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This fourth edition of the Japanese Clinical Practice Guidelines for Prostate Cancer 2023 is compiled. It was revised under the leadership of the Japanese Urological Association, with members selected from multiple academic societies and related organizations (Japan Radiological Society, Japanese Society for Radiation Oncology, the Department of EBM and guidelines, Japan Council for Quality Health Care (Minds), Japanese Society of Pathology, and the patient group (NPO Prostate Cancer Patients Association)), in accordance with the Minds Manual for Guideline Development (2020 ver. 3.0). The most important feature of this revision is the adoption of systematic reviews (SRs) in determining recommendations for 14 clinical questions (CQs). Qualitative SRs for these questions were conducted, and the final recommendations were made based on the results through the votes of 24 members of the guideline development group. Five algorithms based on these results were also created. Contents not covered by the SRs, which are considered textbook material, have been described in the general statement. In the general statement, a literature search for 14 areas was conducted; then, based on the general statement and CQs of the Japanese Clinical Practice Guidelines for Prostate Cancer 2016, the findings revealed after the 2016 guidelines were mainly described. This article provides an overview of these guidelines., (© 2024 The Japanese Urological Association.)

Objective: We investigated preoperative patient factors associated with prognosis in 263 bladder cancer (BC) patients undergoing radical cystectomy (RC). We also developed new risk stratification models for prognosis., Methods: This retrospective study included patients treated at Tottori University Hospital and affiliated hospitals between January 2010 and December 2019. The relationship between preoperative patient factors and overall recurrence-free and cancer-specific survival (CSS) was analyzed. The modified Glasgow prognosis score (mGPS) was calculated using serum albumin and C-reactive protein (CRP) levels. Statistical analyses included the log-rank test and Cox proportional hazards regression., Results: Eastern Cooperative Oncology Group performance status (ECOG-PS), mGPS, and clinical tumor stage independently predicted CSS in multivariate analysis. A new risk stratification model included ECOG-PS ≥2, clinical tumor stage ≥3, serum albumin <3.5 g/dL, and serum CRP >0.5 mg/dL. Risk groups were defined as 0 factors (low risk), 1-2 factors (intermediate risk), and 3-4 factors (high risk). High-risk patients showed significantly poorer 3-year cancer-free survival: 86.9% (low risk), 76.7% (intermediate risk), and 50.0% (high risk)., Conclusions: ECOG-PS, clinical tumor stage, and mGPS are predictive of poor cancer-free survival post-RC for BC. Our model offers the potential for prognostic prediction in these patients., (© 2024 The Japanese Urological Association.)

Pelvic lymph node dissection (PLND) is important for accurate staging and prognosis of prostate and/or bladder cancer. Several guidelines recommend extended PLND for patients with these cancers. However, the therapeutic benefits of extended PLND are unclear. One major reason is that the extent of PLND is not clearly defined. Thus, the working group for standardization of robot-assisted PLND, including nine experienced urologists for PLND in Japan, was launched in January 2023 by the Japanese Society of Endourology and Robotics. This study summarized the discussions to define the individual extent of PLND in urological surgery in a consensus meeting among these experienced urologists. The consensus meeting determined the extent of PLND based on arteries (veins) and anatomical membrane structures rather than a vague concept or approach toward PLND. This concept is expected to allow surgeons to implement the same extent of PLND. Finally, after a total of 10 online web conferences were held, we determined the extent of PLND for the obturator lymph node (LN) area, the internal iliac LN area, the external and common iliac LN area, and the presacral LN area according to the above rules. The extent of PLND suggested here currently does not have a clear therapeutic rationale. Therefore, the extent of our proposed PLND is by no means mandatory. We hope our definition of the extent of PLND will be supported by further evidence of therapeutic benefits for urologic cancers., (© 2024 The Japanese Urological Association.)

Objectives: To investigate preoperative patient factors that may predict the occurrence of perioperative complications following robot-assisted radical cystectomy at a single center in Japan., Methods: From 2013 to 2022, 103 patients underwent RARC at our institution. Complications within 90 days after surgery were assessed using the Clavien-Dindo classification. Preoperative characteristics and surgical outcomes were compared between cohorts with and without complications ≥grade 3. Logistic regression analysis was used to identify the risk factors associated with perioperative complications., Results: Overall, 27% of patients (27/103) experienced grade 3 or higher complications. The cohort that developed complications ≥grade 3 exhibited significantly higher Charlson comorbidity index (p = 0.046) and significantly lower estimated glomerular filtration rate (p = 0.048). Charlson comorbidity index ≥2 (p = 0.037) and estimated glomerular filtration rate <53 (p = 0.008) were independent predictors for the occurrence of complications ≥grade 3. The incidence of complications ≥grade 3 was 61.5% in the group possessing both factors, which was significantly higher than those in the groups possessing neither factor nor only one of the two factors., Conclusions: Our results suggest that the Charlson comorbidity index and preoperative estimated glomerular filtration rate may be predictors of perioperative complications. It is important to evaluate the patient's preoperative characteristics and choose the surgical procedure accordingly., (© 2023 The Japanese Urological Association.)

This article is an English translation of the Clinical Practice Guidelines for Upper Tract Urothelial Carcinoma (2nd edition) published in June 2023. The Japanese Urological Association's (JUA) Guidelines Committee on Upper Tract Urothelial Carcinoma (UTUC) created a 2023 update guideline to support clinicians' current evidence-based management of UTUC and to incorporate its recommendations into clinical practice. The new guideline adhered as closely as possible to the Minds Manual for Guideline Development 2020 ver. 3.0. Findings related to epidemiological, pathological, diagnosis, treatment, and follow-up were reviewed. In addition, seven clinical questions (CQs) were set to determine the grade of recommendation and level of evidence. Preconceptions and biases were removed from the preparation process, the overall evidence was evaluated appropriately, and recommendations were made after fully considering the balance between benefits and harms. Although the evidence is still insufficient to be taken up as a CQ, the latest important information is described in seven columns, and clinical issues that should be resolved in the future related to the CQ are described as recommendations for tomorrow. We hope that these guidelines will help medical professionals, patients, and their families involved in the treatment of UTUC in their decision-making, and hope that a critical review of these guidelines will lead to further refinements in the next edition., (© 2023 The Authors. International Journal of Urology published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Urological Association.)

Objective: To investigate the involvement of pretreatment C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) in the prognosis of patients who underwent intravesical bacillus Calmette-Guérin (BCG) therapy for non-muscle invasive bladder cancer (NMIBC)., Methods: The clinicopathological data of 1709 patients with NMIBC who underwent initial intravesical BCG therapy after transurethral resection of bladder tumor were retrospectively analyzed to evaluate the outcome of intravesical BCG therapy in a multicenter study conducted by the Japan Urological Oncology Group. The prognoses of these patients were analyzed to determine whether the biomarkers (CRP and NLR) could predict the efficacy of intravesical BCG therapy. Patients were divided into two groups according to the pretreatment CRP and NLR, with cutoff values defined as CRP ≥ 0.5 mg/dl and NLR ≥ 2.5, based on several previous reports., Results: In the univariable analysis, CRP ≥ 0.5 mg/dl was significantly associated with intravesical recurrence, cancer-specific survival, and bladder cancer (BC) progression, while NLR ≥ 2.5 was not significantly associated with patient prognosis. In the multivariable analysis, CRP ≥ 0.5 mg/dl was significantly associated with intravesical recurrence and BC progression. The concordance index was used to examine the accuracy in predicting recurrence and progression events. While CRP was slightly, though not statistically significant, inferior to the European Association of Urology risk classification, the combination of them showed improved predictive accuracy., Conclusion: This study suggests that CRP can be a prognostic factor after intravesical BCG therapy and may provide useful data for determining treatment and follow-up strategies for patients with NMIBC., (© 2022 The Japanese Urological Association.)

