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A 71-year-old man with gross hematuria and urinary retention showed a 7×8 cm polycystic mass compressing the prostate on the right ventral side on pelvic magnetic resonance imaging (MRI). The prostate specific antigen (PSA) level was 6.47 ng/ml. Prostate biopsy histopathology was consistent with prostate ductal carcinoma. Considering the difficulty of surgical therapy, endocrine therapy was undertaken prior to surgery for seven months. Almost all of the cyst disappeared ; robot-assisted laparoscopic radical prostatectomy was then successfully performed. Prostate ductal carcinoma is a relatively rare pathology for which radical prostatectomy plays an important role if the disease is localized. However, when ductal carcinoma involves large cysts, surgical treatment may be difficult. This report discusses the usefulness of neoadjuvant endocrine therapy to reduce the size of the cystic lesions.

平成30年度, Radical prostatectomy is associated with complications including urinary incontinence. A significant association between specific features of the vesicourethral anastomosis and urinary incontinence after radical prostatectomy has been demonstrated. The aim of this study was to identify the most useful predictor of postoperative urinary incontinence after robot-assisted laparoscopic radical prostatectomy (RALP) according to the features of the vesicourethral anastomosis as determined by postoperative cystography., The final study cohort consisted of 150 patients. Postoperative cystography was performed within 1week after RALP. The ratio between the longitudinal and horizontal lengths (L/H) of the bladder, the position of the urethrovesical junction (UVJ) and the bladder neck angle as seen on the cystogram were evaluated. Postoperative continence status was evaluated by a 1 h pad test 1 day after catheter removal and by the use of safety pads, retrieved retrospectively from patient records. The association between these variables and urinary incontinence was then analyzed. All patients were followed for at least 1year postoperatively., The continence rates on the 1 h pad test and 1month and 1year after RALP were 31.3%, 56% and 93.3%, respectively. In multivariate analyses, urinary incontinence was significantly associated with nerve sparing, L/H and the vesical angle as determined on the 1 h pad test, but only with the vesical angle at 1month and 1year postoperatively., A narrow vesical angle measured on cystography is a useful predictor of postoperative urinary incontinence after RALP.

We report a patient with seminoma which recurred as late relapse at the pelvis with elevated alphafetoprotein (AFP) levels. A 40-year-old man presented with a left testicular tumor and subsequently underwent high orchiectomy in 2006. Pathological findings showed that the tumor was a seminoma with invasion into the tunica albuginea (pT2N0M0). Seven years after surgery, computed tomography showed a 12×8.7 mm, well-circumscribed, pelvic cystic tumor, and AFP and human chorionic gonadotropin levels were elevated. He was clinically diagnosed with recurrent testicular cancer. Despite the fact that the patient had four courses of bleomycin, etoposide, and cisplatin (BEP), the tumor enlarged and AFP levels were still elevated. Therefore, we performed open excision of the pelvic tumor. Judging from the pathological report, we made the final diagnosis of mature cystic teratoma. The patient was free of recurrence or metastasis within 48 months of follow-up.

The laparoscopic management of urachal remnants has gradually become a common practice. Recently, laparoscopic single-site surgery (LESS), a minimally invasive approach that provides excellent cosmetic results, has been adopted in several surgical procedures for treating urachal remnants. However, when suturing the bladder wall or peritoneal defect during LESS it may be difficult to conduct the procedure manually, and such cases require an additional port for suturing. Our strategy, however, employs a knot pusher to perform the suturing without the need for an additional port. We compared and examined the perioperative parameters of the patients with the additional port and one without it (knot-pusher group). For the additional-port and knot-pusher groups, the average operative time, was 146.8 and 161.7 minutes respectively, pneumoperitoneal surgery time was 90.8 and 88.0 minutes, respectively, suturing time for the bladder wall was 577 and 502 seconds, respectively suturing time for peritoneal defect was 758 vs 779 seconds, respectively, and estimated blood loss was 19 and 9.6 ml, respectively ; there being no significant difference between the two groups. We report our knot-pusher method because it can achieve comparable results without compromising the surgical outcome.

