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Objectives: To identify pre-treatment factors affecting the duration of post-surgical steroid replacement in patients undergoing adrenalectomy for subclinical Cushing syndrome., Methods: The present retrospective analysis included 64 patients who underwent unilateral laparoscopic adrenalectomy for subclinical Cushing syndrome. Adrenal tumor and contralateral adrenal sizes together with various clinical factors were studied in association with the duration of post-surgical steroid replacement. Adrenal tumor and contralateral adrenal size were measured at the level of the maximum transverse plane of the adrenal glands using computed tomography scan or magnetic resonance imaging. Cox's proportional hazards model was used for the statistical analysis., Results: All 64 patients were treated with post-surgical steroid replacement after adrenalectomy. The median duration of the steroid treatment was 6 months. When assessing the duration of post-surgical steroid replacement, contralateral adrenal volume <0.745 cm 3 , contralateral adrenal width <6.15 mm and serum cortisol after a 1-mg dexamethasone suppression test >2.65 μg/dL were significant predictors of prolonged post-surgical steroid treatment on univariate analysis. On multivariate analysis, contralateral adrenal width <6.15 mm was the only independent predictive factor for the prolonged post-surgical steroid replacement., Conclusions: Contralateral adrenal width seems to represent a significant predictive factor for the duration of post-surgical steroid replacement in subclinical Cushing syndrome patients. Pre-surgical assessment of image findings might help clinicians determine the total duration of steroid therapy after adrenalectomy., (© 2018 The Japanese Urological Association.)

Objectives: To determine the predictors of testosterone recovery after termination of androgen deprivation therapy in high/intermediate-risk prostate cancer patients receiving external beam radiation therapy with neoadjuvant and adjuvant androgen deprivation therapy., Methods: A total of 82 patients who underwent external beam radiation therapy with androgen deprivation therapy for prostate cancer were retrospectively analyzed. Serum testosterone levels after androgen deprivation therapy terminations were studied. Cox proportional hazard models and the Kaplan-Meier method were used for statistical analysis., Results: Median age, baseline testosterone, nadir testosterone and duration of androgen deprivation therapy were 73 years, 456 ng/dL, 16 ng/dL and 26 months, respectively. Androgen deprivation therapy duration of 33 months (hazard ratio 0.13; P = 0.0018), nadir testosterone of 20 ng/dL (hazard ratio 0.35; P = 0.0112) and testosterone >50 ng/dL at 6 months after androgen deprivation therapy termination (hazard ratio 0.21; P = 0.0075) were significantly associated with testosterone recovery to normal levels (200 ng/dL) on multivariate analysis. Androgen deprivation therapy duration of 33 months (hazard ratio 0.31; P = 0.0023) and nadir testosterone of 20 ng/dL (hazard ratio 0.38; P = 0.0012) were significantly associated with testosterone recovery to the supracastrate level (50 ng/dL) on multivariate analysis. After dividing patients into three risk groups, the rate of testosterone recovery to the normal level after 2 years of androgen deprivation therapy termination was 100% in the low-risk group versus 20.8% in the high-risk group (P < 0.0001); the rate of testosterone recovery to the supracastrate level was 100% in the low-risk group versus 51.5% in the high-risk group (P < 0.0001)., Conclusions: Duration of androgen deprivation therapy and achievement of nadir testosterone 20 ng/dL both predict testosterone recovery to the supracastrate level in prostate cancer patients undergoing external beam radiation therapy with androgen deprivation therapy., (© 2018 The Japanese Urological Association.)