The objective of this review study is to evaluate the therapeutic role of PDE5 inhibitors (PDE5is) in the amelioration of oligoasthenospermia in infertile males. PDE5is have a beneficial influence on the secretory function of the Leydig and Sertoli cells, the biochemical environment within the seminiferous tubule, the contractility of the testicular tunica albuginea, and the prostatic secretory function. In several studies, the overall effect of sildenafil and vardenafil increased quantitative and qualitative sperm motility. Furthermore, some studies indicate that PDE5is influence positively the sperm capacity to undergo capacitation under biochemical conditions that are known to induce the sperm capacitation process. Additional research efforts are necessary in order to recommend unequivocally the usage of sildenafil, vardenafil, or avanafil for the alleviation of male infertility., (© 2022 The Japanese Urological Association.)

Objective: We sought to evaluate the incidence and extent of orgasmic dysfunction in patients after robot-assisted radical prostatectomy and to identify factors that could predict patients at risk., Methods: A single-center, questionnaire-based, cross-sectional study was conducted on patients who underwent robot-assisted radical prostatectomy (n = 523) between October 2010 and November 2019. In addition to six questions about sexual activity, orgasmic function, altered perception of orgasms, dysorgasmia, and climacturia, the International Consultation on Incontinence Questionnaire Short Form was administered. In February 2020, a letter was mailed inviting patients to participate in the survey. The primary outcome measure was the rate of orgasmic dysfunction. Logistic regression analyses were used to identify predictors of orgasmic dysfunction., Results: Overall, 259 questionnaires were used for analysis. Among sexually active patients (n = 145), 33 (22.8%) reported anorgasmia, and 83 (57.2%) reported decreased orgasm intensity. Twenty-two (15.1%) patients reported dysorgasmia; among these patients, the pain was experienced almost always or always in 13.6%, sometimes in 13.6%, and a few times in 72.8% of cases. Climacturia was reported by 44 patients (30.3%). Nerve-sparing procedures decreased the risk of anorgasmia (odds ratio 0.37, 95% confidence interval 0.15-0.88) and urinary incontinence increased the risk of climacturia (odds ratio 3.13, 95% confidence interval 1.20-8.15)., Conclusions: These results indicate that orgasmic dysfunction after robot-assisted radical prostatectomy is relatively common., (© 2022 The Japanese Urological Association.)

Objectives: Robot-assisted partial nephrectomy is widely performed for small renal masses, achieving excellent perioperative and intermediate oncological outcomes. However, long-term oncological, functional, and quality of life outcomes after robot-assisted partial nephrectomy remain unclear. In this study, we aimed to evaluate quality of life at 1 year and oncological and functional outcomes of robot-assisted partial nephrectomy after a minimum follow-up of 5 years., Methods: Personal, perioperative, postoperative, functional, oncological, and quality of life data were evaluated. The EQ-5D-5L tool, which incorporates health profiles and a EuroQol Visual Analog Scale, was used to assess quality of life preoperatively and 365 days postoperatively. Regarding oncological and functional outcomes, overall survival, recurrence-free survival, and changes in estimated glomerular filtration rate were calculated., Results: There were few changes in levels between the two time points for all EQ-5D dimensions. The mean change in EQ-5D-5L was 0.020 (95% confidence interval 0.006-0.033, P = 0.006), and in EuroQol Visual Analog Scale score 4.60 (95% confidence interval 2.17-7.02, P = 0.0003). Overall and recurrence-free survival 5 years after robot-assisted partial nephrectomy were 97.9% and 92.8%, respectively. After an early postoperative decrease, the estimated glomerular filtration rate remained stable over time., Conclusions: Robot-assisted partial nephrectomy in patients with a T1 renal tumor is safe, feasible, and effective from the perspective of quality of life and survival, even after 5 years. When making treatment decisions, perioperative and quality of life outcomes should be considered together with long-term oncological outcomes., (© 2022 The Japanese Urological Association.)

Objective: To investigate the impact of penile rehabilitation on the recovery of erectile function after robot-assisted radical prostatectomy., Methods: Patients who underwent robot-assisted radical prostatectomy in our department from 2010 to 2019 were included. For penile rehabilitation, a phosphodiesterase-5 inhibitor (tadalafil 20 mg) was administered twice a week for 1-6 months postoperatively. The International Index of Erectile Function questionnaire (question 1 and erectile function domain) and the Expanded Prostate Cancer Index Composite questionnaire (sexual function) were used., Results: After propensity score matching, there were 79 patients in the penile rehabilitation group and 79 patients in the non-penile rehabilitation group. There was no significant difference in baseline characteristics between the two groups. Significantly higher scores were seen in the penile rehabilitation group compared with the non-penile rehabilitation group at postoperative 3, 6 and 9 months in the International Index of Erectile Function questionnaire-question 1, at 3, 6, 9 and 12 months in erectile function domain, and at 3, 6, 12 and 24 months in Expanded Prostate Cancer Index Composite questionnaire sexual function (P < 0.05). There were significant improvements in the erectile recovery rate in the penile rehabilitation group compared with the non-penile rehabilitation group in the nerve sparing (P = 0.006) and partial nerve sparing (P = 0.037) groups., Conclusions: The present findings suggest that robot-assisted radical prostatectomy patients who undergo not only nerve sparing, but also those who undergo patial nerve sparing could benefit from penile rehabilitation using a phosphodiesterase-5 inhibitor., (© 2021 The Japanese Urological Association.)

Objective: To investigate whether robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy is effective for renal hilar tumor removal., Methods: This was a prospective, multicenter, single-arm, open-label trial with a 2-year enrollment period. A total of 22 academic hospitals in Japan participated in the present study. Comparison with historical control values from reported studies of laparoscopic partial nephrectomy was carried out. The warm ischemia time and positive surgical margin rate were set as primary perioperative and oncological outcomes. In the historical control group, these were 27.7 min and 13%, respectively., Results: The analysis population included 105 participants. The mean warm ischemia time was 20.2 (95% confidence interval 16.7-21.8; P < 0.0001 vs 27.7). Two of 103 participants (1.9%) had a positive surgical margin (95% confidence interval 0.5-6.8%). Both results satisfy the prespecified decision criteria for the superiority of robot-assisted partial nephrectomy over the historical control of laparoscopic partial nephrectomy. Resected weight and preoperative estimated glomerular filtration rate were predictive factors of functional loss of the partially nephrectomized kidney after robot-assisted partial nephrectomy., Conclusion: Robot-assisted partial nephrectomy for clinical T1 renal hilar tumors results in shorter warm ischemia time than and comparable positive surgical margin rate to those reported for laparoscopic partial nephrectomy., (© 2020 The Japanese Urological Association.)