Using a questionnaire, we objectively assessed the body image ofdonors who underwent conventional laparoscopic donor nephrectomy (L-DN) or laparoscopic single-site donor nephrectomy (LESS-DN). Subjects were 15 patients who underwent an L-DN and 15 who underwent an LESS-DN. The questionnaire consisted ofthe Body Image Questionnaire (BIQ), including a Body Image Scale (BIS) and Cosmetic Scale (CS), and a Photo-Series Questionnaire (PSQ). A higher score indicated a more favorable assessment, and patient scores were compared. Subjects were also asked which procedure they preferred if they had to undergo donor nephrectomy again. Pain was assessed by comparing the number oftimes an analgesic was administered during hospitalization. The average BIS score was 18.7 points (out of 20) for patients who underwent an L-DN and 19.5 points for patients who underwent an LESS-DN ; those who underwent an LESS-DN had a significantly higher score (p＝0.03). Patients who underwent an L-DN had a median CS score of 17.5 points (out of 24) while patients who underwent an LESS-DN had a median CS score of 19.1 points ; those who underwent an LESS-DN had a higher score, but the difference in average CS scores was not significant (p＝0.123). The average PSQ score was 7.1 points for patients who underwent an L-DN and 8.8 points for patients who underwent an LESS-DN ; the higher score for LESS-patients was statistically significant (p＝0.01). Patients who underwent an L-DN were administered an analgesic a median of4 times during hospitalization (range : 3-10 times) while patients who underwent an LESS-DN were administered an analgesic a median of 2 times (range : 0-4 times), which was significantly less (p＝0.01). Patients who underwent LESS-DN had a better body image and better cosmetic appearance than those who underwent LDN, thus indicating the usefulness of LESS-DN. However, a more prospective larger study needs to be performed.

To facilitate the spread of safe techniques in laparoscopic surgery, in medical faculties in Japan we created two forms for laparoscopic nephrectomy and prostatectomy that consisted of a global rating scale (GS) and our task checklist (TS) using objective structured assessment of technical skill (OSATS). We examined the correlation between the global rating scale total score (GS) and the task checklist total score (TS), and the difference in GS and TS between the instructor' s assessment and the practitioner' s selfassessment, and compared the differences in the scores at each operative step. GS was found to be closely correlated with TS (P＜0.05). Where there were differences between GS and TS, the instructor-assessed GS was higher than the self-assessed score in nephrectomy (P＜0.05). However, there was no significant difference between instructor- and self-assessed scores in prostatectomy. In nephrectomy, the instructorassessed score was higher than the self-assessed score (P＜0.05) for "creation of an operating field" and "dissection of surrounding tissue of the kidney". Assessment forms created using OSATS would be useful for quantifying the surgical skill in laparoscopic surgery. In the future, we plan to use the assessment forms to assist in surgical education and assessment.

A 47-year-old women referred to our hospital with sudden left lower abdominal pain and state of shock in April 2006. Computed tomographic (CT) scan revealed a retroperitoneal hematoma and we suspected a renal tumor or angio myolipoma but enhanced CT scan show bleeding from a left renal artery. We perfomed left renal artery angiography and admitted a arteryal stenosis. Finally we diagnosed renal artery aneurysm caused by fibromuscular dysplasia. We performed left radical nephrectomy on the same day. We report the details of this case., 47歳女。左下腹部痛、意識レベルの低下を主訴とした。左下腹部に疼痛を伴う腫瘤を触知した。CTで後腹膜に広範囲に及ぶ血腫を認めた。腎動脈壁の石灰化は認めず、直径約1.5cmの動脈瘤を認めた。血管造影で左腎動脈の狭小化と腎動脈瘤のpoolingを認めた。以上の所見から、 FMD(fibromuscular dysplasia)を伴う腎動脈瘤破裂の可能性が高いと考えた。FMDによる動脈狭小化が強度であったため、腎動脈形成術を前提とした開腹術を選択した。術中所見で、瘤が腎門部付近に存在し強度の動脈狭窄があったため腎摘除術に切り替えた。Elastica Masson染色で中膜の不規則な膠原線維の増生、平滑筋と弾性線維の走行の乱れを認めた。以上により、線維筋性異形性に起因した腎動脈瘤破裂と診断した。術後経過は良好であった。