Objectives: To validate the ability of contemporary active surveillance protocols to predict pathologically insignificant prostate cancer among Asian men undergoing radical prostatectomy., Methods: We retrospectively reviewed data on 132 patients eligible for any active surveillance criteria out of 450 patients that underwent radical prostatectomy at several institutions between 2006 and 2013. We validated the ability of seven contemporary active surveillance protocols to predict pathologically insignificant prostate cancer. Traditional and updated criteria to define pathologically insignificant prostate cancer were used. Predictive factors for pathologically insignificant prostate cancer were determined by logistic regression analysis., Results: The predictive rate for updated pathologically insignificant prostate cancer of respective active surveillance criteria was 51% for Johns Hopkins Medical Institution, 41% for Prostate Cancer Research International: Active Surveillance Study, 39% for University of Miami, 32% for University of California, San Francisco, 32% for Memorial Sloan-Kettering Cancer Center, 31% for Kakehi and 27% for University of Toronto. Predictive rates for pathologically insignificant prostate cancer in Asian men were far lower than in USA men. On multivariate analysis, predictive factors of updated pathologically insignificant cancer was prostate volume (odds ratio 1.07, P = 0.004). By adding prostate volume to Prostate Cancer Research International: Active Surveillance Study criteria, the predictive rate for updated insignificant prostate cancer was improved up to 66.7%., Conclusions: Active surveillance can be carried out considering the clinical characteristics of prostate cancers depending on ethnicity, as current active surveillance criteria seem to have a lower predictive ability value of insignificant prostate cancer in Asian men compared with men in Western countries., (© 2015 The Japanese Urological Association.)

Objective: Correct interpretation of renal function in patients with primary aldosteronism is difficult before adrenalectomy, because subtle kidney impairment is often masked by glomerular hyperfiltration peculiar to primary aldosteronism. The aim of this study was to investigate postoperative changes in renal function for patients with primary aldosteronism and to identify clinical predictors of chronic kidney disease manifested postoperatively in the patients without pre-existing chronic kidney disease., Methods: Records of 78 Japanese patients who underwent unilateral adrenalectomy for primary aldosteronism were retrospectively surveyed. Patients who had been followed up for <6 months were excluded. Preoperative and postoperative estimated glomerular filtration rate were compared. Furthermore, uni- and multivariate analyses were carried out to identify clinical predictors for chronic kidney disease manifested postoperatively., Results: Patients with preoperative estimated glomerular filtration rate ≥60 mL/min/1.73 m(2) showed a significant decrease after surgery. Of the 66 patients without pre-existing chronic kidney disease, 24 developed chronic kidney disease postoperatively. Multivariate logistic regression analysis identified a medical history of dyslipidemia as an independent predictor for chronic kidney disease manifested postoperatively. According to univariate analyses, additional factors associated with postoperative manifestation of chronic kidney disease included older age, lower diastolic blood pressure and lower estimated glomerular filtration rate., Conclusions: The interpretation of normal or abnormal renal functions by examining estimated glomerular filtration rate heightened by hyperfiltration alone can mislead clinicians before adrenalectomy. Clinicians should pay attention to patients at greater risk of a significant decline in postoperative renal function., (© 2012 The Japanese Urological Association.)

Objectives: To develop and to internally validate a novel nomogram for predicting the stone-free rate after transurethral ureterolithotripsy., Methods: A total of 412 patients with 534 ureteral stones were treated with transurethral ureterolithotripsy using semi-rigid ureteroscopes. Treatment efficacy was evaluated 3 months after the procedure. Multivariate stepwise logistic regression analysis was used to identify independent predictors of being stone-free in the model-building set. A total of 427 stones (80% of 534) were randomly allocated for identification and statistical analysis to build the model, and the remaining 107 (20%) were used for cross-validation. A nomogram for the stone-free rate was developed based on the final logistic regression model., Results: Stone length, number of stones, stone location and the presence of pyuria were independent factors related to the stone-free rate after transurethral ureterolithotripsy treatment, and these were used to develop a nomogram. In this nomogram, the area under the receiver operating characteristic curve was 0.7432 for the nomogram, 0.5641 for stone size, 0.5908 for the number of stones, 0.6594 for stone location and 0.6076 for pyuria. Validation using 20% of the data also achieved a reasonable predictive accuracy (area under the receiver operating characteristic curve = 0.682)., Conclusions: The first nomogram for predicting the stone-free rate after transurethral ureterolithotripsy was developed. It has a reasonable predictive accuracy, and in combination with extracorporeal shock wave lithotripsy nomograms, it might be useful for deciding treatment methods., (© 2012 The Japanese Urological Association.)