Objectives: To investigate the impact on intravesical recurrence and prognosis according to the ureteral ligation timing during radical nephroureterectomy for upper urinary tract urothelial carcinoma., Methods: We carried out a retrospective chart review of 664 patients with non-metastatic upper urinary tract urothelial carcinoma who underwent radical nephroureterectomy with ureteral ligation (supplementary analysis of JCOG1110A). We excluded patients with previous and/or synchronous bladder cancer, clinically node-positive disease, no ureteral ligation data, those without ureteral ligation and those with any missing data. We investigated the cumulative incidence of intravesical recurrence and cancer-specific mortality, and overall survival between patients with ureteral ligation before renovascular ligation (early ureteral ligation), or ureteral ligation after renovascular ligation (late ureteral ligation)., Results: Early and late ureteral ligation was carried out in 243 patients (36.6%) and 421 patients (63.4%), respectively. Intravesical recurrence occurred in 218 patients (32.8%) during follow up (median 3.9 years). No significant difference in the intravesical recurrence was found between early and late ureteral ligation groups. Meanwhile, survival in the early ureteral ligation group was significantly worse compared with the late ureteral ligation group. Multivariable analysis showed that early ureteral ligation was an independent prognostic factor for overall survival (hazard ratio 1.88, 95% confidence interval 1.24-2.85, P = 0.003) and cancer-specific mortality (hazard ratio 1.93, 95% confidence interval 1.14-3.25, P = 0.014)., Conclusions: Our findings suggest that the incidence of intravesical recurrence is not affected by the timing of ureteral ligation during radical nephroureterectomy. However, early ureteral ligation might have a negative impact on survival outcomes., (© 2020 The Japanese Urological Association.)

Objectives: To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers., Methods: Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end-point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan., Results: A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end-point was 91.3% (95% confidence interval 84.1-95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was -10.8 mL/min/1.73 m 2 (95% confidence interval -12.3-9.4%)., Conclusions: Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future., (© 2018 The Japanese Urological Association.)

Objective: To analyze nerve sparing performance at an early stage of robot-assisted radical prostatectomy, and the correlation between the surgeons' experience and the risk of a positive surgical margin in patients treated with robot-assisted radical prostatectomy., Methods: Patients' records from January 2009 to March 2013 were retrospectively reviewed, and 3469 patients with localized prostate cancer were identified at 45 institutions. Individual surgeon's experience with nerve sparing was recorded as the number of nerve sparing cases among total robot-assisted radical prostatectomies beginning with the first case during which nerve sparing was carried out. Patients were selected by propensity score matching for nerve sparing, and predictive factors of positive surgical margins were analyzed in patients with and without positive surgical margins., Results: A total of 152 surgeons were studied, and the median number of robot-assisted radical prostatectomy cases for all surgeons was 21 (range 1-511). In all, 54 surgeons (35.5%) undertook nerve sparing during their first robot-assisted radical prostatectomy case. For 2388 patients selected with (1194) and without (1194) nerve sparing, predictive factors for positive surgical margin were high initial prostate-specific antigen level (P < 0.0001), high biopsy Gleason score (P = 0.0379), presence of neoadjuvant hormone therapy (P = 0.0002) and surgeon's experience with >100 cases (P = 0.0058). Thus, nerve sparing was not associated with positive surgical margins., Conclusion: The surgeon's experience influences the occurrence of positive surgical margins, although a considerable number of surgeons carried out nerve sparing during their early robot-assisted radical prostatectomy cases. Surgeons should consider their own experience and prostate cancer characteristics before carrying out a nerve sparing robot-assisted radical prostatectomy., (© 2017 The Japanese Urological Association.)

Objective: To evaluate the prognostic significance of the neutrophil-to-lymphocyte ratio in patients receiving chemotherapy with docetaxel for castration-resistant prostate cancer., Methods: A total of 57 castration-resistant prostate cancer patients treated between 2009 and 2014 were included in the present retrospective study. All patient data, including clinicopathological factors, were assessed. Univariate and multivariate Cox regression models were used to predict overall survival and progression-free survival after chemotherapy initiation., Results: The median overall survival and progression-free survival were determined as 19.0 months (range 1-61 months) and 10.0 months (range 1-56 months), respectively. The cut-off level of the neutrophil-to-lymphocyte ratio was set as the median value of 3.5 among all patients in this study. In Kaplan-Meier analysis, the median overall survival and progression-free survival were shorter in patients with a high neutrophil-to-lymphocyte ratio compared with those with a low neutrophil-to-lymphocyte ratio (15 vs 20 months, P = 0.0125; and 9.5 vs 15 months, P = 0.0132, respectively). The overall survival and progression-free survival periods in patients with a high neutrophil-to-lymphocyte ratio were significantly shorter than those of patients with a low neutrophil-to-lymphocyte ratio (P = 0.0178 and 0.0176, respectively). In the multivariate analysis, a high neutrophil-to-lymphocyte ratio was an independent predictor of overall survival and progression-free survival (hazard ratio 2.728, 95% confidence interval 1.05-7.09, P = 0.039; and hazard ratio 2.376, 95% confidence interval 1.12-5.06, P=0.024, respectively)., Conclusion: The present study results suggest that the neutrophil-to-lymphocyte ratio is a useful prognostic factor in patients with castration-resistant prostate cancer treated by docetaxel chemotherapy. These findings might be useful in determining treatment strategies in the future., (© 2015 The Japanese Urological Association.)

Objectives: To evaluate the influence of prior abdominal surgery on surgical outcomes of robot-assisted radical prostatectomy in an early single center experience in Japan., Methods: We reviewed medical records of patients with localized prostate cancer who underwent robot-assisted radical prostatectomy from October 2010 to September 2013 at Tottori University Faculty of Medicine, Yonago, Tottori, Japan. Patients with prior abdominal surgery were compared with those with no prior surgery with respect to total operative time, port-insertion time, console time, positive surgical margin and perioperative complication rate. Furthermore, the number of patients requiring minimal adhesion lysis was compared between the two groups., Results: Of 150 patients who underwent robot-assisted radical prostatectomy, 94 (63%) had no prior abdominal surgery, whereas 56 patients (37%) did. The mean total operative time was 329 and 333 min (P = 0.340), mean port insertion time was 40 and 34.5 min (P = 0.003), mean console time was 255 and 238 min (P = 0.145), a positive surgical margin was observed in 17.9% and 17.0% patients (P = 0.896), and the incidence of perioperative complications was 25% and 23.4% (P = 0.825), respectively, in those with and without prior abdominal surgery. In the prior abdominal surgery group, 48 patients (80.4%) required adhesion lysis at the time of trocar placement or while operating the robotic console., Conclusion: Robot-assisted radical prostatectomy appears to be a safe approach for patients with prior abdominal surgery without increasing total operative time, robotic console time, positive surgical margin or the incidence of perioperative complications., (© 2014 The Japanese Urological Association.)

