively reviewed. Regarding the treatment options, the patients were divided into two groups, the conservative therapy group and the drainage group. In each group, background characteristics, culture reports, shape/size of abscess, and the presence of recurrence were evaluated. Results: All 18 patients with a diagnosis of prostatic abscess between 2003 and 2017 were retrospectively reviewed; 13 patients improved with conservative treatment alone, but drainage was performed in five patients with poor response to antibiotic therapy. All five cases requiring transurethral drainage were multifocal abscesses. Conclusions: In making a decision about the approach for drainage, it is important to assess the size and shape of the abscess using transrectal ultrasonography (TRUS), computed tomography (CT) and magnetic resonance imaging (MRI). If the abscess is the multifocal type, drainage should be considered. Based on the present study, whether the abscess is focal type or multifocal type, transurethral drainage should be considered if the abscess size exceeds 30 mm.

Upper urinary tract neuroendocrine carcinoma (UUT-NEC) is extremely rare and has a poor prognosis. Although a few cases of successful treatment have been reported, no treatment has shown established efficacy.We analyzed 70 UUT-NEC patients, including 68 with small cell neuroendocrine carcinoma (SCNEC) and large cell neuroendocrine carcinoma (LCNEC) reported between 1985 and 2017 and 2 treated at our hospital.Median patient age was 66 years, 58.6% were men, and 60% were of Asian descent. Most UUT-NECs were SCNEC (68; 95.7%), whereas LCNEC was very rare (2; 2.9%). More than half of the patients had accompanying other histological components, the most common being urothelial carcinoma (51.5%), whereas 41.4% had NEC alone. Of the 70 patients, 27 underwent additional therapy (e.g., chemotherapy and radiotherapy) along with surgery. Median survival was 15 months. In univariate analysis, stages T1-2 disease showed better prognosis than stages T3-4 (P 0.001). Additional treatment (e.g., chemotherapy and radiotherapy) significantly improved prognosis (P = 0.014). Moreover, platinum-based chemotherapy also was associated with improved prognosis (P = 0.017). For platinum-based chemotherapy, multicollinearity with additional treatments was strong, and, thus, these data were not included in the analysis. Multivariate analysis revealed pathological stage (T1-2 vs. T3-4; P = 0.003) and additional treatment (P = 0.028) to be independent predictors of improved prognosis.Although UUT-NEC has a poor prognosis, additional treatment along with surgery and therapeutic intervention and stage T1-2 disease are independent factors to improve prognosis.

An 82-year-old man underwent radiotherapy (brachytherapy, external beam radiotherapy) for prostate cancer, followed approximately five years later by endocrine therapy for biochemical recurrence, which controlled the prostate-specific antigen (PSA) level. His later admission due to severe gross hematuria and dysuria is described. Computed tomography and magnetic resonance imaging findings revealed a cystic tumor continuous with the prostate between the prostate and rectum, and this tumor was thought to be the cause of the hematuria and dysuria. Transrectal biopsy and transurethral resection of the prostate were performed for pathological diagnosis and improvement of dysuria. The pathological diagnosis was remnant prostate cancer, and the cystic tumor was thought to have developed as a result of prostate cancer recurrence. Although chemotherapy using docetaxel was considered postoperatively, the patient refused this treatment. Even though the PSA level was under control, the patient's condition progressed rapidly, with onset of pulmonary and cervical lymph node metastases within a short period of time, and the patient subsequently died.

(Objective) Enzalutamide is an oral androgen-receptor inhibitor that prolongs survival in men with castration-resistant prostate cancer (CRPC). We retrospectively evaluated clinical efficacy and safety of enzalutamide in CRPC. (Patients and methods) We reviewed clinical records of 73 patients who had received enzalutamide for the CRPC at Showa University and affiliated 7 hospitals. Enzalutamide was given at a dose of 160 mg/day, but some patients were treated at lower dose because of there age or poor performance status. Prostrate-specific antigen (PSA) response, prior docetaxel use and the previously administered agents were evaluated retrospectively. (Results) The median patients age was 77 years, the median Gleason score was 9 and the median PSA level at baseline was 26.9 ng/ml. The patients who had prior docetaxel use were 29 (39.7%) and the median of total docetaxel dose was 460 mg/body. The median number of total prior treatments (anti-androgens, Estramustine and steroid) was 3. Twenty seven (61.4%) patients with docetaxel-naive achieved over 50% reduction of PSA level from baseline, but only 7 (24.1%) in patients previously treated with docetaxel. The most common adverse events included fatigue (24.7%), anorexia (24.7%) and the nausea (16.4%). We found a small proportion of responders to enzalutamide experienced a PSA flare. (Conclusion) Our results of the use of Enzaltamide for CRPC were similar with previous reports. PSA flare was found in some patients with CRPC who responded to enzaltamide. It should be noted that this possible PSA flare phenomenon.

Excessive ammonia is harmful to the body. It is mostly hepatic in origin. Hyperammonemia due to urinary tract infection (UTI) is rare. We report a case of hyperammonemia with UTI and urinary retention. A 94-year-old female arrived at our hospital with impaired consciousness that lasted for a day. On arrival, her Glasgow Coma Scale was E1V1M5, blood ammonia was 272 ng/dl, and urinalysis revealed a large number of white and red blood cells. Abdominal computed tomography scan revealed a distended bladder and wall thickness with no hydronephrosis. Urine cultures were positive for urease-producing Corynebacterium, Escherichia coli, and Staphylococcus aureus. The patient was diagnosed with hyperammonemia with UTI and urinary retention. After urinary catheterization, blood ammonia levels normalized, and consciousness improved. We need to consider ammonia toxicity in UTI patients with urine retention presenting with altered consciousness.

Polyorchidism is a rare congenital condition associated with various anomalies; triorchidism is the most common form of this condition. A 21-year-old patient visited our hospital with pain in the right testis. He was diagnosed with right-sided polyorchidism with torsion and underwent manual detorsion followed by orchidopexy. We preserved the extra testis but did not perform histology, as radiological examination revealed no malignant features.

We report an unusual case of bilateral ureteral polyps causing intermittent hydronephrosis, which developed extensively in the upper part of ureters. The patient was an 8-year-old male. He had several episodes of gross hematuria with right flank pain. Ultrasonography of the kidney showed mild bilateral hydronephrosis, while this finding was markedly aggravated in association with the onset of pain. Intravenous pyelogram and retrograde pyelogram revealed multiple filling defects in both upper parts of ureters. Since the diseased part of the ureter was wide (about 7 cm in length), a segmental resection of the right ureter with mobilization of the right kidney was performed, followed by end-to-end ureteral anastomosis. The pathological diagnosis was fibroepithelial polyps. Regarding the disease of contralateral ureter, no surgical treatment was performed because he had no clinical symptoms. Six years after the surgery, he again developed gross hematuria with left flank pain. Marked dilatation of the left renal pelvis was shown by ultrasonography, which suggested left intermittent hydronephrosis caused by ureteral polyps. He underwent a partial ureterectomy with mobilization of the left kidney for the left ureteral disease. No recurrence of polyps has been observed in the urinary tract since this surgery.