Bone metastases occur in approximately 70% of patients with advanced prostate cancer. Skeletal-related events have been correlated with reduced survival and quality of life of patients with prostate cancer. Biochemical markers of bone metabolism (e.g. bone formation, bone resorption, osteoclastogenesis) might meet an unmet need for useful, non-invasive and sensitive surrogate information for following patients' skeletal health. Recently, zoledronic acid and denosumab have been proven to have the potential for preventing skeletal-related events among prostate cancer patients with bone metastasis. An improved understanding of the mechanisms underlying bone metastasis has also led to the recognition of multiple molecular targets and advances in therapy. However, estimating the efficacy of these agents is difficult. A clinical trial for castration-resistant prostate cancer is currently underway based on the definition of The Prostate Cancer Clinical Trials Working Group, and bone turnover markers are being used as conventional end-points for the clinical trial. Bone turnover markers are useful surrogate markers reflecting the effect of new therapeutic drugs and prognosis, as well as assessment of bone metastases. In particular, N-terminal cross-linked telopeptide of type 1 collagen and bone-specific alkaline phosphatase are widely used bone metabolism markers, and offer reliable surrogate markers to detect bone metastatic spread and to predict prognosis for prostate cancer patients with bone metastases., (© 2012 The Japanese Urological Association.)

Combined androgen blockade is widely used to treat patients with advanced prostate cancer. Recently, zoledronic acid was proven to be effective in preventing skeletal-related events for prostate cancer patients with bone metastases. Aim of the present study was to assess the effect of adding zoledronic acid to combined androgen blockade in the treatment of hormone-naïve metastatic prostate cancer patients by analyzing the changes of biomarker levels. Patients were treated with either a combination of combined androgen blockade and zoledronic acid (n=23) or combined androgen blockade alone (historical control combined androgen blockade group, n=42). Zoledronic acid was injected intravenously at 4 mg every 4 weeks for 2 years. Prostate-specific antigen and bone turnover markers (alkaline phosphatase and pyridinoline cross-linked carboxyterminal telopeptide of type 1 collagen) were examined before treatment and at 3, 6, and 12 months after treatment. Sequential changes of prostate-specific antigen, alkaline phosphatase and pyridinoline cross-linked carboxyterminal telopeptide of type 1 collagen for the two groups versus pretreatment levels were compared. Prostate-specific antigen values in both groups significantly declined at 3, 6 and 12 months compared with pretreatment levels. However, the decline of the prostate-specific antigen was lower in the combined androgen blockade group. Alkaline phosphatase significantly declined at 6 and 12 months in the combination of combined androgen blockade and zoledronic acid group, with no significant changes seen in the combined androgen blockade group. The addition of zoledronic acid to combined androgen blockade showed prostate-specific antigen and bone turnover markers response compared with combined androgen blockade therapy only, suggesting a potential antitumor effect of zoledronic acid in the management of metastatic prostate cancer patients., (© 2011 The Japanese Urological Association.)

The aim of the present study was to compare the accuracy of three prognostic models in predicting recurrence-free survival among Japanese patients who underwent nephrectomy for non-metastatic renal cell carcinoma (RCC). Patients originated from two centers: Chiba University Hospital (n = 152) and Chiba Cancer Center (n = 65). The following data were collected: age, sex, clinical presentation, Eastern Cooperative Oncology Group performance status, surgical technique, 1997 tumor-node-metastasis stage, clinical and pathological tumor size, histological subtype, disease recurrence, and progression. Three western models, including Yaycioglu's model, Cindolo's model and Kattan's nomogram, were used to predict recurrence-free survival. Predictive accuracy of these models were validated by using Harrell's concordance-index. Concordance-indexes were 0.795 and 0.745 for Kattan's nomogram, 0.700 and 0.634 for Yaycioglu's model, and 0.700 and 0.634 for Cindolo's model, respectively. Furthermore, the constructed calibration plots of Kattan's nomogram overestimated the predicted probability of recurrence-free survival after 5 years compared with the actual probability. Our findings suggest that despite working better than other predictive tools, Kattan's nomogram needs be used with caution when applied to Japanese patients who have undergone nephrectomy for non-metastatic RCC., (© 2011 The Japanese Urological Association.)