Objective: To evaluate the impact of anatomical dimensions as measured using preoperative magnetic resonance imaging on the outcomes of robot-assisted laparoscopic prostatectomy., Methods: We retrospectively reviewed 100 consecutive robot-assisted laparoscopic prostatectomy procedures that were carried out by a single surgeon at the Division of Urology, Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan. Preoperative clinical data and anatomical measurements, including the calculated prostate volume pelvic cavity index, were determined based on preoperative magnetic resonance imaging, and their effects on console time, estimated blood loss and surgical margin status were compared., Results: Body mass index, the prostate anteroposterior diameter, and the prostate volume-to-pelvic cavity index ratio were all significantly correlated with console time and estimated blood loss, based on a univariate analysis (P < 0.05). The prostate craniocaudal diameter, prostate transverse diameter and prostate volume also correlated with console time. However, based on the multiple linear regression analysis, only the prostate volume-to-pelvic cavity index ratio was found to be a significant predictor of console time and estimated blood loss. Furthermore, when the 100 total cases were divided into 50 early cases and 50 late cases, the prostate volume-to-pelvic cavity index ratio correlated with console time and estimated blood loss only in the early group, and not in the late group. In contrast, anatomical measurements had no significant effect on surgical margin status., Conclusion: Magnetic resonance imaging can be a valuable adjunct to robot-assisted laparoscopic prostatectomy. Our data show that patients with larger prostates and narrow, deep pelvises might present more difficulty in robot-assisted laparoscopic prostatectomy procedures. However, the present data also show that this problem can be overcome by an experienced operator with improved surgical techniques., (© 2014 The Japanese Urological Association.)

The preoperative prediction of post-radical nephrectomy renal insufficiency plays an important role in the decision-making process regarding renal surgery options. Furthermore, the prediction of both postoperative renal insufficiency and postoperative cardiovascular disease occurrence, which is suggested to be an adverse consequence caused by renal insufficiency, contributes to the preoperative policy decision as well as the precise informed consent for a renal cell carcinoma patient. Preoperative nomograms for the prediction of post-radical nephrectomy renal insufficiency, calculated using patient backgrounds, are advocated. The use of these nomograms together with other types of nomograms predicting oncological outcome is beneficial. Post-radical nephrectomy attending physicians can predict renal insufficiency based on the normal renal parenchymal pathology in addition to preoperative patient characteristics. It is suggested that a high level of global glomerulosclerosis in nephrectomized normal renal parenchyma is closely associated with severe renal insufficiency. Some studies showed that post-radical nephrectomy severe renal insufficiency might have an association with increased mortality as a result of cardiovascular disease. Therefore, such pathophysiology should be recognized as life-threatening, surgically-related chronic kidney disease. On the contrary, the investigation of the prediction of mild post-radical nephrectomy renal insufficiency, which is not related to adverse consequences in the postoperative long-term period, is also promising because the prediction of mild renal insufficiency might be the basis for the substitution of radical nephrectomy for nephron-sparing surgery in technically difficult or compromised cases. The deterioration of quality of life caused by post-radical nephrectomy renal insufficiency should be investigated in conjunction with life-threatening matters., (© 2014 The Japanese Urological Association.)

Objectives: The present study investigated prognostic indicators, including clinicopathological and preoperative hematological factors, and developed a prognostic factor-based risk stratification model in bladder cancer patients treated with radical cystectomy., Methods: Data were collected from 249 consecutive bladder cancer patients treated with radical cystectomy without neoadjuvant therapy. Prognostic values of the preoperative hematological parameters, along with the patients' clinicopathological parameters were evaluated. A risk stratification model was developed to predict disease-specific survival after radical cystectomy using the regression coefficients of multivariate analysis., Results: In the multivariate analysis, preoperative hemoglobin and C-reactive protein levels, as well as the pathological factors of T stage, positive surgical margin and lymph node metastasis, were independently predictive of disease-specific survival. Low hemoglobin (<10.5 g/dL), a high C-reactive protein (>0.5 mg/dL), extravesical T stage (≥pT3a) and positive surgical margin were independent predictors of poor disease-specific survival. The risk stratification model showed significant differences in disease-specific survival between the three subgroups., Conclusions: This is the first report to show the significance of combining preoperative hemoglobin with the pathology of radical cystectomy specimens as an independent predictor for disease-specific survival, and it also represents the largest contemporary series to date demonstrating that two types of preoperative hematological disorders, assessed by hemoglobin and C-reactive protein, are independent predictors in bladder cancer patients treated with radical cystectomy. Our risk stratification model could provide physicians with useful prognostic information for identifying patients who might be candidates for multimodal treatments., (© 2013 The Japanese Urological Association.)

We analyzed whether three-dimensional vision, practice or previous laparoscopic experience improves the surgical performance of the bedside assistant during robot-assisted surgery. Six experienced laparoscopic surgeons and 15 novices carried out three skills drills imitating an assistant's maneuvers in robot-assisted surgery, and times for completing the tasks were recorded. Both the novice and experienced groups showed significantly shorter manipulation times for each drill with three-dimensional vision compared with two-dimensional or glassless three-dimensional vision. The experienced group showed significantly shorter manipulation times than the novice group for all types of vision. A significant improvement was observed 14 out of 18 times in the novice group, but only one out of 18 times in the experienced group. We can conclude that the use of three-dimensional visualization facilitates the performance of the assistant surgeon, especially if a novice, during robot-assisted surgery. Laparoscopic experience also improves the performance, whereas training is beneficial for novice assistant surgeons before carrying out actual operations., (© 2013 The Japanese Urological Association.)

Objectives: To investigate mortality rates and to comprehensively analyze prognostic indicators after radical nephrectomy for renal cell carcinoma., Methods: Data were collected from 147 patients who underwent potentially curative radical nephrectomy for renal cell carcinoma. The following data were analyzed: tumor pathology, patient demographics and clinical parameters, such as pre- and postoperative estimated glomerular filtration rate, as well as the cause of death. Cause-specific survival rates were calculated including deaths caused by renal cell carcinoma and cardiovascular disease. A Cox proportional hazard model was used for statistical analysis., Results: A univariate analysis showed that age at surgery (≥70 years), postoperative estimated glomerular filtration rate (<45 mL/min/1.73 m(2)), pathological high T stage, grade and venous invasion were significant poor prognostic indicators. The multivariate analysis provided evidence that pathological venous invasion was a significant poor prognostic indicator, whereas age at surgery (≥70 years), pre- (<65 mL/min/1.73 m(2)) or postoperative (<45 mL/min/1.73 m(2)) estimated glomerular filtration rate and pathological high grade were significant poor prognostic indicators in T1 tumor cases., Conclusions: Post-radical nephrectomy renal function insufficiency can lead to a poor prognostic outcome, especially in patients with T1 renal cell carcinoma. Physicians should consider a comprehensive follow up focusing on possible causes of death, including those related to both renal cell carcinoma and cardiovascular disease events after radical nephrectomy., (© 2012 The Japanese Urological Association.)

The procedure of radical prostatectomy has changed rapidly since the introduction of laparoscopic and robotic surgery, which allows for clear, highly magnified visualization. The da Vinci surgical system enables three-dimensional visualization and makes use of instruments with seven degrees of freedom. Since its introduction, the use of robot-assisted radical prostatectomy has spread rapidly worldwide. However, adaptation to changes in surgical techniques using knowledge of classical pelvic anatomy has been difficult. In this report, we reviewed the progress in knowledge of pelvic anatomy, particularly regarding the cavernous nerves, prostatic fascia, Denonvilliers' fascia, endopelvic fascia, bladder neck and apex of the prostate, with regard to radical prostatectomy., (© 2012 The Japanese Urological Association.)