The objective of this study was to perform external validation of a previously developed prostate biopsy nomogram (the CHIBA nomogram) and to compare it with previously published nomograms developed in Japanese and overseas populations. Two different cohorts of patients were used: one from the Chiba Cancer Center (n = 392) in which transperineal 16-core biopsy was performed, and another from Chibaken Saiseikai Narashino Hospital (n = 269) in which transrectal 16-core biopsy was carried out. All patients were Japanese men with serum prostate-specific antigen levels less than 10 ng/mL. The predictive accuracy of our CHIBA nomogram and of four other published nomograms (Finne's sextant biopsy-based logistic regression model, Karakiewicz's sextant biopsy-based nomogram, Chun's 10-core biopsy-based nomogram and Kawakami's three-dimensional biopsy-based nomogram) was quantified based on area under the curve derived from receiver operating characteristic curves. Head-to-head comparison of area under the curve values demonstrated that our nomogram was significantly more accurate than all other models except Chun's (P = 0.012 vs Finne's, P = 0.000 vs Karakiewicz's, and P = 0.003 vs Kawakami's). Our nomogram appears to be more useful for the Japanese population than Western models. Moreover, external validation demonstrates that its predictive accuracy does not vary according to biopsy approach. This is the first report to demonstrate that the predictive accuracy of a nomogram is independent from the biopsy method.

Objectives: Laparoscopic surgery is widely accepted for managing renal disease. Thus, the system used to educate and train novice surgeons in laparoscopic surgery becomes important to reduce the risks of surgery during their training. A prospective study was carried out to determine the usefulness of using panoramic views during laparoscopic surgery., Methods: Between April 2004 and March 2007, four novice surgeons started learning laparoscopic radical nephrectomy: two carried out surgery without panoramic views and two used panoramic views. Operating time and blood loss for the initial 10 cases of each surgeon were compared. Panoramic views were obtained by interlacing each video frame of the video images electronically; the images were then processed and displayed during each step of laparoscopic surgery., Results: Panoramic, real-time views could be obtained, and they served as navigation maps. The learning curve of surgeons using the panoramic views was shorter than that of surgeons who did not use panoramic views. Time to ligation of renal artery from port placement and the operating time was shorter (69.0 +/- 21.5 min vs 106.8 +/- 44.9 min, P = 0.0016, 212 +/- 42 min vs 254 +/- 46 min, P = 0.0489, respectively) and the estimated blood loss was less for the surgeons who used panoramic views (87 +/- 109 mL vs 334 +/- 268 mL, P = 0.0005)., Conclusion: Panoramic views during laparoscopic surgery shortened operating time and reduced blood loss, indicating their usefulness in assisting novice surgeons to carry out procedures safely and accurately.

Neuroendocrine (NE) cells originally exist in the normal prostate acini and duct, regulating prostatic growth, differentiation and secretion. Clusters of malignant NE cells are found in most prostate cancer (PCa) cases. NE differentiation (NED) is the basic character of the prostate, either benign or malignant. NE cells hold certain peptide hormones or pro-hormones, which affect the target cells by endocrine, paracrine, autocrine and neuroendocrine transmission in an androgen-independent fashion due to the lack of androgen receptor. NED is accessed by immunohistochemical staining or measurement of serum levels of NE markers. The extent of NED is associated with progression and prognosis of PCa. Chromogranin A (CGA) is the most important NE marker. In metastatic PCa, pretreatment serum CGA levels can be a predictor for progression and survival after endocrine therapy. It is recommended to measure longitudinal change in serum CGA. The NE pathway can also be a therapeutic target.

Objectives: Although several nomograms for prostate cancer detection have been developed for Western populations, the models constructed on Japanese data would be more useful for the Japanese population because of various differences between Western and Asian populations. We previously developed a model for predicting the probability of a positive initial prostate biopsy using clinical and laboratory data from Japanese males. In the present study, a predictive model for Japanese males with a prostate-specific antigen (PSA) < 10 ng/mL was developed to guide decision-making for prostate biopsies., Methods: The age, total PSA level, free to total PSA ratio, prostate volume, and the digital rectal examination findings of 1037 Japanese males with a PSA < 10 ng/mL undergoing initial prostate biopsy as part of individual screening were analyzed. For study validation, 20% of these data was randomly reserved. Logistic regression analysis estimated relative risk, 95% confidence intervals, and P-values., Results: Age and the independent predictors of a positive biopsy result (elevated PSA, decreased free to total PSA ratio, small prostate volume, and abnormal digital rectal examination findings) were used to develop a predictive nomogram. The area under the receiver operating characteristic curve was significantly higher for the model (73.0%) than for PSA alone (55.0%). If externally validated, the use of this nomogram could reduce unnecessary biopsies by 26% and overall prostate biopsies by 7.8%., Conclusions: This predictive nomogram could provide more precise risk-analysis information for individual Japanese patients with PSA levels less than 10 ng/mL and may help to identify patients who need a prostate biopsy.