Objectives: To report our experience with intravesical injection of botulinum toxin type A into the detrusor muscle of patients with neurogenic detrusor overactivity secondary to suprasacral spinal cord lesions or multiple sclerosis., Methods: Between January 2003 and March 2011, 11 patients (aged 23-75 years) were treated with 40 injections of botulinum toxin type A 300 U. The patients were followed up for 4, 8 and 12 weeks after treatment. The King's Health Questionnaire was administered and cystometric studies were carried out at baseline and 8 weeks after treatment., Results: A total of six women and five men were treated. Analysis of the King's Health Questionnaire showed a significant improvement in eight of the nine domain scores at 8 weeks from baseline. On cystometric studies, the mean maximum cystometric capacity increased significantly in all patients at 8 weeks from baseline (P < 0.001). Bladder compliance also increased significantly (P < 0.001). The number of urinary incontinence episodes per day improved significantly from baseline after injection (4 weeks, P < 0.001; 8 weeks, P < 0.001; 12 weeks, P < 0.001). Lack of efficacy appeared 7.15 ± 3.4 months after treatment., Conclusions: Injection of botulinum toxin type A into the detrusor muscle of patients with neurogenic detrusor overactivity secondary to suprasacral spinal cord lesions or multiple sclerosis consistently improves bladder control and quality of life., (© 2012 The Japanese Urological Association.)

Robotic-assisted laparoscopic prostatectomy has consolidated the position of surgical treatment for localized prostate cancer in the USA. In a few years, it is expected to spread rapidly worldwide. However, surgical anatomy has trailed the advance in surgical techniques of robotic-assisted laparoscopic prostatectomy. Therefore, we reviewed the recent literature, which sometimes refutes the established consensus on pelvic anatomy, for the state-of-the-art technique. We also describe the anatomical findings for each basic step during robotic-assisted laparoscopic prostatectomy, and show evidence-based surgical techniques. Of course, these findings will also be useful for radical retropubic, perineal and conventional laparoscopic prostatectomy. Surgical anatomy should always be developing and changing with advances in surgical approaches., (© 2011 The Japanese Urological Association.)

The objective of the present study was to assess the use of salvage chemotherapy using methotrexate, etoposide and actinomycin D (MEA) in men with nonseminomatous germ cell tumor (NSGCT) with a choriocarcinoma component. Nine patients were included. They had initially received bleomycin, etoposide and cisplatin, and high-dose ifosfamide, carboplatin and etoposide as induction chemotherapies. However, they failed to achieve the normalization of ß-human chorionic gonadotropin (ß-HCG). Therefore, MEA therapy (methotrexate: 450 mg/body on day 1, actinomycin D: 0.5 mg/body on days 1–5, etoposide: 100 mg/body on days 1–5) was subsequently administered. After MEA therapy (median: 3 cycles), serum ß-HCG was normalized in five of the nine patients. Of these five, three achieved long-term disease-free survival and one died of disease unrelated to NSGCT, whereas the remaining patient developed disease recurrence and died of disease progression. All four patients who failed to achieve the normalization of ß-HCG died of disease progression. Although several severe toxicities greater than grade 3, which were mainly associated with bone marrow suppression, occurred in all patients, there was no treatment-related death. Considering the current outcomes, MEA regimen could be an attractive option as a salvage chemotherapy for metastatic NSGCT patients with a choriocarcinoma component showing resistance to intensive conventional chemotherapies.

Objective: The aim of this study was to review the association between body mass index (BMI) and perioperative outcomes of laparoscopic radical nephrectomy (LRN) in Japanese patients with renal cell carcinoma (RCC)., Methods: This study included 108 consecutive Japanese patients undergoing LRN for RCC between April 2001 and March 2009. These patients were divided into the following two groups according to BMI: the non-obese group (n= 58, BMI 25 kg/m(2) or less) and the obese group (n= 50, BMI greater than 25 kg/m(2)). Perioperative outcomes between these two groups were retrospectively compared., Results: There were no significant differences in clinicopathological parameters other than BMI between the non-obese and obese groups. There were no significant differences in operative time, estimated blood loss during LRN, and the incidences of open conversion and postoperative complications between these two groups. In addition, there were no significant differences in parameters related to postoperative recovery, including time to walk, time to oral intake and time until permission for discharge, between these two groups. However, significant trends toward a prolonged operative time (P= 0.0050) and increased blood loss (P= 0.012) during LRN in relation to BMI were documented by linear regression analyses., Conclusions: Although the degree of obesity in patients included in this study was comparatively slight, these findings suggest that LRN can be safely performed for patients with RCC irrespective of BMI. However, the difficulty of LRN may increase with BMI considering the trends toward longer operative time as well as greater blood loss.

Objectives: To evaluate the expression levels of multiple molecular markers in radical nephrectomy specimens from patients with metastatic renal cell carcinoma (RCC) who received combined immunotherapy with interferon-alpha (IFN-alpha) and low-dose interleukin-2 (IL-2) and to identify factors predicting susceptibility to this therapy., Methods: This study included 40 patients with metastatic clear cell RCC undergoing combined immunotherapy with IFN-alpha and low-dose IL-2 following radical nephrectomy. Expression levels of 10 markers, including Aurora-A, Bcl-2, clusterin, heat shock protein 27, heat shock protein 90, Ki-67, matrix metalloproteinase-2, matrix metalloproteinase-9, p53 and vascular endothelial growth factor, in RCC specimens were measured using immunohistochemical staining., Results: In this series, one, 10, 15 and 16 patients were diagnosed as showing complete response, partial response, stable disease and progressive disease, respectively. Expression levels of Bcl-2 and Ki-67 had significant impacts on the response to this therapy. Furthermore, cancer-specific survival was significantly associated with the expression levels of Ki-67 and Bcl-2 in addition to performance status, presence of metastases at diagnosis, metastatic organ and C-reactive protein on univariate analysis. Only the presence of metastases at diagnosis and Ki-67 expression level appeared to be independent predictors of cancer-specific survival on multivariate analysis., Conclusions: It would be useful to consider the expression levels of potential molecular markers, particularly Ki-67, in addition to clinical parameters, such as the presence of metastases at diagnosis, to select metastatic RCC patients likely to benefit from combined immunotherapy.

Objectives: To compare the surgical margin (SM) status between open and laparoscopic radical prostatectomy (RRP and LRP, respectively) specimens., Methods: Surgical specimens from 137 patients undergoing LRP and 220 patients undergoing RRP for clinically localized prostate cancer were included in the analysis. SM status in each resected specimen, including the number of positive SM as well as their location, was examined., Results: The incidence of positive SM in the LRP group was significantly greater than that in the RRP group. Despite the lack of significant difference in the proportion of solitary positive SM between these two groups, the proportion of multiple positive SM in the LRP group was significantly greater than that in the RRP group. There was no significant difference in the incidence of anterior positive SM between the two groups, while the incidences of positive SM at the apex, posterior site and bladder neck in the LRP group were significantly greater than those in the RRP group. Furthermore, there were no significant preoperative parameters predicting positive SM in the LRP group. On the other hand, the biopsy Gleason score and clinical T stage were identified as significant predictors of positive SM in the RRP group, of which the biopsy Gleason score was independently related to the presence of positive SM., Conclusions: Clinical T stage and Gleason score could be useful predictors of SM status following RRP, while positive SM in LRP specimens were detected irrespective of preoperative parameters, suggesting the need for an effort for further refining the LRP procedure.