Relationships between androgenic hormones and prostatic tissue growth are complex. It is certainly true that the prostate will not develop without androgens and the gland will atrophy if androgen support is withdrawn. The hormonal hypothesis remains one of the most important hypotheses in the etiology of prostate cancer (PCa), and efforts are continuing to improve the understanding of androgen actions in PCa. Although evidence from epidemiological studies of associations between circulating levels of androgens and PCa risk has been inconsistent, the traditional view that higher testosterone (T) levels represent a risk factor for PCa appears to have little evidentiary support. Reinvestigation of the relationship between T and PCa seems important and necessary if a new, clinically and scientifically rewarding concept is to be constructed. The present review considers the metabolism and intraprostatic action of T, epidemiological evidence, and the association between T and PCa risk.

Objectives: Chromogranin A (CgA) and neuro-specific enolase (NSE) are gaining acceptance as markers of several types of neuroendocrine tumors and the concentration of CgA and NSE have been reported to be elevated in relation to neuroendocrine differentiation of prostate cancer. The aim of the present study was to examine the correlation between the immunohistochemical (IHC) findings and serum value for CgA and NSE in untreated stage D(2) prostate cancer patients., Methods: Immunohistochemistry was carried out using antibodies against CgA and NSE in 58 patients and, pretreatment serum CgA and NSE levels were measured by monoclonal immunoradiometric assay in 18 patients with stage D(2) prostate cancer treated by androgen ablation. We examined the relationship of the pretreatment serum level to IHC findings for CgA and NSE in prostate cancer patients to clinicopathological parameters, and prognosis. Also, we evaluated the correlation of IHC findings to serum levels for CgA and NSE., Results: There was a statistically significant correlation between CgA positivity and serum CgA level (P = 0.0421). However, there was no statistically significant correlation between NSE positivity and serum NSE level (P > 0.05). We divided stage D(2) patients into three groups according to IHC positivity of CgA and NSE. The cause-specific survival was significantly poorer in patients with strongly positive (++) patients for independent CgA and combined CgA with NSE (P = 0.0379). Multivariate analysis of cause-specific survivals in patients with stage D(2) prostate cancer demonstrated that strong IHC stain was considered as independent variable associated with greater risk of death (P = 0.0142)., Conclusion: Neuroendocrine differentiation in stage D(2) prostate cancer has attracted considerable attention as a potentially findings prognosis. Thus, CgA had a stronger relationship between serum levels and IHC positivity in contrast to NSE, suggesting clinical usefulness as a tumor marker in predicting the extent of neuroendocrine differentiation in prostate cancer.

Objective: We evaluated health-related quality of life (HRQOL) in Japanese men receiving androgen deprivation therapy (ADT) for prostate cancer., Methods: Fifty-six men were enrolled in this study. HRQOL was prospectively measured before ADT, and at 3, 6 and 12 months after treatment began, using a general (36-item Short-Form Health Survey) and disease-specific (the University of California, Los Angeles Prostate Cancer Index) HRQOL questionnaire., Results: In the general HRQOL questionnaire, patients with stage B (n = 22) or C (n = 17) disease showed a decline in vitality at 6 and 12 months (P < 0.05 for both). Stage D patients (n = 17) had improvements in bodily pain at 3 and 12 months (P < 0.05 for both), vitality at 12 months (P < 0.05), role-emotional at 6 months (P < 0.05), and mental health at 3 months (P < 0.05). When clinical stages were not considered, there were no significant changes in the 36-item Short-Form Health Survey. As for the disease-specific HRQOL, urinary function improved after ADT at 6 and 12 months (P < 0.05 for both), and urinary bother decreased at 3 (P < 0.05), 6 (P < 0.005) and 12 months (P < 0.05). Sexual function decreased at 3 (P < 0.05), 6 (P < 0.005) and 12 months (P < 0.005) but sexual bother improved at 6 and 12 months (P < 0.05 for both). If patients were stratified by clinical stages, similar findings were observed., Conclusions: General HRQOL was mostly unaffected by ADT in Japanese men. Disease-specific questions indicated an increase in urinary function. Although deterioration of sexual function was marked, most patients did not report sexual bother. Our results shed new light on the impact of ADT on HRQOL and could provide useful information about patient-centered outcome evaluations.