Objectives: To clarify the topographical relationship between the urethral rhabdosphincter and the rectourethralis muscle as these structures lying dorsally to membranous urethra are important factors to post-prostatectomy urinary continence., Methods: Pelvic floor specimens including prostate, bulbus penis, and anorectum, obtained from 15 male cadavers (ages at death 66 to 80 years), were examined with standard histologic and immunohistochemical techniques using semiserial sagittal and transverse sections., Results: The rectourethralis muscle was defined. It was found to be located at the interface between the levator ani muscle and rectum. It was not possible to histologically identify the fibromuscular node known as the perineal body. The urethral rhabdosphincter was found to be inserted into the rectourethralis muscle, which is composed of the smooth muscle fibers. Abundant nerves passed between the rectourethralis muscle and the levator ani, or through the rectourethralis muscle. The urethral rhabdosphincter was closely attached to the apical or ventral portion of the rectourethralis muscle. Morphologically, the membranous urethra was fixed to the rectourethralis muscle through the urethral rhabdosphincter., Conclusions: The rectourethralis muscle influences the stabilization of membranous urethra. The posterior stitches for the reconstruction of the dorsal musculofascial plate might injure the nerve fibers running along and through the rectourethralis muscle.

Objectives: To evaluate the long-term functional outcomes of various types of orthotopic neobladder (NB)., Methods: Eighty-nine patients who underwent orthotopic NB reconstruction after radical cystectomy and were followed for at least 60 months after surgery were included in this retrospective study. The types of NB in this series were: modified Studer type, Hautmann type, Mainz type, Goldwasser type and modified Reddy type in 36, 9, 15, 10 and 19 patients, respectively., Results: Sixty-seven (75.3%) patients could void spontaneously, 15 (16.8%) voided with clean intermittent catheterization (CIC) assistance and seven (7.9%) with CIC alone. After excluding the seven voiding with CIC alone, daytime and night-time continence was achieved in 63 and 50 of the remaining 82 patients, respectively. In addition, the proportion of daytime continence in the modified Studer group was significantly greater than that in the Mainz group, whereas there was no significant difference in the proportion of night-time continence among these groups. Uroflow examination indicated that despite the lack of significant differences in the maximal flow rates and the voided volumes, the post-void residual in the modified Reddy group was significantly smaller than that in the modified Studer group. Blood gas analysis in the 82 patients showed that there were no significant differences in the pH, bicarbonate, chloride and base excess among these groups., Conclusions: Orthotopic NB created with intestinal segments generally has acceptable functional outcomes on long term follow up. These outcomes differ according to the type of NB. To define the optimal procedure for NB reconstruction, it is necessary to understand the long-term functional prospects, on which the subjective success of NB creation is based.

Fluoroquinolones are the most commonly used prophylactic antimicrobials for ultrasound-guided transrectal prostate biopsy due to their broad pathogen spectrum, pharmacokinetics, bioavailability and ease of oral administration. However, although Escherichia. coli (E. coli) is the most common pathogen associated with infections after transrectal prostate biopsy, the prevalence of fluoroquinolone resistant strains of E. coli is increasing. Levofloxacin resistant E. coli sepsis occurred in four (0.6%) of 665 patients who received oral levofloxacin prophylaxis and underwent transrectal prostate biopsy from July 2002 to December 2006 in this institute. All patients had obstructions of the lower urinary tract and three of the four had a history of previous use of quinolones. Although two of the four patients developed septic shock, all of the patients were treated with carbapenems immediately and made a complete recovery. Since a case of multiresistant E. coli sepsis and fatal anaerobic sepsis after transrectal prostate biopsy had been reported, intravenous carbapenem is recommended as antimicrobial therapy for sepsis after transrectal prostate biopsy.

Objectives: The objectives of this study were to retrospectively examine the outcomes of adjuvant cisplatin-based combination chemotherapy following radical cystectomy in patients with invasive bladder cancer in order to identify parameters predicting the prognosis of these patients., Methods: This study included a total of 51 patients with muscle invasive bladder cancer who underwent radical cystectomy between January 1995 and December 2004, and subsequently received at least two cycles of either MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) or MVP-CAB (methotrexate, doxorubicin, vincristine, cyclophosphamide, bleomycin and cisplatin) chemotherapy in an adjuvant setting because of the presence of diseases corresponding to pT3/4 and/or pN1/2 without clinical evidence of metastasis. The significance of several clinicopathological factors as predictors of disease recurrence and cancer-specific death was evaluated using univariate and multivariate analyses., Results: During the observation period of this study (median, 26.5 months), disease-recurrence and cancer-specific death were observed in 21 and 16 patients, respectively. The 5-year recurrence-free and cancer-specific survival rates were 48.6% and 54.1%, respectively. Among several factors examined in this series, lymph node metastasis and concomitant carcinoma in situ (CIS) were identified as significant predictors of both disease-recurrence and cancer-specific death, and these were also independently associated with disease-recurrence and cancer-specific death., Conclusions: Adjuvant cisplatin-based combination chemotherapy for patients with extravesically extended bladder cancer following radical cystectomy resulted in comparatively unsatisfactory outcome concerning cancer-control; accordingly, it would be necessary to develop a more efficacious therapeutic strategy for such patients, particularly for those with lymph node metastasis and/or concomitant CIS.

Objectives: We analyzed the clinical outcomes of instillation therapy with Bacillus Calmette-Guerin (BCG) to treat carcinoma in situ (CIS) and searched for prognostic factors that could predict disease progression., Methods: Between January 1995 and January 2001, 185 patients (male, 155; female, 30) diagnosed with bladder CIS underwent weekly BCG instillations (80 mg of Tokyo 172 strain) for eight weeks. Primary, concomitant, and secondary CIS was found in 62 (33.5%), 60 (32.4%) and 63 (34.1%), patients, respectively. Seventy-five (40.5%) and 64 (34.6%) patients had limited and extensive CIS, respectively. The median follow up period was 37.5 months (range 4-95 months)., Results: The overall complete response rate was 86.5%. The five-year progression-free survival rate was 78.5%. Several factors, such as age (<60 or >or=60 years), gender, previous transurethral resection, type of CIS, and CIS extension (three or more positive sites out of four to six biopsy sites was defined as extensive), were examined by multivariate analysis to predict progression. The extension of CIS was the only independent prognostic factor. The five-year recurrence-free rate of complete responders (n = 160) was 66.0%. Radical cystectomy was performed in 10 patients (6.3%) during follow up incomplete responders, of whom seven had invasive bladder cancer. Extravesical involvement was identified in 30 patients (16.2%) among whom, 21 (11.3%) had upper urinary tract recurrence and nine (4.9%) had prostatic involvement., Conclusion: Therapy with BCG is effective against CIS, the extent of which might be a prognostic factor. Disease progression including extravesical involvement should be carefully monitored over the long-term after BCG therapy.

The aim is to evaluate the efficacy and toxicity of weekly docetaxel and estramustine for Japanese men with hormone refractory prostate cancer who were treated at a single institution. Twenty eligible patients had histologically proven adenocarcinoma of the prostate with metastases that were progressing despite complete androgen blockade and antiandrogen withdrawal. All of the patients received docetaxel 30 mg/m(2) weekly (days 1, 8, 15, 22, 29, and 36). After a two week break, the treatment schedule was repeated. Patients were scheduled to receive daily oral estramustine 560 mg/day throughout the protocol. In the serum prostate specific antigen (PSA) response, three (15%) patients achieved a complete response, and 8 (40%) acheived a partial response. Overall survival and time to progression were 13.4 months and 6.4 months, respectively, however sixty-seven percent of the patients had to discontinue treatment because of toxicity. The high toxicity of this protocol suggests that the regimen and/or the timing should be altered for Japanese patients.

Objective: The objective of this study was to analyze the outcomes of radical cystectomy for patients with pT4 bladder cancer., Methods: Between 1995 and 2003, 583 patients underwent radical cystectomy for bladder cancer at our institution and related hospitals, including 76 pathologically diagnosed as having pT4 disease. Of these 76, this study included 60 patients after excluding 16 with pT4Tis disease, and a retrospective review of their records was carried out., Results: Pathological examinations demonstrated that seven (11.6%) and 53 (88.4%) patients were Grades 2 and 3, respectively, and 48 (80.0%), 38 (63.4%), 10 (16.7%) and 30 (50.0%) were positive for lymphatic invasion, microvenous invasion, surgical margin and lymph node metastasis, respectively. During the observation period of this study (median, 24.5 months; range, 2-89 months), disease recurrence occurred in 38 (63.3%), and the median time to recurrence after radical cystectomy was 7.0 months (range, 1-38 months). One-, 3- and 5-year cancer-specific survival rates of the 60 patients were 68.8%, 48.5% and 23.9%, respectively. Univariate analysis identified lymph node metastasis, lymphatic invasion, microvenous invasion and positive surgical margin as significant predictors for cancer-specific survival; however, only lymph node metastasis was shown to be independently associated with cancer-specific survival by multivariate analysis., Conclusions: The prognosis of patients with pT4 bladder cancer is generally poor, particularly for those with nodal involvement. Therefore, it would be potentially important to carry out careful follow-up for such patients following radical cystectomy and, if necessary, to consider a multimodal therapeutic approach in an adjuvant setting.

Focal segmental glomerulosclerosis (FSGS) is known to recur in some patients after renal transplantation. Recently, laparoscopic nephrectomy has been introduced as a minimally invasive surgery. We present our experience with our first four patients with FSGS who underwent simultaneous bilateral native nephrectomy in the prone position by means of retroperitoneal laparoscopy before renal transplantation. This procedure provided adequate visualization and created enough working space for manipulation. The patients did not need to be repositioned. The mobilized specimens were removed through an incision extending from the first port or by means of morcellation within the sack. Mean operative time was 325 min and mean blood loss was 281 mL. The average time to resumption of oral intake was 1.3 days and all patients started ambulation on postoperative day 1. No major complications were observed. In conclusion, this procedure may become a useful option for native nephrectomy for FSGS patients before transplantation.

Background: The objective of this study was to evaluate the clinical outcome after surgical management of renal cell carcinoma (RCC) extending to the inferior vena cava (IVC)., Methods: This study included a total of 55 patients (41 men and 14 women; mean age, 59.3 years) with RCC (39 right- and 16 left-sided tumors) involving the IVC, who underwent radical nephrectomy and tumor thrombectomy between 1983 and 2005 at a single institution in Japan. The level of thrombus was classified as follows: level I, infrahepatic; level II, intrahepatic; level III, suprahepatic; and level IV, extending to the atrium. Clinicopathological data from these patients were retrospectively reviewed to identify factors associated with survival., Results: There were 11 and 18 patients who were diagnosed as having lymph node and distant metastases, respectively. Twenty-two patients had tumor thrombus in level I, 20 in level II, 10 in level III, and 3 in level IV. Pathological examinations demonstrated that 34 and 21 patients had clear cell carcinoma and non-clear cell carcinoma, respectively, 42, 9 and 4 were pT3b, pT3c and pT4, respectively, and 6, 35 and 14 were Grades 1, 2 and 3, respectively. Cancer-specific 1-, 3- and 5-year survival rates of these 55 patients were 74.5%, 51.4% and 30.3%, respectively. Among several factors examined, clinical stage (P = 0.047), lymph node metastasis (P = 0.016), histological subtype (P = 0.034) and tumor grade (P < 0.001) were significantly associated with cancer-specific survival by univariate analysis. Furthermore, multivariate analysis demonstrated clinical stage (P = 0.037) and tumor grade (P < 0.001) as independent predictors of cancer-specific survival irrespective of other significant factors identified by univariate analysis., Conclusions: In patients with RCC involving the IVC, biological aggressiveness characterized by tumor grade rather than tumor extension would have more potential prognostic importance; therefore, more intensive multimodal therapy should be considered in patients with high grade RCC with tumor thrombus extending into the IVC.

Aim: The objective of this study was to analyze the clinicopathological features of upper urinary tract recurrence following radical cystectomy for bladder cancer., Methods: Between 1995 and 2003, 583 patients underwent radical cystectomy and urinary diversion for bladder cancer at the authors' institution and the related hospitals. A retrospective review of patient records was carried out to evaluate characteristics of patients who underwent upper urinary tract recurrence after radical cystectomy., Results: During the observation period (median, 41.5 months), 12 (2.1%) of the 583 patients had upper urinary tract recurrence. Of the 12 patients with upper urinary tract recurrence, there were multiple tumors in eight at the initial diagnosis of bladder cancer, and eight received transurethral resections two or more times before radical cystectomy. The median time to diagnosis of an upper urinary tract cancer after radical cystectomy was 29.5 months. When upper urinary tract recurrence was detected, five patients had metastatic diseases simultaneously, and two had bilateral upper urinary tract cancers. The cancer-specific survival in patients with upper urinary tract recurrence was significantly poorer than that in those without upper urinary tract recurrence. In addition, eight of the 12 patients (66.7%) died of disease progression within 3 years after the diagnosis of upper urinary tract cancer., Conclusions: These findings suggest that despite the low incidence of upper urinary tract recurrence following radical cystectomy, the prognosis of such patients was markedly poorer compared with that of those without upper urinary tract recurrence. Accordingly, intensive therapies should be considered when upper urinary tract recurrence is detected after radical cystectomy.

Aim: Oncological outcomes including surgical margin status and biological progression-free survival (bPFS) were analyzed in patients who underwent laparoscopic prostatectomy (LRP) only., Methods: A total of 136 patients who underwent LRP only without lymph node metastasis or perioperative supportive therapy between April 2000 and October 2005 were analyzed. All patients received > or =6 months postoperative follow-up. Biological progression was defined as elevation of prostate-specific antigen by >0.2 ng/mL., Results: The positive margin (ew+) rate was 36.8% and the 3-year bPFS was 72.6% for all patients. Positive margin rates in pT2a-b, pT2c, pT3a and pT3b were 10.0%, 27.5%, 77.3% and 53.8%, respectively. Three-year bPFS rates in pT2, pT3a and pT3b were 91.8%, 66.8% and 44.9%, respectively. Although the positive margin rate at posterior and anterior sites decreased as more patients were recruited, no significant improvements were observed at apex and base sites. Three-year bPFS rates in pT2 ew-, pT2 ew+, pT3 ew- and pT3 ew+ were 95.8%, 85.7%, 81% and 48.5%, respectively, indicating that positive margins exert a greater impact in pT3 disease than in pT2 disease., Conclusions: Although 3-year bPFS results were almost identical to previous reports of LRP and retropubic radical prostatectomy, the positive margin rate in pT3a disease was particularly high, probably due to immature surgical skill. Although positive margins at posterior and anterior sites decreased with the leaning curve, improvements are needed to reduce positive margin rates at the apex. Positive margins exert greater impact in pT3 disease than in pT2 disease.