Aim: The clinical significance of the urinary white blood cell (U-WBC) count and serum C-reactive protein (CRP) level was evaluated in an effort to improve the efficiency of prostate biopsies., Methods: We enrolled 228 consecutive patients with serum prostate-specific antigen (PSA) ranging from 3.0 to 20.0 ng/mL, normal digital rectal examination findings, and who underwent prostate biopsies between January 2001 and August 2004. Of these, 157 patients had histologically confirmed benign prostatic disease and the remaining 71 patients had prostate cancer. Patients with a pretreatment U-WBC count < or =3 or >3/high power field were defined as non-pyuria and pyuria, respectively. The patients were also separated into two groups based on the serum CRP level prior to biopsy. Several clinical factors were compared among these subgroups., Results: Inflammation was histologically detected at rates of 58.1% and 34.1% in the pyuria and non-pyuria groups, respectively (P = 0.0014). The rates of cancer detection were significantly lower in the pyuria, than in the non-pyuria group (P = 0.0384). The cancer detection rates did not significantly differ according to serum CRP levels prior to biopsy., Conclusion: The U-WBC count appears to be a reliable indicator of minute prostatic inflammation. The serum PSA level was elevated in patients with asymptomatic prostatitis. Counting U-WBC is a simple, convenient and non-invasive method that should be valuable part of routine urological examinations.

Objective: The purpose of this study was to clarify characteristics of baseline health-related quality of life (HRQOL) during the diagnostic process of prostate cancer., Methods: A prospective study was conducted to measure HRQOL in a cohort of 141 patients in whom prostate cancer was suspected and prostate biopsy was scheduled, using both generic and disease-specific HRQOL measures (SF-36, UCLA-Prostate Cancer Index) at two points: before prostate biopsy (prediagnosis) and after giving biopsy results (postdiagnosis). Seventy-three patients were diagnosed with prostate cancer and 68 were not., Results: Compared to age-gender adjusted population norms, patients demonstrated better physical function (PF) and worse mental health (MH). Characteristic age-related changes were found in PF and sexual function (SXF); however, disease stage exhibited no relevant effects in HRQOL. No significant difference was detected between pre- and postdiagnosis SF-36 and UCLA-PCI scores., Conclusion: The present study discovered no relevant impact of the diagnostic process of prostate cancer on baseline HRQOL using SF-36 and UCLA-PCI. Combined with results of previous studies, it is supportive of regarding pretreatment levels of HRQOL as the baseline.

Erythropoietin (EPO)-producing renal cell carcinomas in two hemodialysis patients are reported. Despite deteriorated kidney function, these patients did not manifest anemia at diagnosis and their elevated serum EPO levels rapidly returned to within the normal range after nephrectomy. Immunohistochemical staining of the resected specimens showed production of erythropoietin in the tumor cells in one case and in the lining cells of the cyst wall in the other case. Renal cell carcinoma could cause an increase of blood hematocrit level in dialysis patients.

A 55-year-old woman was admitted to the Department of Urology at Chiba University Hospital. The patient's chief complaint was frequent urination and micturition pain. Computed tomography of the abdomen demonstrated a mass lesion in contact with the anterior wall of the bladder. Mass extirpation was performed transperitoneally. On dissection of the mass, a thin foreign body shaped like a skewer was detected. A specimen of the mass revealed non-specific inflammation. Elemental analysis with an electron probe microanalyser (EPMA) revealed that the composition of the foreign body was consistent with bone. The perivesical mass was diagnosed as an abscess caused by a fish bone that migrated from the intestinal tract.