Objective: To evaluate the outcome of orthotopic neobladder creation in patients with a solitary functioning renal unit at the time of surgery., Methods: This study included a total of 18 patients (15 men and three women) with a solitary functioning kidney who underwent radical cystectomy for invasive bladder cancer followed by orthotopic neobladder replacement. Of these, an ileal, ileocolic or sigmoid colon neobladder was constructed in 11, three or four patients, respectively. Clinical data from these patients were retrospectively reviewed to clarify the significance of neobladder creation in patients with a solitary functioning kidney., Results: During the observation period of this series (mean, 44.2 months; range, 15-95 months), there were nine early complications in six patients (wound infection, ileus, urine leakage and pulmonary embolism in four, three, one and one, respectively) and 10 late complications in nine patients (severe metabolic acidosis, vesicourethral anastomotic stricture, ureterointestinal anastomotic stricture and neobladder calculi in six, two, one and one, respectively). Severe metabolic acidosis occurred in six (five ileal neobladders and one ileocolic neobladder); however, there were no significant differences in preoperative renal function and serum electrolytes as well as postoperative voiding function between patients with and without severe metabolic acidosis. These six patients required administration of sodium bicarbonate, and their metabolic status was normalized thereafter. Furthermore, there were no significant differences in renal function and serum electrolytes between these two groups throughout the observation period, and none of the patients demonstrated renal deterioration., Conclusions: These findings suggest, despite the analysis including a small number of patients with a short follow-up period, orthotopic neobladder replacement could provide comparatively satisfactory results in patients with a solitary functioning kidney; hence, a solitary kidney should not be regarded as a contraindicated factor for neobladder creation after radical cystectomy.

Laparo- or retroperitoneoscopic biopsy was performed for five male patients with retroperitoneal lymph node swelling of unknown origin. Previous core needle biopsies were useless or inapplicable in all patients. A laparoscopic approach was used for two patients, with a retroperitoneoscopic approach for the remaining three patients. Sufficient specimens for not only pathological diagnosis but also further examinations such as immunophenotyping or DNA analysis were safely obtained. Convalescence was satisfactory and all patients were treated appropriately according to the resulting diagnosis. This technique should be performed by urologists, who are more familiar with laparo- or retroperitoneoscopic approach targeting retroperitoneal organs.

Background: The objective of this study was to evaluate the efficacy and safety of first-line high-dose chemotherapy (HDCT) combined with peripheral blood stem cell transplantation (PBSCT) for patients with advanced extragonadal germ cell tumors (EGGCT)., Methods: Six male patients with advanced non-seminomatous EGGCT were treated with HDCT combined with PBSCT following 2-3 cycles of conventional-dose induction chemotherapy. The regimens used for HDCT were carboplatin, etoposide and ifosfamide (ICE) in five patients and ICE plus paclitaxel (T-ICE) in one patient, and that for induction therapy was cisplatin, etoposide and bleomycin (PEB) in all patients. As a rule, HDCT was continuously administered until alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin normalized (beta-HCG)., Results: Following 1-6 courses of HDCT (median, 4 courses), beta-HCG and AFP were normalized in all patients, and five and one patient were diagnosed as showing partial remission and stable disease, respectively. Five patients underwent surgical resection of residual tumors after HDCT, yielding necrotic tissue in two, mature teratoma in two, and viable cancer tissue in one, and the surgical margin was negative in all patients. At a median follow-up of 36 months, five patients were alive and disease-free, whereas the remaining one died of disease progression. Although all patients had grade 3 hematological toxicity, there was no treatment-related death by combining PBSCT., Conclusions: First-line HDCT with PBSCT could be safely administered to patients with advanced EGGCT, and the antitumor effect of this treatment was comparatively favorable. First-line HDCT therefore may represent an attractive option for patients with advanced EGGCT.

A patient was treated for hydronephrosis caused by an intra-abdominal abscess arising from cecal perforation by an ingested fish bone. To the authors' knowledge there is no previous report of such ureteral obstruction. Ureteral stenting, drainage of the abscess, and ileocecal resection were performed. Six months of stenting were required to attain ongoing ureteral patency following removal.

Today, 20-30% of male patients with advanced germ cell tumor (GCT) do not have durable, complete remission in spite of cis-platinum (CDDP)-based chemotherapy. High-dose chemotherapy (HDCT) has been tried in CDDP refractory GCT patients. Initially HDCT was performed with autologous bone marrow transplantation in heavily treated patients. However, the clinical outcome was not good and the treatment-related death rate was not ignorable. Therefore, earlier introduction of HDCT with peripheral blood stem cell transplantation was preferable as it renders HDCT more effective and less toxic, and multicycle HDCT is feasible. The durable free rate of recent HDCT for refractory GCT patients is 32-65%. HDCT is also performed as first line chemotherapy for poor prognosis GCT patients. Induction chemotherapy followed by multicycles of HDCT was tried. The durable free rate of recent HDCT as first line chemotherapy is 43-73%. Although previous reports suggest the superiority of HDCT, one recent randomized controlled trial (RCT) failed to show an improvement with one cycle of HDCT followed by three cycles of standard-dose chemotherapy (SDCT) compared with four cycles of SDCT. Ongoing RCT comparing multicycles of HDCT with SDCT for poor prognostic GCT patients will clarify the role of HDCT. Recently, new regimens of HDCT containing paclitaxel have been devised. In this review, the history, current status and future of HDCT for advanced or refractory GCT will be discussed.

Background: We evaluated the improvement in the rate of prostate cancer detection when using a 12-core transperineal biopsy protocol including transitional zone biopsy., Methods: Between April 2003 and November 2004, 247 consecutive men underwent transperineal systemic 12-core biopsy of the prostate. Six cores were obtained at the peripheral zone, four at the transitional zone and two at the apex. We examined the cancer detection rate in each of the 12 cores, and also determined the improvement of cancer detection resulting from the extensive 12-core versus standard 6-core biopsy., Results: Using the extensive 12-core biopsy, prostate cancer was detected in 98 cases (39.7%). Prostate-specific antigen (PSA), PSA density, the positive rate in digital rectal examination and transrectal ultrasound findings were significantly higher in the prostate cancer group than in the non-prostate cancer group, and prostate volume was larger in non-prostate cancer group. Every site showed almost the same positive rate, between 17.8 and 21.5%. There were 20 cases which were positive in the extended biopsy, but negative in the sextant. The detection improved significantly (20.4%). The improvement of cancer detection in extended biopsy was better in men with PSA levels of 10 ng/mL or less (28.9%), PSA density 0.3 or less (25.8%), negative digital rectal examination (23.3%), and negative transrectal ultrasound (21.6%). Of these twenty patients, no cases with insignificant tumor were detected in the six prostatectomy cases. In particular, three cases of the six were transitional-zone-only cancer., Conclusion: Transperineal extended 12-core biopsy including 4 transitional zone cores is a more useful procedure than transperineal 6-core biopsy. Routine transitional zone biopsy, that is different from transrectal biopsy, might be useful for detecting biologically significant cancer.